Acupuncture is in an interesting stage as it is slowly but surely bridging the East-West medical divide. To be able to do this it must be able to stand up to rigorous Western trials.
In October 2012 the largest analysis of acupuncture ever conducted involved nearly 18,000 patients and doctors from eight universities and hospitals in the UK, the U.S. and Germany from 29 quality trials. They found that traditional acupuncture works better than a placebo.
In fact, for conditions such as arthritis and chronic headache, acupuncture was twice as effective as the drugs and exercise recommended by most doctors, according to the analysis published in the authoritative Archives of Internal Medicine: Acupuncture for Chronic Pain
One study found acupuncture effective for symptom reduction in Post Traumatic Stress Syndrome (PSTD): PTSD Study
Several studies have found that acupuncture significantly reduces the number of emesis (vomiting) episodes for patients receiving chemotherapy: Acupuncture: Role in Comprehensive Cancer Care
The National Institute for Clinical Excellence (NICE) recommends acupuncture for back pain and arthritis, and is considering whether to add headache.
See also, the National Institute of Health (NIH), the National Center for Complementary and Alternative Medicine for updates: NCCAM, for updates.
Is Acupuncture a Safe alternative?
In an article published in the British Medical Journal, the authors conclude: "The risk of serious events occurring in association with acupuncture has been deemed very low, below that of many common medical treatments." This report came from 12 prospective studies which surveyed more than a million treatments, the risk of a serious adverse event with acupuncture is estimated to be 0.05 per 10,000 treatments, and 0.55 per 10,000 individual patients. The range of adverse events reported was wide, and some events, specifically trauma and episodes of infection, are likely to be avoidable. View the abstract: Acupunture Safety Study or read the entire study: BMJ Article
Is Acupuncture Safe for Children?
A large scale study in 2007 demonstrated Acupuncture is safe for children: Complementary and alternative medicine use among adults and children: United States, 2007
What are the risks?
There is evidence that the media coverage of acupuncture exaggerates and confuses the reader of acupuncture's efficacy and safety. Published in the Daily Mail Online: DailyMailOnline - Acupuncture New Research
Commentary: In this news article prolonged insertion of needles was interpreted as "needles left inside the body." According to the NHS report, some of the incidences that cited 'prolonged needle retention' included patients who were left on the table for more than 3 hours in busy clinics, where staff treating patients had left the department or even gone home at the end of the day. During Acupuncture needle insertion, needles are inserted into the subcutaneous or superficially in the cutaneous layer of the skin and the handle remains outside the body accessible on the surface of the body in all cases. Misquoting the actual incidence of diagnosed cases of pneumothorax as 5 patients leading to an incidence of 1.5%. One actual diagnosed patient out of 325 patients studied is an incidence of 0.06%. Furthermore, the study did not include details of the occurrence, and any extrapolation that this is possible under conditions of a qualified practitioner is remote. In the Chinese literature pneumothorax is the result of poor technique, and cannot occur from proper placement.
Here are the actual items of risk reported on the NHS Choices website: about this relatively small study of 325 patients carried out by the NHS: "NHS choices"
95% of the incidents were categorised by the NHS staff who reported the incidents as of no or low harm where there was:
- Needles left in longer than prescribed
- local pain at site of insertion
- Bruising and soreness at the site
4% were categorised by staff as moderate harm where there was:
- Patients needing emergency assessment and where patients fell off the couch
1% categorised as severe, only one of these 1% being subsequently clinically diagnosed with a pneumothorax caused by acupuncture.
According to Dr. Mike Cummings, medical director of the British Medical Acupuncture Society:
‘The risk of puncturing the lung is well-known...What the study didn’t tell us is how many people get acupuncture on the NHS...We aim to keep harm to an absolute minimum but it looks as if the benefits outweigh the risks.’
You may also wish to refer to the National Institute of Health to learn what scientific experts have said about the use and effectiveness of acupuncture for a variety of conditions.
Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many studies in the past provided equivocal results because of design, sample size, and other factors. The issue has been further complicated by inherent difficulties in the use of what might be deemed appropriate controls by those who are looking for double-blind placebo-controlled studies, such as the use of placebo treatments with sham acupuncture groups.
Several explanations for how acupuncture works have been posited: acupuncture has its own unique concepts and views of the human condition. For example, acupuncture works on an individual basis, meaning that the treatment for one person's headache may not be the same as others. This makes it difficult to undertake randomised controlled trials. Despite this difficulty, acupuncture has performed well. It was found that acupuncture outperformed sham treatments and standard care when used by people suffering from osteoarthritis, migraines and chronic back, neck and shoulder pain.
Promising results have emerged, demonstrating the efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.
Recent studies have consistently confirmed that acupuncture is found to be a safe treatment for adults and children with very few side effects when undertaken by a qualified practitioner. See a list of risk factors: Risk factors of Acupuncture
Further Reading: Excerpts from the British Acupuncture Council Review Papers available online
There have now been many controlled trials of acupuncture for migraine, with some large, high-quality ones in recent years. The results of the latest reviews are quite consistent: acupuncture is significantly better than no treatment/basic care for managing migraine, and appears to be at least as effective as prophylactic drug therapy, with few contraindications or unpleasant side effects (Linde 2009, Wang 2008, Sun 2008, Scott 2008).
Preliminary positive findings for treating chronic anxiety associated with post-traumatic stress disorder (Hollifield 2007), substance misuse (Chae 2008; Courbasson 2007; Grusser 2005), eating disorders (Fogarty 2010), hyperventilation (Gibson 2007), asthma (Scheewe 2008), insomnia (Nordio 2008), post-stroke ((Wu 2008), musculo-skeletal pain (Hansson 2007; He 2005) and various other conditions where anxiety has been measured as a secondary rather than primary outcome.
Although the overall evidence is patchy, it does lie promisingly in a positive direction, and, given the very low level of side effects and lack of demonstrably superior outcomes from other interventions, acupuncture could be considered as one possible therapeutic option alongside the existing repertoire.
Studies indicate that acupuncture can have a specific positive effect on depression by altering the brain's mood chemistry, increasing production of serotonin (Sprott 1998) and endorphins (Wang 2010). Acupuncture may also benefit depression by acting through other neurochemical pathways, including those involving dopamine (Scott 1997), noradrenaline (Han 1986), cortisol (Han 2004) and neuropeptide Y (Pohl 2002).
Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the 'analytical' brain which is responsible for anxiety and worry (Hui 2010). Stress-induced changes in behaviour and biochemistry may be reversed (Kim 2009).
Some of the most recent research suggests that depression is associated with dysfunction in the way that parts of the resting brain interact with each other (Broyd 2008); acupuncture has been shown to be capable of changing the 'default mode network' (Dhond 2007), but the effect goes beyond that of expectation/placebo (Hui 2010).
Acupuncture can be safely combined with conventional medical treatments such as anti-depressants, helping to reduce their side effects and enhance their beneficial effects (Zhang 2007).
Acupuncture treatment can also help resolve physical ailments such as chronic pain (Zhao 2008), which may be a contributing cause of depression. In addition to offering acupuncture and related therapies, acupuncturists will often make suggestions as to dietary and other lifestyle changes that may be helpful in overcoming depression. Finally, people struggling to cope with depression usually find that coming to see a supportive therapist on a regular basis is helpful in itself.
Two recent systematic reviews, both drawing on Western and Chinese data, found that acupuncture was similar in effectiveness to anti-depressant medication and not significantly better than sham acupuncture or waiting list controls. However, they reached very different conclusions, one recommending acupuncture (Zhang 2010) and one stating that the evidence was insufficient (Smith 2010). Major issues to consider in respect of the research evidence are a) how trustworthy are Chinese studies (Ernst 2010), b) how valid are sham controlled trials (Schroer 2010), and c) how relevant to normal practice is the acupuncture provided in trials (Schroer 2010). Notions about acupuncture's placebo properties (Ernst 2010) can only be speculative, and with little relevance to decisions about patient benefit. Given that acupuncture appears to be at least as effective as existing conventional drugs, without their level of side effects, it should be considered as one of the therapeutic options, alongside the existing repertoire. Two specific situations, during pregnancy (Manber 2010) and post-stroke (Zhang 2010; Smith 2010), seem to be particularly favourable for incorporating acupuncture treatment.
A randomised controlled trial in PLOS Medicine published on September 24th, 2013, compared acupuncture with counselling in 755 patients from GP practices. 302 were given acupuncture, 302 were given counselling and 151 received usual care. The patients had consulted their primary health care provider about depression within the past 5 years and had a score of more than 20 on the BDI-II (a score that is defined as moderate-to-severe depression on this depression rating scale) at the start of the study. Patients were randomised to receive up to 12 weekly sessions of acupuncture plus usual care, up to 12 weekly sessions of counselling plus usual care, or usual care alone. The outcome was that both interventions (acupuncture and counselling) were associated with significantly reduced depression 3 months later when compared to usual care alone.
Menstrual problems are a common cause for presentation to both the general practitioner and the gynaecology out patients' clinic. In a British survey (Scrambler and Scambler 1985), 79 women between the ages of 16 and 44 compiled health diaries and 82% reported at least one distressing symptom associated with menstruation. Ten years later in Canada it was found that gynaecological conditions were one of the most frequently mentioned primary health problems and accounted for at least 8% of patients consulting acupuncturists (Kelner & Welman 1997). Acupuncture has been used in China for gynaecological problems for 2000 years.
"…acupuncture is at least as effective, and sometimes superior to, hormonal drug treatment, c) additional acupuncture improves on usual, or self, care, and d) moxibustion is better than no intervention."
Acupuncture may help reduce symptoms of the menopause and perimenopause by:
• regulating serum oestradiol, follicle stimulating hormone and luteotrophic hormone (Xia 2008);
• increasing relaxation and reducing tension (Samuels 2008). Acupuncture can alter the brain's mood chemistry, reducing serotonin levels (Zhou 2008) and increasing endorphins (Han, 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states.
• stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987, Zijlstra 2003, Cheng 2009).
The results of the studies tend to indicate there is benefit in the use of acupuncture in the alleviation of menopausal symptoms, particularly hot flushes and anxiety. The fact that there are so few studies indicates the urgency of planning and carrying out studies that can evaluate its effectiveness.
Evidence from systematic reviews suggests that acupuncture and moxibustion may be a safe and effective treatment for allergic rhinitis with benefits over conventional medicine (Xiao 2009), that acupuncture can help to relieve symptoms of perennial rhinitis (Lee 2009) and that ear acupressure has a similar efficacy to antihistamines (Zhang 2010).
Recent randomised controlled trials have found that acupuncture used as an adjunct to routine care for allergic rhinitis has clinically relevant and persistent benefits (Brinkhaus 2008) and is cost effective (Witt 2009). Such trials have also found that acupuncture is effective in the symptomatic treatment of perennial rhinitis (Xue 2007) and that active acupuncture is more effective than sham acupuncture in decreasing the symptom scores for persistent allergic rhinitis and increasing the symptom-free days (Ng 2004).
Acupuncture may help to relieve pain and congestion in people with allergic rhinitis by:
• regulating levels of IgE and cytokines, mediators of the allergic reaction to extrinsic allergens (Ng 2004; Rao 2006; Roberts 2008)
• stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987; Han 2004; Zhao 2008; Cheng 2009);
• reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007);
• enhancing natural killer cell activities and modulating the number and ratio of immune cell types (Kawakita 2008);
• increasing local microcirculation (Komori 2009), which aids dispersal of swelling.
There is consistent evidence that a course of acupuncture improves IBS symptoms and general wellbeing (Anastasi 2009, Trujillo 2008, Reynolds 2008, Schneider 2007b, Xing 2004, Lu 2000), though there are arguments about the extent to which the effect is placebo-related (Lembo 2009, Schneider 2007a, Lim 2006, Forbes 2005). As yet there is no satisfactory placebo/sham intervention for acupuncture so this is still a matter for conjecture. There are plausible physiological explanations for acupuncture's effects (see above) and it can promote mechanisms not seen with sham treatments (Schneider 2007b).
Acupuncture can be safely and effectively combined with Western biomedicine, and other treatments such as relaxation exercises, herbal medicine and psychotherapy. In addition to offering acupuncture and related therapies, acupuncturists will often make suggestions as to dietary and other lifestyle changes that may be helpful in combating IBS symptoms. Working with a supportive therapist can also help people suffering from IBS to change their negative health beliefs and improve their coping mechanisms, which can have a positive influence on both mood and symptoms.
Research has shown that acupuncture treatment may benefit IBS symptoms by:
• Providing pain relief (Pomeranz 1987).
• Regulating the motility of the digestive tract (Yin 2010, Chen 2008).
• Raising the sensory threshold of the gut. Various possible mechanisms have been identified, involving spinal nerves and NMDA receptors and a range of neurotransmitters (Xu 2009, Ma 2009, Tian 2008, Tian 2006, Xing 2004). A lowered threshold to bowel pain and distention are hallmarks of IBS.
• Increasing parasympathetic tone (Schneider 2007b). Stress activates the sympathetic nervous system, which can stimulate colon spasms, resulting in abdominal discomfort. In people with IBS, the colon can be oversensitive to the smallest amount of conflict or stress. Acupuncture activates the opposing parasympathetic nervous system, which initiates the relaxation or 'rest and digest' response.
• Reducing anxiety and depression (Samuels 2008). The distress provoked by IBS symptoms can lead to a vicious cycle of anxiety-pain-anxiety, while the embarrassing nature of the condition can lead to feelings of depression. Acupuncture can alter the brain's mood chemistry, increases production of serotonin and endorphins (Han 2004), helping to combat these negative affective states.
A search was carried out using the ARRCBASE, the Acupuncture Research Resource Centre database of articles drawn from the British Library's AMED and the US MEDLINE, using the terms 'asthma', 'breathlessness' and 'acupuncture'. Sixty-one references were identified and an additional twenty-two were derived from citations in these papers. Papers were excluded for variety of reasons: no English translation was available; the paper was unobtainable from the British Library; the paper was not primarily concerned with presenting or reviewing clinical evidence; the study involved therapies other than acupuncture or did not use needles. The remainder could be grouped into three categories: reviews, descriptions of a randomised controlled trial (RCT) and descriptions of an outcome study. Reviews were only included if they had been published after 1990, on the grounds that earlier publications would have been superseded. Some RCTs were excluded on the grounds of their weak methodology. For trials prior to 1990, the system of evaluating methodological quality set out by Kleijnen et al (1991) was used to exclude those which scored below 40. Trials since 1990 were included if fully randomised. Outcome studies were included if they used significantly larger sample sizes than the RCTs. The papers finally selected comprise 6 reviews, 11 controlled trials, and four outcome studies.
Research has shown that acupuncture is significantly better than no treatment and at least as good as (if not better than) standard medical care for back pain (Witt 2006; Haake 2007; Cherkin 2009; Sherman 2009a). It appears to be particularly useful as an adjunct to conventional care, for patients with more severe symptoms and for those wishing to avoid analgesic drugs (Sherman 2009a, 2009b; Lewis 2010). It may help back pain in pregnancy (Ee 2008) and work-related back pain, with fewer work-days lost (Weidenhammer 2007; Sawazaki 2008).
Acupuncture can help back pain by:
• providing pain relief - by stimulating nerves located in muscles and other tissues, acupuncture leads to release of endorphins and other neurohumoral factors and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Zhao 2008).
• reducing inflammation - by promoting release of vascular and immunomodulatory factors (Kim 2008, Kavoussi 2007; Zijlstra 2003).
• improving muscle stiffness and joint mobility - by increasing local microcirculation (Komori 2009), which aids dispersal of swelling and bruising.
• reducing the use of medication for back complaints (Thomas 2006).
• providing a more cost-effective treatment over a longer period of time (Radcliffe 2006; Witt 2006).
• improving the outcome when added to conventional treatments such as rehabilitation exercises (Ammendolia 2008; Yuan 2008).
The National Institute for Health and Clinical Excellence guidelines on best practice now recommend that GPs offer a course of 10 sessions of acupuncture as a first line treatment for persistent, non-specific low back pain.
For the World Health Organisation Report: WHO Systematic Review of the Chinese Literature
For the latest compilation of research done by the British Acupuncture Society, Dr Mike Cummings: Compilation for further study.
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