Health: Acupuncture - what's the point?

THE GROWING enthusiasm for complementary medicine has been one of the most striking social trends of the last decade. One person in four is estimated to have tried its treatments, half of all GP practices now offer patients access to complementary therapies, and figures show there are now more therapists than family doctors.

What has been lacking, however, is any independent, authoritative guide to the myriad therapies on offer. Alternative medicine is completely unregulated, patients may be defrauded or put at risk, and there is no way of telling what works from what doesn't.

Today, `The Independent' launches the first such guide by Professor Edzard Ernst, head of the department of complementary medicine at the University of Exeter. As Britain's only professor of complementary medicine, Dr Ernst has earned an international reputation for his systematic studies of alternative therapies, and his work has published widely in many medical journals.

His aim has been to bring the same rigorous standards of scientific analysis to the study of complementary medicine as is already applied to orthodox medicine. Only then, he says, can complementary medicine earn its right to be offered alongside orthodox medicine.

In this eight-week series, his first for any national newspaper or magazine, Professor Ernst seeks to answer basic questions about the most popular therapies, including which conditions they are suitable for, whether they work, and what the risks are. He will summarise the research evidence in each area, and point out the potential dangers as well as the benefits. As a reference guide for anyone using a therapy or thinking of trying a new one, the series will be invaluable.

The first article this week deals with acupuncture, and subsequent therapies to be covered include aromatherapy, healing, herbalism, homoeopathy, massage, spinal manipulation (including chiropractic and osteopathy), and reflexology.

Complementary medicine generates fierce loyalty from its adherents and derision from its critics. Its rising popularity, however, cannot be denied. Consumption of alternative remedies has risen faster in Britain than in any other European country, although it still lags behind that in Germany, France and the Netherlands. Since 1986, when the British Medical Association dismissed it in a report as " a passing fashion" - a most embarrassing gaffe - new adherents have flocked to the cause.

Even the Government's new Chief Medical Officer is a fan. Professor Liam Donaldson, who made his first public appearance yesterday to launch the Government's winter flu campaign, told The Lancet last month that he saw an increasing role for alternative medicine, "because it is what people want and people definitely benefit from it".

Professor Ernst believes that more research is needed, and without it alternative medicine will never win acceptance into the mainstream. He acknowledges, however, that it can provide the medical equivalent of the soothing hand on the brow.

He says: "There is a huge unfulfilled need. People are crying out for it. But we still have a long way to go - we are in the Middle Ages when you compare alternative medicine to mainstream medicine."

What is

Acupuncture?

ACUPUNCTURE ORIGINATED from ancient China, where it was believed that two opposing life forces (Yin and Yang) were circulating in special channels (meridians) throu-ghout the body. Disease, in their view, was characterised by an imbalance of these forces which, in turn, could be rectified by regulating the flow of energy in the meridians. This could be achieved by stimulating acupuncture points located along the meridians. This ancient philosophy lives on in today's "traditional Chinese medicine". Acupuncture is a major part of this concept. Neither the meridians nor the acupuncture points have ever been shown to exist in an anatomical sense, nor has the existence of Yin and Yang been demonstrated convincingly. For these and other reasons critics tend to reject traditional acupuncture.

But acupuncture has also been submitted to scientific analysis and experiment. As a result, modern concepts have been developed where the effects of acupuncture are understandable through neurophysiological mechanisms. For instance, when given as a treatment of pain, acupuncture can be shown to inhibit the transmission of pain signals along nerve fibres and increase the level of the body's own painkiller in the brain. Through this mechanism, the perception of pain could be reduced. This form of acupuncture seems much more acceptable to most scientists.

Today, the two schools of "traditional Chinese" acupuncture and "Western" acupuncture exist side by side. Typically, the latter is practised by physicians, the former by non-medically qualified practitioners.

One acupuncture session will usually cost between pounds 20 and pounds 50. But one session is rarely enough. Normally, acupuncturists will recommend a series of six to 12 sessions, and often they will advise you to repeat treatments at regular intervals.

What is it For?

In the Chinese tradition, acupuncture is considered a true "cure-all": it is meant to restore a balance of vital energy and thought to be helpful for virtually every conceivable complaint. Traditional acupuncturists therefore use the therapy for anything from specific diseases to non-specific or minor ailments. Western acupuncture is employed mainly for painful conditions, particularly chronic musculo-skeletal pain, emotional problems, addictions, asthma and allergies.

There have been many (about 200) controlled clinical trials of acupuncture, aimed at defining whether or not it is more effective than other treatments, including "sham" acupuncture (which usually means sticking needles into non-acupuncture points). As is often the case in medicine, the results differ widely. When considering acupuncture, it's important not just to pick the type of evidence you happen to like. But, in terms of evaluating all available data (a method called "systematic review" by medical scientists), acupuncture can be effective for:

nausea and vomiting;

dental pain;

low back pain when not caused by a specific disease.

Since conventional medicine has effective drugs for dental pain, and for nausea, but no good solution to back pain, acupuncture may have practical relevance for the latter.

Systematic reviews also suggest that acupuncture is not more effective than sham acupuncture for:

smoking cessation;

weight loss.

Finally, there is a long list of conditions for which trial data are available, and where the evidence is neither convincingly positive nor negative. This can be because results are conflicting, or the trials are of poor quality:

osteoarthritis;

inflammatory rheumatic diseases, such as rheumatoid arthritis;

stroke;

drug addictions;

asthma;

neck pain;

ntinnitus.

For all other conditions which are regularly treated with acupuncture, there is altogether too little evidence to provide an informed opinion. The bottom line is that acupuncture seems to be more than "just a placebo" for some conditions, but it is clearly not a "cure-all".

Types of

Treatment

These can include:

ear acupuncture (using only points in the ear);

body acupuncture (using points throughout the body);

formula acupuncture (a given disease is treated with a predefined "formula" or set of points);

traditional acupuncture (treatment is highly individualised and no "formulas" are applicable);

trigger point acupuncture (using painful "trigger" points). There are also different ways of stimulating acupuncture points, for example:

with needles (the conventional method);

pressure (acupressure);

laser (laser acupuncture);

electricity (electroacupuncture);

heat (moxibustion).

There is no compelling evidence to show that one type of acupuncture is better than another. Most of the clinical trials have used needle acupuncture. Acupressure and electroacupuncture can, after some instructions, be employed as self-treatment - the relevant devices are commercially available. All other forms of acupuncture require a skilled and well trained therapist. But even then, it is not clear whether one form of acupuncture is more effective than another.

What Happens

in a Session?

An acupuncturist will take the patient's medical history and perform a physical examination. Subsequently, (s)he may decide that acupuncture is a promising therapy for the complaint.

The patient would normally sit or lie down, and the acupuncturist would insert one to about a dozen thin, disposable stainless steel needles into one or more of the acupuncture points.

Are there

any Risks?

Many people turn to complementary medicine because they (falsely) think that it offers them benefit without any risks at all.

Yet acupuncture - like most other complementary therapies - is not entirely free of unwanted side-effects and complications. Frequently reported adverse effects are bruising and pain felt during the needling, and fainting and drowsiness directly after an acupuncture session. More serious adverse effects and complications (including deaths) are also on record, but we do not know how frequently they occur - probably, and hopefully, they are very rare.

Such complications are related to puncturing a vital organ or tissue (eg lung, heart, nerve structures), or to transmitting infections through non-sterile equipment.

These are, of course, avoidable, and should not happen with properly trained therapists. The fact that they do occur nevertheless, emphasises the need for vigilance when choosing the right therapist (Box 1 and 2), and for proper regulation of this sector.

With all the forms of complementary medicine, there are also some indirect risks. Whenever acupuncturists overstep the limits of their medical competence, patients could be harmed.

This may occur, for instance, when an acupuncturist tries to treat a condition that does not respond to acupuncture and would have been better treated with conventional medical methods.

Even though we can make only rough estimates, the evidence available today suggests that, for certain conditions (such as back pain), acupuncture will do more good than harm.

If you'd like to find out more, try these books:

for those with prior knowledge:

Filshie J White A (eds); `Medical Acupuncture. A Western Scientific Approach'; Edinburgh; Churchill Livingstone, 1998

for lay people:

`Acupuncture: from ancient art to modern medicine'; Alexander Macdonald, George Allen & Unwin

Next week: aromatherapy

Warning Signals

The following signs may prompt you to double-check whether you are using the right therapy or therapist:

acupuncture is very painful;

your condition gets worse after treatment;

your condition has not improved after a series of about six treatments;

severe bleeding or infection at site of acupuncture;

acupuncturist/therapist displays certificates in a foreign language and cannot convincingly explain what they mean;

acupuncturist promises to cure you in no time at all;

acupuncturist interferes with prescribed medicines (eg suggests you don't take them, or alters dosage);

acupuncturist does not use disposable needles, or works from unclean, messy premises;

acupuncturist does not take a thorough history, or does not keep proper records.

(These points may also apply to other forms of complementary therapy, which we will cover in coming weeks.)

To Be On the Safe Side

This is what you can do to make sure that you are in good hands:

ask the acupuncturist exactly what training (s)he has had;

ask about foreign certificates;

ask about professional organisations, and indemnity cover;

ask what experience (s)he has with treating this condition and as a healthcare professional in general;

ask how quickly (s)he expects you to get better;

how much one treatment and the entire series of treatments will cost.

Some professional organisations:

Acupuncture Association of Chartered Physiotherapists

Abbey View Complementary Clinic

Shaftesbury

Dorset SP7 8DH.

British Acupuncture Council

Suite D, Park House

206/208 Latimer Road

London W10 6RE.

British Medical Acupuncture Society

Newton Lane

Whitley

Cheshire WA4 4JA.