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Guide for Physicians Seeking Hospital and HMO Privileges

By Russell J. Erickson, MD

Acupuncture is the third oldest healthcare art, following faith healing and herbology. Its existence, during 3,000 years, when many medical approaches, both good and bad, have winked in and  out of existence, should give us cause to look seriously at its contribution to healing, even though it is part of a paradigm not indigenous to allopathic medicine and was not invented in the USA. It rose in China instead of Europe "because ancient  Chinese science was empirical with a distaste for theories and emphasized holistic patterns, relationships, cycles and  processes" (Bruce Pomerantz). The fact that acupuncture is not a placebo therapy is accentuated by its use in veterinary  medicine for 1,000 years in the Orient and 100 in Europe, with increasing use during the last 20 years in the United  States, and by its effectiveness in treating children down  to infants. It appears effective, especially in areas where allopathic medicine is weak.

At present in the USA, roughly 3500 physicians and  11-12,000 non physician acupuncturists utilize this medical art, with 40 acupuncture schools training non-physicians, and about  500-600 physicians being trained yearly to AAMA standards.

The physiology and biochemistry of acupuncture, highlighted by a Medical Acupuncture Research Foundation (MARF) conference (Arlington,  Virginia, November 1996), has been investigated extensively by  such workers as Bruce Pomerantz of Canada, Ji-Sheng Han of China, Claudie Terral of France, and Daniel Bossut of the USA.Howard  Fields, USA, and others have added knowledge about the nervous  system function and its relation especially to pain, Abraham Liboff to EM studies, Owen Wilson to biophysical modeling of acupuncture, Mark Friedman and Stephen Birch to mathematical systems modeling,  and Beverly Rubik has centered discussion of acupuncture biophysics  and physiology. (1)

Many studies, especially from Bruce Pomerantz' laboratory, and many centers in China and Japan, have shown that acupuncture needling  affects nociceptive, proprioceptive, and autonomic nerve pathways to increase enkephalins and dynorphins in spine and mid-brain,and  to raise endorphins in the hypothalamus-pituitary region. The flow of enkephalins in mid brain causes retrograde release of  the monoamines, serotonin and norepinephrine in the spine which  inhibit spinal pain transmission. Endorphins inhibit substance  P, involved in pain and inflammation. (2) Data exists showing endorphins present in immune system cells as well, where acupuncture has also shown effects. Chinese studies  demonstrate c-FOS increase in effected brain areas following acupuncture. c-Fos is a primary gene protein and a marker for increased metabolic activity, accompanying mRNA increases in brain cells which might explain the long term effects, particularly of repeated acupuncture  sessions. (3) Involvement of  mu opioid receptors in periaqueductal gray matter were shown to  be involved in blood pressure response to acupuncture in rabbit  studies (4) and decreased EEG abnormalities and siezures were accompanied by decreased mRNA  for proenkephalins as enkephalin decreased and dynorphin increased  in the hippocampus accompanied brain normalization. (5) In addition to opioid changes following acupuncture, laboratories  in China have demonstrated elevation of mRNA for proopiomelanocortin, which is metabolized not only to endorphin but to ACTH in equal proportion, perhaps helping to explain part of the long term effect of acupuncture beyond the rapid rise and fall of endorphins. The  hypothalamic arcuate nucleus, among other areas is involved. (6) Other neuromodulators could take part in acupuncture response.

Beverly Rubik and many others believe evidence points to acupuncture effecting electromagnetic wave changes in the body on a very fine  level of nanoamperes and microvolts; difficult to measure, and  only now being looked into with more precise instruments required to circumvent much EM "background noise". Terral's exacting work supports many prior more poorly supported studies showing acupuncture  points as having less electrical resistance than surrounding skin.  (7) Becker and Selden, in their book on electromagnetism and the body, mention the EM possibility for acupuncture. (8) They are most intent on describing the miniscule electrical flow which bodies use for healing, where an initial positive potential in shock state must convert to negative to allow correct healing  of bone and other cellular tissue. The potential of this scientific  field is brought out by their studies of animals, such as salamanders and worms, which are able to regenerate body parts, but only if EM currents are present; so miniscule that a platinum-silver wire combination is enough to supply them. Acupuncture might retune body processes toward normal with minute EM flows, explaining the need for several treatments, as healing of the body by itself is directed with delicate nudges instead of exterior drugs and surgery.

Drs. LaRiccia & Alavi recently demonstrated by SPECT scan that there is abnormal blood flow in some brain areas of patients with chronic pain which returns to normal when acupuncture takes away the pain. (1) Studies from China and Japan have demonstrated effectiveness in changes of blood flow, pain of all types, changes in blood glucose levels in diabetes  and obesity, decrease in hyperprolactinemia and its symptoms, leveling of hyper and hypothyroidism. In China, it is common to do series of 10 daily treatments for 2 to 4 courses, which we can't emulate economically. Despite this, we should not denigrate  all data from the Orient. There is little evident concept in Oriental  countries that acupuncture studies need randomization and blinding, as clinical results in massive volume indicate to acupuncturists  that acupuncture effectiveness isn't even in question. Part of the good results published there, above and beyond the results  found in the "West" to date might be due to better training and technique, and part is undoubtedly due to the ability to treat  many times, with accumulative effect. Part could be "placebo" effect, but "placebo" effect extent itself is in question. (9)

Acceptable refereed articles on acupuncture are included below.  Current desire in the USA is for randomized studies of acupuncture treatment judged against known effective "standard" accepted therapy. Double blinded has been discarded--it is really not feasible; single blinded is difficult. "Sham" acupuncture as a control has been discarded as there are too many acupuncture points, and the factor of "diffuse noxious inhibitory control'" (DNIC) comes in, demanding large numbers for statistical validity, which is difficult, especially since there is no source of funding for acupuncture study, other than OAM, which is severally limited. (Catch 22)

A clinical literature review was done for a conference on biomedical research on acupuncture in Phoenix, Arizona, May, 1992, which reviewed many articles. (10) Jenifer E. Cole should be mentioned for her work on this project.  Of mentioned significance is work by Luo, Shen et al comparing 168 patients with depression treated by electroacupuncture (EA) with 139 controls treated with tricyclics. EA was as effective without the side effects of medication. Martoudis & Christofides calmed labor pains in second stage in 87% of 168 women. Bullock, et al comparing 40 recidivist alcoholics treated with acupuncture to 40 with usual treatment, showing 21 of 40 completing the program vs 1 of 40 controls, with controls having twice the drinking after 6 months. Michael Smith reported on 8,000 crack patients, with 85% of addicts treated by acupuncture completing a program vs 35% without. Kroenig and Oleson noted 86% of narcotic addicted  patients could be withdrawn in 2 to 7 days with minimal side effects  using auricular acupuncture. Helms studied 43 women with dysmennorhea using placebo acupuncture, standard and visitation controls. Ninety  % of acupuncture, 36% of placebo acupuncture, and 18% of controls were relieved of symptoms. Ellis, et al showed 9 of 10 elderly  patients with nocturnal voiding problems were improved by acupuncture after 2 weeks vs 3 patients worsened in the control group. Ballegaard  et al randomized 49 angina patients to acupuncture and sham, with no difference in nitroglycerine use, but a 50% decrease in anginal  attack rate in both (? DNIC effect in sham), and a statistically significant betterment of exercise tolerance in the acupuncture group. Two studies on acupuncture use in asthma failed to show a benefit, except for protection against exercise-induced symptoms. Matched pairs with COPD demonstrated benefit for acupuncture in symptom relief (Jobst, et al). Zhao, et al, with 600 cases of  psoriasis, demonstrated cure in 62% with 20% relapse, again amenable  to therapy. (This requires many sessions compared to Western approaches.) Mann, et al treated knee rheumatoid arthritis with steroid injection in one knee and acupuncture to the other, finding acupuncture pain relief lasted 4 to 12 weeks vs 2 to 6 for steroid, and better motion in the acupuncture knee. Two of three randomized neck pain  studies (Coan, et al and Peng, et al) showed a benefit for acupuncture, one (Petrie & Hazleman) did not. Filshie, for 156 patients with malignant pain found acupuncture significantly relieved 1/3 of tumor pain and 2/3 of treatment-related or other pain. Several studies with low numbers of pain condition patients are also mentioned which showed no acupuncture benefit. Lee and Liao, in 220 LBP patients, found 59% relief lasting over 3 months. Headache study results varied greatly, with numbers too small for statistical significance. Dundee et al, in 3 publications, found acupuncture handy for nausea and vomiting in varied situations. Ho, et al, in a comparative study of 100 post-operative cases, found acupuncture as effective as prochlorperazine for vomiting.

Lewith and Machin did a review article on randomized trials studying the clinical effects of acupuncture. (11) They found overall rates of 70% effectiveness for acupuncture, 50% for sham acupuncture (DNIC?), and 30 % for "placebo". The majority of trials had low power at a conventional rate of 5%.

Richardson and Vincent did a review of studies on acupuncture treatment of pain. (12) They found the overall quality of published reports to be poor, though the group reviewed at least had a no treatment control and involved larger numbers. They provide a number of suggestions to be considered in doing studies. They did conclude that there is good evidence for the short term effectiveness of acupuncture in relieving pain in each area examined, in the 50-80% range. Insufficient data on followup limits knowledge of longer term effect. The study by Coan, et al, where acupuncturists were free to follow normal individualized treatment practice, did show 58% with pain down at 10 months. If one evaluates their list of studies and picks  out only those where 8 or more treatments were given (more akin to traditional use and in keeping with the aforementioned expectation  of build up of effect), rather than just one to a few sessions, then the effectiveness of acupuncture treatment stands out as  very much better than the controls.

terRiet et al, in a criteria based meta-analysis of 51 controlled  studies on acupuncture for chronic pain, using 18 predefined methodologic criteria, found the quality of even the better studies to be mediocre, with findings highly contradictory.(13) They note lack of adequate numbers as a major problem (a strength  of China studies), loss of followup (a weakness of all studies),  and the effect of DNIC in needle controls.

Erickson evaluated all medical care a year before and one after  an average series of 6 acupuncture treatments for 100 consecutive patients with chronic pain of 6 month to over 10 year duration who had not responded to usual medical care. Seventy three percent, rated both subjectively and objectively by medical care facility usage, responded, with 18% possibly helped. Clinic visits dropped 26%, pain visits 52%, and medication use over 50% for 6 months and 35% over a year period. (14) A second series of 68 patients with chronic unresponsive foot and ankle pain demonstrated 31 cured and 19 with 75% pain decrease in an average 4 treatments, on one year followup.(15)

Dr. Yutan, noting 80% of patients with facial paralysis will recover with time, reported 718 treated with acupuncture, had over 95% cure within 2 months, judged clinically and by EMG, including those with lesion at the level of petrosal nerve and geniculate  ganglion.(16)

Chou and Jiang treated 69 patients, with symptom duration one month to one year, with 16 stones in kidney and 62 in ureters  (37 measured over 6 mm). Fifty-nine percent were eliminated in two treatments, with 23% moving down over 20 mm. (17) This was backed by Liu and coworkers with 120 patients and over  82% relief of stones. (18)
Lu reported 103 patients with postpartum urine retention treated with 30 minutes of needling, with 85% urinating spontaneously after one or two treatments (94% cured if symptoms less than 4 days). (19)

Shi and coworkers reported 120 dysmennorheac women with 87% improving  markedly with acupuncture compared to 32% of 44 given "Western" medication. (20)

Visetti and Costa stopped interoperative hiccups in 93% with auricular acupuncture at 3 points. If one point (Oleson "diaphragm") only was used, 50% stopped. (21)

Ballegaard and coworkers found, in 49 angina patients treated with acupuncture, that exercise tolerance rose slightly, while anginal attacks dropped 38% and nitroglycerine use 58%. (22). This is backed by Wang's group, comparing 39 acupuncture treated with 39 medically, randomized even-odd. Blood flow was more normal, high glucose and lipids decreased, pain relief was superior and abnormal ST EKG changes subsided.(23)

Johanssen and workers found acupuncture increased Bethel's Living  Index from 71 in controls (usual PT & OT) to 90, while reduced  hospitalizations over a 3 year period saved $26,000 (US terms) per patient. (24). The result  is backed by Xian and Zhishun in 60 treated stroke patients vs 40 controls (25), Dong and Yulin with 101 (26), and Yukang,  et al in 120 (27).

Li, et al treated 31 patients with hyperprolactinemia, compared with 15 controls with bromocryptine, with 17 cures (6 became pregnant) and 11 good effect, equal to medication. Up to 40-50 treatments were used. (28)

Deluze and coworkers randomized 70 patients with fibromyalgia (strict criteria) and found acupuncture raised pain threshold  70% vs 4% in controls. (29)

Two recent reviews give estimates of acupuncture side effects, with Rampes & James of England finding 100 serious side effects in 25 years literature search (30), and a recent Scandinavian review estimating one serious side effect per 4 to 5 years of practitioner therapy.

I have mentioned only a few of 1542 recent acupuncture references, some 0 to 400 of which I and colleagues have reviewed the past 4 years. Many good studies remain to be done, if biases can be overcome and sources of funding for biostatistical and data gathering help can be obtained. I have no doubt that acupuncture is an effective  healthcare approach, from literature review, discussions with  many excellent clinicians, and my own clinical experience over  18 years of part-time acupuncture usage. It took me years, while working without contact with other acupuncture-utilizing physicians, to overcome the emotional feeling that my results must be luck  or placebo, as needling results made no sense by US training information.
 
Russell J. Erickson, MD
American Academy of Medical Acupuncture
Medical Acupuncture Research Foundation

Bibliography

1. Medical Acupuncture Research Foundation Syllabus, "Physiology of Acupuncture" Available via AAMA/MARF administration, 1970 E. Grand Ave, Ste 330, El Segundo, CA 90245.Back to section
2. Pomeranz & Stux, Scientific Basis of Acupuncture, 1-34, 1986, Springer-Verlag, Back to section
3. Lee, J-h and Beitz, AJ. The distribution  of brain-stem and spinal cord nuclei associated with different  frequencies of electroacupuncture analgesia. Pain 52: 11-28, 1993. Back to section
4. Ming, G et al. Involvement of mu opioid receptors of periaqueductal gray (PAG) in acupuncture inhibition  of noxious blood pressure response in rabbits. Acup Electro-Ther Res. 19(2-3): 81088 (1994). Back to section
5. Wang, B-e, et al. Effect of electroacupuncture  on the level of proenkephalin mRNA in rat during penicillin-induced  epilepsy. Acup Electro-Ther Res. 19(2-3): 129-140, 1994. Back to section
6. He, et al. Temporal alterations of proopiomelanocortin  mRNA level in rat hypothalamic arcuate nucleus following electroacupuncture. World J Acup-Moxi. 5(3): 36-41, 1995. Back to section
7. Terral, C. Identification et essai d'interpretation des points de moindre resistance electrique du revetement cutane. D.E.R.B.H. 1986, resume in ref. 1 above. Back to section
8. Becker, RO and Selden, G. The Body Electric.  Wm Morrow, NY 1985. Back to  section
9. Kienle, GS and Keinle, H. Placebo effect  and placebo concept: a critical methodological and conceptual  analysis of reports on the magnitude of the placebo effect.  Alternative Therapies 2(6): 39-54, 1996. Back to section
10. Biomedical research on acupuncture: an agenda for the 1990s. AAMA Conference summary, Phoenix, Arizona,  May 1992. Available via AAMA administration, 1970 E. Grand Ave, Ste 330, El Segundo, CA 90245. Back to section
11. Lewith, GT and Machin, D. On the evaluation  of the clinical effects of acupuncture. Pain 16: 111-127, 1983. Back to section
12. Richardson, PH and Vincent, CA. Acupuncture  for the treatment of pain: a review of evaluative research. Pain 24: 15-40, 1986. Back to section
13. ter Riet, G et al. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol. 43(11):  1191-1199, 1990. Back to section
14. Erickson, RJ Acupuncture for chronic pain: a study of its efficacy and an evaluation of its effect on utilization of medical services in a prepaid health plan. Med Acup 7(1): 5-10, 1995. Back to section
15. Erickson, RJ Medically unresponsive foot and ankle pain treated successfully with acupuncture. in press,  Acup in Med. Spring, 1997. Back to section
16. Yutan, L. A new classification system  and combined treatment method for idiopathic facial nerve  paralysis: a report of 718 cases. Amer J Acup 23(3): 205-210, 1995. Back to section
17. Chou, Y-i and Jiang, C-y. Therapeutic  effects of acupuncture in treating urinary calculus. Inter  J Clin Acup. 6(2): 229-232, 1995. Back to section
18. Liu, Y et al. Clinical study on the treatment  of olithiasis with acupuncture. World J Acup Moxi. 5(1): 11-16,  1995. Back to section
19. Lu, X et al. A report on the treatment of 103 cases with postpartum retention of urine. World J Acup  Moxi. 5(2): 15-17, 1995. Back to section
20. Shi, X et al. An analysis on the therapeutic effect of acupuncture at Sanyinjiao point for the treatment  of 120 cases of primary dysmennorhea. World J Acup Moxi. 5(3):  28-30, 1995. Back to section
21. Visetti, E. and Cost, P. Auriculotherapy for the inter-operative hiccup in anesthetized patients. Amer  J Acup 23(2): 105-108, 1995. Back to section
22. Ballegaard, S. et. al. Acupuncture in  angina ctoris: do psychosocial and neurophysiological factors relate to the effect? Acup ElectroTher Res. 20(2): 101-116, 1995. Back to section
23. Wang, X-t. et al. Acupuncture treatment  of angina pectoris based on catagorical identification: a  clinical report of 39 cases. (compared to 39 controls). Inter  J Clin Acup 6(1): 5-9, 1995. Back to section
24. Johanssen, BB et al. Acupuncture in stroke rehabilitation. Acup in Med 13(2): 81-84, 1995. Back to section
25. Xian, S and Zhishun, Y. Clinical study of the choice region of scalp acupoints for the treatment  of apoplectic hemiplegia. Inter J Clin Acup 4(1): 27-32, 1993.Back to section
26. Dong, L and Yulin, Z. Puncturing the empirical point Shengen in treatment of 101 cases of apoplectic hemiplegia.  J Tradit Chin Med 14(2): 110-114, 1994. Back to section
27. Yukang, L et al. Treatment of apoplectic hemiplegia with scalp acupuncture in relation to CT findings. J Tradit Chin Med. 13(3): 182-184, 1993. Back to section
28. Li, Y et al. Clinical study on the treatment of idiopathic hyperprolactinemia with acupuncture and conventional drug therapy: perspectives and mechanisms, East and West.  Amer J Acup 23(2): 109-121, 1995. Back to section
29. Deluze, et al. Electroacupuncture in fibromyalgia--a controlled study. BMJ 305: 1249-1252, 1993. Back to section
30. Rampes, H and James, R. Complications  of acupuncture. Acup in Med 8(1): 26-31, 1995. Back to section

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