Acupuncture: A Clinical Review

Scientific Evidence for Clinical Application

Given the popularity and wide usage of acupuncture, patients self-refer to acupuncturists for a variety of indications. Trained physicians need to become familiar with when and how they might refer their patients to an acupuncturist. To inform clinicians and researchers, the National Institutes of Health (NIH) convened a consensus panel to review the available literature about acupuncture.^[15] They wished to assess not only clinical efficacy and effectiveness but also biological effects, implications on the healthcare system, and the need for further research. Because much acupuncture research has been done by enthusiastic practitioners rather than trained researchers, the quality of many studies was poor. Because of this, the NIH Consensus Panel concluded that acupuncture was proven to be evidence-based for only two indications: dental pain and nausea (postsurgical, chemotherapy induced, or nausea related to pregnancy). Their panel concluded that it was time to take acupuncture seriously and that their systematic review of the literature indicated that it might also be useful for a longer list of indications (see Table 1. ), but that better-designed studies were needed to confirm its utility in these areas. These include investigations of the basic science of acupuncture and appropriate sham needle approaches for the placebo arm.^[16]

Further acupuncture research trials have been funded by the NIH/National Center for Complementary and Alternative Medicine (NCCAM) and other agencies. Examples of recent NCCAM-supported projects include:

Studying the safety and effectiveness of acupuncture treatment for osteoarthritis of the knee
Investigating whether electroacupuncture works for chronic pain and inflammation
Finding out how acupuncture affects the nervous system by using magnetic resonance imaging technology
Looking at the effectiveness of acupuncture for treating high blood pressure
Studying the effects of acupuncture on the symptoms of advanced colorectal cancer
Testing the safety and effectiveness^[17] of acupuncture

Other organizations have also addressed the potential benefits of acupuncture. Their recommendations are derived by consensus panels as well as current standards of practice and common clinical applications rather than through rigorous, evidence-based review of the literature. The World Health Organization has identified more than 40 medical conditions effectively treated with acupuncture ( Table 2. ).^[18] The American Academy of Medical Acupuncture has suggested a listing for use by hospital credentialing committees in which the matter of medical acupuncture privileges are considered ( Table 3. ).^[19] Although there is some overlap in these categories, they are by no means identical. It is curious that the NIH consensus panel findings on the efficacy of acupuncture for nausea and vomiting do not appear explicitly in the other lists, emphasizing the rather subjective and consensus nature of these tables of indications.

Overall, in the United States, acute and chronic musculoskeletal indications for acupuncture treatments have found greatest acceptance. Although traditional usage and consensus recommendations encompass many conditions, a number of limitations must be noted. Limited benefit can be expected when using acupuncture for spinal cord injuries, cerebrovascular accidents, neurodegenerative diseases, thalamically mediated pain, severe and chronic inflammatory and immune-mediated disorders, especially those having progressed to requiring corticosteroid usage, or as a primary treatment for human immunodeficiency virus infection, malignancy, or chronic fatigue states.^[10] It may, however, serve an important adjunctive role in several of these conditions by improving quality of life, reducing pain, and potentially improving immune status. Acupuncture treatment may be useful in difficult conditions such as asthenic states (tired all the time, low energy), autonomic dysregulation disorders (anxiety, sleep disturbance, bowel dysfunction), and immune dysregulation disorders (recurrent infections and inflammations).^[10]