Acupuncture: filling the effectiveness gaps in Western medicine?

ACUPUNCTURE IN DIFFERENT HEALTH SYSTEMS

The use of acupuncture in clinical medicine can be traced back to ancient China where, as an integral part of the healthcare system, acupuncture was used to treat a variety of conditions within the context of traditional Chinese medicine (TCM). Since the 6th century, the medical use of acupuncture has become more widespread in Asia and nowadays acupuncture is used widely throughout the world.

Among the various alternative and complementary therapies, acupuncture is perhaps one of the most popular therapies, especially in its role to fill the ‘effectiveness gaps’ of medical care provided by conventional Western medicine.1 These ‘effectiveness gaps’ include conditions for which conventional medicine often fails to achieve satisfying outcomes for patients, and include chronic back pain, neck pain, headache, and other medically unexplained symptoms. As these conditions are often managed in primary care, it is not surprising to find that acupuncture is one of the most popular complementary and alternative therapies used by primary care providers. In the UK, it has been estimated that each week, about one in 10 GPs either refer patients to have acupuncture for their problems or practise it themselves.2

The NHS in the UK currently supports the use of acupuncture for persistent low back pain lasting between 6weeks and 12months in accordance with the 2009 National Institute for Health and Clinical Excellence guideline.3 Similarly, in the US, a large national cross-sectional survey4 has shown that about one in four acupuncture users are referred to acupuncture by a conventional medical professional, and there is a growing professional interest in the use of acupuncture among family doctors, physiotherapists, and other primary care providers. Besides the UK and the US, a similar popularity in the use of acupuncture is also found in many other countries. In Australia, a recent large representative survey showed that one in four adult Australians have used acupuncture in the previous 12 months.5 In Japan, it has been similarly shown that one in four Japanese adults have used acupuncture in their lifetime.6 In these developed countries, acupuncture is used mainly to fill the ‘effectiveness gaps’ left by conventional medicine. However, in many other east Asian countries, acupuncture is an integral part of the healthcare environment where the practice is closely related to the local culture and history. For example, in China, the practice of acupuncture is more individualised and is used according to the ‘syndrome type’ of the individual patient that is classified by the TCM doctor. Instead of treating pain, acupuncture is most popular among patients with neurological conditions in China, for example, a study conducted at outpatient clinics showing that Bell’s palsy and cerebrovascular accident rehabilitation were the most prevalent conditions treated.7

Besides pain, other conditions commonly treated by acupuncture in China include strabismus, tinnitus, cervical spondylosis, and diabetes. In Korea, where the development of medicine has been influenced by TCM, acupuncture is also used in more diverse healthcare settings,8 although the Koreans have developed their own unique types of acupuncture methods apart from those used in TCM. Acupuncture is also used in resource-poor countries. For example, in rural northern Thailand, acupuncture has been used as a low-cost intervention to provide symptom relief and to improve quality of life for patients with HIV who suffer from side effects of antiretroviral therapy and symptoms associated with chronic HIV infection.9

ACUPUNCTURE AND CLINICAL EVIDENCE

Despite the growing enthusiasm for the use of acupuncture in various healthcare systems, evidence for its clinical effectiveness has been controversial, probably due to the difficulty in finding the best study design to evaluate its efficacy or effectiveness. However, recent reviews have suggested that there is good evidence to use acupuncture for a number of pain-related conditions including low back pain, knee osteoarthritis, chronic neck pain, and headache.10

In this issue of the BJGP, the pragmatic randomised controlled trial (RCT) conducted by Paterson et al11 offers more evidence for the effectiveness of acupuncture in dealing with difficult-to-treat conditions and medically unexplained symptoms that are related to high healthcare service use and often managed by primary care doctors. In their trial, Paterson et al showed that the addition of up to 12 five-element acupuncture consultations to usual care was associated with improved wellbeing and individualised health status, with high acceptability among these patients. To increase the understanding of how patients perceive and experience their use of acupuncture, an additional qualitative study12 was nested within the RCT and provides further information on patients’ views and perceptions on acupuncture, as well as documenting the psychological and social changes experienced by patients following its use.

Similar pragmatic RCTs that evaluate the effectiveness of acupuncture in treating other common ‘difficult to treat’ conditions in primary care should be encouraged, as although there is good evidence of the efficacy of using acupuncture in improving pain-related clinical conditions, the evidence for the use of acupuncture in other common conditions, such as medically unexplained symptoms, is weaker. Despite its popularity, recent meta-analyses from the Cochrane Collaboration have found that there was insufficient evidence to recommend acupuncture for a number of common conditions in primary care including depression.13,14 In these areas, the authors of the Cochrane article suggested that more trials of higher quality are needed.

Another strength of the reported trial is the inclusion of the nested qualitative study in its design.12 This component of the study is important because knowing the ‘why’ and ‘how’ patients benefit from acupuncture can help healthcare providers identify the types of patients who may find acupuncture most acceptable. Moreover, understanding patients’ experiences of acupuncture can shed light on potential psychosocial factors that can contribute to the effectiveness of acupuncture.

Few studies have evaluated the cost effectiveness of acupuncture.15 This area of research is particularly important because, as with the aging population and an increasing prevalence of chronic conditions, most health systems are seeking ways to provide more cost-effective healthcare services. Thus, findings from cost-effectiveness studies can provide healthcare policy makers with information that can help them to make better decisions about which interventions should be supported in an environment with limited resources. This is especially important if alternative or complementary therapies are to be integrated into mainstream medical care.