News & Articles

Volume XII, Number 1: Winter 2005
Acupuncture Found To Be of Benefit in Knee Osteoarthritis

On December 21, 2004, the Annals of Internal Medicine published the results of an NCCAM-funded study of acupuncture for osteoarthritis of the knee. The study team was led by Brian M. Berman, M.D., Director of the Center for Integrative Medicine and Professor of Family Medicine at the University of Maryland School of Medicine in Baltimore.

Acupuncture is one of the oldest, most commonly used medical procedures, having originated in China more than 2,000 years ago. The term acupuncture describes a family of procedures involving stimulation of anatomical points on the body by a variety of techniques. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

The randomized clinical trial at the University of Maryland followed 570 participants for 6 months, making it the longest and largest study of acupuncture to date. In the study, 190 of the participants received acupuncture treatment and 191 received a "sham" acupuncture procedure that the team had developed and tested in earlier research. A third group (189) attended an educational program developed by the Arthritis Foundation. All participants could continue to use some conventional care for osteoarthritis, such as certain anti-inflammatory medicines, if they so chose.

By week 8, the acupuncture group had better function than either the sham or the education group. By the 14th week, the acupuncture group also reported significantly less pain than the two other groups.

CAM at the NIH spoke to Dr. Berman about this study.

NCCAM: Why did you choose to study acupuncture for knee osteoarthritis?

Dr. Berman: Arthritis costs about $86 billion each year in direct and indirect costs in the United States. Osteoarthritis is the most common form of arthritis, affecting 20 million Americans a year. The knee is a common site. Osteoarthritis is also a problem for which we don't have all the answers in conventional medicine. And the available drugs have side effects, particularly in the elderly. We wanted to see if acupuncture could make a difference.

NCCAM: How do your findings add to our knowledge about the use of acupuncture for osteoarthritis?

Dr. Berman: In this study, we developed a model of a progression for acupuncture trials [from phase I to phase II and III studies]. Also, the outcomes are important. We found that traditional Chinese acupuncture is effective for reducing pain and improving physical function in patients with symptomatic knee osteoarthritis who were having moderate pain despite conventional medical therapy. The patients receiving true acupuncture had a 40 percent decrease in pain from baseline and a 40 percent increase in function--which was significantly better than those receiving the sham procedure. We also found that the acupuncture was well tolerated. Our conclusion is that acupuncture may have an important role as adjunctive [i.e., added] therapy in a multidisciplinary, integrative approach to patients with osteoarthritis of the knee.

NCCAM: How common is the use of acupuncture for different types of arthritis? Have you seen any trends in its use?

Dr. Berman: Surveys say 2.1 million Americans use acupuncture, accounting for around 5 million visits a year to practitioners, and most visits are for pain and musculoskeletal problems. When we started our center in 1991, acupuncture was very much outside the realm of conventional medicine. Now we're seeing pain clinics, primary care doctors, orthopedic surgeons, and rheumatologists making more referrals for this type of procedure. In an article we published in the journal Pain in 2000, we surveyed pain specialists to see what they thought of different nonpharmacological therapies. Acupuncture had more acceptance than we realized.

There is no cure for arthritis; the goals of the American College of Rheumatology's treatment guidelines are to improve function and to decrease pain. Now acupuncture is one of the methods that can be used for first-line treatment for osteoarthritis along with some of the nondrug treatments. Also, acupuncture doesn't have a lot of side effects.

NCCAM: Do you have any advice for people who may have arthritis and wonder whether acupuncture could help them?

Dr. Berman: I think they ought to talk to their physicians. It's worth giving acupuncture consideration as part of a multidisciplinary approach--not necessarily to forgo other treatments that have been recommended, but as part of a whole approach to osteoarthritis. Also, in acupuncture treatment, it's important to find a good, licensed practitioner.

For an NCCAM fact sheet on acupuncture, go to nccam.nih.gov/health/acupuncture or contact the NCCAM Clearinghouse

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Acupuncture Today

August 2000 Vol 01 Issue 08

BMA Acknowledges the Benefits of Acupuncture
Report Recommends Treatment Be Integrated into National Health Service

By Michael Devitt, Managing Editor

In the past decade, several national and international organizations have issued reports concerning the safety and efficacy of acupuncture. The most well-known of these reports, the National Institutes of Health Consensus Development Statement, concluded in 1997 that "there is sufficient evidence • of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and value."1

Now, the British Medical Association has offered its opinion on the subject. At the BMA's annual conference in London this June, the association published a report, Acupuncture: Efficacy, Safety and Practice,2 which acknowledges the scientific benefits of acupuncture and recommends that the treatment be incorporated into the National Health Service, Britian's national health care program

"(Acupuncture) is clearly something that people are turning to in large numbers," said Dr. Vivienne Nathanson, head of health policy at the BMA. "And it is clearly something that GPs (general practitioners) are turning to in increasing numbers."

The current report is the result of a resolution passed at the BMA's annual representative meeting in 1998, at which a resolution was passed to "investigate the scientific basis and efficacy of acupuncture and the quality of training and standards of competence in its practitioners." The paper also represents the third time in the last 15 years that the BMA has published a major report on complementary and alternative care.

Acupuncture: Efficacy, Safety and Practice contains sections that study the efficacy and safety of acupuncture; the ways in which acupuncturists are taught; and the future development of the profession. The report also summarizes a BMA survey of general practitioners and their feelings toward complementary and alternative care, and issues recommendations as to how the delivery of acupuncture can be improved.

Safety and Efficacy of Acupuncture

The traditional "gold standard" of whether a treatment or procedure is effective is the randomized controlled trial (RCT). After examining several clinical trials of acupuncture for various medical conditions, the report concludes that acupuncture "is more effective than control interventions" for back pain, nausea and vomiting (most convincingly for post-operative symptoms in adults), migraine and dental pain.

Regarding the safety of acupuncture, the report states that most adverse reactions generally fall into three main areas: physical injuries (such as cardiovascular trauma); infections from blood-borne viruses; and other adverse reactions (such as drowsiness or fainting after treatment).

Transmission of infectious agents could be greatly reduced by improving sterilization techniques or using only pre-sterile disposable needles instead of reusable needles.

Education and Training of Acupuncturists

Acupuncture can - and has been - taught and practiced in a variety of ways. In fact, the report concludes that "within agreed parameters," a certain amount of diversity in acupuncture training can be considered "healthy" in meeting the individual needs of students and the different approaches and practices among acupuncture instructors.

With such diversity, the report recommends that "a core curriculum for practitioners" be put in place that includes instruction in anatomy and physiology, research methods, acupuncture techniques, fundamentals of diagnosis, and ethics. These courses should be "of a credible duration" to provide students with the ability to practice acupuncture with an acceptable level of competency.

The report also recommends greater undergraduate training and accredited postgraduate training in acupuncture at medical schools.

"Because patients and doctors are turning to acupuncture in increasing numbers," said Dr. Nathanson, "doctors need more information about its safety, and medical students need better training while at university to give patients advice."

Future Developments in Acupuncture

Although there are no comprehensive acupuncture guidelines for general practitioners or patients, and there are no national regulatory and safety standard in place for acupuncturists in Great Britain, the profession continues to flourish. For acupuncture to continue growing, however, the BMA feels that more collaborative studies should be conducted to study the costs and benefits of treatment.

"There is a need for greater consensus on the part of the government, Department of Health, NHS Executive, the medical profession, and acupuncture organizations to provide guidelines and agree how acupuncture and other complementary and alternative medicine services can be integrated into the UK healthcare system," the report stated.

"We need to see more high-quality research into the effectiveness of acupuncture," added Dr. Nathanson. "We welcome complementary medicines into medical practice, but only based on robust research and robust training."

Recommendations

The report lists several recommendations for the integration, regulation and funding of acupuncture. Among the most noteworthy:

Consideration should be given to the creation of policies and guidelines that would make acupuncture more widely available to patients under the National Health Service.
A general list of all acupuncturists, medically and non-medically qualified, should be produced and maintained to facilitate the referral process for NHS doctors.
Further research should be conducted into the cost-effectiveness of acupuncture treatment, particularly for those conditions in which acupuncture has been identified as an effective form of care. Research should also be conducted into other conditions that may be usefully treated by acupuncture.
Acupuncture organizations should collaborate in creating a national system for the reporting of adverse events.
Relationships between acupuncturists, general practitioners and patients must be strengthened. An atmosphere of mutual respect should be promoted between GPs and their patients regarding the use of acupuncture. Doctors should ask about their patients' use of acupuncture and other alternative forms of care; acupuncturists, in turn, should recommend that their patients inform their GPs of their treatment.
Acupuncture should be included in any familiarization course on complementary and alternative medicine. Accredited postgraduate courses should be provided to inform doctors and other clinicians about acupuncture and its possible benefits.
All acupuncturists should be fully trained in infection control procedures, and immunization against hepatitis B should be considered for the protection of acupuncturists and their patients.

BMA Survey of Acupuncture in Primary Care

In addition to its review of acupuncture and recommendations, Acupuncture: Efficacy, Safety and Practice summarizes a survey of general practitioners in the United Kingdom to assess their use of (and attitudes toward) complementary and alternative medicine. A total of 365 GPs completed the survey, which was sent to every general practitioner in the country.

Of those who responded to the survey, more than half (58%) had arranged complementary or alternative therapies for their patients. Almost half of those surveyed reported arranging acupuncture treatment for their patients.

Acupuncture was also the most common form of alternative care used by general practitioners, and was used most commonly for pain relief and treating musculoskeletal disorders. It was most often performed in pain clinics or physiotherapy departments.

GPs' overall knowledge of acupuncture was found to be low. Only 16% said they had "considerable knowledge" of acupuncture or "knew a lot" about the subject; 82% said they had "very little" or only "basic" knowledge of complementary and alternative medicine. However, nearly half (46%) said they would like to receive further training in acupuncture in order to treat their own patients in the future.

In one of the most surprising statistics, a full 79% of practitioners reported that they would like to see acupuncture provided in the National Health Service. For this to happen, however, the survey concluded - as did the full report - that more rigorous clinical trials would need to be conducted.

Report Available Online

Acupuncture: Efficacy, Safety and Practice is available from the British Medical Association for £12.99 plus shipping and handling (note: at press time, £12.99 was roughly equal to $19.59 US). Practitioners interested in ordering a copy may visit the BMA's website (www.bma.org.uk), or they send an e-mail to the BMA's online bookstore (orders@bmjbookshop.com).

References

National Institutes of Health Consensus Panel. Acupuncture. National Institutes of Health Consensus Development Statement. Bethesda, MD: November 3-5, 1997. Available online at
http://odp.od.nih.gov/consensus/cons/107/107_statement.htm
British Medical Association Board of Science and Education. Acupuncture: Efficacy, Safety and Practice. London: Harwood Academic, 2000.

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American Cancer Society
Acupuncture Curbs Urge to Light Up
Article date: 2002/01/24

For those who want to quit smoking, acupuncture directed to selected points in the body may help curb the desire to smoke, according to a report in the journal Preventive Medicine (Vol. 33: 364-372).

Acupuncture is a technique in which very thin needles of varying lengths are inserted through the skin to treat a variety of conditions. Acupuncture originated 2,000 to 3,000 years ago and is an important component of current traditional Chinese medicine.
In this study, 46 participants were followed for five years. Twenty-six people were given acupuncture treatment at points selected to affect smoking-related organs such as the lungs, airways, and mouth. The 20 participants in the control group (used for comparison) received acupuncture at points that were related to skeletal and muscular systems assumed not to have any effect on smoking.

The participants in the test group who were given the strategically placed treatment reported smoking less and had a decreased desire to smoke. In addition, the blood levels for smoking-related chemicals were lower for this group than in the control group up to eight months after treatment.

The control group received no lasting effect from the treatment they were given in terms of reducing their smoking or desire to smoke.

Blood Tests Keep Them Honest
Researchers asked the participants how many cigarettes they smoked. In addition, they measured participants' blood for the concentration of two chemicals: cotinine and thiocyanate, said lead author He Dong, MSc, physiologist and acupuncturist at the Institute of General Practice and Community Medicine at the University of Oslo, Norway.

"The cotinine concentration reflects the smoking during the last few days," said He. "The thiocyanate concentration reflects the smoking during the last two to three weeks before the sample is taken."
"Thus, by measuring both parameters we got an independent measure of the honesty or possible dishonesty in the subjects' reported smoking," said He.

Treatment Led to Reduced Smoking or Quitting
The average length of time the participants had smoked was 23 years, with an average of 10 to 30 cigarettes a day. All participants wanted to quit, and all agreed to use no other form of smoking cessation during the three-week treatment period. Participants were not told which group they were in.
He and her co-authors found that among the participants in the test group about a third of them had cotinine concentration similar to that of non-smokers, both right after treatment and again eight months later. Cotinine levels were not measured at the five-year point.

After five years, four participants in the test group had quit smoking compared with two in the control group.

Adequate Treatment Stressed
For both groups, the acupuncture consisted of body electroacupuncture, ear acupuncture, and ear acupressure. The participants were instructed to perform their own ear acupressure four times a day, according to the article.
The authors wrote that it is important for acupuncture to be adequate. Both groups received treatments twice a week, for three weeks — a total of six treatments, in addition to the self-administered ear acupressure.

"A trained acupuncturist should be able to reproduce the treatment from our description," He said. "We used treatments on acupoints that are known to affect organs directly influenced by tobacco smoke like the mouth, throat, airways, and lungs."

She said the participant ought to be able to feel an effect.
"It is a widespread experience that if the treatment is effective, the patient will note an effect during the first three treatments," said He. "If a patient does not feel any changes after three treatments, he or she should discuss [that] with the acupuncturist."

Five-year Follow-up Was Ambitious
Two components of the study were important: a long follow-up period and the use of periodic blood tests for an objective measure of whether participants were smoking, said noted tobacco control expert, Alan Henderson, DrPH, professor at California State University, Long
Beach and a past president of California's division of the American Cancer Society (ACS).

"All too often, participants in studies inadvertently report compliance to support the study while in some state of non-compliance," said Henderson, who recently was appointed to a committee for tobacco education by California Gov. Gray Davis. "Wherever possible the methods used by [these] authors should be included in cessation studies."

One of the major drawbacks of this study was the fairly small number of participants, and further studies will be needed to confirm these results, Henderson said. But the five-year followup was ambitious, he said.
Still, the long period brings up the question of what other social factors during those five years might have affected the participants. For example, what kind of support or discouragement did these participants get from the people and regulations around them?

Is Cutting Back a Worthy Goal?
This acupuncture study measured not just quitting, but also the reduction of smoking. Henderson said this approach raises the issue of whether reducing smoking is a worthwhile goal rather than focusing only on getting smokers to quit.
"We know … those who smoke more, for longer, have more tobacco-related diseases than those who smoke less, for a shorter period," Henderson said. "And those who don't smoke at all have significantly less disease."

Henderson said that the authors noted that the actual treatment has varied in past studies that included acupuncture. This, he said, points out the need to establish minimum criteria for treatment that has a therapeutic effect.

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