Acupuncture

Category: Body work

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Description: Placement of small diameter solid needles into the skin and muscles as part of the Traditional Chinese Medicine (TCM) medical system of disease and medical condition treatment.  There are several subtypes (see below)    There are over 2,000 described acupuncture points although mainly around 300 are used in practice, and only about 40 commonly used points.

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Theory:  In Eastern medicine philosophy, energy or blood flow imbalance leads to disease in the body.  Acupuncture needles places into one of the 635 acupuncture points can improve vitality, blood circulation, and restore natural balance of the body. TCM is a pseudoscience based on the imagined presence of 20 energy meridians (12 main and 8 secondary) connecting the acupuncture points on the skin to the internal organs.

 

History: Chinese origin from 3500 years ago

 

Protocol: 8-10 needles, usually 0.2mm-0.3mm in diameter (about half the diameter as commonly used small injection needles) are inserted and left in place for 15-20 min, usually once-twice a week.  Chinese acupuncturists charge $25-50 per session while American acupuncturists frequently charge $100 per session for exactly the same results.

 

Training: In China and other countries, there may be little training other than at most, apprenticeship, and at the least self taught.  In the US, most states have acupuncture boards of licensure that have specific training requirements prior to being permitted to provide acupuncture.  Medical physicians may engage in much shorter training courses since the anatomy, physiology, and disease diagnosis training was already achieved in medical school. Naturopathic doctors will frequently use or recommend acupuncture.  Some chiropractors use acupuncture. Medical, laser, moxibustion, or electroacupuncture may be practiced without a specific acupuncture licensure

 

Subtypes: include Chinese acupuncture, Western (Medical) acupuncture, auriculotherapy (ear acupuncture), moxibustion (use of burning elements to transmit heat into the acupuncture needles), laser acupuncture (using a laser), gold thread acupuncture (placement of scores of permanent fine gold threads under the skin around joints using acupuncture needles), sonoacupuncture (use of ultrasound or tuning forks on acupuncture points), and electroacupuncture (application of electricity to the needles). 

 

Touted uses of acupuncture:  Stress, muscle tension, chronic pain, headaches, menstrual irregularities, etc.   Only recently has acupuncture been subjected to randomized trials to demonstrate effectiveness.  

 

Level of evidence:  Most studies show benefits of acupuncture for pain control from a variety of pain sources.  However the majority of studies using sham acupuncture (not in specific acupuncture points) show nearly equal pain reduction compared to verum (true) acupuncture, suggesting acupuncture works but not on the basis of meridians or acupuncture points.  This brings into question whether there should be any acupuncture board oversight of training since randomly sticking needles into people has the same effect as a trained acupuncturist.

CHINESE STUDY DISCLAIMER: Many Chinese studies have severe flaws in construction making them functional invalid, however these studies are included in Chinese databases that are frequently referenced in alpha level research papers.  Many acupuncture studies are Chinese. Chinese studies are frequently not reproducible in the West due to poor Chinese techniques that even the Chinese admit are severely problematic (Chin J Integr Med 2018 Feb;24(2):83-86) thereby giving conflicting evidence of effectiveness.  All levels of Chinese studies should be viewed with extreme scrutiny and routinely discarded in final analysis of effectiveness until the Chinese can bring their standards up to modern medicine standards. 

ALPHA LEVEL:

Sham acupuncture is equivalent to real acupuncture in many studies and meta-anlysis {PLoS One 2013 Jul31:8(7),  Am J Chin Med 2013; 41(1):1-19,  Med Acupunct 2012 Dec:24(4):233-240,    J Orthop Surg Res 2012 Oct 30;7:36,  Pain 2012 Sep:153(9):1883-9

Acupuncture for depression confers a small reduction in depression scale vs sham acupuncture (Cochrane Database Syst Rev 2018 Mar 4;3:CD004046)

For chronic pain, sham acupuncture confers a very small effect improvement over true acupuncture and a moderate effect improvement over no acupuncture controls for chronic musculoskeletal, headache, and osteoarthritis pain (J Pain 2017 Dec 2)

Acupuncture for immediate effect of pain relief is superior to sham acupuncture or analgesic injections (Evid Based Complement Alternat Med 2017;2017:3837194) however this study incorporated Chinese database studies that are extremely biased.

Ineffective for knee chronic knee pain RCT (JAMA 2014, Oct 1;312(13):1313-1322)

Ineffective for fibromyalgia (Meta-analysis) J. Tradit Chin Med 2014 Aug;34(4):381-91

Acupuncture studies suffer from extreme risk of bias, that may invalidate many acupuncture studies  (BMJ Open 2018 Mar;8(3):e019847)

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NON CHINESE SYSTEMATIC REVIEWS:

• Scand J Prim Health Care. 2018 Jan 17:1-14. Acupuncture for infantile colic- NOT RECOMMENDED

• J Pain. 2017 Dec 2. pii: S1526-5900(17)30780-0  Acupuncture is effective for the treatment of chronic musculoskelatal pain, chronic headaches, and chronic osteoarthritis

• JAMA Surg. 2017 Oct 18;152(10):e172872. Low level evidence exists acupuncture improves pain and delays opioid use while electroacupuncture reduces opioid consumption after knee arthroplasty surgery

• Eur Spine J. 2017 May 18.  Acupuncture is recommended for neck pain but not for cervical radiculopathy. 

• Ann Intern Med. 2017 Apr 4;166(7):493-505  There is moderate evidence in some reviews acupuncture is useful in the treatment of low back pain for short term results

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Auricular therapy slightly effective for pain: meta-analysis (1.59 improvement on 1-10 scale of pain)  Evid Based Complement Alternat Med 2014:934670

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HARMS:   Acupuncture is not harmless as touted by many acupuncture practitioners.  It can be associated with organ injuries, deaths, infections, and local reactions.  It may also be associated with dizziness or syncope.  (Sci Rep 2017 Jun 13;7(1):3369)   Gold fiber placement (hundreds of thin gold fibers permanently embedded around the joints have had complications reported.  Moxibustion may be associated with burns to the skin.  A common criticism of acupuncture studies is that they fail to report adverse events therefore the scope of harms is probably much higher than the reported harms that are mainly noted in Western literature during treatment with Western medicine after complications have occurred during acupuncture.

 

Recommendation:  One thumb up for traditional needle acupuncture.  Many studies show benefit, covered by many insurances, safe procedure.  The only caveat is that it doesn’t work the way the acupuncturists think or tell their patients. However there is little evidence ultrasound, tuning forks, etc work.