Acupuncture

Essentials

  • Acupuncture is a treatment modality where the treatment process itself, with the associated interaction involved, has a positive effect on the treatment outcome.
  • Acupuncture involves needling but not all needling is acupuncture.
  • The treatment, when carried out carefully, is virtually harmless and cost-effective.

Indications and limitations

  • Acupuncture provided by a physician is always based on a diagnosis. Treatment should not be provided at the request of the patient without a medical indication and consideration of various treatment options.
  • Randomized trials have been carried out to compare acupuncture points based on the Asian conception of disease to placebo points. As no difference has been found between various needling points, acupuncture has been considered ineffective when, in fact, the trials have only involved comparison between different modes of stimulation.
  • Any stimulation of the peripheral nervous system (by blowing, touching, needling or even by surgical incision) alleviates pain even if the actual cause of the pain was not interfered with at all.
  • For treatment, it is of secondary importance to separate the effect of the choice of needling points from the overall effect of the treatment encounter.
  • Acupuncture offers limited possibilities. It should not be the last resort for a desperate patient but one of many available treatment modalities.
  • The most common indication for acupuncture is pain.
    • Acupuncture is used to alleviate musculoskeletal pain, for example.
    • It may be helpful in recurrent or chronic tension headache [Evidence Level: C]
    • It is worth trying in soft tissue injuries in the shoulder region and pain due to strain and sprain of back muscles, after conditions requiring surgical procedures have been ruled out.
    • Pain associated with osteoarthritis may be alleviated by acupuncture [Evidence Level: C] as muscle tension caused by pain-induced changes in the gait pattern may be relaxed and the pain may thus be alleviated.
    • Acupuncture is ineffective in the treatment of rheumatoid arthritis [Evidence Level: C].
    • Symptoms of fibromyalgia may be alleviated in some patients [Evidence Level: D].
    • Treatment of migraine [Evidence Level: B] and other recurrent or chronic types of headache [Evidence Level: C] is worth trying. Acupuncture administered at the classical points does not reduce migraine headaches more than random needling of other points. Both interventions are, however, more effective than leaving the patient without treatment.
    • Patients with sciatica or other prolonged back pain often get relief from acupuncture [Evidence Level: C] but patients requiring surgery must be identified before starting treatment. Patients suffering from spinal stenosis may obtain relief for their symptoms while waiting for surgery or when surgery is not feasible.
    • Treatment of neuralgias, neuropathies and phantom limb pain requires more thorough understanding of acupuncture and usually a longer series of therapy sessions but can result in a long-term and positive patient-physician relationship.
  • Treatment can be provided by physicians and physiotherapists.
  • Neurological disorders
    • Restless legs may respond well to acupuncture, even though a systematic review did not find evidence supporting its efficacy [Evidence Level: D].
  • Sleep and mood disorders
    • Sleep disorders may sometimes disappear during the treatment of other disorders, but acupuncture is not suited for actual treatment of insomnia [Evidence Level: D].
    • In the treatment of depression, acupuncture cannot compete with drug therapy and is therefore not recommended [Evidence Level: D].
  • Addictions
    • The treatment of drug addiction generally requires electroacupuncture, and favourable short-term results have at times been achieved.
    • Acupuncture has not been shown to be effective for smoking cessation [Evidence Level: B]. Acupuncture is used in many alcohol addiction clinics as an adjunct to detoxification.
  • Other conditions

Evidence Summaries

Contraindications

  • Other ailments or age are rarely contraindications to acupuncture.
  • The indications should be carefully considered if the patient has a heart valve prosthesis or a recently implanted prosthetic joint or is receiving immunosuppressive therapy.

Education and training

  • Acupuncture should not be practised without appropriate education and training. In addition to textbooks, there are training courses arranged by health care professionals.
  • Traditional Chinese Medicine is taught globally but for physicians with Western training it may be more appropriate to participate in acupuncture training specially designed for them. It may be advantageous to postpone learning about the oriental philosophy of man, disease, and therapy until one has obtained a sufficiently clear understanding of the possibilities of Western medicine. The most significant differences are related to the terminology used, not so much to actual therapeutic practices.
  • Good knowledge of the segmental structure of the nervous system helps to understand and explain the effects of acupuncture. Knowledge of the functioning of the autonomic nervous system, in particular, helps to implement acupuncture and to choose suitable patients.
  • As a start, one can learn to palpate the trigger points in patients with musculoskeletal symptoms. Needling of trigger points alone, however, is often perceived as unpleasant by the patients and does not always result in as favourable long-term effects as the use of general acupuncture points.

Implementation of the treatment

  • Use disposable needles only.
  • Using one needle once is experimenting, not acupuncture. Three to four sessions at one-week intervals will often suffice or at least indicate if it is worth continuing.
  • Inform your patient in advance that the symptoms may worsen after the first three sessions.
  • Exact anatomical knowledge improves the diagnostics and safeguards from malpractice. Examine your patient carefully.
  • To avoid collapse, the patient should lie down during the session; do not leave him/her alone, at least during the first few sessions – during the session you will have an excellent opportunity for complementary history taking.
  • Acupuncture may temporarily reduce the need for certain drugs. Follow-up is particularly important in patients with diabetes or hypertension.
  • One patient out of three will not respond to acupuncture but in two patients out of three, symptoms will be alleviated to some extent, at least.
  • Even lengthy experience with acupuncture will not guarantee identification of optimal patients. Try out!

Adverse effects and complications

  • Most complications are due to lack of skill. Insufficient anatomical knowledge, hurry, and inadequate preparation of the patient may have harmful consequences that could be avoided by using careful acupuncture techniques.
  • At least one patient in ten is tired after the session, and some are even slightly disoriented. Take this into consideration in advance, and observe your patient after the session.
  • Even if the treatment is carried out with utmost care, it may cause bruising, especially at the corners of the eyes, momentary increase of pain, euphoria, etc.

References

1. Vas J, Ortega C, Olmo V et al. Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial. Rheumatology (Oxford) 2008;47(6):887-93.  [PMID:18403402]

2. Yuan J, Purepong N, Kerr DP et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine (Phila Pa 1976) 2008;33(23):E887-900.  [PMID:18978583]

3. Linde K, Streng A, Jürgens S et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA 2005;293(17):2118-25.  [PMID:15870415]

4. Cox J, Varatharajan S, Côté P et al. Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review. J Orthop Sports Phys Ther 2016;46(6):409-29.  [PMID:27117725]

5. Chen Z, Wang Y, Wang R et al. Efficacy of Acupuncture for Treating Opioid Use Disorder in Adults: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2018;2018():3724708.  [PMID:30622598]

6. Meissner K, Fässler M, Rücker G et al. Differential effectiveness of placebo treatments: a systematic review of migraine prophylaxis. JAMA Intern Med 2013;173(21):1941-51.  [PMID:24126676]


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