Acupuncture in Physiotherapy

Hospital Authority

Coordinating Committee in Physiotherapy Hospital Authority March 2003

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1. Introduction Acupuncture has been introduced as one of physiotherapy modalities in treating pain syndromes and neurological conditions in recent years. This paper describes the development of acupuncture in physiotherapy and the physiotherapists’ theoretical basis of acupuncture practice in the Hospital Authority settings. It also delineates the distinct practice of acupuncture of the physiotherapists from those acupuncturists or practitioners of Traditional Chinese Medicine (TCM). The quality assurance system is also described in the end of the paper. 1.1 History of Acupuncture It is generally believed that acupuncture is originated in China and has been practised for more than 2000 years. Acupuncture has also been practised in other East Asian countries - in Japan for over 1450 years, Korea for at least 1500 years, and Vietnam for about 2000 years (Birch & Kaptchuk, 1999). In China, acupuncture was first described in the Yellow Emperor’s Classic of Internal Medicine (Huang Di Nei Jing ¶À«Ò¤º¸g), which was dated in about 200 BC. Acupuncture is rooted in the Daoist philosophy of change, growth, balance and harmony, and its use is based on the principles of natural law and balance of Yin and Yang (³±¶§) and the Five Elements/Phases ( æ¦-¤ ). 1.2 Definition of Acupuncture The term “acupuncture” is a loose translation of the Chinese term “zhenjiu” (°w¨b) and was coined in Europe in the late seventeenth century (Birch & Kaptchuk, 1999). Strictly speaking, acupuncture refers to the use of needles (Latin “acus” means “needles” and “punctura” means “to puncture”; Rotchford & Kobrin, 2002) in treating or preventing symptoms and conditions (White & Ernst, 1999). 2. Theoretical Bases of Acupuncture There are two major theoretical bases of acupuncture – Traditional Chinese Acupuncture (TCA) and Modern Acupuncture (MA) or Western Medical Acupuncture (British Medical Association, 2000): 2.1 Traditional Chinese Acupuncture TCA is viewed as an integral part of the TCM. According to the TCM, the workings of the human body are controlled by a vital energy called “Qi” (®ð ), which circulates between different organs along the channels called meridians (¸gµ¸ ). When there is hindrance or obstruction of the flow of Qi through the meridians, illness will result. The goal of acupuncture is to restore the proper circulation of Qi along the meridians. 2.2 Modern Acupuncture/ Western Medical Acupuncture Modern Acupuncture (MA) or Western Medical Acupuncture (WMA) is a more recent development practised by doctors and physiotherapists, who use acupuncture as an adjunctive intervention on the basis of a clinical diagnosis (British Acupuncture Council, 2002). It is stated that “[t]he principal difference between a traditional eastern and western scientific acupuncture approach is the method of diagnosis and the relentless pursuit of a scientific rationale for treatment” (Filshie & Cummings, 1999, p.35). Based on modern concepts of neuroanatomy and physiology, acupuncture is known to produce analgesia effects at segmental level by stimulating the A-delta afferents and at higher level by stimulating the mid-brain to release enkephalin and endorphin, which activate a descending pain inhibition system (Pomeranz, 1987, cited in LaRiccia, 2000).

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The differences of TCA and MA are contrasted and summarized as follows: Modern Acupuncture (Western Medical Acupuncture) 1. Theroetical Basis • TCA as a part of the traditional • MA as "the scientific Chinese medicine (TCM) application of acupuncture as a TCM is practiced through an therapy following orthodox • holistic approach with clinical diagnosis" (Filshie & emphasis on the unity of the Cummings, 1999, p.31) human body and its Based on modern concepts of • environment (British Medical neuroanatomy and physiology Association, 2000) (British Medical Association, 2000) 2. Patient Based on 4 inspections: Based on systematic evaluation • • Assessment of clinical history, physical (1) Visual inspection (±æ ) examination and other (2) Listening/smelling (»D) supplementary information (3) Questioning (°Ý) (including radiographic and (4) Palpation (¤Á) laboratory findings) to reach a clinical diagnosis 3. Selection of Based on meridian theory Based on positive results of • • Acupoints empirical studies for particular conditions Using a combination of trigger • points, tender points, segmental points, and traditional points 4. Intended Restoration of free flow of "Qi" • Acupuncture as a technique of • Therapeutic Effects and balance of "Yin" and sensory stimulation, which "Yang" inside the body triggers complex responses in human body with neurophysiological and neuropharmacological mechanisms Endorphin release as the • hypothesized major mechanism for analgesic effect of acupuncture 3. Efficacy and Safety of Acupuncture 3.1 Efficacy of Acupuncture The efficacy of acupuncture has been equivocal, despite its practice for thousands of years. There are quite a number of systematic reviews in acupuncture for different conditions. However, there are many problems of existing systematic reviews in acupuncture (White et al, 2002):
• • • •

Traditional Chinese Acupuncture

Incomplete literature search Poorly described or inadequate inclusion criteria Lack of definition of “acupuncture” Inconsistent assessment of quality of studies

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• • •

Lack of assessment of the adequacy of acupuncture Impact of low sample size Inappropriate evaluation of results

While many existing systematic reviews in acupuncture are not methodologically sound, many existing trials upon which the systematic reviews have been based are also methodologically flawed (Ernst, 1999). It is stated that “the need for the near future is not for additional systematic reviews but for new, high-quality RCTs of acupuncture that meet the design and reporting standards called for in recent articles and in the STRICTA guidelines …” (White et al, 2002, p.30). One has to be cautious in interpreting the results of systematic reviews in acupuncture in stating that there is no evidence of effect of acupuncture. The absence of evidence is not equal to the evidence of absence. Ernst (1999) attempts to categorize the existing evidence regarding acupuncture into 3 levels - “conclusively positive”, “inconclusive”, and “conclusively negative”: Conclusively Positive Evidence Dental pain • Low back pain • Nausea/Vomiting • Inconclusive Evidence
• • • • • • • •

Experimental pain Neck pain Headache/migraine Osteoarthritis Inflammatory rheumatic diseases Stroke Addictions Asthma

Conclusively Negative Evidence Smoking cessation • Weight loss •

We, as physiotherapists, hold the view that acupuncture should not be given as primary or adjunctive intervention in those conditions that there is conclusive evidence to show that acupuncture is ineffective. For those conditions that there is inconclusive evidence for acupuncture, acupuncture may be used as one of the adjunctive interventions when indicated. For those conditions that there is convincing evidence to support the efficacy of acupuncture, acupuncture may even be considered as the primary intervention, after considering the indications and contraindications of individual patients. 3.2 Safety of Acupuncture It is reported that “[acupuncture] seems to be relatively safe form of treatment with low incidence of serious adverse events” (Vickers & Zollman, 1999, p.975). Surveys indicate the incidence of serious side-effects of acupuncture ranging from 1:10,000 to 1:100,000 (White el al, 1997; cited in Rampes and Peuker, 1999, p.144). It is held that the serious adverse effects reported in the literature may easily be prevented by straightforward precautions (Rampes & Peuker, 1999).

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4. Acupuncture Practice in Physiotherapy Acupuncture has become a popular modality in physiotherapy practice, both locally (see Appendix) and overseas (Kerr et al, 2001). In Hong Kong, physiotherapists practise acupuncture with distinguishable differences from that based on TCM, according to the subsection 3 of the Section 108(2) of the Chinese Medicine Ordinance CAP 549. Within this legal framework, physiotherapists practise the Modern Acupuncture in Hong Kong. Birch and Felt (1999, p.267) have proposed a framework of acupuncture practice of relative pre-dominance of traditional and modern concepts: Level 1 Level 2 Level 3 Level 4 Level 5 Adherence to and belief in traditional (East Asian) concepts only; and complete rejection of biomedical (scientific) model Adherence to and belief in traditional and biomedical concepts, with a limited utilization of biomedical concepts An interweaving and mixing of traditional and biomedical concepts Adherence to and belief in biomedical concepts, with the subsuming of traditional concepts where they can be subsumed Adherence to and belief in only biomedical concepts, with complete rejection of traditional models

In acupuncture practice, physiotherapists would adhere to the biomedical concepts, allowing the subsuming of acupuncture concepts based on TCM. Therefore, physiotherapists practise acupuncture at the Level 4 of the framework described by Birch and Felt (1999). Within this practice framework, it is evident that physiotherapists’ acupuncture practice has de facto distinguishable difference from the practice of TCA. 5. Quality Assurance System In order to uphold the standards and quality of acupuncture practice by physiotherapists, a quality assurance system has been established by the Coordinating Committee in Physiotherapy of the Hospital Authority, illustrated as follows: 5.1 Accreditation System All physiotherapists, who work and practise acupuncture in the Hospital Authority, are required to go through the accreditation procedures set out by the Hong Kong Physiotherapy Association (HKPA). The HKPA (2003) has established the standards of acupuncture practice in benchmarking with the International Acupuncture Association of Physical Therapists (IAAPT) 5.2 Development of Operation Guidelines An Operation Guidelines for Physiotherapists Practising Acupuncture in Hospital Authority has been promulgated to assure the standards of practice and safety precautions. Physiotherapists would also adhere to the Practice Guidelines on Acupuncture by Physiotherapists in Hong Kong 2003 of the HKPA. 5.3 Development of Protocols Intervention protocols for specific conditions such as osteoarthritis and stroke are in the process of development by the Working Group on Acupuncture, Coordinating Committee in Physiotherapy of the Hospital Authority. These intervention protocols will serve as the practice guides for physiotherapists in practising acupuncture for those specific conditions.

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5.4 Incident Reporting System An incident reporting system has been set up to record and evaluate incidents and adverse events in acupuncture practice. 5.5 Continuing Education Physiotherapists working in the Hospital Authority are required to attend continuing education programmes on the contemporary developments in Modern Acupuncture. 6. The Way Forward With the necessary training and accreditation in acupuncture practice, strict adherence of safety precautions in practice and the application of evolving evidence from high-quality clinical trials, more physiotherapists of the Hospital Authority would be equipped with the necessary competency to practise safe and effective Modern Acupuncture for patients. References Birch SJ, Felt RL (1999) Understanding Acupuncture, UK: Churchill Livingstone. Birch S, Kaptchuk T (1999) History, nature and current practice of acupuncture: an East Asian perspective. In Ernst E, White A (Eds) Acupuncture: a Scientific Appraisal, Oxford: Butterworth-Heinemann, pp.11-30. British Acupuncture Council (2002). Available at URL: http://www.acupuncture.org.uk/content/AboutAcupuncture/acupuncture.htm (Access on 23 December 2002) British Medical Association (2000) Acupuncture: Efficacy, Safety and Practice, Amsterdam: Harwood Academic Publishers. Ernst (1999) Clinical effectiveness of acupuncture: an overview of systematic reviews. In Ernst E, White A (Eds) Acupuncture: A Scientific Appraisal, Oxford: ButterworthHeinemann, pp.107-127. Filshie J, Cummings, M (1999) Western medical acupuncture. In Ernst E, White A (Eds) Acupuncture: A Scientific Appraisal, Oxford: Butterworth-Heinemann, pp.31-59. Hong Kong Physiotherapy Association (2003) Practice Guidelines on Acupuncture by Physiotherapists in Hong Kong, HKSAR Kerr DP, Walsh DM, Baxter GD (2001) A study of the use of acupuncture in physiotherapy, Complementary Therapies in Medicine 9: 21-27. LaRiccia PJ (2000) Acupuncture and physical therapy, Orthopaedic Physical Therapy Clinics of North America 9: 429-442. Rampes H, Peuker E (1999) Adverse effects of acupuncture. In Ernst E, White A (Eds) Acupuncture: A Scientific Appraisal, Oxford: Butterworth-Heinemann, pp.128-152.

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Rotchford JK, Kobrin LE (2002) The importance of a modern and comprehensive definition for acupuncture in clinical research: preliminary perspectives, Medical Acupuncture 13(3). Available at URL: http://www.medicalacupuncture.org/aama_marf/journal/vol13_3/articles5.html [Access on 23 December 2002] Vickers A, Zollman C (1999) Acupuncture, British Medical Journal 319: 973-976. White A, Ernst E (1999) Introduction. In Ernst E, White A (Eds) Acupuncture: A Scientific Appraisal, Oxford: Butterworth-Heinemann, pp.1-10. White A, Trinh K, Hammerschlag R (2002) Performing systematic reviews of clinical trials of acupuncture: problems and solutions, Clinical Acupuncture and Oriental Medicine 3: 2631.

Appendix Common Practice Patterns of Acupuncture in Physiotherapy Departments of Hospital Authority 1. Adjunct Physiotherapeutics: 1.1. Neurology i. Stroke ii. Peripheral & Cranial Nerve Lesions 1.2. Orthopaedics i. Heel pain ii. Osteoarthritis with or without surgical intervention iii. Chronic Low Back Pain iv. Frozen Shoulder v. Tennis Elbow vi. De Quervain Disease 1.3.Cardiopulmonary Conditions i.Allergic rhinitis ii.Post-cardiothoracic Surgery 1.4 Other painful conditions 2. Clinical Research Studies

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