Acupuncture

Essentials

  • Medical acupuncture is a treatment method that involves inserting needles as thin as a thread into tissues. It represents an adapted form of Chinese acupuncture and is based on modern knowledge of anatomy, physiology and pathology, as well as evidence-based medicine.
  • The most essential indication of acupuncture is pain. There are significant individual differences in response.
  • Treatment provided correctly is safe. Risks of complications are associated with the use of unsterile needles and lack of needling skill (such as a needle piercing the pleura, resulting in pneumothorax).
  • Minor local bleeding is the most common problem. There is usually significantly less bleeding than in association with injection therapy, as a cutting needle used for injections necessarily causes more extensive tissue injury.
  • Acupuncture is best used as an adjunct to more ordinary medical treatment.

Mechanism of action

  • Needles are used to stimulate peripheral nerves and, through mechanisms mediated by such nerves, to affect tissues locally, and to affect the modulation of sensory signals on the spinal cord level and the release of endogenic opioids in the brain.
  • The efficacy of the treatment depends largely on a placebo effect that can be significant.
    • Response independent of placebo effect has been shown in some indications.
    • The placebo effect would not appear to depend directly on the patient’s beliefs 1 .

Background

  • The gate control theory in its modernized form continues to be a central model to explain pain modulation mechanisms at central nervous system level.
    • A painless signal generated concomitantly with the pain signal, in the same innervated region closes the “gate” to the pain signal.
    • This can more commonly be detected as, for example, the immediate effect of cold on pain or by the analgesic effect of massage or light touching of the painful area.
  • Increased beta-endorphin levels have been detected in cerebrospinal fluid after acupuncture 10 .
  • Myofascial pain syndrome 9 is probably the central mechanism behind many myalgias.
    • Myofascial trigger points show a strong correlation with Chinese acupuncture points.

Methods

  • In medical acupuncture, a sterile disposable acupuncture needle is inserted into the chosen point and rotated or otherwise manipulated to cause an apprehension reaction, i.e. a strong sensation that may also be felt as pain. This is most probably due to activation of Aδ nerve fibres.
  • The needle can subsequently be either manipulated for several minutes to produce tactile stimulation and then be withdrawn (so-called dry needling) or left in the target tissue for 20–30 minutes, manipulating it every once in a while. The stimulus should not be particularly painful.
    • As an alternative to manual stimulation with the needle, electricity can be applied, using a TENS-type device to produce low-energy painless electric stimulation between two needles acting as electrodes.
    • In Chinese acupuncture, stimulation can also be produced by heating (moxibustion).
  • The number of needles chosen and the location of the chosen points are determined by either prepared “prescriptions” or (for myalgia) more purely by trigger points assessed by the clinician as relevant for the treatment. Ten to twenty needles are normally used.
  • About 1–2 weeks should elapse between treatment sessions. A response may be seen only after the third session.
    • There is no particular rule of thumb for the number of treatment sessions, and there is great variation in the literature. If no response is achieved even after the third session, continuation of the treatment is not justified.
    • The maximal response is usually achieved after about 5–7 sessions, and booster treatments can subsequently be given less frequently (such as every 1–2 months) to maintain the response. There is wide individual variation here, though.
  • After the treatment, some patients may experience even significant transient drowsiness and/or confusion. Slight bruising is not unusual. A few drops of blood may appear at the injection site after withdrawing the needle. Bleeding can be controlled by pressing the site with gauze dressing for a while.

Indications

  • The evidence for the use of acupuncture is strongest in the treatment of episodic migraine 4 [Evidence Level: B].
  • Tension headache 5 [Evidence Level: C]
  • Osteoarthritis pain 3
  • Chronic nonspecific back pain (evidence mostly for short-term benefit) 2
  • Fibromyalgia pain 7

Contraindications

  • Infection in the skin area to be injected
  • Inability of the patient to stay still during the treatment
  • Contraindications for electroacupuncture are the same as for TENS (Chronic pain).

Training

  • Check local legislation on the qualification requirements for professionals providing acupuncture treatment.
  • Training may be available by a national acupuncture society or by other professional associations. Check local availability.
  • There is high-quality literature available in English 6 8 .

References

1. Lembo A, Kelley JM, Nee J, ym. Open-label placebo vs double-blind placebo for irritable bowel syndrome: a randomized clinical trial. Pain 2021;162(9):2428-2435
2. Mu J, Furlan AD, Lam WY, et al. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev 2020;12(12):CD013814  [PMID:33306198]
3. Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip osteoarthritis. Cochrane Database Syst Rev 2018;5(5):CD013010  [PMID:29729027]
4. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev 2016;2016(6):CD001218  [PMID:27351677]
5. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev 2016;4(4):CD007587  [PMID:27092807]
6. Filshie J, White A. Cummings M. Medical Acupuncture – A Western Scientific Approach. Elsevier; 2016.
7. Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev 2013;2013(5):CD007070  [PMID:23728665]
8. White A, Cummings M, Filshie J. Report on acupuncture in patients with valvular heart disease and prosthetic valves--the opinion of COPE. Acupunct Med 2004;22(3):159  [PMID:15551944]
9. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2. painos. USA; Lippincott Williams & Wilkins; 1998.
10. Clement-Jones V, McLoughlin L, Tomlin S, et al. Increased beta-endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain. Lancet 1980;2(8201):946-9  [PMID:6107591]
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