Acupuncture in Primary Care
Section snippets
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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Cited by (39)
Has acupuncture benefit in the management of migraine? A scoping review
2022, Revista Internacional de AcupunturaCitation Excerpt :Acupuncture evidence is growing regarding its implementation in several conditions like migraine, supported by different medical associations that consider this therapy useful as management in acute attacks and prophylaxis of chronic migraine,33 but there are two important factors that might explain why acupuncture has been unexposed as plausible treatment, first, patient’s belief and thoughts regarding acupuncture as management of chronic conditions. Based on Mao et al.34 work, lack of communication between primary care physician and the patient, can lead to a non-use of this therapy, but also, as second reason, when the patient does not have proper address, it can lead to create unrealistic expectations of this treatment, prove of it was the systematic review made by Prady et al.,35 where they evaluated 58 papers regarding the impact of expectations in the clinical outcome of acupuncture trials, finding some evidence that pre-randomization response expectancies can show an interaction with outcomes, and, that acupuncture has increased its application, especially in conditions difficult-to treat or medically with non-specific symptoms but with high-burden use of healthcare services,36 then, a proper counseling should be addressed from primary and specialized care physicians, but also, from licensed acupuncturist, closing the gap between allopathic and traditional medicine. Implementation of therapies in patients with chronic disease is usually expensive, especially with high-burden disease like migraine.
Acupuncture for chronic primary pain – are UK guidelines now consistent with other countries?
2021, European Journal of Integrative MedicineCitation Excerpt :This new NICE guideline should open the way for better and more equitable NHS coverage for acupuncture in the treatment of chronic pain. The fact that acupuncture shows evidence of cost-effectiveness for chronic pain should also inform the process of funding for this NICE recommendation [40–46]. In recent guidelines NICE has emphasised acupuncture-sham comparison results above all else, leading to recommending against acupuncture for low back pain and osteoarthritis [35–37].
From knowing silence to curious engagement: The role of general practitioners to discuss and refer to complementary and alternative medicine
2017, Journal of Interprofessional Education and PracticeCitation Excerpt :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.
Patients' perspectives on integrating acupuncture into the radiation oncology setting
2014, European Journal of Integrative MedicineCitation Excerpt :Acupuncture, an ancient CAM modality, involves the use of thin sterile needles placed at specific points on the body. Traditionally, acupuncture was believed to promote energy flow and enhance wellbeing; basic science research suggests that acupuncture may affect cognition and emotional and pain processing [12]. Although acupuncture's mechanism of action is still not fully understood, emerging evidence suggests that it may be effective in reducing several cancer-related symptoms commonly seen in patients undergoing RT (i.e. fatigue [13], pain [14], nausea [15], and xerostomia [16]).
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.