DR. BERMAN: Thank you, Dr. Kaplan. There are 2 nonpain conditions that I believe we haven’t mentioned yet. First, there’s nausea and vomiting due to chemotherapy or after operations, and second, chronic obstructive pulmonary disease (COPD) breathlessness. I was wondering if the three of you have encountered patients with these symptoms and employed acupuncture to control these conditions?
DR. KAPLAN: We have used acupuncture successfully in women with hyperemesis gravidarum. Most of the medications are contraindicated because of the potential harm to the fetus. Acupuncture has been successful in at least providing these women with some level of relief in treating this condition.
I don’t have experience with acupuncture therapy for postoperative nausea/vomiting. We have used it a little bit in nausea/vomiting associated with chemotherapy, and again, we’ve been able to reduce the amount of medications that the patients require in order to control it; in some cases, we’ve actually been able to eliminate the need for medications.
Further, I want to go over what Dr. Helms was talking about—the importance of integrating acupuncture into a comprehensive treatment program. It is sometimes the main therapeutic modality that we use, but on many occasions, it is integrated into our medication regimes. In a comprehensive approach, we may use it in conjunction with physical therapy, and we will also be probing trigger points. We may also do prolotherapy with the patients.
Acupuncture gives us the ability to treat a wider range of conditions with fewer medications. We are frequently able to address irritable bowel syndrome (IBS), sleep disorders associated with the medical conditions, as well as the psychiatric conditions I was talking about earlier. Acupuncture is a beautiful adjunctive therapy and sometimes can be used as the sole therapeutic approach.
DR. BERMAN: In general, we’re now talking about acupuncture being part of a comprehensive approach to a number of chronic disorders.
DR. KAPLAN: That’s absolutely correct. You want to use all of the tools you have available, and acupuncture is a very powerful therapeutic modality in the treatment of these conditions.
DR. LAO: One of the nonpain areas that I think people should consider using acupuncture as a therapy is infertility. Many women now come to the clinic, particularly after the publication of the enhanced success rate of in vitro fertilization (IVF) in women receiving acupuncture treatment.8 Even those patients who elect to not go through IVF come for acupuncture treatment to enhance their chances of getting pregnant.
DR. BERMAN: Dr. Lao, is there evidence to support acupuncture for infertility?
DR. LAO: There’s a paper that was published a couple years ago through our center.8 The authors show a higher success rate of conventional IVF procedure when combined with acupuncture than with sham control. Current studies give clear evidence of the benefits of acupuncture to IVF patients.
DR. BERMAN: With the breathlessness COPD I was referring to, there was a study in the Archives of Internal Medicine just this past June 2012,9 which was a very well-done clinical trial aimed at studying COPD and using acupuncture in addition to conventional care, that showed clear outcomes of the benefits of acupuncture in this particular condition.
Dr. Helms, you have experienced acupuncture in the military setting. Can you talk a little bit about that?
DR. HELMS: In the last 5 years, 3 branches of the US Military have shown interest in pursuing acupuncture training for physicians to provide these services to their population. This interest reflects what’s happening in the civilian population and is more intensively motivated by the report of the Army’s pain management task force that identified some severe shortcomings in managing acute and chronic pain.
The feedback we’ve received from the military physicians we’ve trained has been very rewarding. The bulk of their treatments are for pain, ranging from headache to cervical, lumbar, and peripheral pain. Much of this pain is caused by the weight of their 75-pound protective gear, which they wear no matter where they are in the world, and of course, the physical trauma of battle. Interestingly, an almost equal percentage of treatments for active duty service members are for psychoemotional problems (anxiety, insomnia, depression, acute stress, and chronic stress) as for pain and physical trauma.
DR. BERMAN: Let me move on to the next subtopic. Dr. Lao, can you talk to us about how safe acupuncture is?
DR. LAO: There are few reported cases of complications in the English literature from 1965 to 1999, a 35-year span. There were a total of 202 case reports, which is about 5–6 cases per year.10 I have completed 2 reviews of case reports on adverse events associated with acupuncture. One was published in 200310 and the other one is accepted for publication.11 Events are divided into complications and adverse reactions. Complications such as injured organs or infections occur if acupuncture is not carefully performed. Adverse reactions include syncope and allergic reaction.
Infections constituted 50% of all complications. Needle infections may cause hepatitis. However, since the late 1980s, acupuncturists started using disposable needles, resulting in lower incidence of hepatitis and other infections.10 In recent years, another infection emerged that involves many different invasive procedures in medical settings such as methicillin-resistant Staphylococcus aureus (MRSA). This is likely due to the unsanitary conditions of these clinical settings, such as the use of contaminated disinfectant. It’s not the acupuncture needle itself that caused infection.
A larger survey12 showed that approximately 7% to 8% of the adverse events were classified as mild. These events include local site bleeding, pain in local needling site, nausea, or light-headedness. The occurrence of these mild adverse events is very low especially in the context of the large numbers of patients attended to acupuncture clinic every year.
In the last 10 years, 308 cases of side effects were noted from 26 countries.11 In the United States, only 17 cases have been reported, which is a very small percentage. I believe that this is due to extensive professional licensing requirement that is called Clean Needle Techniques (CNT) training. This requirement has dramatically decreased the risk of unnecessary side effects.
Other types of adverse events such as organ and tissue injuries are associated with knowledge of anatomy. Therefore, proper training of the acupuncturist could help reduce the occurrence of side effects due to acupuncture.
DR. BERMAN: From these prospective studies,10–12 we can conclude that serious adverse events are very rare with acupuncture and that there is, depending on the surveys, a 2% to 7% probability of occurrence of a mild side effect such as local site bleeding or occasional dizziness or localized pain to the area. Is there anything else on safety that either, Dr. Kaplan or Dr. Helms would like to add?
DR. HELMS: In addition to reinforcing that acupuncture is a very safe and forgiving therapeutic approach, I’d like to discourage readers from concluding that useful indications for acupuncture in medical practice are limited to what is published in the evidence-based literature. Acupuncture has been used for simple and complex problems by responsible practitioners in oriental and occidental cultures for much longer period than we have been documenting its efficacy. Acupuncture comes from a long tradition of the practice of medicine, albeit in cultures and eras quite distant from ours. Our hybrid medical acupuncture allows remarkable creativity in the hands of well-trained practitioners, to treat many problems that are not included among those already studied in the pharmaceutical model.
DR. BERMAN: I think that’s a very important point, but let’s talk a little bit about the research first, and then go back to this when we’re putting the research into the context of clinical practice. How should we take this into account?
DR. KAPLAN: Let’s briefly look at the clinical research, and then talk about some of the problems that we run into with research and what the research shows us in terms of how to better study procedures such as acupuncture, because studying procedures is different from studying drugs. The clinical studies roughly fall into 2 categories: effectiveness studies and efficacy studies, and many studies overlap and attempt to do both.
An effectiveness study looks at the extent to which a drug or procedure achieves its intended effect in the usual clinical setting. In these circumstances, you’re randomizing acupuncture against something such as a wait list control or usual care such as physical therapy or medications.
In 2009, a Cochrane database review studying acupuncture for prophylaxes of migraine showed that acupuncture was at least as effective, and possibly more effective, than prophylactic drugs with fewer adverse effects.13
In 2012, Andrew Vickers and his colleagues4 performed individualized patient data meta-analysis of 17,922 patients with a variety of back, neck, shoulder, osteoarthritic-related and headache pains and concluded that acupuncture was, in fact, effective for the treatment of chronic pain. Some effectiveness trials have shown acupuncture to be useful for some specific conditions, pain being the number one condition.
Efficacy is the extent to which a drug or procedure has the ability to bring about its intended effect under ideal circumstances, that is, acupuncture compared to a placebo. In the Vickers study,4 Vickers looked at the efficacy of acupuncture in the treatment of chronic pain and again concluded that true acupuncture was statistically slightly more efficacious than sham. Although this was not a big effect, it was nonetheless statistically significant.
From the 2012 Cochrane database review of IBS14 it was concluded that acupuncture was not efficacious as compared to a creditable sham, but there were several effectiveness trials where acupuncture tested better against 2 antispasmodic medications, which have some effect on both the severity and quality of life in patients with IBS.
While the Vickers study reported the efficacy as well as effectiveness of acupuncture, the IBS trial did not find any efficacy, when compared to the placebo, but did find evidence of the effectiveness of acupuncture.