Acupuncture for pain relief

Is there an evidence base for acupuncture in primary care? By Dr Prashini Naidoo

Acupuncture has a long history of use in traditional Chinese medicine; however, its efficacy is the subject of continuing debate among GPs (Photo: iStock)
Acupuncture has a long history of use in traditional Chinese medicine; however, its efficacy is the subject of continuing debate among GPs (Photo: iStock)

There is now a growing evidence base for the use of acupuncture in pain relief.

In a meta-analysis of 29 high quality RCTs involving approximately 18,000 patients using acupuncture to treat chronic back and neck pain, osteoarthritis and chronic headache, acupuncture produced a significant difference in pain levels.1

Acupuncture as a treatment incites divergent views among UK GPs.

The sceptical group wants to understand its mechanism of action and finds the explanation that it 'unclogs' chi (energy) flows incompatible with western medicine.

The pro-acupuncture group believes studies have shown plausible mechanisms of action – acupuncture produces local effects (vasodilation, blood vessel proliferation and local nerve growth), effects at spinal cord level (enhancing descending inhibition in the spinal cord) and effects at hormone level (causing endorphin, adrenocorticotropic hormone or oxytocin release), all of which encourage pain relief and healing.

There are no national policy directives for CCGs about setting up and training practitioners to offer acupuncture in NHS clinics. The number of trained NHS staff varies from area to area and seems to be a matter of luck and availability, rather than planned countrywide initiatives. With the cost of acupuncture, whether a policy is needed remains a separate debate.

This article discusses which UK practitioners offer acupuncture, the conditions for which it is used, accessing it within the NHS and how GPs could train in acupuncture.

UK-registered practitioners

There are four major UK-based acupuncture practitioner associations: the Acupuncture Association of Chartered Physiotherapists, the British Acupuncture Council (independent acupuncturists who complete a three- to four-year degree course), the British Academy of Western Medical Acupuncture (doctors, nurses and physiotherapists) and the British Medical Acupuncture Society (doctors).

According to a 2009 survey of these associations, 40% of all surveyed practitioners worked in the NHS.2 NHS settings include GP surgeries, physiotherapy departments, midwifery and obstetric settings, pain and oncology outpatient departments.

Roughly 60% of the respondents used a western medical acupuncture style and 40% practised from a traditional Chinese philosophy.2

A western medical acupuncture style involves the use of acupuncture as a therapy following orthodox clinical diagnosis - taking a history and examining the patient, and ordering special investigations such as X-ray or blood tests.

In traditional Chinese medicine, the diagnosis is made following a detailed examination of the tongue and peripheral pulses.

Western-style acupuncturists tend to use acupuncture to treat musculoskeletal pain and insert the acupuncture needle into a tender muscle knot, a myofascial trigger. Following needle insertion, practitioners seek a twitch response, an involuntary spinal cord reflex in which the fibres in the taut band of muscle contract.

Traditional Chinese medicine practitioners select acupuncture points according to traditional concepts, such as the balancing of yin and yang (feminine and masculine elements), improving the flow of chi and treating disease that can result from damp and cold. They seek a 'de qi' response, which refers to a sensation of numbness or electrical tingling at the needle site which may radiate to a distal part of the body.

Conditions treated

NICE supports the use of acupuncture in the treatment of two conditions – low back pain and chronic headache. Some GPs offer their patients the option of acupuncture for conditions other than these.

The merits of acupuncture in the treatment of insomnia have also been discussed.

The offer of acupuncture as a treatment, as with some other complementary and alternative medicine modalities, may be based on pragmatic grounds – the risk of serious adverse effects with acupuncture is low and it may help the individual patient (whereas other treatments consider the effect of the modality on a population), the patient may prefer it to taking medication, it may be locally available on the NHS, or the patient may be willing to pay for it.

On its website, the British Medical Acupuncture Society states that acupuncture is used to treat a wide variety of conditions, including pain, particularly musculoskeletal, arthritic and rheumatic pain.

It is also used to treat headaches, migraines, trapped nerves, functional bowel (IBS) and bladder problems (urgency), and menstrual and menopausal symptoms. It is used in palliative care to treat hot flushes, psychological distress, dyspnoea, nausea, vomiting and sleep disturbance.3

Acupuncture in the NHS

The use of acupuncture in the NHS is limited and most patients pay for private treatment. The cost varies widely – initial sessions can cost between £35 and £60, and further sessions between £25 and £50.

The cost of providing one-to-one acupuncture in NHS settings varies; some quote as high as £200 per NHS outpatient appointment. A recent innovation is nurse-led group acupuncture clinics in primary care settings for patients with osteoarthritic knee pain and tension-type headache.4

Training in acupuncture

Many doctors undertake their training with the British Medical Acupuncture Society, which has a foundation course comprising four days of training. Doctors are already trained to assess and diagnose patients; the course teaches safe acupuncture techniques.

After satisfactorily completing some supervised assessments on the foundation course, doctors need to submit a British Medical Acupuncture Society logbook for 30 of their acupuncture cases.

Two cases need to be written up in detail, with a discussion of why acupuncture was chosen as the therapeutic option and a rationale for the selected acupuncture points.

The doctor also needs to have practised acupuncture for at least three months before obtaining the certificate of basic competence in medical acupuncture.

Some doctors go on to study for a diploma or MSc in western medical acupuncture.

Conclusion

While most of my patients have accessed acupuncture privately, some obtain treatment from their NHS GPs, physiotherapists, pain clinic specialists and midwives.

I have also become interested in the potential use of acupuncture in palliative care (see resources).

  • Dr Naidoo is a GP trainer in Oxford

References

1. Vickers AJ, Cronin AM, Maschino AC et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012; 172(19): 1444-53.

2. Hopton AK, Curnoe S, Kanaan M et al. Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open 2012; 2: e000456.

3. British Medical Acupuncture Society

4. White A, Richardson M, Richmond P et al. Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service. Acupuncture in Medicine 2012; 30; 170-5.

Resources

Cancer Research UK. Acupuncture

University of Maryland Medical Centre. Podcasts. Medically Speaking ... Acupuncture for cancer patients

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