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Acupuncture

Updated Friday, 13th January 2006

Rosey Grandage explores the history of acupuncture's relationship with Western medicine

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There can be no doubt that from an historical perspective Chinese medicine, and acupuncture as one of its modalities, have as illustrious a pedigree as any other established medical discipline, be it allopathic or ayurvedic. The question is, does this long history have any relevance or practical application today?

The ancient Greeks may have believed the body to be composed of bile, black bile, blood and phlegm, but for modern western medicine things have moved on somewhat. From early times, Chinese medicine developed a different conceptual and theoretical basis to that of the west, relying on observation they investigated not only the material substance of things, but also the natural energy within the universe, which connects things together and is a catalyst for change.

They call this energy qi (chi) and its movement explains the patterns and rhythms of life, for example the changing seasons, the growth from foetus to child to adult to death and so on. Thus the Chinese never developed a detailed knowledge of physical anatomy, but instead focused on understanding how different parts of the physical and energetic body relate to one another and affect each other and how the individual relates to the environment and nature as a whole. The core theories which underpin Chinese medicine were in place by the 1st - 2nd centuries BC; these included the concepts of qi (vital energy), wu xing (5 phases) and yin yang. The body was viewed as a microcosm of the universe and as such could be affected by the same influences of heat, dryness, damp, cold and wind. Good health could be maintained through an understanding of the natural movement of qi, in particular through the zangfu (organ systems) and jingluo (meridians) and then using pressure, needles, herbs or exercises to restore this movement.

In short, as Joseph Needham states in his book Celestial Lancets "Acupuncture is simply a system of medical treatment which was already two thousand years old when modern science was born, and which had developed in a civilisation quite different from that of Europe."

The earliest medical texts describing the jingluo were discovered in a tomb dating from 167 BC, but the ideas within them certainly developed over the preceding centuries. Acupuncture treatment is first mentioned in a text dating from 90 BC, when it is recorded as being used to revive an unconscious prince who lived in the 6th century BC. We can therefore be fairly confident that the technique has existed well into antiquity with the use first of stone and bone needles, perhaps to press or puncture points, and later of ones made of bronze, silver or gold. Early texts describe its use in the treatment of a wide variety of conditions including fevers, skin conditions and tumours.

Over the intervening two thousand or so years the practice of Chinese medicine has been, by no means, static or unchanging. Although these core theories have remained remarkably intact, the manner in which they have been interpreted and applied has been adapted and changed to suit both time and place. Individual doctors over the centuries have left their imprint, recorded in an impressive body of case studies. These, together with the classical texts and their accompanying commentaries, make up a body of knowledge which continues to be advanced today.

The use of acupuncture quickly became established across the Far East, with many neighbouring states sending doctors to train in China and forming their own schools, such as the Imperial Medical College of Japan which opened in the 7th century. The most recent changes have occurred since Chinese medicine has come into contact with the western model. Acupuncture was known in Europe from as early as the 16th century, as western traders and missionaries gained footholds in the Far East; over the following centuries there was some interest in its practice and use across Europe.

However, it was in the 20th century, with the advent of communism and the subsequent opening of China during the 1970s, that the practice has become really well known. In particular, during President Nixon’s 1971 visit, westerners were for the first time able to witness the impressive effects of acupuncture as part of the established medical system. As part of their systemising and modernising of the country the communist government created Traditional Chinese Medicine (TCM), a standardised form of teaching and practice which draws on some of the ancient ideas and techniques, but presents them as a fixed methodology. This has the advantage of being easy to teach and reproduce, resulting in acupuncture being used throughout China alongside allopathic medicine and it becoming increasingly popular throughout the world, but the disadvantage that it has lost much of its flexibility and intuitiveness. To a large extent it is this growing popularity which answers the question of whether acupuncture has a place in the modern world.

 
Japanese acupuncture chart Copyrighted  image Icon Copyright: photos.com

According to the Acupuncture Regulatory Working Group, which was formed to investigate the process of statutory regulation, "The last three decades have witnessed considerable growth and development in the use of complementary and alternative medicine (CAM) in the UK. Acupuncture has been at the forefront of this development and is among the most widely used CAM therapies."

In the UK today, practitioners of acupuncture fall into three main categories. At one end of the scale are practitioners who are of Chinese origin, who have completed six years training and have settled in the UK either permanently or for periods of up to three years. This group is becoming increasingly visible as they set up Chinese medicine centres across the country, but although their knowledge of Chinese medicine may be excellent they may have a more limited understanding of the English language and local culture.

At the other end of the scale are the doctors, physiotherapists and nurses who undertake short courses in acupuncture to use as an adjunct to their existing practice. Many do not accept the traditional theories underlying Chinese medicine and explain the effects of needling in scientific terms of stimulating the nervous system and the release of chemicals such as endorphins. They term their style of treatment as "medical acupuncture" or "trigger point acupuncture".

In the centre ground are a growing number of practitioners who have undertaken three to four year courses in the UK. These courses offer a foundation in allopathic medicine together with their focus on traditional Chinese medicine and culture. Eight are regulated by the British Acupuncture Accreditation Board, which was formed in 1993 and is now connected with the British Acupuncture Council. According to the House of Lords Report on Science and Technology, "Establishing an independent accreditation board along the lines of the BAAB is a positive move, other therapies with fragmented professional representation may wish to use this as a model." Some courses have also been validated by universities, which now offer BSc and MSc programmes in acupuncture and Chinese herbal medicine. Many practitioners using acupuncture will combine it with the traditional techniques of moxibustion and cupping and in addition may be qualified in herbal medicine and massage, they call themselves professional or traditional acupuncturists.

The problem for both the general public and the NHS is knowing which practitioner to use. At present the profession is not regulated by the government and has no protection of title or standardised form of training or qualification. Over the past few years, the process towards statutory self-regulation for all the CAM professions has begun, but with such a range of views and practices just amongst the acupuncturists this is proving to be a complicated and lengthy process. The majority of NHS treatment is undertaken by medical acupuncturists, though this situation is changing and there are some notable exceptions in specialist areas.

Two such exceptions are the Gateway Centre in South London, which started by providing treatment for HIV and drug rehabilitation, but now works with local GPs and hospitals treating a wide range of conditions, and the maternity service provided by the Derrisford Hospital in Plymouth. Both provide traditional acupuncture and have won the Award for Good Practice in Integrated Health Care from The Prince of Wales Foundation for Integrated Health.

The World Health Organisation has reported that at present "acupuncture is being used in at least 78 countries. Although there is some clinical evidence that it does work, there is no definitive explanation for how it works." It is this lack of a substantial evidence base which is one of the major concerns for the profession. It is one thing to know that growing numbers of patients are interested in acupuncture, but quite another to persuade GP practices or hospital trusts to fund its use.

In response to the situation there have been a substantial number of projects initiated across the world to investigate its efficacy for a wide range of conditions, including back pain, neck pain, knee pain, menstrual problems, gynaecological conditions, anxiety and depression, addiction and substance abuse, migraine and stroke to name but a few. In many studies the effect of acupuncture is found to be positive in both the short and the long term and in some cases to demonstrate significant financial benefits.

For example in Sweden, in 1993 Johansson carried out a study on the treatment of stroke patients with acupuncture which showed both ‘lasting benefits’ in neurological function and also a saving of

In the UK today, practitioners of acupuncture fall into three main categories. At one end of the scale are practitioners who are of Chinese origin, who have completed six years training and have settled in the UK either permanently or for periods of up to three years. This group is becoming increasingly visible as they set up Chinese medicine centres across the country, but although their knowledge of Chinese medicine may be excellent they may have a more limited understanding of the English language and local culture.

At the other end of the scale are the doctors, physiotherapists and nurses who undertake short courses in acupuncture to use as an adjunct to their existing practice. Many do not accept the traditional theories underlying Chinese medicine and explain the effects of needling in scientific terms of stimulating the nervous system and the release of chemicals such as endorphins. They term their style of treatment as "medical acupuncture" or "trigger point acupuncture".

In the centre ground are a growing number of practitioners who have undertaken three to four year courses in the UK. These courses offer a foundation in allopathic medicine together with their focus on traditional Chinese medicine and culture. Eight are regulated by the British Acupuncture Accreditation Board, which was formed in 1993 and is now connected with the British Acupuncture Council. According to the House of Lords Report on Science and Technology, "Establishing an independent accreditation board along the lines of the BAAB is a positive move, other therapies with fragmented professional representation may wish to use this as a model." Some courses have also been validated by universities, which now offer BSc and MSc programmes in acupuncture and Chinese herbal medicine. Many practitioners using acupuncture will combine it with the traditional techniques of moxibustion and cupping and in addition may be qualified in herbal medicine and massage, they call themselves professional or traditional acupuncturists.

The problem for both the general public and the NHS is knowing which practitioner to use. At present the profession is not regulated by the government and has no protection of title or standardised form of training or qualification. Over the past few years, the process towards statutory self-regulation for all the CAM professions has begun, but with such a range of views and practices just amongst the acupuncturists this is proving to be a complicated and lengthy process. The majority of NHS treatment is undertaken by medical acupuncturists, though this situation is changing and there are some notable exceptions in specialist areas.

Two such exceptions are the Gateway Centre in South London, which started by providing treatment for HIV and drug rehabilitation, but now works with local GPs and hospitals treating a wide range of conditions, and the maternity service provided by the Derrisford Hospital in Plymouth. Both provide traditional acupuncture and have won the Award for Good Practice in Integrated Health Care from The Prince of Wales Foundation for Integrated Health.

The World Health Organisation has reported that at present "acupuncture is being used in at least 78 countries. Although there is some clinical evidence that it does work, there is no definitive explanation for how it works." It is this lack of a substantial evidence base which is one of the major concerns for the profession. It is one thing to know that growing numbers of patients are interested in acupuncture, but quite another to persuade GP practices or hospital trusts to fund its use.

In response to the situation there have been a substantial number of projects initiated across the world to investigate its efficacy for a wide range of conditions, including back pain, neck pain, knee pain, menstrual problems, gynaecological conditions, anxiety and depression, addiction and substance abuse, migraine and stroke to name but a few. In many studies the effect of acupuncture is found to be positive in both the short and the long term and in some cases to demonstrate significant financial benefits.

For example in Sweden, in 1993 Johansson carried out a study on the treatment of stroke patients with acupuncture which showed both ‘lasting benefits’ in neurological function and also a saving of $26,000 per patient.

However, as The Acupuncture Research Resource Centre has pointed out, many of the surveys undertaken are "small and encounter problems of finding a suitable control," and many other reviewers complain of poor methodology or lack of funding. This situation will have to change as acupuncture moves more into the mainstream and the process of regulation advances.

Echoing the demands of the scientific community as a whole, the House of Lords Report on Science and Technology, which examined CAM therapies and regulation, has called for research to take a high priority recommending "that CAM practitioners and researchers should attempt to build up an evidence base with the same rigour as is required of conventional medicine, using both randomised controlled trials (RCTs) and when appropriate other research designs." However, the use of RCTs as the ‘gold standard’ methodology is not a straightforward issue for many CAM therapies.

For acupuncture this approach is possible, but restrictive. For the majority of acupuncturists the therapy requires skilled practitioners, who diagnose patients as individuals, rather than diseases, and then involve the patient as much as possible in the treatment. There is no problem with randomly selecting patients and a ‘blind’ control is possible, though very strange to most practitioners, with the use of sham points or ‘placebo acupuncture’, but the need for skilled practitioners precludes the use of ‘double blind’.

In the same House of Lords Report Dr David Peters, a GP and osteopath "suggested that although RCTs and meta-analysis of RCTs are valuable, in that they provide certainty about the efficacy of a medication for a particular condition, real-life primary care does not mirror the way illness and treatment are defined in such research… Thus, the simple definitions of clinical problem and treatment that good RCTs require do not always mirror the complexity of CAM practice."

Although there is undoubtedly a need for well-funded, large-scale studies, they must include a wide range of imaginative methodologies, both quantitative and qualitative, which are relevant to the holistic approach of acupuncture in practice.

6,000 per patient.

However, as The Acupuncture Research Resource Centre has pointed out, many of the surveys undertaken are "small and encounter problems of finding a suitable control," and many other reviewers complain of poor methodology or lack of funding. This situation will have to change as acupuncture moves more into the mainstream and the process of regulation advances.

Echoing the demands of the scientific community as a whole, the House of Lords Report on Science and Technology, which examined CAM therapies and regulation, has called for research to take a high priority recommending "that CAM practitioners and researchers should attempt to build up an evidence base with the same rigour as is required of conventional medicine, using both randomised controlled trials (RCTs) and when appropriate other research designs." However, the use of RCTs as the ‘gold standard’ methodology is not a straightforward issue for many CAM therapies.

For acupuncture this approach is possible, but restrictive. For the majority of acupuncturists the therapy requires skilled practitioners, who diagnose patients as individuals, rather than diseases, and then involve the patient as much as possible in the treatment. There is no problem with randomly selecting patients and a ‘blind’ control is possible, though very strange to most practitioners, with the use of sham points or ‘placebo acupuncture’, but the need for skilled practitioners precludes the use of ‘double blind’.

In the same House of Lords Report Dr David Peters, a GP and osteopath "suggested that although RCTs and meta-analysis of RCTs are valuable, in that they provide certainty about the efficacy of a medication for a particular condition, real-life primary care does not mirror the way illness and treatment are defined in such research… Thus, the simple definitions of clinical problem and treatment that good RCTs require do not always mirror the complexity of CAM practice."

Although there is undoubtedly a need for well-funded, large-scale studies, they must include a wide range of imaginative methodologies, both quantitative and qualitative, which are relevant to the holistic approach of acupuncture in practice.

 
Japanese acupuncture chart Copyrighted  image Icon Copyright: photos.com

One area of research which has been attracting considerable interest and funding in recent years has been the use of Functional Magnetic Resonance Imaging (fMRI) and other brain scanning equipment to examine the effect stimulating specific acupuncture points has on the brain. Amongst the hundreds of acupuncture points on the body there are many which the Chinese have always used for treating specific conditions or parts of the body. For modern scientists this presents a dilemma, how can a point on the foot or shin, for example, treat eye disease or one on the hand effect the perception of pain?

 

Now, with the use of fmri there are numerous studies which are finding that specific points do affect specific brain regions, despite there being no direct nerve pathway. As ZH Cho et al reported in a study published by the Proceedings of the National Academy of Science, "the results obtained demonstrate the correlation between activation of specific areas of brain cortices and corresponding acupoint stimulation predicted by ancient acupuncture literature."

Apart from giving positive feedback about the effect of acupuncture, this also opens up new questions for scientists about how the body communicates and functions.

In addition to looking at efficacy, a number of surveys have been undertaken to investigate adverse events. Both the British Medical Acupuncture Society and the British Acupuncture Council have been involved in studies involving at least 32,000 consultations, finding "no serious adverse events" and concluding that "acupuncture seems, in skilled hands, one of the safer forms of medical intervention".

Finally the largest ongoing demonstration of the use of acupuncture in mainstream medicine, treating a complete range of health conditions is of course in China itself. Here the two approaches of east and west work alongside one another, providing an integrated medical model and offering the patient a choice of treatments both modern and traditional.

For many living and working in the modern scientific world, the appeal of acupuncture is its search for balance, its acknowledgement of the whole, of the connection and flow between things, its use of intuition and its lack of side effects. In the UK today we are fortunate that this choice is becoming available to an increasing number of people. Despite all the uncertainties caused by lack of regulation and research, our willingness to investigate and experiment with different approaches to health care, to argue and debate about concepts and efficacy, to form organisations and research forums with the aim of drawing the best from both east and west must surely be a good thing for the vitality of the nation.


 

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