DR. BERMAN: I’m Brian Berman, director of the University of Maryland Center of Integrative Medicine and Professor of Family and Community Medicine at the University of Maryland, School of Medicine.
Acupuncture (a traditional Chinese medical practice systematically used for over 2000 years) involves insertion of thin stainless steel needles into specific points on the body to facilitate recovery and good health. This practice was first brought to Europe in the 17th Century,1 and the first journal article on acupuncture appeared in the 1820s.2 Not until recently has acupuncture been widely accepted because of the clash of east versus west paradigms.
Scientific advances in acupuncture research, coupled with the side effects of treating pain by conventional drugs, have dramatically promoted the use of acupuncture in the last 20 years. It is estimated that over 1 million practitioners (outside China) administer acupuncture treatments for chronic pain. Of these practitioners, over 300000 are physicians.3 An estimated 3 million American adults receive acupuncture treatments each year, and chronic pain is the most common presentation.4
One of the most significant events in the 1990s for acupuncture was the decision taken by the US Food and Drug Administration in March 1996 to reclassify the legal status of acupuncture as safe and effective medical devices.
Further, in November 1997, there was a consensus conference on acupuncture by the National Institutes of Health.5 This was a 2.5-day conference conducted to evaluate the scientific and medical data on the uses, risks, and benefits of acupuncture for a variety of conditions. The findings after reviewing approximately 2300 studies stated that “Promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and postoperative dental pain.”
“There are other conditions such as stroke rehabilitation, headache, tennis elbow, osteoarthritis, lower back pain, carpal tunnel syndrome, and asthma, for which acupuncture may be useful as an adjunct treatment or could be included in a comprehensive management program. Although many issues remain to be clarified, there is sufficient evidence to prove the value of acupuncture in order to expand its use in conventional medicine and encourage further studies of its physiology and clinical value.”
Since the consensus conference in 1997, there has been a huge increase in the number of scientific studies conducted on acupuncture. The Cochrane Collaboration’s database includes now 6035 clinical trials and 53 systematic reviews on acupuncture in their database.6 This roundtable today will focus on the current indications for acupuncture, and we will discuss how it is used in clinical settings, its safety issues and clinical evidence, and how it works.
The other participants are Dr. Joseph Helms, Dr. Gary Kaplan, and Dr. Lixing Lao. Dr. Helms is the founding president of the American Academy of Medical Acupuncture. In 1980, Dr. Helms developed the Medical Acupuncture Physicians program as a continuing medical education course for the University of California, Los Angeles (UCLA), School of Medicine; has chaired the program since then through the Helms Medical Institute (HMI); and has trained over 6000 physicians during this period. Dr. Helms is professor of medical acupuncture on the adjunct clinical faculty of the Stanford Medical School and the author of Acupuncture Energetics: A Clinical Approach for Physicians.
Dr. Kaplan is the medical director of the Kaplan Center for Integrative Medicine in McLean, Virginia, and is an associate professor in the Department of Community and Family Medicine at Georgetown University, School of Medicine. He served on the board of the American Academy of Medical Acupuncture and was president of the Medical Acupuncture Research Foundation.
Our final participant, Dr. Lao, is a professor of Family Medicine and the director of Traditional Chinese Medicine Research program at the Center for Integrative Medicine, University of Maryland School of Medicine. Dr. Lao graduated from the Shanghai University in the Traditional Chinese Medicine Program, holds a PhD in physiology from the University of Maryland in Baltimore, and has practiced acupuncture for 30 years and conducted research for 20 years.
To begin this discussion, Dr. Helms, can you describe for us the different types of acupuncture, training, and how acupuncture is used in a clinical setting?
DR. HELMS: Thank you, Dr. Berman. Acupuncture is relatively new in the collection of American medical disciplines. It has been in constant evolution since President Nixon’s visit to China in 1972. This evolution is driven by public interest and demand as well as scientific evidence of its mechanism and clinical value. This started with linking the impact of acupuncture on pain to the endogenous opioid peptide cascade, which is currently being reinforced through functional magnetic resonance imaging studies that confirm an intracranial response to peripheral needling.
The 1997 Consensus Development Conference report5 that endorsed a handful of acupuncture applications was based on the quality of research design to evaluate acupuncture’s impact on different problems, rather than on the actual practice of acupuncture. Since that paper, over 400 randomized control trials have been published in peer review journals internationally. These studies demonstrate the favorable impact of acupuncture on a wide spectrum of medical problems, including, but not limited to, pain.
There are many different styles of acupuncture. This discipline has evolved through multiple cultures over the last 2000 years. Each culture and era of its blossoming has contributed its enduring quality and approach. Many of these styles of acupuncture were retained only in family traditions, while others were propagated nationally. It is only in the late 20th century and beginning of the 21st century that we have had the privilege to access many of the family and most of the national traditions of acupuncture training and practice.
The tradition, with which I’m most familiar with, is known as medical acupuncture. Medical acupuncture would best be described as a hybrid approach combining our understanding of acupuncture neuroanatomy and physiology with traditional precepts from the classics of acupuncture. Medical acupuncture is generally practiced by licensed practitioners of conventional biomedical medicine and is considered an additional qualification to their scope of practice. These would include doctors of medicine, doctors of osteopathy, doctors of dental surgery, and doctors of podiatric medicine.
Traditional Chinese Medicine is the approach most widely practiced in this country. It is an approach exported from post-Maoist China, having been developed to provide basic healthcare to the Chinese population as the country was transitioning from its revolutionary period in the 1950s and 1960s into a more stable political and social period. The Traditional Chinese Medicine model doesn’t contain the totality of the classics, but rather is an extraction that can be taught and absorbed by the western community. The Traditional Chinese Medicine approach covers internal medicine problems as well as pain problems.
Two additional, commonly used subdivisions of acupuncture are auricular acupuncture and Chinese scalp acupuncture. Auricular acupuncture was developed in France in the 1950s and 1960s and uses points exclusively on the ear to influence pain and organ function. Chinese scalp acupuncture is a recent development in Chinese medicine. It involves placing needles in the scalp overlying the cortical surfaces that relay pain signals.
DR. BERMAN: Could you elaborate on auricular acupuncture a little more and on what it is used for?
DR. HELMS: Auricular acupuncture is the least complex and most easily learned approach to acupuncture. It can be effective either as a standalone treatment or as an adjunct to body acupuncture. The scientific foundation of auricular acupuncture involves the ear’s complex innervation that links it to all 3 embryologic germ levels. Thus, with neurological representation of endoderm, mesoderm, and ectoderm, the ear manifests a homunculus of all body parts. Ear points that correspond to painful or disturbed structures demonstrate increased electrical conductivity, and thereby allow the ear to serve as a diagnostic tool and a therapeutic signal.
DR. BERMAN: I think in the past, auricular acupuncture was also used for problems of addiction but I don’t know if it’s still being used for this purpose.
DR. HELMS: There are several widely used acupuncture point combinations that have been shown to be useful in assisting a multidisciplinary approach to substance abuse problems, referred to as the “NADA protocol” that was developed by Michael Smith, MD. There is also a 5-point formula called battlefield acupuncture that is useful in dealing with acute traumatic pain.7
DR. BERMAN: Thank you, Dr. Helms. Dr. Kaplan and then Dr. Lao, could you comment about what’s being done in clinical settings and how acupuncture is used to treat certain diseases beyond what Dr. Helms has just explained?
DR. KAPLAN: We do a great deal of work for the treatment of pain and find acupuncture to be extremely effective for conditions such as headaches, back pain, and neck pain. We also find it useful for the treatment of peripheral neuropathies. In addition, because we deal with many chronic pain patients, we also see a lot of psychoemotional issues comorbid with the chronic pain. Acupuncture has proven to be very helpful as an adjunctive therapy dealing with the psychoemotional components that we see associated with chronic pain.
In my practice, approximately 20% of our pain population has posttraumatic stress syndrome, while approximately 60% has comorbid anxiety disorders or major depressive disorders. Acupuncture has been particularly unique as a therapeutic modality because it addresses both the pain and the psychological component of an individual’s illness at the same time. We’re able to talk about the totality of the individual as opposed to segmenting them into psychiatric versus pain versus sleep issues. From an acupuncture perspective, these conditions are not separate issues but different manifestations of a pattern of disharmony in the individual.
DR. LAO: I agree with Drs. Kaplan and Helms. In my practice, I see patients with a variety of complaints. In addition to pain, they also experience menstruation disorders, depression, and attention deficit disorder (ADD) (in children). A wide variety of diseases can be treated by acupuncture. Evidence of the effectiveness of acupuncture for the treatment of pain has recently been published by Vickers.4
Individual raw data show the full area of musculoskeletal pain, which includes neck pain, low back pain, headaches (migraine and tension headaches), osteoarthritis in the knees, and shoulder pain. There is a significant difference between acupuncture and conventional treatment in terms of their therapeutic effectiveness. There was also a significant difference between acupuncture and sham acupuncture, ie, placing of needles at points on the body that are not thought to be acupuncture points (off site points). Although the benefits were modest, they were highly significant.4
Dr. Berman, do you also want me to cover a little bit about the side effects or shall we save that for later?
DR. BERMAN: Let’s stick to the clinical use first, and then we’ll go to the side effects.
DR. KAPLAN: I’d like to chime in here. I’m boarded in family medicine and pain medicine and started my clinical practice in a general medical setting. As my practice evolved, I began seeing a greater number of individuals suffering with chronic pain and illness issues.
Over the last 30 years, acupuncture has heavily influenced my approach to patient care. Acupuncture is not simply a tool but a philosophy of care that has greatly enriched my western medical training. At times, when treating a patient, I believe the prism of a western approach will be more effective; there are also times when I rely exclusively on an acupuncture approach, but more commonly, I integrate the two in designing and implementing a care program.
Pain can be very effectively managed with acupuncture alone or as an adjunct. Many so-called functional or psychosomatic problems can be more effectively addressed using acupuncture in place of pharmaceutical agents. Likewise, the conventional approaches to organic problems can be reinforced and facilitated with acupuncture treatment.
Acupuncture covers a much broader range of clinical applications than simple neuromusculoskeletal pain or psychoemotional issues. It really covers the full spectrum of medicine.