INTRODUCTION OF

ACUPUNCTURE IN MEDICAL
PRACTICE

Lecture by: M.K. Sastry

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: Acu-points 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 acu-point is 450 microns for

humans
 Meridians

 Meridians
 6 paired
 2 unpaired

 Acupoints
 365 main
points

 Extra Points
 Traditional Chinese Medicine
Principles

 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.
Fluids
Water
Damp

YANG = Male energy, represents traditional male

qualities of aggression and stimulation.
Fire
Movement
 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)
 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
 Brain and Acupuncture

New approach to old acupuncture. Conceptual relationship of

therapeutic acupuncture, functional MRI, and the role of the
brain.
 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
 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”
 NIHCDP

 Clear evidence for

acupuncture’s efficacy for
treating:
• postoperative and
chemotherapy-induced nausea
and vomiting
• nausea of pregnancy
• postoperative dental pain
 NIHCDP
Acupuncture may be helpful in, but not limited
to the following:
• Low-back pain • Menstrual cramps
• Carpal tunnel syndrome • Epicondylitis
• Asthma
• Fibromyalgia
• Stroke rehabilitation
• Addiction
• Headache
 Acupuncture for Chronic Low Back Pain
(CLBP) in Long-Term Follow-Up

A Meta-Analysis of 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
 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.
 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.
 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 and Migraine
 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).
 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.
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%).
 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
 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
 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.
 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 in America Today

25000
Number of Acupuncture Licenses in America

20000

15000

10000

5000

0
1992 1993 1994 1996 1998 2000 2004
 Acupuncture in America Today

 An estimated 3.1 million U.S. adults and 150,000 children

received acupuncture as a form of medical treatment.
 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.
I feel good!
 Acupuncture in America
Tomorrow
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 America
Tomorrow 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!!!

Thank You