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Acupuncture

Definition

Acupuncture is a therapeutic technique that involves the insertion of fine needles into the skin and underlying tissues at specific points for therapeutic or preventative purposes (White et al. [194]). In the UK, there are two main types of approach to acupuncture: Chinese medical acupuncture and conventional (sometimes termed Western) medical acupuncture. In the NHS, conventional medical acupuncture is most commonly used for the treatment of chronic pain. The selection of acupuncture points is based on the region affected and there is minimal needle manipulation (as is the practice in Chinese acupuncture) except for in the use of electro‐acupuncture. This section focuses on conventional (Western) medical acupuncture.

Anatomy and physiology

Acupuncture has been used in China for over 2000 years. The history of Western medical acupuncture started in the 1970s when a medically qualified doctor took a rational, scientific approach to exploring acupuncture and its benefits (White et al. [194]).
There is evidence to show that acupuncture works on the nervous system and the muscles. Electro‐acupuncture activates the endogenous opioid system, causing analgesia and mediating anti‐hyperalgesia effects (Yap [200]). Acupuncture also affects the endocrine system, leading to an increased release of adrenocorticotropic hormone (ACTH), producing an anti‐inflammatory effect (Yap [200]). However, how and why insertion of needles can cause such physiological responses is still largely unknown (Yap [200]), and the variability in individual responses is also not well understood.
Five mechanisms have been identified, although these can overlap: local effects, segmental effects, extra‐segmental effects, central effects and myofascial trigger point effects (White et al. [194]).

Local effects

Action potentials in nerve fibres in the skin and muscle are activated by the acupuncture needles. Various substances are released as a result and this causes an increase in local blood flow. This can often be seen as a red mark around the acupuncture needle during treatment. The local effect can also cause an increase in the blood supply in the deeper tissue, which can aid wound healing.

Segmental effects

The action potentials activated by the local effects continue to travel up the nerve to the spinal cord and reduce the painful stimuli by reducing activity at the dorsal horn. This is the main mechanism by which acupuncture relieves pain.

Extra‐segmental effects

This is a response in which the effect of acupuncture is not restricted to a single area. This is due to the action potentials continuing to the brainstem, with the result that every segment of the spinal cord is affected (White et al. [194]).

Central effects

Acupuncture affects other structures in the brain, such as the hypothalamus and the limbic system. In these areas, acupuncture can have a regulatory effect; this can be used to treat nausea, hormone imbalances and drug addiction. These effects have been shown on MRI scans.

Myofascial trigger point effects

People can experience pain due to ‘tight bands’ or ‘pressure or trigger points’ in their muscles. Acupuncture is effective in treating this pain; the needles are inserted directly into the painful area and often the patient experiences instant pain relief. It is thought that acupuncture was originally developed for this type of pain (White et al. [193]).

Evidence‐based approaches

Rationale

Acupuncture is used for a number of different conditions: both acute and chronic pain, nausea (post‐operative and chemotherapy induced), fatigue, addiction and infertility. There are a number of Cochrane reports (e.g. Lee and Ernst [94]) indicating the effectiveness of the use of acupuncture in various conditions. They concluded that acupuncture is effective for migraines, neck disorders, tension‐type headaches and peripheral joint osteoarthritis. There have also been numerous RCTs showing the effectiveness of acupuncture (White et al. [193]).

Indications

Acupuncture is indicated for:
  • pain – both acute and chronic
  • xerostomia
  • nausea and vomiting (post‐operative, secondary to chemotherapy and in pregnancy)
  • intractable fatigue
  • breathlessness
  • anxiety
  • vasomotor symptoms (e.g. hot flushes)
  • encouragement of wound healing
  • addiction (e.g. to help patients stop smoking and to aid treatment of alcohol dependence)
  • infertility and dysmenorrhoea
  • asthma
  • urological conditions (e.g. irritable bladder).
Clear evidence for the effectiveness of acupuncture in treating pain conditions has been obtained through high‐quality sources such as RCTs (Molsberger et al. [116], Shin et al. [169]) and through other sources such as individual patient data meta‐analysis (Vickers et al. [190]). Figures 10.15, 10.16 and 10.17 show some common acupuncture points used in practice.
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Figure 10.15  A generic acupuncture point (PC6) often used for nausea and pain.
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Figure 10.16  A point (LI4) used for relief of pain such as headaches and toothache, for relief of sinus infections, or as a generic point in conjunction with other points specific to the painful area.
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Figure 10.17  Points used to treat migraines and headaches.

Contraindications

Acupuncture is contraindicated in patients who:
  • refuse (e.g. in cases of extreme needle phobia)
  • have pain originating from an unknown cause
  • are unable to give informed consent or co‐operate with treatment
  • have severe clotting dysfunction or bruise spontaneously.
Needling should be avoided:
  • directly onto a tumour nodule or into an area of ulceration
  • in lymphoedematous limbs or limbs prone to lymphoedema
  • in the ipsilateral arm in patients who have undergone axillary dissection (because there is a risk of the development of swelling and lymphoedema after insertion of any needle)
  • in areas of spinal instability because of the risk of cord compression (due to acupuncture's muscle‐relaxing properties)
  • into a prosthesis (could cause leakage of saline or silicone)
  • over intracranial deficits following neurosurgery.
Caution should be taken with:
  • patients who are underweight (so as not to needle too deeply over the chest wall)
  • patients who are confused
  • patients who are agitated
  • patients with a metal allergy
  • patients receiving anticoagulation therapy
  • patients who are immunocompromised
  • patients with peripheral vascular disease
  • patients with blood‐borne infections (e.g. HIV)
  • patients who are pregnant
  • patients who are prone to keloid scar formation
  • all cancer patients as they may be very sensitive to acupuncture, so close supervision is advised, especially during the first treatment.
Various authors have reviewed the safety aspects of acupuncture for palliation of symptoms. Reported adverse effects of acupuncture have been categorized as follows:
  • delayed or missed diagnosis (i.e. orthodox diagnostic categories)
  • deterioration of disorder under treatment
  • vegetative reactions (e.g. syncope, vertigo or sweating)
  • bacterial and viral infections (e.g. hepatitis B and C, and HIV infection)
  • trauma of tissues and organs.

Clinical governance

All acupuncture practitioners must have completed a recognized, validated, formal training course within their scope of professional practice (e.g. the Foundation Course in acupuncture provided by the British Medical Acupuncture Society (BMAS)). Any nurses who practise acupuncture should check with their union to ensure they have appropriate indemnity cover.

Pre‐procedural considerations

Equipment

Acupuncture needles consist of a shaft and a handle. The handle is made of either plastic or metal. The needles are single use and disposable and are covered by a safety guide tube.
There are various dimensions of needles available. However:
  • 0.25 or 0.30 mm diameter needles are standard.
  • 25 or 40 mm length needles are standard.

Assessment and recording tools

Record the patient's treatment in the hospital notes or hospital computer system. Documentation should include the patient's condition, the acupuncture points used and the outcome (Figure 10.18).
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Figure 10.18  A sample acupuncture treatment record chart. Rx, prescription. Source: Adapted from BMAS ([13]).

Specific patient preparation

Patients should be treated in a comfortable, well‐supported position on a couch, either lying down or sitting with the facility to lie down quickly in case they feel faint during or after the procedure. A healthcare professional should remain with the patient throughout their first treatment as their reaction to acupuncture will be unknown.

Consent

All patients must sign a consent form to agree to treatment, as per local policy. An example of a consent form to use can be found on the BMAS website (BMAS [13]).

Post‐procedural considerations

If the patient is having treatment in an outpatient setting, they can travel home immediately after treatment. If the patient feels dizzy or faint, they should rest and drink fluids until the feeling passes.

Complications

Although rare, there can be some complications when practising acupuncture:
  • Fainting can occur in some patients who are tired, nervous or stressed. This occurs in 5–10% of patients. To avoid this, all patients should be treated while lying down.
  • Pain can be felt during insertion of the needles, but this is due to clumsy technique. It can also occur if a patient moves during treatment, and therefore patients should be treated on a stable bed.
  • Pneumothorax: this is very rare in practice and is caused by practitioners having poor anatomical knowledge (Park et al. [139]).
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