Acupuncture in Primary Care

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A case presentation

Ms Smith (not her real name) is an 82-year-old woman with a history of hypertension and high cholesterol. She presented with 6 months of low back pain. She denied any acute onset of pain. She described her pain as fairly constant, worse with standing and walking, and relieved by sitting. However, prolonged sitting could make the pain worse as well, she said. She described the pain as achy in nature and sometimes traveled down along her left buttock. On a scale of 0 to 10, with 1 being no pain

Historical perspective

Acupuncture is part of the much larger system of healing called traditional Chinese medicine (TCM).1 TCM is one of the oldest healing systems still used by significant numbers of Chinese and others around the world. In this medical paradigm, therapeutic options include those involving herbs; diet; exercise, such as tai chi; massage (tuina); and qi gong (energy therapy); in addition to acupuncture. TCM focuses on promoting the “inner balance” or homeostasis of the individual within the larger

What is acupuncture like?

Regardless of the style of acupuncture, the practitioner often uses hair-thin metal needles, which the practitioner inserts in specific acupuncture points along the meridians or at the tender points, known in Chinese medicine as ashi points. In the TCM style, the needles are often manipulated until either the physician perceives the needle being grabbed by the tissues or the patient experiences de qi, a sensation described as a mixture of heaviness, soreness, distention, tingling, and numbness,

Current state of acupuncture use in the United States

In 2002, approximately 2 million United States adults 18 or older had used acupuncture.8 By 2007, this number had exceeded 3 million, representing a 50% growth in the 5 years.9 In the United States, the most common reasons for seeking acupuncture treatment are to relieve low back pain (34%), joint pain (16%), neck pain (14%), and headache/migraine (10%).10 Among the estimated 2 million users, 44% of individuals sought acupuncture care because conventional medical care would not help, while 57%

Basic scientific basis of acupuncture

The exact mechanism of action for acupuncture is not fully understood. Animal and human studies have demonstrated an analgesic effect mediated in part by endogenous opioid release,11, 12, 13, 14 and the non–naloxone-responsive component is blocked by both serotonin and norepinephrine antagonists.15, 16, 17, 18 Recently, neuroimaging techniques, including positron emission tomography scan,19, 20, 21 single-photon emission CT,22 and functional MRI,23, 24, 25, 26 have provided new ways to study

Clinical evidence related to acupuncture

Over the last 40 years, thousands of acupuncture clinical trials have been conducted for diverse conditions. Before discussing the clinical evidence, it is important to have an understanding of the challenges of methodology in evaluating acupuncture, particularly the choice of control. The question of what constitutes an appropriate placebo for acupuncture has been debated through the years and remains controversial.35 Each control helps answer a small and specific question about the effects of

Specific conditions

Musculoskeletal complaints are extremely common in the primary care setting. In 2005, the National Ambulatory Medical Care Survey showed that musculoskeletal problems tied with respiratory complaints as the number one symptom category of patients seeing their family physicians, each with 9.9% of visits.64 Back pain and knee pain accounted for one third of these visits. In treating these patients, more and more physicians have turned to acupuncture as an adjunct or alternative to conventional

Putting clinical evidence into patient-centered care

In analyzing these trials as a whole, the consistent take-home message is that acupuncture is effective for the treatment of chronic painful symptoms when compared with no treatment, routine care, or even enhanced care of short-term efficacy. The achieved effects of acupuncture appear to last over a long-term period (6 months). Therefore, acupuncture seems to be a reasonable adjunct or alternative to offer to patients for whom usual care is ineffective or unsatisfactory. What is less clear is

Education of physicians in acupuncture

While an estimated 16,000 nonphysician acupuncturists practice in the United States, 6000 physicians have the training to incorporate acupuncture into their practices.10 PCPs continue to dominate the physician-acupuncturist population, although anesthesiologists and pain management specialists make up significant proportions.68 Ten acupuncture training programs are certified by the American Board of Medical Acupuncture for doctors. Each program requires at least 300 hours of training, 100 of

Practical concerns for integrating acupuncture into primary care

There are two ways to integrate acupuncture into primary care and thus provide patients with more therapeutic options. One is to establish a trusted and competent referral partner who practices acupuncture. With close collaboration, the acupuncturist can address patients' clinical issues while the PCP coordinates care. Another way is to obtain additional training through the above-discussed certified courses. This is particularly useful for those PCPs who like a hands-on approach to patients.

Patient-physician communication in regards to acupuncture care

The essence of evidence-based medicine rests on the shared decision making with patients by aligning patients' preference with the best available evidence for the specific health conditions in the context of patients' social, cultural, and financial circumstances. The discussion of acupuncture in the context of conventional medicine not only needs to cover the efficacy of acupuncture and various therapies, but also their safety and potential harm. Secondly, because acupuncture is not covered by

Summary

Acupuncture is a safe, traditional Chinese medical therapy that patients often find both calming and relaxing. Animal and human studies have found a physiologic basis for acupuncture needling that involves both central and peripheral networks. Although it is unclear whether real acupuncture is more beneficial than sham/placebo acupuncture, acupuncture care yields both clinically relevant short- and long-term benefits for low back pain, knee osteoarthritis, chronic neck pain, and headache. Also,

Acknowledgments

We thank Dingyun Chan for performing literature search and technical assistance.

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      Indeed the essence of evidence-based medicine should rest on shared decision making with both patients and between practitioners by aligning patients' preference with the best available evidence for the specific health conditions. This needs to be done in the context of patients' social, cultural, and financial circumstances.20 While evidence plays a role in the development of clinical practice, it is rarely the only determinant.

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    Dr Mao is supported by National Institutes of Health–National Center for Complementary and Alternative Medicine (NIH/NCCAM) grant 1 K23 AT004112 and an American Cancer Society Cancer Control Career Development Award for Primary Care Physicians. The grant agencies played no role in shaping the content of this manuscript. Dr Mao is the founder and president of Acupuncture Education International, Inc.

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