Essentials

  • Acupuncture is a therapeutic whole where the treatment event as such, with the interaction involved, improves the treatment result.
  • Acupuncture is needling but all needling is not acupuncture.
  • The treatment, when carried out carefully, is virtually harmless and economically advantageous and does not put significant physical strain on the patient.

Indications and limitations

  • Acupuncture provided by a physician is always based on a diagnosis. A treatment asked for by the patient should not be haphazardly implemented.
  • A number of randomized comparative trials have been carried out to prove that the acupuncture points based on the Asian disease conception are superior to the ”wrong” points. As there has not been any difference in the treatment results as for the choice of needling points, this has often been erroneously interpreted as evidence on the ineffectiveness of acupuncture. In fact, the trials have only involved comparisons between different modes of stimulation.
  • It seems that stimulation of the peripheral nervous system one way or another (blowing, touching, needling or even by surgical incision) alleviates pain even if the actual cause of the pain was not interfered with at all 5.
  • From the viewpoint of the patient and the health care professional providing the treatment it is of secondary importance to separate the effect of the actual needle pricks and the choice of the needling points from the overall effect of the treatment encounter.
  • Acupuncture has its therapeutic limitations. It cannot be the last resort of a desperate patient, but it is one of the many treatment modalities applied in medicine. Reasonably often it alleviates symptoms with minimal harms.
  • The most common indication for acupuncture is treatment of pain.
    • Acupuncture is used in alleviation of musculoskeletal pain and pain associated with malocclusion of the teeth B.
    • Acupuncture may be helpful in recurrent or chronic tension-type headache C.
    • Acupuncture is worth trying in soft tissue injuries in the shoulder region 1 and pain due to strain and sprain of back muscles 2, after conditions requiring surgical procedures are ruled out to avoid delay in appropriate surgical therapy.
    • Pain related to osteoarthritis may be alleviated with acupuncture C. The osteoarthritic changes cannot be reversed but the muscle tensions caused by the pain-induced changes in the gait pattern can be relaxed and the pain thus alleviated.
    • Acupuncture has no effect in the treatment of rheumatoid arthritis C.
    • Acupuncture may provide help for the symptoms of fibromyalgia in some patients D.
    • Treatment of migraine B and other recurrent or chronic, correctly diagnosed types of headache C with acupuncture is worth trying. Acupuncture administered into the classical points does not reduce migraine headaches more than random needling outside these points. Both interventions are, however, significantly more effective than just being on a waiting list for treatment 3.
    • Patients with sciatica and other prolonged back pain often get relief from acupuncture C, but patients requiring surgery must be identified before needles are applied. Patients suffering from spinal stenosis may obtain relief for their symptoms while waiting for surgery or when surgery is not feasible. Evidence on effectiveness is lacking.
    • Treatment of neuralgias, neuropathies and phantom limb pains requires a more thorough understanding of the principles of acupuncture and usually longer series of therapy sessions but results at times in a long-term and positive patient-physician relationship. Evidence on the efficacy is scarce.
  • The use of acupuncture as a supportive therapy for physiotherapy and rehabilitation has increased. Training in acupuncture has been available for e.g. physiotherapists in some countries, e.g. in Finland. The treatment is carried out on the order and under the supervision of a physician, and the indications are close to the usual scope of treatments provided by physiotherapists.
  • Neurological diseases
    • Patients with symptoms of hemiplegia should be treated without delay because acupuncture appears to have favourable effects on circulation. The results concerning faster recovery after needling are conflicting 4.
    • Facial paralysis is treated with acupuncture D in the Far East, but during the long treatment courses it is difficult to differentiate spontaneous healing from the effects of the treatment.
    • Restless legs usually respond well to acupuncture, even if systematic reviews have not found evidence on its efficacy D.
  • Sleep and mood disorders
    • Sleep disorders D may sometimes disappear during the treatment of other disorders, but acupuncture is not suited for actual treatment of insomnia.
    • In the treatment of depression, acupuncture cannot compete with drug therapy C.
  • 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 B. For this kind of "lightweight" addiction, as well as for supporting weight loss D, the use of acupuncture can be regarded as a temporary fad. Acupuncture is used in many alcohol addiction clinics as an adjunct to detoxification.
  • Other conditions
    • Acupuncture may be useful in the treatment of postoperative or chemotherapy-related nausea and vomiting B.
    • Attempts have been made to treat menstrual disorders D and unexplained infertility with acupuncture but the results still remain mostly anecdotal. Labour pains have occasionally been relieved with acupuncture D.
    • Chronic eczemas and a vast spectrum of psychosomatic disorders may be indications for treatment for the experienced acupuncturist.
    • Acupuncture is apparently ineffective as a treatment for tinnitus B or asthma D.

Evidence Summaries

Contraindications

  • The patient's other ailments or age rarely are a contraindication for acupuncture.
  • The indications should be carefully considered if the patient has a heart valve prosthesis or a recently implanted prosthetic joint, or receives immunosuppressive treatment.

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 convenient to participate in training specially designed for them. It may be advantageous to postpone learning about the oriental philosophy of man, disease, and therapy until one's own understanding of the possibilities of Western medicine has become clear. The most significant differences are related to the terminology used, not so much to the actual therapeutic practices.
  • Good knowledge of the segmental structure of the nervous system helps to understand and explain the effects of acupuncture without the "smoke screen of mysticism". Knowledge of the functioning of the autonomic nervous system in particular helps the implementation of acupuncture and the choosing of suitable patients.
  • For starters one can learn to palpate the trigger- (tender) points in patients with musculoskeletal pain disorders. Needling of trigger-points alone, however, is often perceived unpleasant by the patients. This does not always result in as favourable long-term effects as does the use of general acupuncture points.

Implementation

  • 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 about the fact that the symptoms may worsen after the first three sessions.
  • Exact anatomical knowledge of what is beneath the surface of the skin improves diagnostics and safeguards against accidentally perforating organs. 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 of certain drugs. Follow up is particularly important in patients who have diabetes or are on antihypertensive medication.
  • One third of the patients do not react to acupuncture. Another third clearly get relief for their symptoms. The results achieved in the last third of the patients keep the reputation of acupuncture alive and makes acupuncture meaningful for the physician.
  • Even a considerable experience in acupuncture does not help recognizing in advance the optimal patients. Try out!

Adverse effects and complications

  • Most complications are caused by physicians who are unfamiliar with the correct techniques C. Insufficient knowledge of anatomy, 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, some are even disoriented. Inform the patients in advance about this possibility and keep them under observation after the session.
  • Even if the needling were carried out most carefully it may cause bruises especially at the outer corners of the eyes, momentary increase of pain, drowsiness, euphoria, etc.
  • Leaving a needle accidentally in place e.g. in the neck under a long hair is not a highly unusual incident but may be an indication of too much hurry during the therapy session.
  • Perforations of internal organs, such as pneumothorax, and complications from using non-sterile needles, e.g. hepatitis epidemics and septicaemias, are mostly caused by lay therapists.

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. Wu P, Mills E, Moher D et al. Acupuncture in poststroke rehabilitation: a systematic review and meta-analysis of randomized trials. Stroke 2010;41(4):e171-9.  [PMID:20167912]

5. 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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