Clinical Uses for Acupuncture

Keith Berndtson, M.D., Kirk Moulton, Dipl.Ac., Alan Uretz, Dipl.Ac., PhD.med. (China)

Acupuncture is part of a system of medicine which originated in China more than 3000 years ago. This system is based on a paradigm unlike that used in Western medicine. Practitioners of traditional Chinese medicine (TCM) refer to the foundational concept of "Qi" (pronounced chee), which can be loosely translated as energy and its effects on physiological function and health.1 Qi represents a positive, animating life force. The underlying goal of traditional Chinese medical treatment is the creation or maintenance of harmony - within the individual, and between the individual and the environment. Health is reflected as harmony which, in turn, is influenced by Qi. For example, if the process of attacking a disease has the undesired effect of dissipating a person's Qi, the result will interfere with that person's recovery toward optimal health. In this sense, acupuncture, as a tool of TCM, not only helps to control symptoms, but works to restore the strength and resilience of the body by building Qi.

Education and Licensing Requirements for Acupuncturists

Acupuncture has been offered in the United States for more than 150 years. Over the past thirty years it has become a widely recognized form of treatment with more than 30 states allowing legal practice of acupuncture. An additional 14 states are working on legislation to regulate acupuncture. On January 31, 1997, Governor Edgar signed the Illinois Acupuncture Act, paving the way for Illinois to issue licenses for the practice of acupuncture. The act stipulates that licensed acupuncturists must obtain their patients by written referral from a licensed physician, and that the prescription must be kept on file by the acupuncturist. Accreditation methods have yet to be determined, but will likely reflect current education and exam standards required by the National Commission for the Certification of Acupuncturists (NCCA).

NCCA certification typically requires 1,800 hours of education and 1,000 of internship, passage of the comprehensive written and practical examination, successful completion of the Clean Needle Technique Course, and commitment to the professional code of ethics.2 Diplomates undergo recertification every 2 years based on continued activity, professional competence, and current knowledge in the field. The American Academy of Medical Acupuncture trains physicians in acupuncture. Membership requires 220 hours of formal training and two years of clinical experience.

Conditions Amenable to Acupuncture Treatment

In 1979, the World Health Organization conducted an interregional seminar on acupuncture, reviewed published reports, and issued a position statement concerning clinical conditions that have been shown to respond to acupuncture (see Table 1).3 In 1992, Helms reviewed the international literature on clinical research in acupuncture printed or abstracted in western European languages since 1960.4 Over 2,500 articles were grouped and sub-grouped according to the medical discipline of the problem being studied. The findings are summarized in Table 2. While this information does not address the merits of the research, it does indicate the range and distribution of medical problems approached via acupuncture. If the review criterion is controlled studies appearing in peer-reviewed journals, however, only several dozen articles deserve closer scrutiny.5

Possible Mechanisms of Action

Acupuncture began receiving widespread attention in the West when its effects were linked to endorphin release. Summarizing research findings from several labs, Pomerantz has proposed that the neural mechanisms of acupuncture analgesia are initiated with the stimulation of high-threshold, small-diameter nerves in muscle.6 These type II and III muscle sensory nerves send messages to the spinal cord and proceed to activate centers in the midbrain and pituitary, resulting in the release of monoamines and endorphins capable of blocking pain messages.

The pathways and mediators involved in acupuncture's reported success as therapy for allergies, asthma, chronic sinusitis, irritable bowel, chemical dependency and other conditions where pain is at most a secondary feature remain unknown. From the traditional Chinese medical standpoint, however, the absence of Western mechanistic explanations has been no hindrance to continued use of an ancient and empirically successful healing tradition.

Survey of Controlled Clinical Research

In separate reviews, both Reed and Birch et. al., analyzed human studies showing analgesic effects of acupuncture for various acute and chronic pain conditions and found that acupuncture outperformed controls in the treatment of facial pain, operative and post-operative dental pain, headache (both muscle tension and migraine), neck pain, low back pain, tennis elbow, dysmenorrhea, osteoarthritic pain, myalgia, fibromyalgia, angina, and renal colic.7,8

Culliton and Kiresuk reviewed controlled studies of acupuncture in the treatment of substance abuse and found significant benefits versus control for addiction to alcohol, cocaine, heroin, and nicotine.9 Parfitt found significant benefits of acupuncture over control in the prevention of chemotherapy-induced nausea and vomiting during treatment of lymphoma, breast, and testicular cancer.10

Jobst reviewed 16 studies in patients with asthma or chronic bronchitis and found that acupuncture did better than control in 10 of those studies, same as control in three, and worse than control in three.11 In a series of cases, Naeser reviewed the use of acupuncture in the treatment of paralysis due to central nervous system damage and concluded significant benefits could be obtained in cases of stroke, head injury, multiple sclerosis, pseudobulbar palsy, cerebral palsy, spinal cord injury, Bell's palsy, and coma.12>

Standards of Practice

The most basic credential for acupuncture practice is certification by the NCCA. When practicing acupuncture, care must be taken to prevent the transmission of bloodborne pathogens. The use of alcohol swabs and individually packaged, disposable needles is required for the practice of "clean needle technique." Disposal of used needles should follow OSHA guidelines for the disposal of potentially hazardous waste.

The administration of acupuncture to a patient should be preceded by a physician's evaluation and, when possible, an established diagnosis. Patients eligible for acupuncture therapy should receive a basic orientation about what to expect from treatment. This can be supplied by the referring physician (through patient education brochures, discussion, etc.). The acupuncturist will supply more detailed information at the time of the first visit.

Ancillary acupuncture treatment should adhere to the physical therapy model for referrals. For purposes of clinical documentation and utilization review, the referring physician should receive from the acupuncturist periodic reports concerning response to treatment, progress toward treatment goals, and the anticipated duration of therapy. Local procedural codes for acupuncture can be used for insurance reimbursement purposes, although insurance coverage for acupuncture varies from plan to plan.

Summary

NCCA certification testifies to the rigorous education of acupuncturists, whose skills and training are being brought to bear on a growing range of medical problems. With the signing of the Illinois Acupuncture Act, acupuncturists will be licensed to accept physician referrals and will assume a more prominent role in ancillary medical care. Controlled research suggests that current indications for acupuncture referral should include chronic pain, a range of musculoskeletal syndromes, muscle tension or migraine headaches, chemical dependency, chemotherapy-induced nausea and vomiting, asthma, and bronchitis. Reported empirical experience would suggest that additional indications for acupuncture referral may include a miscellaneous variety of clinical conditions. Refining the clinical uses of acupuncture will require careful outcomes monitoring supported by high quality, controlled research. By applying high standards of practice, acupuncture referral programs can enlarge the physician's toolbox and be put to work to enhance clinical outcomes and the quality of patient care.

References

1. Bienfield H and Korngold E. Between Heaven and Earth: a Guide to Chinese Medicine. New York:Ballantine, 1991.
2. Mitchell BB. Educational and licensing requirements for acupuncturists. Journal of Alternative and Complementary Medicine, 1996;2:33-36.
3. Bannerman RH. The World Health Organization viewpoint on acupuncture. American Association of Acupuncture and Oriental Medicine, 1981.
4. Helms JM. Review of medical and clinical literature. Journal of Alternative and Complementary Medicine, 1996;2:71-2.
5. Biomedical Research on Acupuncture: an Agenda for the 1990s (conference summary). Los Angeles:American Foundation of Medical Acupuncture, 1993.
6. Pomeranz B. Scientific research into acupuncture for the relief of pain. Journal of Alternative and Complementary Medicine, 1996;2:53-60.
7. Reed JC. Review of acute and chronic pain published studies. Journal of Alternative and Complementary Medicine, 1996;2:129-144.
8. Birch S, Hammerschlag R, and Berman B. Acupuncture in the treatment of pain. Journal of Complementary and Alternative Medicine, 1996;2:101-124.
9. Culliton PD and Kiresul TJ. Overview of substance abuse acupuncture treatment research. Journal of Alternative and Complementary Medicine, 1996;2:149-159.
10. Parfitt A. Acupuncture as an antiemetic treatment. Journal of Alternative and Complementary Medicine, 1996;2:167-173.
11. Jobst K. Acupuncture in asthma and pulmonary disease: an analysis of efficacy and safety. Journal of Alternative and Complementary Medicine, 1996;2:179-206.
12. Naeser MA. Acupuncture in the treatment of paralysis due to central nervous system damage. Journal of Alternative and Complementary Medicine, 1996;2:211-248.