Introduction of Acupuncture in Medical Practice Hong Wu, M.D. Associate Professor Departments of Physical Medicine and Rehabilitation & Anesthesiology.

Introduction of Acupuncture in Medical

PracticeHong Wu, M.D.

Associate ProfessorDepartments of Physical Medicine and

Rehabilitation & AnesthesiologyMedical College of Wisconsin

[email protected]

Medical College of Wisconsin

Presenter Disclosure

Hong Wu, M.D, M.S

– No disclosures to make.

The topics

• Brief Introduction of acupuncture

• History of acupuncture in the USA

• Clinical Indications of acupuncture

• Clinical questions related to

acupuncture

• License, insurance coverage, billing…

• The future practice of acupuncture

Acupuncture

• Acupuncture is a type of traditional medicine in China while it is considered an alternative and complementary medicine in the USA

• It has been practiced in China for more than 2000 years

Acupuncture

• Acupuncture is an ancient Chinese method that involves placing fine needles at specific points on the body’s surface.

• The belief is that there is a continuous circulation of energy, or life force, “Qi” in the organism.

• Blockage in the flow of Qi cause “imbalance” that may result in disease.

• These imbalance can be corrected by inserting needle into skin at identifiable sites.

What are Acupuncture Points?

– A simple analogy: Acupoints are like wells that connect water from underground waterways to the earth's surface

– Lower skin resistance, higher conductivity

– Comprised of connective tissue, interwoven with the blood vessels, nerves, lymph-system

– The approximate size of an acupoint is 450 microns for humans

Y Lo, Acupuncture Today, 2004, 05 (5)

Meridians

Meridians6 paired2 unpaired

Acupoints 365 main points

Extra Points

Traditional Chinese MedicinePrinciples

• Diagnosis is based on 8 Principles of Disease– Yin & Yang– Interior & Exterior– Cold & Hot– Deficiency & Excess

Traditional Chinese medicine describes the body’s balance in terms of Yin and Yang.

YIN = Female energy, represents traditional female

qualities of peacefulness and calm.

FluidsWaterDamp

YANG = Male energy, represents traditional male qualities of aggression and stimulation.

FireMovement

Yang syndrome

• Anxious, insomnia, agitated

• Sedate with Yin Points:HT7, PC6, LV3, KI6, SP6

Yin syndrome

• Depressed, tired, lassitude

• Stimulate with Yang points:LI4, LI11, ST36, GV14

Biological Effects of Acupuncture

• Acupuncture can cause multiple biological responses:

– Through sensory neurons to central nervous system, locally or distantly.

• Activation of pathways affecting various physiological systems in the brain as well as in the periphery.

– Activation of the hypothalamus/the pituitary gland → alteration in the neurotransmitters → a broad spectrum of systemic effects.

– The production of endogenous Opioid. • The analgesic effects of acupuncture are at least partially explained

by their actions. • Naloxone can reverse the analgesic effects of acupuncture.

– Alterations in immune functions.

fMRI and visual stimulation

The vision-related acupoints VA1 (BL 67)

VA2 (BL 66)VA3 (BL 65)VA8 (BL 60)

Cho et al 1998, 95 (5)

Proc Natl Acad Sci

fMRI and visual stimulation

The activation maps of the visual cortex resulting from visual stimulation of the eye and acupuncture stimulation at VA1, and non-acupoint stimulation, respectively Cho et al 1998, 95 (5), Proc Natl Acad Sci

Brain and Acupuncture

New approach to old acupuncture. Conceptual relationship of therapeutic acupuncture, functional MRI, and the role of the brain.

Cho et al 1998, 95 (5), Proc Natl Acad Sci

Acupuncture Styles and Techniques

• Traditional Chinese acupuncture

• Japanese Style acupuncture

• American Style

• Moxibustion

• Cupping

Needle Insertion Technique

1. Using a guide tube sterile and disposable needle is gently inserted in an acupuncture point along a meridian.

2. The acupuncture needle is stimulated to obtain “de qi”, so called “Qi” sensation, varies from heaviness, warmth, “dull achiness”, numb or tingling in the area of insertion.

3. Another acupuncture point is carefully palpated before needle insertion.

4. Patient experiences deep relaxation during acupuncture treatment.

Acupuncture Needles

• Needles made of flint, thorns of plants, bamboo slivers or bone in old days

• Very fine and flexible about ½” (0.6cm) to 1 ½” (38cm), around 36G

• Attract or disburse energy along meridians

• FDA approved needles by use of licensed practitioners in 1996. Sterile, non toxic, single use only

Historic Review of Acupuncture in USA

• 1822 – The 1st medical publication about acupuncture in America

• 1971 – “Now, About My Operation in Peking; Now, Let Me Tell You About My Appendectomy in Peking” by New York Times reporter James Reston.

• 1973 – 1st Acupuncture practice law passed in Maryland, Nevada and Oregon

• 1982 – The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) was established to set national standards of competence

• 1988 – The Accreditation Commission for Acupuncture Oriental Medicine (ACAOM) was formed, Masters degree and Masters level acupuncture can be offered.

• 1996 – FDA approved acupuncture needles as Class II medical devices.

• 1997 – NIH Consensus Conference showed “clear evidence” of acupuncture efficacy in various clinical conditions

• 2002 – NIH conducted the largest, most comprehensive survey of complementary and alternative medicine (CAM) – over 8 million adults have used acupuncture, 2.1 million U.S. adults had used acupuncture in the previous year.

NIH Consensus Development Panel (NIHCDP) on Acupuncture

in 1997

– “There is sufficient evidence of acupuncture’ value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value”

– JAMA 280:1518-1524, 1998

NIHCDP

• Clear evidence for acupuncture’s efficacy for treating:– postoperative and chemotherapy-induced

nausea and vomiting– nausea of pregnancy– postoperative dental pain

NIHCDP

– Low-back pain– Carpal tunnel

syndrome– Asthma– Fibromyalgia

– Stroke rehabilitation

– Addiction– Headache– Menstrual

cramps– Epicondylitis

Acupuncture may be helpful in, but not limited to the following:

Acupuncture for Chronic Low Back Pain(CLBP) in Long-Term Follow-Up

A Meta-Analysisof 13 Randomized Controlled Trials

2678 patients from 13 RCT to compare acupuncture with sham acupuncture and other treatments.

• Conclusion: – Acupuncture is Effective in Relieving CLBP Compared to Blank or no

Treatment.– Acupuncture Effects are Produced by Nonspecific Effects Arising from

Skin Manipulation– Acupuncture Should Be Used in Combination with Other Treatments– Acupuncture often obtains a better outcome when treating acute pain

than chronic pain

• The American Journal of Chinese Medicine, 41 (1), 1–19, 2013

Acupuncture for Neck Pain- systematic review and meta-analysis

• Data collected from MEDLINE (PubMed), ALT HEALTH WATCH (EBSCO), CINAHL, and Cochrane Central) were conducted on randomized controlled trials of acupuncture for neck pain.

• 14 studies were included in this review. 7 out of 9 meta-analyses yielded positive results.

• Conclusion: the short-term effectiveness and efficacy of acupuncture in the treatment of neck pain was confirmed. Further studies that address the long-term efficacy of acupuncture for neck pain are warranted.

• J Altern Complement Med. Fu et al. 2009 Feb;15(2):133-45

Acupuncture and Osteoarthritis of the Knee

- A Review of Randomized, Controlled Trials

• The objective of this article is to review the English-language articles, indexed in MEDLINE or CINAHL, describing randomized, controlled trials of the effects of needle or electro-acupuncture on knee osteoarthritis.

• 10 trials representing 1456 participants met the inclusion criteria and were analyzed.

• Conclusion: acupuncture should be considered a viable adjunct or alternative treatment of knee pain and dysfunction associated with OA.

• Fam Community Health. TK Selfe et al. 2008 Jul–Sep; 31(3): 247–254.

Acupuncture and Migraine• Headache (HA) is the leading cause of lost work time in the United States.

– Migraine HA occur in 18% of women and 5% of men. – > 2.1 million U.S. adults report use of all-cause acupuncture in the previous 12 months, and 10 % received acupuncture for migraine – In England, 21.4 % physicians perform acupuncture or refer it to patients . – In Germany, acupuncture is the most commonly used preventive treatment for migraine HA.

• Acupuncture reduces the frequency of migraine HA when used as an adjunct to, or in place of, medical management. (Strength of Recommendation: A, based on meta-analyses).

– A 2009 Cochrane review of acupuncture and prophylaxis for migraine HA analyzed 22 RCTs with 4,419 patients. The trials included comparison to traditional acupuncture vs. sham acupuncture with no prophylactic treatment or standard therapy. At 4 months, traditional acupuncture reduced migraine HA frequency compared with drug treatment (standard mean difference [SMD] = –0.26; 95% confidence interval [CI], –0.41 to –0.11), and compared with no treatment (SMD = –0.43; 95% CI, –0.60 to –0.27).

– Conclusion: traditional acupuncture is as effective as traditional migraine HA prophylaxis, but not statistically more effective than sham acupuncture (SMD = –0.18; 95% CI, –0.44 to 0.07).

Am Fam Physician. 2010 Apr 15;81(8):1036-1037

Acupuncture for Chronic Pain Individual Patient Data Meta-analysis

• One of the largest, most rigorous and robust analyses to date on the effectiveness of acupuncture treatments for the amelioration of pain.

• 29 RCT studies, included nearly 18,000 people being treated for chronic pain from OA, HA, back, or shoulder pain. In the study, true acupuncture treatments was compared to one of the two alternatives: treatment as usual or sham acupuncture.

• Conclusion: – 1. the specific effect of needling at true acupuncture points was statistically superior

to sham needling– 2. acupuncture was an effective and reasonable treatment option for the conditions

evaluated.

Vickers et al, Arch Intern Med. Sept., 2012

Acupuncture in Post-Stroke Rehabilitation

• A Systematic Review and Meta-Analysis of Randomized Trials .

• 7 English and 2 Chinese databases up to Sept. 2009 were included. 35 articles in Chinese and 21 articles in English were included.

• The overall quality of the studies was “fair” and most studies were small (median n=86; range, 16 to 241).

• 80% of the studies reported a significant benefit from acupuncture; however, there was some evidence of publication bias. 38 trials were available for meta-analysis and metaregression. OR in favor of acupuncture compared with controls (OR=4.33, 95% CI: 3.09 to 6.08; I2=72.4%).

•

• Stroke 2010:41:e171-e179

Acupuncture, Needles of the Future? Ashley Boyes from Arizona, stroke pt, treated at Tianjin, China

Gained some improvements in speech and motor after 3 sessions of treatment 20,000 pts go to Tianjin Hospital for acupuncture treatment each year

By Brenda Duran, writer and senior associate editor for Acupuncture Today 2013

Effect of Acupuncture on Cancer

• Effect of acupuncture on immune function– At least seven human studies have evaluated the effect of

acupuncture on immune system function in patients with cancer (acupuncture may enhanced or regulated immune function).

• Effect of acupuncture on cancer related pain

• Effect of acupuncture on nausea/vomiting related to cancer or cancer treatment

• Effect of acupuncture on other cancer related or treatment related symptoms– Xerostomia– Edema– Hot flashes– Fatigue– Depression– More

National Cancer Institute, www.nci.org

Adverse Effects of Acupuncture

• The sense of relaxation, sometimes feeling of fatigue.

• Light-headedness, anxiety, agitation.

• Syncope, puncture of an organ, infection, a retained needle.

• Pneumothorax, Pneumoperitoneum, hemothorax, cardiac tamponade, penetration of the kidney/bladder/spinal medulla.

• Soreness at the site of needle entry.

• Contact dermatitis, local inflammation, bacterial abscesses, chondritis (ear).

Contraindication/Precaution of Acupuncture

• Pregnancy (early and late phase)

• Bleeding diathesis

• Anticoagulation therapy

• Rheumatic/valvular heart disease

• Lymphedema

• Refusal

Acupuncture Practice in USA

• In USA, acupuncture is performed by both physician and non-physician practitioners.

• Currently 23 states require full NCCAOM certification. 43 states plus the District of Columbia require the passage of the NCCAOM examinations or NCCAOM certification as a prerequisite for licensure.

• State rules and regulations – Each state regulatory board carries unique requirements for licensure.

You should always confirm current requirements for licensure with your state board.

• www.nccaom.org/regulatory-affairs/state-licensure-map

Acupuncture use in America

• Acupuncture use has doubled in the past 10 years and continues to grow

• An estimated 20 million Americans have tried acupuncture

• Over 4.5 billion dollars is spent on Asian Medicine each year and continue growing

• Over 3 billion dollars is spent on acupuncture each year and growing

Acupuncture Today January, 2003, Vol. 04, Issue 01

Acupuncture in America Today

Number of Acupuncture Licenses in America

0

5000

10000

15000

20000

25000

1992 1993 1994 1996 1998 2000 2004

Acupuncture in AmericaToday

• An estimated 3.1 million U.S. adults and 150,000 children received acupuncture as a form of medical treatment.

• The 2007 National Health Interview Survey

CPT Codes of Acupuncture

• 97810 Acupuncture w/o e-stim, initial 15 min

• 97811 Acupuncture w/o e-stim, each add’l 15 min

• 97813 Acupuncture w/ e-stim, initial 15 min

• 97814 Acupuncture w/e-stim, each add’l 15 min

Insurance Coverage

• Varied

• Limited coverage– Medical necessity– Practitioner– Diagnosis/ICD codes

• Growing coverage– Increased Diagnoses Codes For Acupuncture Benefits.

Acupuncture Today Dec 2012, 13 (12)

I feel good!

Acupuncture in AmericaTomorrow

The following areas are shaping the future of Acupuncture

• Legislation – Attaining Acupuncture Licensure in all 50 states

• Insurance – Passing the Federal Acupuncture Coverage As compared to impairment of the whole person and greater inclusion in managed care and insurance plans

Acupuncture in AmericaTomorrow

Research & Education

• As of March 2013, in www.clinicaltrials.gov, over 447 trials on acupuncture research funded by NIH and other agencies have been conducted since 2000

• NIH Funding for biomedical research in the field of integrative medicine has increased dramatically over the past several years from $2 million to $121 million from 1992 to 2005

• Educational programs/clinical services in Integrative Medicine are being provided at many medical schools or hospitals such as UCLA, Harvard Medical School, Johns Hopkins, Duke University, University of Maryland, Georgetown University, University of Texas M.D. Anderson Cancer Center and others.

• 60 schools are accredited by ACAOM to provide AOM programs.

• NCCAM is the only national organization that validates entry-level competency in the practice of acupuncture and Oriental medicine (AOM) through professional certification

Acupuncture in AmericaTomorrow and Beyond

• Acupuncture in America will continue to grow and thrive

• Once the public and medical communities learn and understand more, a real integration and collaboration can take place between East medicine and Western medicine

Conclusion

• Acupuncture represents part of an ancient system of comprehensive health care

• As scientific knowledge expands, modern correlations are being developed which help translate this ancient wisdom into today's terms

• May the Qi be with you!!!

References• www.who.int/mediacentre/factsheets

• www.medicalacupuncture.org

• nccam.nih.gov/health/acupuncture

• www.clinicaltrials.gov

www.osher.ucsf.edu/About/IntegrativeMedicine

www. acupuncturetoday.com

• www. aaaomonline.org

• www.nccaom.org

• www. acaom.org

• www. nationalacupuncturefoundation.org

• www. Acupuncture.com

• National Center for Complementary and Alternative Medicine

• Acupuncture and Oriental Medicine States Laws and Regulations, 2005 Edition

• www.gancao.net/acupuncture/review-of-acupuncture-insurance-coverage-in-the-usa-5521

Thank You !