How much acupuncture treatment is adequate?
How much acupuncture treatment is adequate? This is the most frequently asked question from patients. This is a good question, but it is difficult to get accurate answers.
The effect depends on the points chosen by the acupuncturists
If you go to see different acupuncturists, you would probably notice that different acupuncturists do acupuncture differently. Many different styles of acupuncture practice exist. Acupuncture is so individualized and there is no agreement on the optimal acupuncture treatment for any particular condition. Birkeflet O et al did a research about the agreement of acupuncture diagnosis and treatment in 30 infertile and 24 previously pregnant women. These women were examined for traditional Chinese medicine (TCM) patterns by two acupuncturists who would independently decide on the TCM patterns and the prescription of acupuncture points. They found that 39 different TCM patterns and 36 different acupuncture points were used. Poor to no agreement was found for the choice of acupuncture points. On one hand this makes acupuncture unique; on the other hand this makes it difficult to be recognised. Some research trials failed to distinguish the differences between acupuncture treatment and sham controlled treatment because of the generalization of acupuncture and inadequate treatment received. There was review by Errington-Evans N on effect of acupuncture for anxiety. They found that there was enormous variety regarding the points used, number of points used in a session, duration of sessions, frequency of treatment and duration of treatment programme; all of these makes conclusion difficult. White A et al analysed 47 acupuncture trials to evaluate the adequacy of acupuncture treatment which leads to reliable conclusion. They recommend the concept of dose of acupuncture treatment. Different doses may be required for different conditions and adequate dose is established by clinical experiences or basic research studies. They found that out of 47 reviews only 6 met the criteria of adequacy of the acupuncture treatment.
The effect also depends on the individual body’s response to the acupuncture treatment
Why different people have different sensitivity to acupuncture?
Acupuncture is used to treat variety of conditions worldwide. This is a safe intervention and effective treatment for many people, but different people have different sensitivity to acupuncture. Everyone is different, but why is that? Researchers found a scientific explanation for this. Li LM et al in China studied effect of acupuncture stimulation of Zusanli (ST36) on cerebral regional difference in healthy subjects with different acupuncture analgesia sensitivity using MRI techniques. There are 45 healthy subjects with different sensitivity to acupuncture. These people were divided into three groups: insensitive group, normal group and sensitive group. The pressure pain threshold (PPT) of the Zusanli ST 36 region before and after acupuncture stimulation at the point was assessed. And two weeks later after acupuncture stimulation, resting-state fMRI images were obtained using MRI scan to assess the cerebral regional homogeneity (ReHo). They found that there was significant increase in PPT levels in the normal and sensitive groups after acupuncture at ST36 point, while there was no change in insensitive group. In normal group there was a significant increase of ReHo in the regions including left brainstem, the right cerebellum posterior, right parahippocampa gyrus, right fusiform gyrus, left angular gyrus, temperal lobe and the left frontal lobe; and a significant decrease of ReHo in the regions including the occipital lobes and the right superior temperal gyrus after acupuncture at ST36. In sensitive group a marked increase of ReHo was found in the regions includig the left brainstem, bilateral cerebellum posterior lobes, left inferior temporal gyrus, basal ganglia, the left insular lobe, anterior cingutate, frontal lobe, inferior parietal lobule and the right supplementary motor area; decrease ReHo was found in the regions including the bilateral occipital lobes, fusiform gyrus, posterior central gyrus, the right posterior cingutate, the left temporal lobe and the left paracentral lobule. While in the insensitive group, only a significant decrease of ReHo was found in the regions including the left fusiform gyrus, left inferior temporal gyrus, bilateral postcentral gyrus, and left anterior central gyrus. So brain constitution associated needling sensation may be an important factor for acupuncture analgesia effect. Brain react differently in different people which is responsible for different sensitivity to acupuncture.
Acupuncture response is not associated with needle sensations
Needles stimulate nerves at acupuncture points and have been used to treat illness. During the application of needling, people are experiencing different sensations. There was a study that investigated the sensations of the transcutaneous electrical nerve stimulation over acupuncture points (acu-TENS) and the changes of the sensations related to changes in autonomic nervous system activity. There were 36 healthy subjects who were in three groups experimental group which was given acu-TENS on right LI4 and LI11points, control group which was given acu-TENS to bilateral kneecaps, or placebo group (sham acupuncture on right LI4 and LI11 points). There were significantly physiological changes in experimental group and control groups which were given acupuncture at different sites. There was no physiological change in placebo group which was not given active acupuncture. There was significant difference between the groups. There was no association between sensation intensity and physiological responses in any groups. From this study, we can see that even if people experience different sensation during acupuncture, they all have physiological responses to the needling.
Acupuncture dosage comprise two components: the numbers of points selected in a single treatment and total number of the treatments that patients received. It is possible for patients to have beneficial effects from a couple of treatments together with a couple of points selected for stimulation, but this is rather more exceptional than general. The nature and duration of the condition is a very significant determining factor that how many treatments are effective. Acute conditions of short duration in younger patients are most likely to respond to small dosage of acupuncture. On the contrary, chronic conditions of long term duration need larger dosages of acupuncture.
How many sessions of acupuncture are needed for lower back pain?
During the past 40 years, acupuncture, a therapeutic technique of oriental medicine, has become more and more popular, evolving into one of the most utilized forms of complementary integrative medicine interventions in the United States. More than 10 million acupuncture treatments are administered annually in the United States alone. Its rise in popularity, particularly in the West, can be attributed in part to its effectiveness for pain relief and in part to the fact that scientific studies have begun to prove its efficacy.
Non-specific low back pain is the most common application of acupuncture. It is listed in NICE guidelines in the UK. A course of acupuncture needling comprising up to a maximum of 10 sessions may be offered for non specific back pain over a period of up to 12 weeks. In some cases with long history of lower back pain, much more sessions are needed to completely live in pain free life.
What clinical evidences used for NICE guidalines for low back pain treatment with acupuncture?
Five studies were included to support the application of acupuncture: 4 RCTs and 1 systematic review on acupuncture. In these trials patients received 6 x 30min over 6 weeks in one, 20 x 30min over 12 weeks in another, 8 x 30min over 4 weeks in the third trial and 12 x 30min (3 times a week) in the fourth one.
For example, One randomised controlled trial recruited patients through their GPs (a total of 16 GP practices were involved which included 39 GPs) (Thomas, K. J., MacPherson, H., Ratcliffe, J. et al , 2005). Patients included had to be between age 18-65 and had nonspecific low back pain for 4-52 weeks. They also had to have been assessed by their GP to check that primary care management was suitable. A total of 289 patients were identified and approached to join the study, of these 241 accepted and met the criteria. 160 were allocated to receive acupuncture and 81 were allocated to receive usual care, however, 1 patient from each group dropped out, 159 actually received acupuncture (146 were followed up at 3 months, 147 at 12 months and 123 and 24 months) and 80 received usual care (71 were followed up at 3 months, 68 at 12 months and 59 and 24 months). Participants in the acupuncture group received 10 individualised acupuncture treatments over 3 months from one of 6 qualified acupuncturists. The usual care group received 10 NHS treatment sessions according the GPs assessment of the patients clinical need; this was a mixture of interventions, including drugs and recommended back exercises. Half the group also received physiotherapy or manipulation during the first three months. Both groups also received adjunctive care which included massage and advice on diet, rest and exercise. The results showed that acupuncture does give a greater long-term benefit compared to usual care. Acupuncture was significantly more effective in reducing pain at 24 months than usual care. The study also showed that traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain.
Can the effect of acupuncture stay?
People who have acupuncture treatment always like to know that how long the effect of acupuncture stays. A new research has shown that this effect can last very long time. This research used a large individual patient dataset from high quality randomised trials of acupuncture for chronic pain. The available individual patient dataset included 29 trials and 17,922 patients. The chronic pain conditions included musculoskeletal pain (low back, neck and shoulder), osteoarthritis of the knee and headache/migraine. In trials comparing a course of acupuncture to no acupuncture control (wait-list, usual care, etc), the result suggests that about 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. The effects of a course of acupuncture treatment for patients with chronic pain do not appear to decrease importantly over 12 months. Longer term outcomes of acupuncture need further research to measure.
References
White A et al Acupunct Med (2008) 26:111-20
Errington-Evans N CNS Neurosci Ther (2012) 18:277-84
Birkeflet O et al Acupunct Med (2011) 29:51-7
Anderson B and Rosenthal L. Complement Ther Clin Pract (2013) 19:1-5
http://www.nice.org.uk/guidance/cg88/resources/cg88-low-back-pain-full-guideline3
Shi Y et al Evid Based Complement Alternat Med (2015) 2015:210120. doi: 10.1155/2015/210120. Epub 2015 Jun 16.
Guo L et al Biomed Mater Eng 2014 24 1063-9 doi:10.3233/BME-130904
Yu DT et al Acupunct Med 2013 Nov 1.doi10.1136/acupmed-2013-010428
Li LM et al Zhen Ci Yan Jiu (2013) 38:306-13
The effect depends on the points chosen by the acupuncturists
If you go to see different acupuncturists, you would probably notice that different acupuncturists do acupuncture differently. Many different styles of acupuncture practice exist. Acupuncture is so individualized and there is no agreement on the optimal acupuncture treatment for any particular condition. Birkeflet O et al did a research about the agreement of acupuncture diagnosis and treatment in 30 infertile and 24 previously pregnant women. These women were examined for traditional Chinese medicine (TCM) patterns by two acupuncturists who would independently decide on the TCM patterns and the prescription of acupuncture points. They found that 39 different TCM patterns and 36 different acupuncture points were used. Poor to no agreement was found for the choice of acupuncture points. On one hand this makes acupuncture unique; on the other hand this makes it difficult to be recognised. Some research trials failed to distinguish the differences between acupuncture treatment and sham controlled treatment because of the generalization of acupuncture and inadequate treatment received. There was review by Errington-Evans N on effect of acupuncture for anxiety. They found that there was enormous variety regarding the points used, number of points used in a session, duration of sessions, frequency of treatment and duration of treatment programme; all of these makes conclusion difficult. White A et al analysed 47 acupuncture trials to evaluate the adequacy of acupuncture treatment which leads to reliable conclusion. They recommend the concept of dose of acupuncture treatment. Different doses may be required for different conditions and adequate dose is established by clinical experiences or basic research studies. They found that out of 47 reviews only 6 met the criteria of adequacy of the acupuncture treatment.
The effect also depends on the individual body’s response to the acupuncture treatment
Why different people have different sensitivity to acupuncture?
Acupuncture is used to treat variety of conditions worldwide. This is a safe intervention and effective treatment for many people, but different people have different sensitivity to acupuncture. Everyone is different, but why is that? Researchers found a scientific explanation for this. Li LM et al in China studied effect of acupuncture stimulation of Zusanli (ST36) on cerebral regional difference in healthy subjects with different acupuncture analgesia sensitivity using MRI techniques. There are 45 healthy subjects with different sensitivity to acupuncture. These people were divided into three groups: insensitive group, normal group and sensitive group. The pressure pain threshold (PPT) of the Zusanli ST 36 region before and after acupuncture stimulation at the point was assessed. And two weeks later after acupuncture stimulation, resting-state fMRI images were obtained using MRI scan to assess the cerebral regional homogeneity (ReHo). They found that there was significant increase in PPT levels in the normal and sensitive groups after acupuncture at ST36 point, while there was no change in insensitive group. In normal group there was a significant increase of ReHo in the regions including left brainstem, the right cerebellum posterior, right parahippocampa gyrus, right fusiform gyrus, left angular gyrus, temperal lobe and the left frontal lobe; and a significant decrease of ReHo in the regions including the occipital lobes and the right superior temperal gyrus after acupuncture at ST36. In sensitive group a marked increase of ReHo was found in the regions includig the left brainstem, bilateral cerebellum posterior lobes, left inferior temporal gyrus, basal ganglia, the left insular lobe, anterior cingutate, frontal lobe, inferior parietal lobule and the right supplementary motor area; decrease ReHo was found in the regions including the bilateral occipital lobes, fusiform gyrus, posterior central gyrus, the right posterior cingutate, the left temporal lobe and the left paracentral lobule. While in the insensitive group, only a significant decrease of ReHo was found in the regions including the left fusiform gyrus, left inferior temporal gyrus, bilateral postcentral gyrus, and left anterior central gyrus. So brain constitution associated needling sensation may be an important factor for acupuncture analgesia effect. Brain react differently in different people which is responsible for different sensitivity to acupuncture.
Acupuncture response is not associated with needle sensations
Needles stimulate nerves at acupuncture points and have been used to treat illness. During the application of needling, people are experiencing different sensations. There was a study that investigated the sensations of the transcutaneous electrical nerve stimulation over acupuncture points (acu-TENS) and the changes of the sensations related to changes in autonomic nervous system activity. There were 36 healthy subjects who were in three groups experimental group which was given acu-TENS on right LI4 and LI11points, control group which was given acu-TENS to bilateral kneecaps, or placebo group (sham acupuncture on right LI4 and LI11 points). There were significantly physiological changes in experimental group and control groups which were given acupuncture at different sites. There was no physiological change in placebo group which was not given active acupuncture. There was significant difference between the groups. There was no association between sensation intensity and physiological responses in any groups. From this study, we can see that even if people experience different sensation during acupuncture, they all have physiological responses to the needling.
Acupuncture dosage comprise two components: the numbers of points selected in a single treatment and total number of the treatments that patients received. It is possible for patients to have beneficial effects from a couple of treatments together with a couple of points selected for stimulation, but this is rather more exceptional than general. The nature and duration of the condition is a very significant determining factor that how many treatments are effective. Acute conditions of short duration in younger patients are most likely to respond to small dosage of acupuncture. On the contrary, chronic conditions of long term duration need larger dosages of acupuncture.
How many sessions of acupuncture are needed for lower back pain?
During the past 40 years, acupuncture, a therapeutic technique of oriental medicine, has become more and more popular, evolving into one of the most utilized forms of complementary integrative medicine interventions in the United States. More than 10 million acupuncture treatments are administered annually in the United States alone. Its rise in popularity, particularly in the West, can be attributed in part to its effectiveness for pain relief and in part to the fact that scientific studies have begun to prove its efficacy.
Non-specific low back pain is the most common application of acupuncture. It is listed in NICE guidelines in the UK. A course of acupuncture needling comprising up to a maximum of 10 sessions may be offered for non specific back pain over a period of up to 12 weeks. In some cases with long history of lower back pain, much more sessions are needed to completely live in pain free life.
What clinical evidences used for NICE guidalines for low back pain treatment with acupuncture?
Five studies were included to support the application of acupuncture: 4 RCTs and 1 systematic review on acupuncture. In these trials patients received 6 x 30min over 6 weeks in one, 20 x 30min over 12 weeks in another, 8 x 30min over 4 weeks in the third trial and 12 x 30min (3 times a week) in the fourth one.
For example, One randomised controlled trial recruited patients through their GPs (a total of 16 GP practices were involved which included 39 GPs) (Thomas, K. J., MacPherson, H., Ratcliffe, J. et al , 2005). Patients included had to be between age 18-65 and had nonspecific low back pain for 4-52 weeks. They also had to have been assessed by their GP to check that primary care management was suitable. A total of 289 patients were identified and approached to join the study, of these 241 accepted and met the criteria. 160 were allocated to receive acupuncture and 81 were allocated to receive usual care, however, 1 patient from each group dropped out, 159 actually received acupuncture (146 were followed up at 3 months, 147 at 12 months and 123 and 24 months) and 80 received usual care (71 were followed up at 3 months, 68 at 12 months and 59 and 24 months). Participants in the acupuncture group received 10 individualised acupuncture treatments over 3 months from one of 6 qualified acupuncturists. The usual care group received 10 NHS treatment sessions according the GPs assessment of the patients clinical need; this was a mixture of interventions, including drugs and recommended back exercises. Half the group also received physiotherapy or manipulation during the first three months. Both groups also received adjunctive care which included massage and advice on diet, rest and exercise. The results showed that acupuncture does give a greater long-term benefit compared to usual care. Acupuncture was significantly more effective in reducing pain at 24 months than usual care. The study also showed that traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain.
Can the effect of acupuncture stay?
People who have acupuncture treatment always like to know that how long the effect of acupuncture stays. A new research has shown that this effect can last very long time. This research used a large individual patient dataset from high quality randomised trials of acupuncture for chronic pain. The available individual patient dataset included 29 trials and 17,922 patients. The chronic pain conditions included musculoskeletal pain (low back, neck and shoulder), osteoarthritis of the knee and headache/migraine. In trials comparing a course of acupuncture to no acupuncture control (wait-list, usual care, etc), the result suggests that about 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. The effects of a course of acupuncture treatment for patients with chronic pain do not appear to decrease importantly over 12 months. Longer term outcomes of acupuncture need further research to measure.
References
White A et al Acupunct Med (2008) 26:111-20
Errington-Evans N CNS Neurosci Ther (2012) 18:277-84
Birkeflet O et al Acupunct Med (2011) 29:51-7
Anderson B and Rosenthal L. Complement Ther Clin Pract (2013) 19:1-5
http://www.nice.org.uk/guidance/cg88/resources/cg88-low-back-pain-full-guideline3
Shi Y et al Evid Based Complement Alternat Med (2015) 2015:210120. doi: 10.1155/2015/210120. Epub 2015 Jun 16.
Guo L et al Biomed Mater Eng 2014 24 1063-9 doi:10.3233/BME-130904
Yu DT et al Acupunct Med 2013 Nov 1.doi10.1136/acupmed-2013-010428
Li LM et al Zhen Ci Yan Jiu (2013) 38:306-13
