Acupuncture: A Clinical Review

Victor S. Sierpina, MD; Moshe A. Frenkel, MD


South Med J. 2005;98(3):330-337. 

In This Article

Practical Implications for Referrals and Follow-Up

In many contemporary acupuncture practices, the most common indication is for chronic pain unresponsive to standard therapy. By and large, physicians will exhaust their range of options for chronic pain management with standard treatments including medication, surgery, nerve blocks, physical therapy, psychologic therapy, pain clinics, or other specialty referrals. Because evidence for the effectiveness of acupuncture in pain management is inconclusive by the standards of best evidence as adopted by the NIH Consensus Panel and others using a purely evidence-based medicine standard, the referring physician often sees it as the last resort for patients. This places the acupuncturist at the unenviable end of a long chain of evaluations, consultations, treatments, and procedures before the patient is finally referred for acupuncture. It also creates an adverse selection bias, leaving acupuncture as an option only for those patients who fail to respond to all other methods, and sometimes creates unrealistic expectations for patients.

A more rational approach would be to recognize the potential role of acupuncture earlier in the treatment of potentially disabling and chronic illnesses. An example would be its use earlier in the treatment of low back pain, perhaps at the critical juncture of between 6 and 8 weeks, when acute back pain often starts to convert to chronic back pain. Starting earlier in the chain of treatment may reduce the cost of expensive evaluations, can lower the burden of patient suffering, and might improve back-to-work statistics. More extensive outcome studies are needed in evaluating the role of acupuncture in low back pain before it can be recommended as the standard of care, though certain patients may clearly benefit.

Because of the popularity of complementary and alternative medicine (CAM)-with estimates of popular use in the US adult population exceeding 40%,[20]-physicians ought to expect to receive questions from patients regarding the integration of acupuncture in their health care. On the other hand, the physician can be proactive in searching for other care options when conventional treatments are ineffective or there is a high probability of risk or complications from conventional therapies, for example, possible gastrointestinal side effects from nonsteroidal anti-inflammatory drugs for the chronic pain patient. Given patients' demands and utilization of CAM therapies, despite the lack of strong evidence, there is an increasing need to address how CAM therapies can be integrated into conventional medical systems.[21]

As a first step in integrating acupuncture into medical care and the referral process, physicians must learn the most common indications (see Table 1 , Table 2 , and Table 3 ) or search MEDLINE or other online sources for information ([22] In this search, the physician can look for available studies on safety and efficacy. After assessing the risk compared with the benefit, one can consider the referral. A mutual discussion with patient and family is necessary, along with documentation of such a conversation.

After referring the patient, one has the continuing responsibility of monitoring the patient for benefit, adverse reactions, or failure to respond. If the patient does not respond to treatment in 4 to 10 treatment sessions, he or she should be advised to consider changing to another therapeutic approach (see Figure).

Although busy physicians may not take such a systematic approach, the fact is that most practices have a relatively narrow band of indications for acupuncture, for example, chronic musculoskeletal pain, back pain, or headache, which can be mastered rather quickly.

Whenever the conventional standard of care is not effective, acceptable to the patient, or has intolerable side effects, acupuncture may be considered as one option in an integrative care plan. Although not a panacea, it is often an option physicians consider seldom or too late.