Am Fam Physician. 1998 May 15;57(10):2545-2546.
The National Institutes of Health (NIH) has issued a consensus development statement on acupuncture. The two and one-half day conference that culminated in the consensus statement was organized by the NIH Office of Alternative Medicine and the NIH Office of Medical Applications of Research. Panelists at the conference included experts from the fields of acupuncture, pain, psychology and psychiatry, physical medicine and rehabilitation, drug abuse, family practice, internal medicine, physiology and biophysics, health policy, epidemiology and statistics.
The consensus statement discusses the efficacy of acupuncture, the role of acupuncture in the treatment of various conditions, the biologic effects of acupuncture, the issues that need to be addressed so that acupuncture is appropriately incorporated into the health care system and the directions for future research. The following is a summary of these key areas.
Efficacy of Acupuncture
According to the consensus statement, the quality of a number of studies is sufficient for assessing the efficacy of acupuncture for certain conditions. However, the report also notes that high-quality research in which acupuncture is compared with placebo or sham acupuncture is scant. Most of the published research is on needle acupuncture (needle or electroacupuncture) and does not encompass the full spectrum of acupuncture techniques and practices. The assessment of efficacy by the consensus panel focused on high-quality clinical trials that compared acupuncture with sham acupuncture or placebo.
The report notes that clinical experience suggests that the majority of patients have a beneficial response to acupuncture. Clinical outcomes research, however, suggests that a larger proportion of patients may not respond.
Much of the research on acupuncture has been directed to its use for pain. According to the consensus statement, the evidence clearly shows that needle acupuncture is efficacious for providing relief from postoperative pain, chemotherapy-induced nausea and vomiting and, probably, nausea of pregnancy. Studies suggest that acupuncture may control the pain of menstrual cramps, tennis elbow and fibromyalgia. Some studies, however, have not found acupuncture to be efficacious for pain relief.
The panelists concluded that the evidence does not indicate that acupuncture is effective for smoking cessation, and it may not be effective for other conditions as well. Although the use of acupuncture for a variety of conditions has been reported in the literature and research points to “exciting potential areas,” neither the quality nor the quantity of the research is sufficient enough to yield firm evidence for efficacy.
The report includes comments on the use of sham acupuncture, noting that there is disagreement concerning correct needle placement and that sham acupuncture seems to have intermediate effects between placebo and real acupuncture points. Because placement of a needle in any position elicits a biologic response, interpreting the results of sham studies is complicated. For this reason, controversy exists over the use of sham acupuncture as a control measure in clinical studies.
Role of Acupuncture in Various Conditions
The consensus statement notes that the World Health Organization cites more than 40 conditions for which acupuncture may be indicated. The report states that data to support the use of acupuncture for some conditions are as strong as data for many accepted Western therapies. This point is made in the context of the commonly held belief that substantial research supports the use of many conventional therapies, when in fact this is frequently not the case. The lack of evidence, however, does not necessarily signify that a treatment is ineffective.
An advantage of acupuncture is that the incidence of adverse effects is substantially lower than that associated with the use of many drugs or other accepted interventions. The report states that acupuncture may be a reasonable option for a number of conditions, including postoperative pain, myofascial pain and low back pain. Less convincing evidence has been found for addiction, stroke rehabilitation, carpal tunnel syndrome, osteoarthritis and headache, although the report states that there are positive clinical reports for the use of acupuncture in these conditions as well.
Biologic Effects of Acupuncture
The consensus statement reports that considerable evidence shows that opioid peptides are released during acupuncture, which may partially explain the analgesic effects of acupuncture. Acupuncture stimulation may also activate the hypothalamus and pituitary glands. Studies have documented that acupuncture is associated with alterations in the secretion of neurotransmitters and neurohormones and changes in blood flow. Evidence also indicates that acupuncture affects immune function.
The consensus statement mentions that some of the biologic effects of acupuncture have been observed in sham acupuncture, which underscores the importance of defining appropriate control groups when assessing the biologic changes in response to acupuncture. In addition, therapeutic outcomes may be influenced by other factors, such as the relationship between the clinician and the patient and the patient's expectations and belief systems.
Incorporating Acupuncture into the Health Care System
The consensus statement emphasizes that training and credentialing of acupuncture practitioners is an important issue for integrating this technique into medical practice, as is coverage by insurance providers. Educational standards have now been established for training acupuncturists, and a national credentialing agency now exists and is recognized by some of the major acupuncture organizations. In addition, a majority of states provide licensure or registration for acupuncture practitioners, but the scope of practice allowed under state requirements varies.
Another important issue is safety. The consensus statement notes that safeguards need to be in place to protect patients. Although the incidence of adverse events is rare, they do occur and some have been life-threatening, such as pneumothorax.
The statement also mentions the importance of improving the communication between physicians and acupuncturists. If a patient is receiving care from a physician and an acupuncturist, both practitioners should be informed.
Directions for Future Research
The consensus statement enumerates a number of areas for future research, such as patterns of use, the efficacy of acupuncture and whether different theoretic bases for acupuncture result in different treatment outcomes. Clinical studies should be rigorous, randomized, controlled trials. In addition, studies that utilize clinical epidemiology and outcomes research would provide information on the efficacy of acupuncture for a variety of conditions. Research should also assess the merits of the different theoretic orientations, such as Chinese versus Japanese versus French systems. Fixed acupuncture points should be investigated, as well as the Eastern medical systems that are the foundation for acupuncture therapy. The report concludes that evidence for the potential value of acupuncture is strong enough to warrant further studies on its physiology and clinical value.
Copyright © 1998 by the American Academy of Family Physicians.
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