Clinical and Health Affairs
A Primer on Acupuncture
By Miles Belgrade, M.D., and Elizabeth Huntoon, M.D.
Abstract
Although widely practiced in China for 2,000 years, acupuncture was introduced in the United States 40 years ago, and it has only gained acceptance by the medical establishment here in recent years. Now, a growing body of evidence supports its efficacy for a number of conditions, and it is being routinely recommended for them. This article provides an overview of acupuncture and reviews some of the evidence showing its effectiveness for treating various conditions.
Many of us still remember the reaction in this country when New York Times reporter James Reston wrote about his experience with acupuncture following an emergency appendectomy while covering the U.S.–China ping pong games in 1971. How could his postoperative pain be alleviated by inserting, of all things, needles into his body? It was unfathomable to the Western mind that needles alone would produce an effect without injecting something through them. Words like “voodoo,” “magic,” “trickery,” and “scam” were found in nearly every media report about Reston’s experience, and teams of American scientists were sent over to verify and scrutinize this mystical procedure. The Chinese must have been surprised and puzzled by this flurry of interest. After all, acupuncture, along with herbal therapies, had been part of their system of medicine for more than 2,000 years.
Nearly 4 decades later, acupuncture is one of the most recognized, and most researched, complementary medicine techniques. It has the strongest scientific foundation of any complementary therapy and an expanding body of evidence regarding its efficacy in clinical trials. Chiropractic education now routinely incorporates acupuncture training, and the American Academy of Medical Acupuncture has more than 1,800 physician members.
What is Acupuncture?
Acupuncture, in the broadest sense, is the stimulation of specific points on the body to achieve a therapeutic effect. A component of traditional Chinese medicine, it involves stimulation at specific points on the body, which lie along channels or meridians. A vital energy known as chi is purported to flow within those channels. When disease occurs, the flow of chi is accelerated or blocked. Acupuncture regulates that flow and restores balance and health.
Acupuncture is an ancient healing technique. Written documentation of acupuncture practice dates to around 600 BC, long before iron and steel became available for fashioning needles (Figure).1 It is unknown whether acupuncture points and techniques were derived empirically or by some other means.
How Acupuncture is Done
Acupuncture needles are generally fashioned out of stainless steel but are sometimes made of gold or silver, which for some unknown reason achieve energizing or sedating effects. Twenty-eight to 32-gauge solid needles are used. The length of the needle used in a treatment and the depth of penetration depends on the thickness of the underlying soft tissue. Many acupuncture points overlie muscle, and the needle is usually inserted to the center of the muscle belly. Needles may be inserted perpendicularly, obliquely, or tangentially. The acupuncturist usually tries to elicit a sensation called deqi (pronounced day-chee), which refers to a deep, heavy, warm, or aching sensation that is believed to be crucial to achieving a therapeutic effect.2
Stimulation of the acupuncture points is a necessary part of treatment. This may be done manually, by thrusting up and down or twisting back and forth, or by tapping or scraping the handle of the needle. Electrical current may be applied to pairs of needles. Frequencies can be in the 3 Hz to 5 Hz range or they can be much higher, in the 100 Hz to 1,000 Hz range. The amplitude is adjusted according to the patient’s ability to tolerate stimulation.
Needles and acupuncture points may also be heated in various ways including through moxibustion, a technique in which the Artemisia moxa plant is burned near the acupuncture point or on the needle. It is believed that some active component in this plant penetrates the skin to provide a sense of well-being. Burning tobacco, wood, or cotton at acupuncture sites has not been found to produce that effect.1
The duration of an acupuncture session is usually 20 minutes to 45 minutes. The frequency of sessions depends on the clinical problem, its chronicity, and the patient’s resources (see “Insurance Coverage”). Typically, treatments are carried out 1 to 3 times per week. Sometimes treatments are offered daily or as infrequently as once or twice a month. A course of treatment consists of 10 to 20 sessions; but for intractable chronic conditions, periodic maintenance therapy may be necessary. Ultimately, the intervals between treatments and the duration of a course of acupuncture remain empiric.2
Insurance Coverage
A number of third-party payers cover acupuncture. One notable exception is Medicare, which does not. Reimbursement rates are variable, and there are typically limits on the number of treatments allowed. Costs vary from about $50 per session to about $150, depending on whether the session is the initial one, which may involve a physical assessment and a more detailed patient history, the duration of the session, and whether or not electrical stimulation is added to the needles during treatment. The CPT procedure codes typically used for acupuncture are 97810 for the first 15 minutes and 97811 for each additional 15-minute session without electrical stimulation. If electrical stimulation is used, the codes are 97813 and 97814.
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There are 2 approaches to choosing points for treatment: the traditional Chinese medicine approach and a formula approach. Traditional Chinese medicine uses a diagnostic system that is based on Taoist concepts of the natural order of the universe and life:
yin and
yang; the flow of vital energy,
chi; and the relationships between the 5 elements that make up all things in the universe—fire, earth, metal, water, and wood. Human diseases are diagnosed in part by history; but the physical examination is quite different from that used in Western medicine. The appearance of the tongue and the qualities of the radial pulse are the primary means for assessing the patient. Equally acceptable, and commonly used in China and around the world, is a formula approach to point selection. It is based on some of the concepts from traditional Chinese medicine but uses a limited number of rules for point selection:
1. For localized symptoms, points are near the site of the symptom on any meridian for a particular organ. Acupuncture meridians are named after organs such as the lung, spleen, large intestine, etc. But the connection with the organ as we know it is more functional and metaphorical than physical. For example, treating the Heart meridian affects not just the action of the heart muscle but also the mind, emotions, and spirit.
2. Tender points on the body are often chosen for therapy.
3. Points on a meridian will influence symptoms or disorders along the entire meridian.
4. Six important distal points on the upper and lower limbs have effects on specific regions of the head, neck, and trunk. For example, the point Hoku (Large Intestine – 4) in the first dorsal interosseous muscle between the thumb and first finger affects the head and neck.
5. Subsets of points have certain general effects such as sedation, tonification (energizing), and immune system regulation; they also can influence certain tissues such as muscle, tendons, bone, and cartilage.
6. A somatotopic map of the surface of the ear can be used to choose points on the the ear that can influence other parts of the body.
The Mechanism of Acupuncture
There is no doubt that acupuncture analgesia occurs at least in part by stimulating the endorphin system. Three lines of evidence and multiple studies in animals and in human subjects prove this: 1) reversal of acupuncture analgesia by naloxone, 2) direct measurements of endorphins in cerebrospinal fluid and other tissues during acupuncture, and 3) the blunting of acupuncture analgesia by antiendorphin antisera. Other chemical mediators of pain including biogenic amines, substance P, calcitonin gene-related peptide, cholecystokinin, and c-fos have been shown to be involved in animals treated with acupuncture.
Why acupuncture may have a lasting effect is still a matter of speculation. It is now known that the brain and spinal cord can change, ie, they show plasticity. Organized stimulation of peripheral tissue by acupuncture may direct long-lasting changes in brain networks that help normalize bodily functions and response to stimuli.
Conditions for Which Acupuncture is Effective
Acupuncture research has increased significantly in the years following the 1997 NIH consensus conference statement that supported its use for several medical conditions. Since then, researchers have studied the use of acupuncture for a number of conditions. For example, acupuncture has been found to be beneficial for women with premenstrual syndrome and dysmenorrhea as well as for patients with cancer who suffer from nausea.3 It is also useful for:
Infertility. Preliminary evidence published as a meta-analysis by Manheimer et al. in the British Medical Journal suggests that acupuncture treatments provided at the time of embryo transfer improved rates of pregnancy.4
Labor. The use of transcutaneous electrical nerve stimulation at several acupuncture points in parturients was found to reduce the incidence and severity of hypotension after spinal anesthesia during Caesarean section.5
Headache. A 2008 study published in Anesthesia and Analgesia reviewed 31 clinical trials involving adult chronic headache patients who were treated with acupuncture. This review of the literature concluded that acupuncture was an effective treatment for chronic headache, reducing the intensity and frequency of pain when compared with sham acupuncture, medication, and wait-list controls.6
Postoperative pain. A meta-analysis by Sun et al. from Duke University in 2008 looked at acupuncture (and other techniques) as an adjunct for analgesia during the acute postoperative period. Researchers analyzed 15 papers that reviewed the cases of 1,166 patients (668 of whom received acupuncture). The patients who received acupuncture indicated their postoperative pain was significantly reduced as was their opioid consumption and opioid-related side-effects.7
Cardiovascular problems. A number of controlled studies have shown the benefit of acupuncture in medically intractable angina pectoris. Some of these studies also showed measurable changes in cardiac performance.8-10 Although the methodological quality of the studies has been questioned, there seems to be a trend toward efficacy of using acupuncture to treat certain types of arrhythmias.11
Rheumatoid arthritis and osteoarthritis. A review from Tufts Medical Center reported on 8 studies of 536 patients with rheumatoid arthritis in which the authors found favorable results in active-controlled trials when assessing joint pain, morning stiffness, and inflammatory markers (CRP, ESR). However the authors concluded that conflicting evidence existed in placebo-controlled trials.12 A randomized controlled trial of acupuncture versus sham acupuncture in 570 patients with osteoarthritis of the knee found improvement in pain and function among the group that received true acupuncture at 26 weeks.13
Fibromyalgia. A study published in the Journal of Rehabilitation Medicine in 2008 looked at the 6-, 12-, and 24-month outcome of a group of fibromyalgia patients who had received acupuncture treatments. The authors found that the patients who received acupuncture were significantly better at 6 and 12 months but reported no significant differences in any outcome measures at 24 months.14 A 2006 Mayo Clinic study of acupuncture for fibromyalgia compared active treatment with a sham procedure and found significant improvement in overall fibromyalgia symptoms among those who received acupuncture, with a durable benefit at 7 months.15
Battlefield injuries and post-traumatic stress. During Operation Iraqi Freedom, some soldiers received acupuncture for their injuries during a 7-month period. This noncontrolled study found that troops were able “to function while being treated, reducing or avoiding sick in quarters or light limited-duty status and saving operational man-days.”16 Battlefield acupuncture proved to be especially effective among patients suffering from a combination of physical wounds (burns, traumatic brain injury, limb amputation, etc.) as well as mental distress (severe disorientation and anxiety). This approach to treating injury was so successful that the Air Force will begin teaching battlefield acupuncture this year to physicians deploying to Iraq and Afghanistan.
The Risks of Acupuncture
Common side effects of acupuncture include syncope or near-syncope (less than 1% of patients—more likely if they are sitting up during the treatment), bruising around the needle site (in about 2% of needle sticks), and persistent soreness from needling that may last for hours or days.
In most patients, acupuncture is associated with minimal discomfort; however, the acupuncturist is trying to create a needling sensation—a mild ache or soreness at and around the needle site that probably corresponds with stimulation of unmyelinated C-polymodal nociceptors. Some patients with chronic pain are so sensitized that any stimulation is intolerable. For those patients, acupuncturists try to use few needles and insert them very superficially to achieve a tolerable level of stimulation. In some cases, patients may experience a brief flare-up of pain symptoms after the initial treatment; in those cases the number of needles or the amount of stimulation is reduced in subsequent sessions. Some patients have also reported contact dermatitis caused by the nickel in stainless steel needles.
Licensing Acupuncturists
The Minnesota Legislature enacted a law in 1995 establishing a licensure system for acupuncturists. The Minnesota Board of Medical Practice enforces the requirements of the acupuncturist licensure system. Physicians and chiropractors in Minnesota are exempt from the licensure requirement because acupuncture is within the scope of their professional licenses. (A number of courses are available to physicians who want to learn acupuncture, including one taught through the UCLA Extension.) However, every acupuncturist in Minnesota who is not a physician or chiropractor should have their Minnesota license displayed. Although it doesn’t guarantee quality, it does ensure a basic knowledge of acupuncture and clean-needle technique.
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Acupuncture also may cause organ or tissue damage and infections. The lung is the organ most likely to be injured during acupuncture. Several cases of unilateral and bilateral pneumothorax have been reported. Cases of spinal cord and peripheral nerve injury have been associated with migration of a broken needle fragment or a purposefully retained needle. Boxall reported 29 cases of serologically proven hepatitis B traced to an acupuncture clinic in Birmingham, England.
17 Four cases of hepatitis B were traced to acupuncture treatment received at a chiropractic clinic in Florida in 1980. In both clinics, the cases were attributed to poor needle management: reuse of needles, use of hollow syringe-type needles, and use of unsterilized needles.
18
Acupuncture should be avoided during pregnancy or used with caution because of the possibility of stimulating uterine contractions and causing miscarriage. However, acupuncture can be effective for hyperemesis gravidarum and other complications of pregnancy, so the benefit may outweigh the risk in some cases, if the acupuncturist avoids stimulating points known to produce uterine contractions.
Patients with neuropathies or spinal cord injuries also may need special approaches to care. Early experiments in animals showed that if an acupuncture point is pretreated with a local anesthetic then acupuncture at that site will not produce analgesia. Thus it appears that an intact peripheral nervous system is needed for acupuncture to be effective. On the other hand, one study from Japan showed that acupuncture could produce analgesia in unconscious humans who were undergoing surgery via general anesthesia.19 Patients treated for painful diabetic neuropathy have reduced sensation in the distal lower extremities but often say they can feel the sensation of acupuncture needling. In patients with spinal cord injury who have no sensation below the level of injury, acupuncturists should choose points at or above the level of injury or stimulate points on the ear that correspond with points on the body.
Conclusion
Every physician knows the frustration of trying to treat chronic illnesses with a limited number of tools. Drugs, surgery, and behavioral and physical therapies are often inadequate for conditions such as chronic pain, headache, fatigue, depression, and anxiety. Sometimes we can sense that a completely different model is needed.
Acupuncture has been used for thousands of years, longer than allopathic medicine. It has withstood the test of time, held up to the scrutiny of scientific method, and become an accepted treatment for a number of conditions. Nearly 4 decades after its introduction in the United States, shouldn’t acupuncture be promoted from complementary and alternative medicine to mainstream medicine? MM
Miles Belgrade is a neurologist and Elizabeth Huntoon is a physiatrist at Fairview Pain Management Center at the University of Minnesota Medical Center, Fairview. Both use acupuncture in their practice of pain medicine.
References
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18. Hepatitis B associated with acupuncture-Florida. MMWR. 1981;30:1-3.
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