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Acupuncture:

efficacy, safety and practice

Acupuncture:

efficacy, safety andpractice

Board of Science and EducationBritish Medical Association

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Copyright © 2000 British Medical Association

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ISBN 0-203-98996-1 Master e-book ISBNISBN 90-5823-164-X (soft cover)

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Contents

List of tables xi

List of figures xii

1 Introduction 1

Growth in the use ofComplementary andAlternative Medicine (CAM)

1

BMA policy on CAM 4

Annual Representative Meeting1998 policy

5

Scope of the report 6

2 The evidence base ofacupuncture

7

Introduction 7

Clinical trials of acupuncture 12

Methodological difficulties 22

Future research 24

3 Safety: a review of adversereactions to acupuncture

37

Introduction 37

Physical injuries 38

Infections 39

Other adverse reactions 41

Contraindications ofacupuncture

43

Difficulties with the evaluationof adverse reaction reports

44

Adverse reactions toacupuncture in perspective

46

4 Education and training 49

Introduction 49

Principles of CAM education 50

Teaching acupuncture 53

Acupuncture organisations 57

National guidelines foracupuncture training

60

Summary 61

5 Acupuncture in primary care 63

Introduction 63

Provision of CAM by generalpractitioners

64

GPs’ knowledge aboutacupuncture

65

BMA survey—The use ofacupuncture in primary careservices

67

Discussion 77

6 Future developments 83

Introduction 83

Efficacy, safety and training 83

v

Survey of GPs 84

Funding 85

Cost-effectiveness 88

Integration into the NHS 89

Recommendations 94

Appendix I: Glossary 99

Appendix II: Acupuncture organisations 105

Appendix III: Current position ofacupuncture in the UK

107

References 115

Index 127

vi

Editorial Board

A publication from the BMA Science Department andthe Board of Science and Education.

Chairman, Board of Scienceand Education

Sir William Asscher

Head of ProfessionalResources and ResearchGroup

Professor VivienneNathanson

Editor Dr David MorganResearch and writing Laura ConwayContributors Marcia Darvell

Lisa DaviesProfessor Edzard ErnstHilary ForresterKate ThomasDr Adrian White

Editorial secretariat Nicholas HarrisonDawn Whyndham

Indexer Richard jones

Board of Science andEducation

This report was prepared under the auspices of theBoard of Science and Education of the British MedicalAssociation, whose membership for 1999/00 was asfollows:

Sir Peter Froggatt President, BMAProfessor B R Hopkinson Chairman, Representative

Body, BMADr I G Bogle Chairman of BMA CouncilDr W J Appleyard Treasurer, BMASir William Asscher Chairman, Board of Science

and EducationDr P H Dangerfield Deputy Chairman, Board of

Science and EducationDr A ElsharkawyDr H W K FellDr R Gupta (Deputy)Dr S HajioffDr V LeachDr N D L OlsenProfessor M R ReesDr S J RichardsMiss S SomjeeDr P Steadman (Deputy)Dr S Taylor

Dr D M B Ward

Approval for publication as a BMA policy report wasrecommended by BMA Executive Committee ofCouncil on 7th June 2000.

ix

Acknowledgements

The Association is grateful for the help provided by theBMA Committees and many outside experts andorganisations, and would particularly like to thank: DrJoel Bonnet, Dr Imogen Evans, Val Hopwood, SimonFielding, Simon Mills, Felicity Moir, the acupunctureorganisations listed in Appendix II, Butterworth-Heinemann, and the researchers who providedinformation about their current work. We are alsoindebted to the GP members who took time to provideus with detailed responses to our postal survey.

List of tables

Table 1: Summary of methodological details ofreviews of the clinical effectiveness ofacupuncture

26

Table 2: Controlled clinical trials ofacupuncture for back pain

27

Table 3: Controlled trials of acupuncture forneck pain

29

Table 4: Controlled trials of acupuncture forosteoarthritis

31

Table 5: Systematic reviews of acupuncture forvarious indications

32

Table 6: Controlled clinical trials ofacupuncture for smoking cessation

33

Table 7: Controlled clinical trials ofacupuncture for stroke

33

Table 8: Controlled trials of acupuncture fordental pain

35

Table 9: GPs’ views on which type of healthcareprofessional should provideacupuncture services

71

Table 10: Source of GP knowledge aboutacupuncture

74

List of figures

Figure 1: Percentage of GPs arranging specificCAM therapies for their patients

69

Figure 2: Percentage of GPs arrangingacupuncture treatment for differentconditions

70

Figure 3: Which healthcare professionalsactually provide the acupuncturetreatment?

72

Figure 4: GPs’ reasons for not arrangingacupuncture treatment for theirpatients

74

Figure 5: GPs’ reasons for wanting acupunctureavailable on the NHS

76

1Introduction

The British Medical Association (BMA) Board ofScience and Education was established to supportthe Association in its founding aim ‘to promote themedical and allied sciences and to maintain thehonour and interests of the medical profession’. Part ofthe remit of the Board is to undertake research studieson a wide range of key public health issues on behalfof the Association and to provide reports and guidanceto the profession and information to the public onhealth related matters which are of general concern.When endorsed by BMA Council, the reports arepublished as BMA policy reports to influence doctors,Government, policy makers, the professions, the mediaand the public. Over the past two decades particularly,the Board has helped to formulate BMA policy oncomplementary and alternative medicine (CAM) andpublished two major reports (BMA, 1986; BMA, 1993).

Growth in the use of Complementaryand Alternative Medicine (CAM)

The NHS spends considerable money on the treatmentof chronic and undifferentiated disease, conditions forwhich patients often seek help from CAM. The Officeof Health Economics in 1991 recorded an NHSexpenditure of £1 billion per annum with respect to

these conditions, which in 2000 is likely to beexceeded. By 1995 it was estimated that 39.5% of GPpartnerships in England were providing access tocomplementary therapy for their NHS patients(Thomas et al., 1995). This provision may be via theprimary care team itself, referral to one of six NHShomoeopathic hospitals, to pain clinics or to privatepractitioners, or through the employment ofcomplementary practitioners in GP practices. Thomaset al. (2000) estimated that the NHS provided 10% ofcontacts to six established CAM therapies(acupuncture, medical herbalism, chiropractic,osteopathy, homoeopathy and hypnotherapy) in theyear 1997/8.

In its second report to the Department of Health, theCentre for Complementary Health Studies in Exeterestimated that up to 5 million people may haveconsulted a practitioner specialising in CAM in thelast year, and an incalculable extra number may haveconsulted a statutory health professional practisingCAM (Mills and Budd, 2000). Up to one third of UKcancer patients use complementary therapies andmany oncology units and hospices offer at least oneCAM therapy to patients (Kohn, 1999). Acupunctureand homoeopathy are the most commonly providedtherapies, and acupuncture is now reported to beavailable in 86% of NHS chronic pain services (DoH,1999).

Current estimates indicate that there could be morethan 60,000 CAN practitioners and possibly 20,000statutory health professionals regularly practising avariety of CAM therapies in the UK Of these, there areabout 2,050 acupuncture practitioners (an increase of36% in two years) and 3,530 statutory healthpractitioners practising acupuncture (an increase of51% in two years).

2 ACUPUNCTURE: EFFICACY, SAFETY AND PRACTICE

The rapid growth in popularity of CAM suggests agreater degree of public awareness with what they maysee as the limitations of orthodox medicine andconcern over the side effects of ever more potent drugs(FIM, 1997). It coincides with the growing view withinconventional healthcare practice that a renewedemphasis needs to be placed on the patient-doctorrelationship and on seeing patients as individuals inthe personal and social settings in which their problemsdevelop. This view is reflected in both the GMC’s 1993report, Tomorrow’s Doctors, and the BMA’s report,Complementary Medicine: New Approaches to GoodPractice, published in the same year. It is alsoconsistent with the current emphasis in the NHS ofbasing treatment on proven effectiveness and on valuefor money.

A shift in attitude within the medical profession isreflected in the BMA’s present policy and in the use ofthe term ‘complementary’ rather than ‘alternative’. Alarge national postal survey of GPs showed that manyhave an ‘open mind’ as to the value of such treatmerits(GMSC, 1992), with many GP partnerships in Englandproviding access to some form of complementarytherapy for NHS patients (Thomas et al., 1995).

Writing in 1998, the President of the Royal Collegeof Physicians of London (RCP) commented, “we can nolonger ignore the existence of alternative therapies…we, in the Royal College of Physicians, haveestablished a committee to advise the college on howwe should handle the alternative therapies. Disbeliefamong conventional practitioners has at least beenreplaced by a healthy skepticism and a clear wish toexamine the evidence sensibly and logically” (RCP,1998). The RCP has since sent a questionnaire to itsmembers to gauge their use of CAM and attitudetowards it.

INTRODUCTION 3

BMA policy on CAM

The 1993 BMA policy report continues to reflect theAssociation’s policy on CAM. Patients are increasinglyasking doctors about CAM therapies, and it is currentlydifficult for patients and doctors to identify thosetherapists who are competent and adequately trainedto carry out such treatments. Doctors are duty bound todelegate care only to those whom they believe arecompetent, and it may be important for the patient’sdoctor to maintain continuing clinical control of thepatient’s treatment. While medical practitioners arefree to practise whatever form of medicine isappropriate for the patient, they remain accountable tothe General Medical Council for all treatments.However, how can doctors be certain that theirpatients are safe when delivered into the hands of aCAM practitioner?

The BMA’s policies on CAM have reflected aparticular interest in the discrete clinical disciplines ofhomoeopathy, osteopathy, chiropractic, acupunctureand herbal medicine. These are distinguished fromother therapies by having more establishedfoundations of training, are increasingly the therapiesof choice for the UK public, but also have in commonthe greatest potential to do harm to the patientdirectly, since they involve physical manipulation orinvasive techniques, and/or by misdiagnosis oromission (BMA, 1993).

Last year the BMA’s General Practitioner Committee(GPC) issued guidance on referrals to complementarytherapists indicating that GPs can safely refer patientsto complementary therapists who are registered asdoctors or nurses, and also to registered practitionersin osteopathy and chiropractic, and confirmed thatGPs can delegate treatment to other CAM practitioners,


subject to a number of criteria (GPC, 1999). Indelegating to a CAM practitioner GPs are advised to:

• Satisfy themselves that the treatment seemsappropriate and is likely to benefit the patient

• Pass on any necessary information about the patientto the therapist, with the patient’s clear consent

• Retain responsibility for managing the patient’s care(as stated by the GMC, 1998).

Annual Representative Meeting 1998policy

The 1998 BMA Annual Representative Meeting raisedissues concerning efficacy and safety, with specificreference to acupuncture, and the following resolutionwas passed:

“That this Representative Body asks the Board ofScience [and Education] to investigate the scientificbasis and efficacy of acupuncture and the quality oftraining and standards of competence in itspractitioners”.

The BMA Board of Science and Education hasundertaken a comprehensive review of some of themajor aspects of acupuncture, examining the publishedliterature, obtaining education and traininginformation from acupuncture organisations,universities and so forth, and communicating withpractitioners. Importantly, a national postal survey of arandom sample of GPs was undertaken in 1999 whichhas provided new comprehensive data and informationabout GPs’ knowledge and use of acupuncture in theUK today.

To ensure that a wide range of views was obtained insupport of this study, the BMA science secretariatsought information from the main organisations which

INTRODUCTION 5

act as professional bodies for acupuncturists from thecomprehensive list provided by the University ofExeter (Mills and Peacock, 1997; Mills and Budd,2000) (see Appendix II).

Scope of the report

The majority of issues considered in this report, such assafety, efficacy and training, are important to all usersof acupuncture, whether NHS patients, or private, self-referred patients. However, the issue ofcost- effectiveness applies most strongly to itsprovision in the NHS, and not to private practices.With 90% of the consultations being private, anestimated £450 million per annum is spent on out-of-pocket fees for treatment (Thomas et al., 2000).

This first chapter has provided background to theBMA’s policies on CAM and the remit of this report.The question of the clinical effectiveness and efficacyof acupuncture treatment for a variety of medicalconditions is addressed in chapter 2, where the resultsof key clinical trials are summarised. Chapters 3 and 4discuss the important issues of the safety ofacupuncture, and the training and education of itspractitioners. The main results of the BMA 1999 postalsurvey of UKGPs are presented in chapter 5, gaugingthe attitudes and knowledge that GPs have aboutacupuncture, and the extent to which it is being offeredto patients. Finally, future developments in theprovision of CAM, particularly acupuncture, areexamined in chapter 6, including funding and researchissues, cost-effectiveness, and its integration into theNHS. The BMA’s recommendations for future actionare presented.


2The evidence base of

acupuncture

Introduction

The study and practice of complementary andalternative medicine (CAM) is now at a newcrossroads. In the West, the growth in the number andvariety of CAM therapies is a fairly recentphenomenon, and the rate of patient consultations fortreatments is increasing rapidly (Eisenberg et al., 1998),with ‘snapshots’ in time illustrating this phenomenon(Eisenberg et al., 1993; Thomas et al., 1995;MacLennan et al., 1996; Ernst and White, 2000). Withthis increase comes the question of its position withinthe UK healthcare system, and whether the time hascome to aim for its integration into the NHS. For this tooccur, a sound evidence base of the therapies’ efficacyis required.

Practitioners of acupuncture generally follow one oftwo broad theoretical bases, Traditional ChineseMedicine (TCM) or Western acupuncture.Acupuncture research is complicated by the numberand diversity of practices and schools of instruction(see chapter 4). Each may use a different approach andmost are based on the concepts of TCM, although thereis a growing interest in purely biomedical or Westernacupuncture. Since there is no evidence that any one

approach is superior, this report does not distinguishbetween the training or techniques covered byindividual schools or courses.

Traditional Chinese Medicine

Complementary medicine and ‘natural therapies’ havetheir origins in the civilisations of Babylon, Egypt andChina, of about 3,000 years ago. The Chinesedeveloped a system of medicine based on anextraordinarily detailed knowledge of herbal remedies,combined with acupuncture. TCM is practised throughan holistic approach and focuses on the unity of thehuman body with its environment.

The TCM picture of the human body presents aconstruction of ‘energetic functions’, as opposed to thetraditional Western view of the body based onstructure (anatomy) and function (physiology), withthe various parts operating together as systems in amechanical manner. TCM suggests that about 365acupuncture points are present on the human body,arranged in lines or channels (meridians)—there are 12main meridians along which energy or ‘Qi’ flows in acoherent and ordered manner. If the flow is interruptedfor any reason, then ill health can occur. It is thoughtby some that acupuncture is preventive medicine,enabling them to maintain and improve their level ofhealth, perhaps even enhancing an individual’sresistance to infections. In illness, acupuncture seeksto stimulate the appropriate ‘point’ along the affectedchannel, permitting the energy to become balanced andto flow freely once more. Diagnosis is based on closeexamination of the patient’s tongue and pulse, withcareful questioning to explore the signs and symptomsof the diseases. Treatments are based on the evaluation


of the diagnosis to rebalance the Yin and Yangdeficiency or excess in the body (ie, the negative andpositive polarisations of Qi).

The ‘Western’ approach toacupuncture

The ‘Western’ approach to acupuncture, as oftenpractised in the UK, is a non-traditional version basedon modern concepts of neuroanatomy and physiology.This considers the ‘gate theory’ of pain, acting via thenervous, endocrine and immune systems, rather thanthe traditional theory of meridians. Fewer needles maybe used and are left in situ for a much shorter timecompared to TCM practice. An important concept isthat of the ‘trigger point’—an area of increasedsensitivity within a muscle thought to cause acharacteristic pattern of referred pain in a related areaof the body.

This brief report cannot explore the theories andpractice that make up the art and science ofacupuncture in detail. Readers are advised to consultspecialist literature; two new contributions fromHarwood Academic Publishers are currently ‘in press’(Chan and Lee, in press; Cheung, Li and Wong, inpress). However the chapters that follow are based on acomprehensive study of the published literature frompeer-reviewed journals and present an up-to-datereview of the efficacy, safety and application ofacupuncture in the UK

Views on acupuncture

Practitioners of some CAM therapies support the viewthat science does have a place within their fields ofpractice. Concepts of ‘science-based’, ‘evidence-based’

THE EVIDENCE BASE OF ACUPUNCTURE 9

and ‘placebo-controlled’ are being discussed, with newresearch trials planned or underway.

Some major providers of complementary medicinewithin the NHS, such as the Royal LondonHomoeopathic Hospital (RLHH), are clearly seeking toestablish CAM as a form of evidence-based medicine.This CAM centre provides a range of different CAMtreatments including acupuncture, and has an ongoingprogramme of research involving clinical trials,clinical audit and literature reviews. These haveconcluded that there is “strong evidence thatacupuncture can have specific therapeutic effects”(RLHH, 1999).

For others, traditional concepts of life force, Qi,energy, potentisation, and ‘healing’ continue to be ofgreater importance than the science base of thetherapies. The holistic approach aims to treat thewhole person, and may lead to an improvement inthe patient by inducing a feeling of wellbeing, even ifthe physical condition is not markedly improved.However, this does not preclude the measurement ofoutcomes, and it is necessary to identify theappropriate ones. The relationship between thetherapist and patient, the degree of confidence inspiredwithin the patient for both therapy and therapist, andany placebo effect, could be significant factors inachieving a successful outcome.

A number of differing views on the value ofacupuncture have been expressed by keyorganisations. The World Health Organizationencourages and supports countries to identify safe andeffective remedies and practices for acupuncture use inpublic and private health services, and has producedguidelines on basic training and safety in acupuncture(WHO, 1999). The Royal Society, in providingevidence to the House of Lords Inquiry (1999) on


CAM, reported that meta-analyses of published studieshave largely shown “beneficial effects for the treatmentof pain” but commented that reports may showpublication bias (i.e. the selective publication ofpapers).

However, the European Commission in their five-year study (“Co-operation in Science and TechnologyAction B4”, 1998) of unconventional medicine,concluded that the only good evidence available forthe effectiveness of acupuncture was for nausea andvomiting, while the evidence for the effectiveness ofacupuncture in the treatment of various painfulconditions, smoking cessation and asthma, was notconvincing. Despite this, they conclude,“acupuncture…is recommended by a number ofexperts and organisations including the World HealthOrganization”. The American National Institutes ofHealth concluded in their consensus statement (1997)that promising results have emerged, for example inadult postoperative and chemotherapy nausea andvomiting, and in postoperative dental pain. Theystated, “there is sufficient evidence of acupuncture’svalue to expand its use into conventional medicine andto encourage further studies of its physiology andclinical value”.

Ernst and White (1999a) have recently published acomprehensive appraisal of acupuncture, commenting,“since the development of the concept of evidence-based healthcare, therapies must establish theirefficacy, safety and cost-effectiveness by means ofrigorous studies”. Indeed they suggest that scientificvalidation of CAM therapies has become an ethicalimperative due to its prevalence in the UK (Ernst andWhite, 2000). Information on the evidence base ofacupuncture should help doctors, patients, researchersand purchasers of healthcare become more informed


on the value of acupuncture and its likely place withinthe NHS.

Clinical trials of acupuncture

In conventional medicine the randomised controlledtrial (RCT) is the ‘gold standard’ of evidence(van Haselen and Fisher, 1999), hence there is a callfor the same standard to be used for unconventionalmedicine. In a RCT, patients for whom a certaintreatment may be of benefit are randomly allocated to atreatment or control group and followed forward intime. If participants are unaware of their assignedstatus, then they are said to be ‘blinded’ or ‘masked’.Studies where only the research participants areunaware of their assigned status are known as ‘single-blind’ studies, whereas when both the researchparticipants and the investigators are unaware of theirassigned status, the studies are known as ‘double-blind’.

Trials of acupuncture must be ‘single blind’, as theacupuncturist is aware if the participant is in thecontrol group where a placebo is being administered(Filshie and White, 1998). Different forms of controlprocedures have emerged: sham acupuncture can beemployed, involving needling away from classicalpoint locations. Sham acupuncture has been shown tohave some clinical effect mainly due to placebo,although this is most marked in painful conditions andnausea (Filshie and White, 1998). However, it has beendifficult to find suitable sham acupuncture techniquesthat appear indistinguishable from a needle, yet areinert. Tapping the skin, placing needles onlysuperficially, or needling the wrong points, have beenused, but are likely to produce a physiologicalresponse similar to needling and thus lead to anunderestimate of the effect of acupuncture. This


problem appears to have been solved recently(Streitberger and Kleinhenz, 1998) with thedevelopment of a placebo acupuncture needle whichappears to result in a similar sensation to a normalacupuncture needle without actually piercing the skin.

Randomised controlled trials can provide evidence ofwhether acupuncture can work, but only in anexperimental setting on a selected group of patients. Afurther form of clinical trial is known as the pragmaticrandomised controlled trial, where studies usingrandom allocation to intervention or control groups areused to compare two different treatments. They aredesigned to assess the comparative effectiveness of thedifferent treatments as they are delivered in a realworld setting. In the context of acupuncture research,their aim would be to determine whether it is betterthan other available treatment options. Cost-effectiveness assessments can also be made using thismethodology. Cost-effectiveness is a comparativeconcept—treatment can only be more or less cost-effective than some other form of management ortreatment (Thomas and Fitter, 1997).

This chapter evaluates the evidence for and againstthe effectiveness of acupuncture, based on systematicreviews of controlled clinical trials for the followingconditions:

• Back pain (Ernst and White, 1998)• Neck pain (White and Ernst, 1999)• Osteoarthritis (Ernst, 1997a)• Recurrent headache (Melchart et al., 1999)• Nausea and vomiting (Vickers, 1996)• Smoking cessation (White et al., 1999)• Weight loss (Ernst, 1997b)• Stroke (Ernst and White, 1996)• Dental pain (Ernst and Pittler, 1998)


A thorough search of all published controlled clinicaltrials on each subject was conducted by the researcherslisted above, with precedence being given to trials inwhich the design controlled for placebo effects. Thesearch strategies used in the majority of these reviewsare summarised in table 1 (see page 26). The fulldetails of each review can be found in the respectivereports. The papers for each review were chosenaccording to predefined inclusion/exclusion criteria,followed by standardised data extraction and (wherepossible) data synthesis. The majority of RCTs havebeen conducted according to the Western approach toacupuncture. Acupuncture administered using theTCM philosophy is often accompanied by the use ofherbs and a different diagnostic procedure to orthodoxmedicine (although elements of orthodox diagnosismay be used). High quality research in this area is to beencouraged, both to assess its efficacy for differentconditions, and to ensure the safety of the herbs used.

Acupuncture for back pain

A systematic review and meta-analysis of acupuncturefor back pain located twelve RCTs (Ernst and White,1998). Quality was assessed by the Jadad score (Jadadet al., 1996). Several methods for assessing the qualityof studies have been devised, but most have thedisadvantage that there is no basis for scoring thedifferent items. The Jadad method is derived fromresearch with blinded assessors, and was demonstratedto measure the quality of studies reliably. Points (up toa maximum of five) are awarded for randomisation,blinding and description of withdrawals and drop-outs.In addition to this assessment, the adequacy of theacupuncture for back pain was also assessed by sixmedical acupuncturists in a blinded study. There was


sufficient agreement to separate the trials into threelevels of adequacy of acupuncture.

Of the twelve included studies of back pain (seetable 2, page 28), nine provided details of responderrate and could be combined in a metaanalysis. A totalof 377 participants were included. Six of thesestudies reached the threshold of three points onthe Jadad scale. The overall Odds Ratio was 2.30(95% CI 1.28–4.13), indicating that acupuncture wassignificantly better than various control interventions.The results of three out of the twelve studies weremarkedly more positive, but no explanation for thiscould be found. Combining the results of the fourplacebo controlled studies produced an Odds Ratio of1.37 (95% CI 0.84–2.25), indicating that there was nosignificant difference between real and placeboacupuncture.

A subsequent review (van Tulder et al., 1999) ofessentially the same studies used different assessmentcriteria, concluding that the studies could not becombined in a meta-analysis since the form ofacupuncture used and type of participants involvedwere not sufficiently homogeneous. They concludedthat because the review did not clearly indicate thatacupuncture is effective in the management of lowback pain, they would not recommend it as a regulartreatment for patients with low back pain.

However, as van Tulder and colleagues pointed outthemselves, the levels of evidence used in their reviewwere arbitrary, since there is no agreement on how toassess the strength of evidence. Other levels ofevidence could lead to different conclusions. TheJadad score was used for quality assessment in Ernstand White’s (1998) review, and indeed a differentconclusion was reached. In terms of the heterogeneityof the studies, although different forms of acupuncture


were used in the studies, it is likely that there was acommonality at least of point-selection: all involvedtreatment using either classical acupuncture points inthe area of the pain, or tender/trigger points in theassociated muscles. It would therefore seem reasonableto combine the results of these studies under thegeneral heading of ‘acupuncture’. Patient populationswere diverse, some having leg pain as well as backpain, and some having previously undergone backsurgery. The inclusion of patients with diversediagnoses should not be particularly problematic sinceacupuncture treatment would not be altered drasticallyto account for symptoms, and in any case this diversitywould tend to bias the results against acupuncturerather than being in favour. Therefore, the balance ofevidence does seem to suggest that acupuncture can beuseful in the treatment of back pain.

There is clearly a need for more research into the useof acupuncture for back pain. At present, the NHS isfunding a pragmatic randomised controlled trial intothe clinical and economic benefits of providingacupuncture services to patients with low back painassessed as suitable for primary care management(Thomas et al., 1999).

Acupuncture for neck pain

A systematic review found fourteen RCTs whichcompared acupuncture (White and Ernst, 1999) withvarious interventions for the treatment of neck pain(see table 3, page 30). Half scored at least three pointson the Jadad scale. The overall results of these studieswere precisely balanced, with seven positive and sevennegative. Looking at the individual comparisons,acupuncture was superior to waiting list (that is, noadditional treatment) in one study, and either equal to


or superior to physiotherapy in three studies. In fivestudies, needling did not prove to be superior toplacebo controls. The clinical impression exists amongacupuncturists that neck pain usually responds well toacupuncture.

This review concludes that neck pain does improvewith acupuncture, but there is no clear evidence thatthis is due to the needling or the overall effect of thetherapeutic encounter.

Acupuncture for osteoarthritis

Thirteen studies were identified in a systematic reviewof acupuncture for osteoarthritis in any joint, (Ernst,1997) of which seven reported a positive result and sixa negative one (see table 4, page 32). Of the positivestudies, the majority failed to control for placeboeffects. Of the five placebo-controlled studies, fourfound no difference between the effect of acupunctureand the effect of sham. As with neck pain, it is unclearwhether the clinical benefits which many patientsexperience from acupuncture are a specific or a non-specific response.

Acupuncture for recurrent headache

In a systematic review of RCTs for migraine andtension headache, 22 RCTs were included (see table 5,page 33) (Melchart et al., 1999). The quality of studieswas variable, with a median Jadad score of two.Acupuncture was compared to sham acupuncture in14 studies, the majority of which showed at least atrend in favour of acupuncture. Pooled results for theresponder ratios were 1.55 (95% CI 1.04–2.33) formigraine and 1.49 (95% CI 0.96–2.30) for tensionheadache. The authors concluded that, overall, the


existing evidence suggests that acupuncture has a rolein the treatment of recurrent headache but the qualityand amount of evidence is not fully convincing.

Nausea and vomiting

For the treatment of nausea and vomiting, acupunctureis usually given at a single site, known as P6 on theinner wrist. An early review found 33 controlled trialsof acupuncture (and related forms of stimulation) fornausea and vomiting either postoperatively, or in earlypregnancy or due to chemotherapy (see table 5, page33) (Vickers, 1996). In four trials, the acupuncture wasgiven under anaesthetic: all these were negative. Of theremaining 29 trials, 27 demonstrated a significant effectof acupuncture compared to various controlprocedures.

In a subsequent review restricted to treatment fornausea in pregnancy (Murphy, 1998), seven studies onacupressure were found, but none on acupuncture.(Acupressure involves the stimulation of acupuncturepoints by finger pressure rather then needles). Thereliability of the studies and success of the controlinterventions were called into question, and anadditional rigorous study was included, which had anegative outcome. Murphy concluded thatacupuncture seemed to be both safe and probablyhelpful to pregnant women with nausea, but that itwas far from clear whether this effect depended on theprecise positioning of the stimulus.

A meta-analysis of acupuncture for postoperativenausea and vomiting (Lee and Done, 1999) combined19 studies involving 1,679 participants. The medianJadad score was three. In four studies involvingchildren, there were no differences between P6stimulation and control groups for nausea or vomiting


at any time period. In adults, the results favoured P6stimulation over sham controls for both nauseaexperienced within six hours after surgery (relativerisk 0.34, 95% CI 0.20–0.58) and vomiting experiencedwithin six hours after surgery (relative risk 0.47, 95%CI 0.34–0.64). Numbers needed to treat, that is, thenumber of patients that would need to receiveacupuncture to avoid nausea or vomiting in onepatient compared with the control condition, were four(3 to 6) and five (4 to 8) respectively. Sample size ortypes of control did not affect this result, but when theanalysis for nausea was restricted to high qualitystudies the result was no longer significant. The resultsfor nausea and vomiting experienced 0–48 hours aftersurgery did not find that P6 stimulation was superiorto placebo. The results also show that P6 stimulationhas equivalent effectiveness to antiemetic drugs inpreventing vomiting, both shortly after surgery (0–6hours), and a while after surgery (up to 48 hours after).

Stimulation of the P6 point has also been implicatedin the prevention of motion sickness (Gahlinger, 1999),and wristbands can be purchased as a therapeutic aid.One study of such bands found no evidence of areduction in motion sickness symptoms (Bruce et al.,1990), but a possible reason for this failure was theinfrequent stimulation of the point due to lack of wristmovement. In a later study, however, which involvedregular manual pulse pressure of the P6 point, asignificant reduction in the severity of symptoms wasfound (Hu et al., 1995).

Acupuncture for smoking cessationand weight loss

Acupuncture has gained a reputation for assisting themanagement of certain behaviours, particularly


smoking (see table 6, page 34) and overeating. ACochrane Review for smoking (White et al., 1999)included 18 reports with 20 trials which comparedacupuncture to various control interventions.Acupuncture was no better than placebo acupuncture,whether assessed immediately after treatment or at sixor twelve-month follow-ups. On the basis of threestudies, acupuncture was better than no treatment atall immediately, but this benefit had disappeared bysix months.

A systematic review of acupuncture for weight lossfound four studies (Ernst, 1997). Their quality waspoor: the two most rigorous studies were negative andthe two less rigorous were positive. Thus, at presentthere is no evidence to support any role foracupuncture in the management of smoking cessationor weight loss.

Acupuncture for stroke

Six controlled trials of acupuncture treatment to assistrecovery from stroke were reviewed (see table 7, page34) (Ernst and White, 1996). All showed some benefitof acupuncture compared to the control intervention.None of these trials was placebo-controlled, so it isimpossible to say whether the effect was due to theplacement and stimulation of the needles, or due tothe extra attention and mental stimulation given to thesubjects. In a more recent study, (Gosman Hedstroemet al., 1998) this question seems to have been answeredin acupuncture’s disfavour. This rigorous, placebo-controlled RCT found no effect of either genuine orplacebo acupuncture compared to a group who had noadditional treatment. The interaction betweenacupuncturists and patients was strictly controlled andminimised. Collectively, these data suggest that the


effects of acupuncture in improving the recovery fromstroke are mostly non-specific in nature.

Acupuncture for dental pain

Dental pain provides an accessible, temporary andrelatively reproducible model for testing the analgesiceffect of acupuncture. It has been studied both inlaboratory experiments and during actual dentalsurgery; 16 controlled trials of either sort of dental painwere included in a systematic review (see table 8, page36). The quality of the studies was generally poor, withonly two scoring at least three out of a possible fivepoints on the Jadad scale. The great majority of studiessuggest that acupuncture does have an effect greaterthan placebo in reducing dental pain. In particular, allfour studies of acupuncture for experimental dentalpain were positive. Of the eight studies in which someblinding was incorporated, only one was negative.This suggests that acupuncture does have genuineeffects in reducing dental pain, though the effect issmall and probably not important clinically. Thisresult has theoretical importance in indicating thatacupuncture can have measurable analgesic effects.

Other conditions

Systematic reviews of acupuncture for fibromyalgia,(Berman et al., 1999) and temporomandibular jointdysfunction (Ernst and White, 1999b) have promisingresults but more research is required, particularly sham-controlled RCTs. Systematic reviews of acupuncture forasthma (Linde et al., 2000), rheumatic diseases(Lautenschlaeger, 1997), and for tinnitus (Park, et al. inpress) have shown no evidence of an effect in theseconditions.


Summary

According to the current evidence, acupunctureappears to be more effective than sham acupuncture orother control interventions for nausea and vomiting(most convincing for post-operative symptoms inadults), and for back pain, dental pain and migraine.The present evidence is unclear as to whether theresponse of osteoarthritis and neck pain toacupuncture is more than non-specific. Acupuncture’srole in recovery from stroke, and the treatment oftension headache, fibromyalgia andtemporomandibular joint dysfunction is stilluncertain. Acupuncture appears not to be superior tosham acupuncture for smoking cessation or weightloss.

Methodological difficulties

Research in complementary and alternative medicinein general is limited by lack of funding, lack ofresearch skills, lack of an academic infrastructure andlack of patients (RLHH, 1999). In 1996 only 0.08% ofresearch funding in the NHS was allocated tocomplementary medicine (Ernst, 1996). In addition,clinical trials are not without their critics; they havebeen criticised for investigating conditions and usingtreatment techniques which may not be representativeof those treated and used in practice (RLHH, 1999).The use of the randomised controlled trial inacupuncture studies has been considered a particularintellectual challenge, as it is often considered thatthere are more potential difficulties than in therandomised, double-blind, crossover controlledclinical trials used to evaluate pharmaceutical agents.

A common assertion among skeptics is that theresults of complementary therapies, including


acupuncture, are built solely on what is known as theplacebo effect, that is, an improvement in the conditionof an ill individual that occurs in response totreatment but cannot be considered due to the specifictreatment used. The placebo effect is often consideredin a pejorative sense, as it is confused with the ‘non-specific noise’ of placebo that must be eliminated fromclinical trials in order to determine the effectiveness ofparticular pharmacological interventions (Harrington,1997). However, the placebo effect may have a value forpatients. Cochrane, an early advocate of therandomised controlled trial and former director of theMedical Research Council’s Epidemiology Unit,indicated that ‘effectiveness’ due to placebo should notbe discounted without consideration of the economiceffects. He argued (Black et al., 1984) that the use ofplacebos in the correct place should be encouraged,but that what is inefficient, is the use of relativelyexpensive drugs as placebos. Further research isrequired to investigate the presence of a placebo effectin acupuncture, comparing acupuncture with shamacupuncture and other placebo controls.

Clearly, in real clinical situations, effectiveness andefficacy include issues such as cost-effectiveness andclinical safety, as well as issues related to clinicaltrials. The placebo effect in itself should not be areason for discounting complementary therapyresearch, as the usefulness of a medical intervention inpractice is different from assessing formal efficacy(NIH, 1997). It has been stated that one possibleadvantage for acupuncture use is that the incidence ofadverse effects is “substantially lower than that ofmany drugs or other accepted medical procedures usedfor the same condition.” (NIH, 1997). In a recent surveyof GPs and directors of public health in the UK (vanHaselen and Fisher, 1999) it was found that although


randomised controlled trials and safety were the keyconsiderations for the purchasing of complementarytherapies, “audit outcome data from homoeopathichospitals, economic evaluation and availability ofliterature” were also rated highly for importance. TheEuropean Committee for Homoeopathy also recentlyemphasised the importance of effectiveness research—for example, using observational studies (EuropeanCommittee for Homeopathy 1997), and Black (1996)called for the advocates of RCTs and the advocates ofobservational studies to work in mutual recognition ofthe complementary roles of the two approaches.

However, the randomised controlled clinical trial,and the pragmatic RCT, remain important linchpins ofmedical research. Although they may be considered inconjunction with other forms of research such asobservational techniques, acupuncture research mustprovide evidence of clinical efficacy which enablesacupuncture techniques to be compared withconventional medicine.

Future research

The Royal London Homoeopathic Hospital (1999) hasidentified questions that need to be answered byresearch in the field of complementary medicine,which can be applied specifically to acupunctureresearch:

• How large is the effect of acupuncture?• Are the overall long-term effects of a acupuncture

treatment greater than some reasonable alternativesuch as surgery or drug treatment?

• How cost-effective is acupuncture?• Is acupuncture additional to, or can it replace,

conventional treatments such as drugs?


• Which conditions is acupuncture most effective for?• Which patients benefit most from acupuncture?

Randomised controlled trials with rigorousmethodological controls are essential if medicalpractitioners are to make decisions for referral toacupuncturists based on a scientific basis. However, itmay also be the case that ‘ complementary research’ isrequired in order to answer some of the questions aboveand provide a full picture of the effectiveness andefficacy of acupuncture in clinical practice—forexample, case studies, health status measurement(Jenkinson and McGee, 1998), cost-effectivenessanalysis and observational studies (Black, 1996). Sucha combination of research methods, including therandomised controlled trial, may provide answers tothe outstanding questions raised by the Royal LondonHomoeopathic Hospital, but it is clear that currentstandards of research into the clinical effectiveness ofacupuncture require greater methodological rigour.

Finally, it is important to consider that effectivenessmeasures in clinical trials do not take intoconsideration the comparative merits of particularforms of treatment. As health service resources arefinite, considerations of cost and unwanted effects ofparticular treatments need to be considered. In the UK,the National Institute of Clinical Excellence has beenestablished to consider the value of particulartreatments in clinical practice, and is well placed toconsider acupuncture and produce guidance for theNHS.


Table 1: Summary of methodological details of reviews of theclinical effectiveness of acupuncture

Source: Ernst E (1999). Clinical effectiveness of acupuncture:an overview of systematic reviews. In E Ernst & A White(eds.) Acupuncture: a scientific appraisal. Oxford:Butterworth-HeinemannReprinted by permission of Butterworth-Heinemann


Table 2: Controlled clinical trials of acupuncture for

back pain

Acup=acupuncture; EA=electroacupuncture; NS=notsignificant; VAS=visual analogue scale.


Table 3: Controlled trials of acupuncture for neck pain

Acup=acupuncture; EA=electroacupuncture;OA=osteoarthritis; ROM=range of movement; stats=statistics;VAS=visual analogue scale.


Table 4: Controlled trials of acupuncture for osteoarthritis

RCT=randomised controlled trial; ROM=range of motion;TENS=transcutaneous nerve stimulation; VAS= visualanalogue scale.Source: Ernst E (1999). Clinical effectiveness of acupuncture:an overview of systematic reviews. In E Ernst & A White(eds.) Acupuncture: a scientific appraisal. Oxford:Butterworth-HeinemannReprinted by permission of Butterworth-Heinemann


Table 5: Systematic reviews of acupuncture for variousindication s


Table 6: Controlled clinical trials of acupuncture forsmoking cessation

1Two parallel groups unless stated otherwiseEA=electroacupuncture

Table 7: Controlled clinical trials of acupuncture for stroke

RCT=randomised controlled trial.1Experimental groups received regular acupuncture inaddition.


Table 8: Controlled trials of acupuncture for dental pain

CCT=controlled clinical trial; RCT=randomised clinical trial.


3Safety: a review of adversereactions to acupuncture

Introduction

It has been assumed in the past that acupuncture posesno risk, or very little risk, to the patient, and being anatural and holistic therapy is safer than conventionalmedicine and drug therapy (MacPherson, 1999).However, with its growth in popularity in Westernsociety came the need for evidence of its safety, andwith that came reports of adverse events from aroundthe world (Rampes and James, 1995; Ernst and White,1997, 1999; Peuker and Filler, 1997). A review byRampes and James (1995), after a search of twodatabases (Medline and AMED), identified only 216instances of serious complications worldwide over a20-year period. The authors concluded thatconsidering that 3% of the adult population of the UKwere found to have consulted acupuncturists in 1984,that is, approximately 1.7 million people (Fulder,1988), these figures are reassuring, particularly as thegrowth in the number of acupuncturists in the UK inthe past two years has been substantial (seeAppendix III). The complications generally fall intothree main areas, physical injuries, infections andother adverse reactions.

Physical injuries

The most serious adverse effect that can be incurredduring acupuncture is unilateral or bilateralpneumothorax. Insertion of needles into the thorax,particularly the intercostal spaces, paraspinal areas andsupraclavicular regions can result in the puncture ofthe pleura and the lung parenchyma, and is potentiallyfatal. Several cases have been documented, forexample, Rampes and James (1995) discovered 32reported cases worldwide over a 27-year period, whilstRampes and Peuker (1999) conclude thatapproximately 100 cases can bc found in scientificpublications worldwide. A Norwegian study (Norheimand Fønnebø, 1996) estimated that pneumothoraxmight be seen once every 120 years in a full timeacupuncture practice.

Other documented physical injuries includecardiovascular traumas (Schiff, 1965; Nieda et al.,1973; Cheng, 1991; Hasegawa et al., 1991; Halvoren etal., 1995; Kataoka, 1997), deep vein thrombosis andlocalised nerve damage (Bensoussan and Myers, 1996).Traumas to the spinal cord during needle insertion ordue to migration of retained needles have also beenreported, although the majority of these cases are aresult of the Japanese practice of ‘Okibari’ involvingpermanent deep needle insertion. This technique isneither taught nor practised in the West, although itsside effects are frequently cited in the literature,adding to the confusion surrounding the issue of thesafety of acupuncture (MacPherson, 1999).

Many of the injuries can be avoided by ensuringacupuncturists are fully trained in anatomy andphysiology, with particular emphasis on teaching thelocation and depth of the major organs. Even the mostbasic first aid course has such a component.


Infections

The invasive nature of acupuncture lends itself to thespread of infection when not practised safely orhygienically. Acupuncture has been implicated in thetransmission of hepatitis, HIV and various bacterialinfections including septicaemia (Pierik, 1982). TheBritish Blood Transfusion Service lists acupuncture asa condition necessitating temporary deferral for twelvemonths after the completion of the treatment ifperformed by someone other than a registered medicalpractitioner or health professional, or a member of theBritish Acupuncture Council (BAcC). (For furtherinformation telephone 0845 7711711). Members ofBAcC can provide their patients, who wish to donateblood, with certificates confirming that the treatmentwas provided by an acupuncturist registered with theorganisation.

Reports in the UK in the late 1970s of viral hepatitisinfections from acupuncture needles (CDSC, 1977;Boxall, 1978) were influential in encouragingpractitioners to use sterile disposable needles and thesituation improved (Rampes and Peuker, 1999).However, there have since been further reports, withRampes and James (1995) listing 126 reported cases ofviral hepatitis, and Norheim’s 1996 review revealing100 cases of acupuncture-related hepatitis B and Creported between 1981 and 1994. All reports have incommon the fact that sterilising procedures wereinadequate.

There is no definitive evidence to support anyconcern that acupuncture needles can spread the HIVvirus (Rampes and Peuker, 1999). However, there havebeen three cases of individuals acquiring HIV whoreportedly had no other risk factors for the virus, otherthan attending an acupuncture clinic (Vittecoq et al.,1989a, Castro et al., 1988). However, due to lack of

A REVIEW OF ADVERSE REACTIONS TO ACUPUNCTURE 39

information in these cases it cannot be proven thatacupuncture was the causal factor (Chamberland et al.,1989; Vittecoq et al., 1989b), and there could have beensome other undisclosed risk factors, such as sexualpractice (MacPherson and Gould, 1998).

The Department of Health has issued advice topractitioners of complementary and alternativemedicine on the precautions to take to avoid thetheoretical risk of transmission of variant Creutzfeldt-jakob Disease (vCJD) (DoH, April 2000). They state thatalthough there is currently no evidence to link anycases of vCJD to date with any surgical procedures orwith transmission by blood, the Department cannotrule out a possible risk and so considers it prudent totake precautions to avoid this theoretical transmissionwherever possible. Practitioners of acupuncture arespecifically told to have regard to this advice, and areadvised to ensure that any needles or studs thatpuncture the skin are used only once, in line with theguidelines issued by WHO (1999).

Inadequate or improper sterilisation techniques are aserious risk factor and this is recognised byacupuncture professional bodies, and reflected in theircodes of practice. Transmission of infections can beavoided if all practitioners use only pre-steriledisposable needles rather than reusable needles thatrequire sterilisation. As Norheim’s (1996) reviewfound, all the cases of hepatitis transmission had incommon inadequate sterilisation procedures, and mostof the adverse events were due to “insufficient basicmedical knowledge, low hygiene standards andinadequate acupuncture education”.


Other adverse reactions

A range of other adverse events has been documentedwhich are perhaps less serious than those documentedhere. These include bleeding on withdrawal of theneedle (Chung, 1980), bruising at the site of insertion(Redfearne, 1991; Tuke, 1979), depression, insomnia,increased pain, burns from moxibustion (Bensoussanand Myers, 1996), and fainting (Chen et al., 1990;Rajanna, 1983; Verma and Khamesra, 1989). Cases ofskin reaction to metals have also been described(Castelain et al., 1987; Fisher 1976; Tanii et al., 1991)which can be avoided by using stainless steel needleswithout chrome and nickel.

One of the most frequently reported side effects isdrowsiness, which may have implications for thosewho drive following treatment. One study (Brattberg,1986) found that 56% of patients would have been atrisk of an accident had they driven after treatment. Theauthor speculated that this drowsiness might be theresult of a fall in blood pressure or blood sugar, or therelease of endogenous opiates, but that it would beimpossible to predict who would experience it. Henceit was advised that, as with medication which mightinduce fatigue, patients should be warned againstdriving a car immediately after receiving acupuncturetreatment. The study did not mention patients’concurrent medication however, and whether suchmedication may have contributed to or enhancedacupuncture drowsiness (Rampes, 1998). TheAcupuncture Association of CharteredPhysiotherapists advises their members in their Code ofEthics and Practice to recommend to their patients thatthey should not drive after treatment, until they recoverfrom any drowsiness.

The risk of indirect adverse events such as mis-diagnosis or risk of omission has been discussed (Ernst,


1995) and needs to be addressed since it hasimplications for training, practice and health caredelivery mechanisms. Since the extent of the problemis difficult to quantify due to its very nature,precautionary measures must be taken to reduce therisk. Practitioners should receive sufficient training toenable them to know the jurisdiction of their practiceand its limitations. This is essential in order to preventthe application of inappropriate treatments (BMA,1993). Acupuncturists should also encourage theirpatients to inform their GPs that they are receivingacupuncture treatment. Australia’s National Health andMedical Research Council (1989) proposed that theundetected presence of a serious pathology by apractitioner of acupuncture is probably the mostimportant of risks. Mills (1996) advocates the provisionof a level of orthodox diagnostic training equivalent tothat received by medical practitioners to counteractthis possibility. A system of quantifying the risk isrequired in order to end the current state ofspeculation.

Practitioners should consider the potential forinteractions between adverse reactions to acupunctureand adverse reactions to orthodox drugs being taken atthe time of treatment. For example, acupuncturistsshould have some awareness of drugs that causedrowsiness, since overall drowsiness experienced bythe patient after acupuncture treatment may beexacerbated. The importance of acupuncturepractitioners finding out their patients’ medicalhistories and general practitioners knowing about theirpatients’ use of acupuncture is paramount to theavoidance of such situations.


Contraindications of acupuncture

Acupuncture is contraindicated in a number ofsituations which practitioners should be well aware of,and include: when patients are taking anticoagulantmedication, when press needles (for auricularacupuncture) are used in patients with prosthetic ordamaged heart valves, or when patients withpacemakers receive electroacupuncture.Electroacupuncture is also contraindicated if there islack of skin sensation and in case of impairedcirculation, severe arterial disease, undiagnosed fever,or severe skin lesions (WHO, 1999). The WHO (1999)advises that acupuncture is only used duringpregnancy with great caution since the needling andmanipulation of certain points may induce stronguterine contractions. The report advises “traditionally,acupuncture, and moxibustion are contraindicated forpuncture points on the lower abdomen andlumbosacral region during the first trimester. After thethird month, points on the upper abdomen andlumbosacral region, and points which cause strongsensations should be avoided, together with earacupuncture points that may also induce labour”. TheOrganization lists pregnancy as a condition that iscontraindicated by electroacupuncture.

Rampes (1998) advises particular caution whenacupuncture involves points on the thorax andimmunosuppressed patients, and identified generalprecautions, which are always necessary:

• Remember orthodox diagnostic skills• Use sterile disposable needles• Use aseptic technique with press needles• Lie the patient down during treatment• Advise patient to avoid driving after treatment• Count needles before and after treatment


• Observe patients for bleeding.

Difficulties with the evaluation ofadverse reaction reports

The system of reporting adverse reactions to drugs andtreatment in orthodox medicine is an area whichattracts a great deal of debate in the medical world,with concerns about under-reporting (Pierfitte et al.,1999) and problems with spontaneous reporting.Hence, it is hardly surprising that there are issuessurrounding the reporting of adverse reactions inacupuncture. A major problem with the adversereaction case studies which characterise this field ofwork is that often they do not contain sufficientinformation with which to critically appraise them(Ernst, 1995). Ernst suggested that future case studiesshould contain details of:

• Which acupuncture techniques were used• Who gave it• The timing of the adverse reaction• Its reversibility• Confounding factors.

White et al., (1997) described different methods whichcould be used to assess the incidence of adversereactions in complementary medicine, ie systematicliterature reviews, surveys of patients andpractitioners, case control studies, case registers,spontaneous reporting and observational studies. Theyconcluded that spontaneous reporting is the mostpowerful method available, and is used widely in post-marketing surveillance of drugs. Systematic literaturereviews, as cited in this chapter, are dependent oncurrent databases for their literature. However, these


may not be complete due to under-reporting of minorinjuries by practitioners due to the frequency of theiroccurrence, or of more significant injuries due to GPs’lack of knowledge that their patient receivedacupuncture (Norheim and Fønnebø,1996). They alsocannot be used to accurately estimate incidence, sincethe number of treatments given per year is unknown. Asurvey, using members of the British MedicalAcupuncture Society, of adverse events is currentlyunderway using the spontaneous reporting technique atthe Department of Complementary Medicine in Exeter.

Aside from academic work to assess the occurrenceof adverse events, it is important to consider whatindividual practitioners can do. Mills (1996) suggeststhat awareness needs to be raised among CAMpractitioners, and recommends that the researchdepartments of the professional CAM organisationsestablish adverse effect reporting schemes. The firststage of this, he suggests, would be to familiarise thepractising members with the process, perhaps usingthe organisations’ annual conferences to introduce themeasure and develop and pilot an appropriate reportformat. Rampes (1998), on the other hand,recommends the establishment of a national databasefor acupuncture adverse reactions similar to the BritishCommittee of Safety of Medicines system of reportingof drug adverse reactions. This would collect andevaluate all reports of reactions to acupuncture,disseminate results to practitioners, and could beextended to cover other CAM therapies.

MacPherson and Gould (1998) recommended thatthe acupuncture profession undertake a UK-wide studyto examine the key risks and their frequency ofoccurrence, which could demonstrate that theprofession is concerned and responsible, as well asbeing useful in helping to promote good practice in the


areas of risk. The British Acupuncture Council iscurrently funding such a survey through the collationof data from the effects of approximately 30,000treatments. It is being conducted and co-ordinated bythe Foundation for Traditional Chinese Medicine inYork and aims to estimate the frequency and severity ofadverse reactions, both minor, transient reactions andmore serious, significant responses. It involves 1,850members of BAcC monitoring their work with patientsthrough May 2000. Their results should be directlycomparable to those obtained in the Exeter surveymentioned previously.

Adverse reactions to acupuncture inperspective

The US National Institutes of Health (1997) stated that“one of the advantages of acupuncture is that theincidence of adverse effects is substantially lower thanthat of many drugs or other accepted procedures forthe same conditions”. The difficulty of estimating theincidence of these reactions has been discussed, butnonetheless some researchers have attempted thecalculation. Norheim and Fønnebø (1996) estimatedthat for each year of full time acupuncture practice inNorway, 0.21 complications would arise(complications were classified as mechanical organinjuries, infections, and other adverse effects, notincluding point-bleeding or small haematomas).Bensoussan and Myers’ Australian study (1996)estimated that the average number of adverse eventsper year of full time Traditional Chinese Medicinepractice was one every eight months. Umlauf’s (1988)study of acupuncture over a period of 10 years in aCzechoslovakian hospital evaluated 139,988acupuncture treatments and found 8.9%


(approximately 12,459 treatments) resulted in adverseevents (faintness, fainting, haematoma, pneumothoraxand retained needles). Considering that the MedicinesControl Agency receives approximately 17,000–18,000UK reports of suspected adverse reactions to allmedicines each year, of which 55% are serious and 3%are fatal (Hansard, 2000), the incidence of adversereactions to acupuncture appears relatively low.


4Education and training

Introduction

There are a variety of ways in which acupuncture canbe taught and practised. Broadly speaking, apractitioner of traditional acupuncture will make anindividual diagnosis by interpreting the patient’ssymptoms and signs according to Chinese theory andassessment of yin-yang energy status, and will thenapply needles to specific ‘points’ to rebalance energy,or ‘Qi’. However, they may often also incorporateelements of orthodox medical diagnosis, whichconstitute the curriculum of many TCM acupuncturecourses. Adjunctive therapies, including moxibustion(burning of herbs), massage, prescription for Chineseherbs, and advice on lifestyle and diet, are commonlyalso given. A practitioner of ‘Western-style’acupuncture will take a conventional medical historyand perform an examination. Acupuncture will beregarded as one of a number of therapeutic options andrather than moving the ‘life force’ or Qi, brief needling,(perhaps with fewer needles) is intended to stimulatenerve endings, and stimulate the release of endogenousopioids and other neurotransmitters. Within agreedparameters, a certain amount of diversity inacupuncture training establishments is healthy in

catering for the individual needs of students and thedifferent approaches and expertise among the teachingstaff.

Principles of CAM education

The BMA (1993) suggested certain broad principleswhich could be applied—albeit at different levels fordifferent therapies—to all training programmes forpersons who intend to use CAM. As a primary step, itis essential that each therapy should establish a corecurriculum, setting out the basic competenciesrequired for the practise of that therapy by allpractitioners, medical and non-medical alike. Coursesshould be of credible duration and type, to providecompetent practitioners. Good practice would alsosuggest that a minimum, ‘core’ basic science/medicalcurriculum should be compulsory for all practicesclaiming to have a therapeutic influence. Thisfoundation course might include some basicknowledge of pharmacology and an appreciation of thehazards in removing patients from prescribedmedication, for instance, in interrupting a course ofantibiotics. Most fundamentally, such a basic coursewould instil in all practitioners understanding of theways in which apparently innocent symptoms—oftenthe common ones—can often be indicative of seriousdisease. This element of core ‘medical’ knowledge isassociated with the need for therapists to establish thelimits of their competence, and to be aware of when itis necessary to actively encourage the involvement ofthe patient’s doctor (Box 1).

Secondly, a regulatory body for a given therapyshould assume responsibility for the clinical andprofessional accreditation of training establishments,by assessing compliance with established minimum


standards in a particular therapy. The accreditationstatus could be renewable, probably every five years.Agreement on minimum requirements of training toensure competence is needed for different levels ofpractitioners.

Box 1: Competencies that acupuncturists and otherCAM therapists should be able to demonstrate (BMA,1993)

Competencies for CAM therapists

• A sound knowledge of anatomy, physiology,pathology, basic medical therapeutics, andthe principles of their own therapeuticmodality. The practitioner must also haveacquired a sufficient depth of knowledge ofthe principles of medicine and thepathological process of disease, and be awareof the physiological basis for their treatmentand modality.

• The ability to collect relevant informationfrom the taking of an appropriate case historyand an examination of the patient enablingthe practitioner to formulate an appropriatediagnosis and effective treatment plan, aswell as the likely prognosis and any suitableprophylaxis.

• An ability to conduct and interpret a relevantclinical examination and use currentlyaccepted clinical testing procedures as wellas an ability to interpret any ancillary tests.

• In reaching a diagnosis, a practitioner mustbe able to show that he or she has thoughtdifferentially using a rationale based uponcurrent knowledge of anatomy, physiology,

EDUCATION AND TRAINING 51

and pathology, demonstrating that he or shehas considered not only the potentialcontraindications of treatment but also has anawareness that symptoms manifested by thepatient may be emanating from a site or causedistant from the presenting problem, and maybe indicative of serious underlying disease.

• The practitioner should demonstrate anawareness of the relevance of a patient’spersonal life history, including psychologicalaspects, inherited predispositions, previousmedical history, life-style factors, and socialand occupational background. This isparticularly important so that the patient’sown expectations will be considered informulating a treatment plan.

• Practitioners should show an awareness oflimits of competence and the scope of theirparticular therapy, together with a knowledgeof absolute and relative contra-indications totherapy. With this goes the ability torecognise conditions where a particulartreatment is inappropriate, and also when apatient is suffering from a condition thatrequires immediate referral to the patient’sGP.

• They should show an awareness of the needto plan a particular course of treatment andbe able to anticipate its effectiveness with thepatient concerned. A practitioner should beable to communicate his or her findings,diagnosis, prognosis and prophylaxis, whereappropriate, not only to the patient’s GP butalso to the patient, in such a way that thepatient’s own expectations are taken intoconsideration.

• Practitioners should show an awareness ofthe need to evaluate and monitor the


patient’s progress in line with the proposedtreatment plan and an awareness that, ifanticipated outcomes are not met,consideration should be given to referral tothe appropriate agency.

Teaching acupuncture

Techniques and philosophies in acupuncture havebeen evolving for over 3,000 years in a wide range ofcountries and these diverse traditions have beenreflected in the training provided in national colleges.Many schools of Traditional Chinese Medicine in theWest teach acupuncture based on the ‘twelve pulses’and the ‘law of five elements’. Some current Chineseteaching can be based on much simpler forms of TCMand in many instances just local acupuncture pointsare used to treat pain and no attempt is made toevaluate or treat the underlying imbalances of ‘vitalenergy’. Western science seeks to explain the possibleeffects of acupuncture in terms of effects on humoralmediation via the circulation of neuro-transmitters andother hormones in the cerebrospinal fluid and bloodstream (Hopwood, 1993), whilst also recognising thevalue of the ‘holistic approach’.

Acupuncture treatment is now very popular in theUSA and it is estimated that 9–12 million patients visitacupuncturists each year for treatments that involve upto 120 million needles (Lao, 1996). American doctors,osteopaths and chiropractors may use acupuncturewithout any or only limited extra training, according toindividual State law. Other practitioners requirespecific training and for about the past 20 years State


law has required acupuncturists to be licensedaccording to criteria developed by an AcupunctureExamining Committee and subsequently the NationalCommission for the Certification of Acupuncturists(NCCA). The examinations consisted of both writtenand practical tests.

At the present time, anyone within the UK can usethe title ‘acupuncturist’ and, in common with manyother CAM therapies, acupuncture is not regulated bystatute and there are a number of differentorganisations, colleges and so forth offering training,education or registration in the subject.The major acupuncture bodies listed by the Universityof Exeter (Mills and Peacock, 1997; Mills and Budd,2000) are:

• The British Acupuncture Council• The British Medical Acupuncture Society• British Academy of Western Acupuncture• The Acupuncture Association of Chartered

Physiotherapists• The Fook Sang Acupuncture and Chinese Herbal

Practitioners Association

• The European Federation of Modern Acupuncture• The Modern Acupuncture Association.

(See Appendix II)

British Acupuncture AccreditationBoard (BAAB)

As a result of a joint initiative of the Council forComplementary and Alternative Medicine and theCouncil for Acupuncture (CCAM/CFA) in the UK, astructure for accrediting independent schools andcolleges of acupuncture was developed, and in


November 1990 the British Acupuncture AccreditationBoard (BAAB) was formally established. The Councilfor Acupuncture became the British AcupunctureCouncil (BAcC), in l995.

Important questions to be addressed in acupuncturetraining include:

• what constitutes minimum professional standardsfor new practitioners?

• what constitutes an acceptable standard for on-goingpractice?

• when is ‘full competence’ achieved?• what professional monitoring or ‘training input’ is

required in post-registration years?• what are key training issues related to safety,

referral and management of patients?

The core syllabus now published by the UK BAAB andsupported by the British Acupuncture Councilincludes topics such as history taking, basic theory,knowledge of acupuncture points, methods ofdiagnosis and treatment principles and techniques,including issues of safety and sterile procedures,anatomy, physiology, and research methods. TheBAAB also puts great emphasis on professionalcompetencies. The aim of training should also be to“encourage the development of a reflective, research-minded practitioner with qualities of integrity,humanity, caring, trust, responsibility, respect andconfidentiality” (Shifrin, 1995).

Acupuncture courses

A BMA survey of CAM bodies (1993) reflected thatthere was a considerable range of standards,aspirations, and levels of training for practitioners ofCAM therapies. At one end of the spectrum, the


discrete clinical disciplines require levels of trainingcommensurate with the responsibilities such therapistshave to patients in their care, and courses for suchdisciplines are now likely to be degree equivalents. ABMA survey of UK higher education establishments in1996 revealed that over 100 modules or completecourses in CAM subjects were being provided inuniversities, medical schools and faculties of nursing(Morgan et al., 1998). Little information, however, wasprovided about specific research projects or researchinfrastructure, and none related directly toacupuncture.

The BMA 1993 report recognised that particularskills need to be acquired in order to achievecompetence in different therapies, and highlighted theGeneral Medical Council’s statement that a question ofserious professional misconduct may arise by “a doctorpersisting in unsupervised practice of a branch ofmedicine without having the appropriate knowledgeand skill or having acquired the experience which isnecessary”. Therefore, doctors (and nurses,physiotherapists and other healthcare professionals)may undertake specialised training to provide themwith the necessary skills to understand and/or carry outacupuncture or other CAM therapies. One provider ofCAM treatment specified that treatment is“complementary to conventional medicine and notalternative” and that all staff are members of theappropriate state registered health professions (RLHH,1997). The BMA recommended in ComplementaryMedicine: New Approaches to Good Practice (BMA,1993) that all medically qualified practitioners whowish to carry out acupuncture (and indeed any CAMtherapy) should undertake recognised training in thatfield.


University teaching

Acupuncture is now established as a degree course atBachelor level in at least two UK universities, run overthree or five years, with a higher degree Masters courseavailable for qualified physiotherapists. Graduatesshould have spent considerable time gaining clinicalexperience with patients, together with a soundknowledge of basic medical sciences, point selectionand research methodology. Colleges and otherinstitutions offering acupuncture education andtraining are able to apply to the BAAB for theinstitution and/or courses to be accredited. Therigorous accreditation process should ensure that onlythose organisations complying substantially with 17essential requirements achieve recognised status(BAAB, 1998). The assessment programme shouldensure that each training establishment is externallymonitored against known assessment criteria. It shouldbe expected that acupuncture students from anytraining background, as well as those practising theother ‘discrete clinical disciplines’, should be able todemonstrate the levels of competence recommendedby the BMA (1993) (Box 1).

Acupuncture organisations

Medically qualified individuals can undertake part-time training (for example, short courses of up to fivedays duration or during weekends) provided by theBritish Medical Acupuncture Society (BMAS).Qualifications are awarded at basic, intermediate andadvanced level and BMAS accreditation requires 100hours of learning and a presentation of 100 fullydocumented cases. Full training and clinicalexperience in acupuncture leads to the Diploma inMedical Acupuncture. BMAS promotional literature


confirms that teaching on the basic course is based onscientific explanations for acupuncture as far aspossible, but it also involves traditional Chineseconcepts “at a simple level, when there is still noWestern explanation for the effects in particulardisease”.

The Acupuncture Association of CharteredPhysiotherapists (AACP) provides four categories ofmembership, according to the degree of trainingundertaken. An ‘advanced member’ will be a fullyqualified state registered physiotherapist who willhave undertaken at least 200 hours of training—theAACP confirms that individuals in this category arelikely to be practising Traditional ChineseAcupuncture, but also to be involved in research.

The British Acupuncture Council has providedsubstantive guidelines for acupuncture education forinstitutions wishing to be accredited by BAcC. Suchcourses require study over 3,600 hours, with 200 hourspersonal management of patients through all aspects oftheir treatment. Courses will include biomedicalsciences, anatomy and safe needling, diagnosis ofserious underlying pathology, ethics and practicemanagement.

The British Academy of Western Acupuncture(BAWA) is affiliated with BMAS, and was founded “inorder to promote, enhance and unify the practice ofacupuncture in the UK”. It aims to ensure a highstandard of practice within the NHS and privatesectors. Membership is open to those with “suitablemedical qualifications” including medical doctors,physiotherapists, and registered general nurses with aminimum of three years post-graduate experience.There are two grades of membership, granted tograduates of the BAWA Education Department’sLicentiate Course.


The Fook Sang Association is an independent bodyoffering specialist professional training in scientificand traditional methods of Chinese acupuncture andherbal medicine ‘as taught in China’. The organisationoffers flexible prescriptions in natural Chinese herbalmedicine, including Chinese Folk Medicine using‘genuine Chinese diagnosis’.

The European Federation of Modern Acupuncture is‘an umbrella organisation enabling trainingestablishments to enter into dialogue on matters oftraining standards’. Individual membership level isdependent on the degree of training undertaken atbasic, intermediate and advanced level. Practitionerspractise ‘modern acupuncture’ using a variety ofmeans to measure the activity of acupuncture points/meridians, prior to treatment. Electronic, electrical andbioresonance devices are commonly used.

Members of the Modern Acupuncture Associationundertake acupuncture training, clinical and tutorialstudies, together with bioresonance or Voll systems,clinical kinesiology and auricular therapy.Practitioners vary widely in their approach, fromneedling to electroacupuncture, to changing theelectro-potential of points by touch.

While differences in the training requirements of thevarious organisations do to some extent reflect the prioreducational background of the students, there is a needfor a consensus on the minimum standards of trainingrequired for all potential acupuncture practitioners. Asdiscussed earlier, this should encompass basicknowledge of anatomy and physiology, awareness oflimitations of competence, and so forth.

An updated edition of the University of Exetersurvey of CAM bodies (Mills and Budd, 2000) providesan important overview of the current status ofpractitioners, differentiating between those who work


as statutory health professionals (mainly doctors andphysiotherapists) and those who work primarily asspecialist acupuncturists. As well as differentregulatory concerns, the report comments that theformer “sometimes take the view that acupuncture is atechnique to complement their conventional practicerather than an autonomous therapy (this is reflected intheir educational requirements)”. (See Appendices IIand III for more information about theseorganisations).

National guidelines for acupuncturetraining

With the increasing use of acupuncture, the need for acommon language to facilitate communication inteaching, research, clinical practice and exchange ofinformation became essential. The World HealthOrganization (WHO) convened a scientific groupwhich approved a standard international nomenclatureand published Guidelines on Basic Training and Safetyin Acupuncture in 1999, (WHO 1999). This documentconsiders:

• the use of acupuncture in national health systems• levels of training• training programmes• safety• the importance of disinfection, equipment

sterilisation, etc

The WHO recommendations for acupuncture trainingprogrammes cover personnel at various levels,including:

• acupuncture practitioners intending to work innational health services, who would have completed


secondary schooling, university entrance orequivalent (and covered ‘the basic sciences’)

• full training/limited training for qualifiedphysicians

• limited training for primary health care personnel.

National occupational standards inCAM

In the UK, an independent national trainingorganisation, Healthwork UK, is assessing trainingneeds for some professions within the health caresector. Its declared aim with regard to CAM is to assistpractitioners in each area of CAM to work together toset high standards of practice, ensure quality educationand training, and promote effective self-regulation.They recommend the establishment of a single leadbody for each therapy that should represent at least80% of the CAM practitioners currently practising aparticular therapy. So far, national occupationalstandards have been published in aromatherapy,hypnotherapy, reflexology and homoeopathy(Healthwork UK, 1999, 2000). Healthwork UK hasentered into discussions with the key UK acupunctureorganisations about education and training standards.

Summary

With such a diversity of acupuncture organisations andqualifications, there is a need for the acceptance of acore curriculum for practitioners, including aspects ofanatomy and physiology, research methodology,acupuncture techniques, fundamentals of orthodoxdiagnosis, and ethics. The courses should be of acredible duration and type to provide competent


practitioners, with the ability to equip the studentswith the core competencies outlined in Box 1.


5Acupuncture in primary care

Introduction

Previous studies undertaken in a number of countrieshave investigated the use of complementary medicineas a treatment option by general practitioners (GPs).Researchers have examined the demographic details ofGPs to discover whether there are any noticeablecharacteristics that influence CAM use. Younger GPshave demonstrated a more positive attitude towardsCAM, more use of CAM, and greater inclination torefer their patients to CAM practitioners than theirolder colleagues (Visser and Peters, 1990; Bermanet al., 1998). It has also been suggested that they havegreater interest in receiving training in at least oneCAM therapy (Franklin, 1992) and to refer to non-medically qualified practitioners (Wharton andLewith, 1986). The type of general practice has alsobeen found by some to relate to the practice of CAM;Verhoef and Sutherland (1995) found that those GPsworking alone were more likely to refer to CAMtherapists than those in a group practice, as didAnderson and Anderson (1987). Practitioners workingalone may be more individualistic and more likely totry unorthodox treatment options, or they may besubject to less peer influence. Gender differences have

been reported by some (Verhoef and Sutherland, 1995;White et al., 1997), but not by others (Hadley, 1988),while referral has been reported to be more likely if theGP has personally used CAM (Reilly, 1983).

Provision of CAM by GPs

In England, a large postal survey found that 21.3% ofGPs had referred patients for CAM in the preceedingweek, and that 44.8% had endorsed or recommendedCAM in the same period (Thomas et al., 1995). Theauthors estimated that 39.5% of GP practices inEngland provide access to some form of CAM for theirNHS patients. Acupuncture is one of the most populartherapies with reports citing from 19.8% (Andersonand Anderson, 1987) to 66% (Perkin et al., 1994) of GPssampled suggesting acupuncture treatment to theirpatients and arranging the treatment for them. Onestudy in the south-west of England found 8% of GPssurveyed had arranged for their patients to visit anacupuncturist in one week alone, 4.3% had givenacupuncture treatment themselves and 19.3% hadendorsed acupuncture treatment (White et al., 1997).Conditions for which GPs arrange acupuncturetreatment include chronic pain, general pain, asthma,musculoskeletal indications, headaches, smoking,obesity, and tenosynovitis (Reilly, 1983; Knipschildet al., 1990; Franklin, 1992; Verhoef and Sutherland,1995).

Reasons given by GPs for arranging treatment bycomplementary therapists for their patients includedoctors’ confidence in the practitioner or the therapyitself, with some GPs believing that the treatmentinvolves ideas and methods from which the orthodoxpractices might benefit. Half of GPs in one study citedlack of response to conventional treatment, 21% cited


patient preference or request, and a further 21%believed in the effectiveness of CAM for certaindisorders (Visser and Peters, 1990). Reasons given bydoctors for non-referral include lack of availableinformation, lack of belief in its efficacy, or that thetreatment was not discussed (Franklin, 1992). Ernstand White (1999a), however, conclude that in surveysof doctors conducted since 1990, usually over one halfof the respondents “have a positive attitude or believethat acupuncture works”.

In terms of which healthcare practitioners GPs preferto provide the treatment to their patients, preferenceseems to lie with other medical practitioners orphysiotherapists (Hadley, 1988; Visser and Petas,1990), although 87% of doctors in one study supportedthe right of “lay persons” to practise CAM (Franklin,1992). Fairly high numbers of GPs have reporteddiscussing CAM options with their patients (Andersonand Anderson, 1987; Visser and Peter, 1990), althoughfew doctors in a study of 461 GPs in south-westEngland reported feeling confident enough to discussacupuncture with their patients (White et al., 1997).Perkin et al. (1994) reported 68% of GPs’ patients hadrequested referral for acupuncture.

GPs’ knowledge about acupuncture

Interestingly, despite the relatively high numbers ofGPs arranging for their patients to visit acupuncturists,GPs tend to rate their knowledge about the therapy asrelatively poor—for example, 78% of GPs in Avon,England rated their knowledge as poor or very poor(Wharton and Lewith, 1986). Perkin et al. (1994) foundthat although 95% of GPs knew the principles ofacupuncture, only 24% knew the qualifications of thepractitioners. As the authors point out, this is

ACUPUNCTURE IN PRIMARY CARE 65

significant since doctors have an obligation to knowthe potential benefits and harm of making suchreferrals and fundamental to this is an awareness ofwhat constitutes a properly trained practitioner. Inaddition to this, the NHS Confederation (1997) foundthat whilst patients do not necessarily see the NHS astheir provider of CAM treatment, they do see NHShealth professionals as an information source for CAM.With low levels of knowledge, GPs may be unable tofulfil this patient expectation.

The majority of the doctors still regardedacupuncture as a useful therapy despite their limitedknowledge, and a small number had received sometraining in it. These numbers varied betweenstudies, ranging from 3% in the UK (Wharton andLewith, 1986), to 12% in New Zealand (Hadley, 1988),to 20% in Canada (Verhoef and Sutherland, 1995).Greater numbers expressed the desire to receive someform of training in acupuncture (ranging from 6% to50%), or in another CAM therapy.

These studies are open to criticism since many havebeen based on small samples which may not berepresentative of the GP population as a whole. Thosethat were conducted outside the UK cannot necessarilybe applied to the UK situation, and UK studies weregenerally not nationwide. They have tended toconcentrate on complementary and alternativemedicine as a whole and have not focused on anyspecific therapy. The BMA Board of Science andEducation carried out a postal questionnaire survey ofGPs to address the 1998 BMA ARM resolution, and toestablish to what extent acupuncture is being usedwithin primary care services in the UK at the presenttime.


BMA survey—The use of acupuncturein primary care services

A random sample of 650 UK general practitioners wasselected from the BMA GP members’ database of27,922, representing 1.6% of the GP population overalland 2.3% of BMA GP members. The GPs were sent afour-page questionnaire containing 31 questions inJune 1999, and an initial response rate of 43% (n=280)was obtained, which increased to 56% (n=365) aftersending a reminder to non-responders. Somerespondents did not answer all of the questions; thepercentages reported here were calculated from thevarying number of responses provided to eachquestion, and these numbers are indicated. For mainquestions the number of ‘no replies’ is stated. The time-scale used was whether the GP had ever used CAM, inparticular acupuncture, in their treatment options.

Major aims of the survey were:

1. To determine the extent to which acupunctureservices are now being offered to patients viaprimary care services in the UK

2. To investigate GP opinions on who should provideacupuncture treatment

3. To investigate reasons why GPs may not arrangeacupuncture treatment for their patients

4. To investigate levels of knowledge and training ofacupuncture among GPs

5. To assess GP attitudes towards the provision ofacupuncture in the NHS.

A summary of the main results can be seen in thediscussion section, page 77.


1.Extent of acupuncture services beingoffered to patients via primary care

services in the UK

A large proportion of the responding GPs (58%; n=208/358) reported that they had arranged CAM for theirpatients, with the most popular therapies beingacupuncture (47%; n=169), followed by osteopathy(30%) and homoeopathy (25%) (Figure 1). As well asthese main therapies, some GPs specified arranginghealing, massage, reflexology, clinical ecology, BachFlower remedies, Bowen technique, and hypnotherapy.No significant differences in referral were foundbetween age groups or gender. A significant, but small,number of the GPs (11%; n=41) employed acomplementary therapist in their practice, whilst 41%(n=150) provided the services of a physiotherapist.

Location of acupuncture treatmentprovision

Of the 169 GPs arranging acupuncture treatment fortheir patients, 160 provided details of where it wasadministered. It was reported to be provided mainlywithin an orthodox healthcare setting such as the GPs’own surgeries (48%), in pain clinics (23%),physiotherapy departments (16%) and other NHSsurgeries, clinics or non-homoeopathic hospitals(23%). Very few doctors arranged treatment at privatehomoeopathic clinics or hospitals (11%), NHShomoeopathic clinics or hospitals (4%), or in hospices(3%).


Conditions treated

Of the 169 GPs who reported arranging acupuncturetreatment for their patients, 161 gave details of whichmedical conditions they did so for, shown in Figure 2.Pain relief and musculoskeletal disorders were themost frequently cited. Miscellaneous conditions whichGPs treated using acupuncture included recurrenturinary infections, drug withdrawal, migraine, Bell’sPalsy, hayfever and phantom limb syndrome, irritablebowel syndrome, anosmia (loss of sense of smell), andmorning sickness.

Figure 1: Percentage of GPs arranging specific CAMtherapies for their patients (n=358, no replies=7/365)


2.GPs’ attitudes towards which

healthcare professionals shouldprovide acupuncture treatment

Attitudes towards which healthcareprofessionals should provide

acupuncture treatment

The GPs who reported not having arranged treatmentfor their patients (n=191) were asked which healthcareprofessionals they thought should provide the service.There was a significant bias in favour of registeredmedical practitioners, followed by physiotherapistsand dentists. Less than half thought traditional ChineseMedical Practitioners should provide the service. Thesame question was asked of those GPs who had

Figure 2: Percentage of GPs arranging acupuncturetreatment for different conditions (n=161, no replies=8/169)


arranged acupuncture treatment, and they were foundto have very similar attitudes. (Table 9). Theseattitudes and the actual referral practices as shown inFigure 3 differ markedly.

Table 9: GPs’ views of which type of health professionalsshould provide acupuncture services

Which healthcare professionalsactually provide the treatment

Of the 169 GPs who reported arranging acupuncturetreatment for their patients, 162 gave details of whichhealthcare professionals provided the treatment. Anumber of GPs reported using more than one type ofhealthcare professional to provide acupuncturetreatment for their patients, with the majority using theservices of those already established in primaryhealthcare, another doctor (57%), a physiotherapist(24%), or themselves (15%). Although 19% stated thatthey arranged treatment by another complementarymedicine practitioner, only 5% arranged treatment bya Traditional Chinese Medicine practitioner. A smallnumber of doctors also reported referring to nurses,midwives, consultant anaesthetists, and healthcare


workers in pain clinics, rheumatology clinics and drugclinics. (Figure 3).Many respondents commented on how they wouldchoose an acupuncturist (n=156, no replies=13/169); alarge number relied upon ‘word of mouth’ (48%). Only2% consulted a professional acupuncture organisation,the same percentage chose through local advertising,while 23% said they assessed the qualifications ortraining of an individual themselves.

Figure 3: Which healthcare professionals actually providethe acupuncture treatment? (n=162, no replies=7/169)


3.Reasons why GPs may not arrange

acupuncture treatm ent for theirpatients

While acupuncture was reported to be the most widelyused CAM treatment, just over half of the respondentshad never used it in their treatment options (53%,n=191/358). Three main reasons for this were cited bythose who gave reasons (n=188/191) (some GPsprovided more than one reason):

• Lack of demand from the patients• Lack of knowledge/information of services available

(63%)• Lack of guidelines to assess the competency of

acupuncturists (45%) (See Figure 4 for furtherreasons).

4.Levels of knowledge and training of

acupuncture among GPs

The majority of GPs reported having either very littleknowledge of complementary medicine (30%) or onlyknowing the basic details (52%). This was also true fortheir personal awareness of acupuncture (n=364, noreplies=1/365), with 31% having very littleknowledge, 53% knowing only the basic details, 6%knowing a considerable amount, and 10% felt theyknew a lot about the subject. Most of the GPs whospecified where they had received their knowledge andtraining about acupuncture (n=63) reported that theyhad attended a course. None reported receiving anyacupuncture education at medical school. (Table 10).


Table 10: Source of GP knowledge about acupuncture(n=63)

The proportion of doctors who personally performedacupuncture for their patients (15%, n=25/162) and

Figure 4: GPs’ reasons for not arranging acupuncturetreatment for their patients(n=188/191)


those who considered themselves to have sufficientknowledge and training to perform it (12%, n=41/354),closely corresponded.

Almost half of the GPs (46% n=156/340) said theywould like to receive some training in acupuncture inorder to treat their patients in the future. This attitudewas the same for those GPs who were already usingacupuncture in their treatment options and those whowere not, suggesting a large number of GPs areinterested in the therapy regardless of whether theyhave made arrangements for their patients to receive itin the past.

Communication

Communication between patients and GPs appearsmixed; in terms of patients initiating the discussionabout acupuncture, the majority of GPs reported thattheir patients rarely (49%, n=176/359) or onlyoccasionally (37%, n=134/359) do so. Only 6% of GPssaid their patients frequently initiated the discussion,and 8% said patients had never raised the subject.

However, on uptake of the acupuncture treatment,communication between GP and patient is high, withonly 3% (n=5/160) of GPs stating that they neverreceive feedback from the patient on the efficacy of thetreatment, and most (49%, n=78/160) stating that they‘usually’ receive feedback. In terms of communicationbetween the GPs and the acupuncturists (n=158, noreplies=11/169), the majority of GPs ‘sometimes’ liaisedirectly with the acupuncturist about the patient’streatment (36%) or ‘usually’ do (27%). Only 18%‘always’ liaise with the acupuncturist and a similarnumber (19%) never do.


5.GPs’ attitudes to the provision of

acupuncture in the NHS

Overall, 79% (n=265/336) of the GPs agreed that theywould like to see acupuncture available on the NHS.Similar reasons for this belief were given by GPs whohad not referred patients to an acupuncturist, as weregiven by those who had (Figure 5).Of the 21% (n=71/336) of doctors who felt that itwould be inappropriate to make acupuncture availableon the NHS, the principal reasons given were:

• lack of evidence (34%)• lack of time and financial resources (54%)• belief that it is a non-essential service (5%).

Figure 5: GPs’ reasons for wanting acupuncture available onthe NHS (n=265 no replies=29/365)


Discussion

The main findings are as follows:

• The results are based on the responses of 365 GPs(56% response rate)

• 58% of responders had arranged CAM for theirpatients

• 47% (n=169) of responders had arrangedacupuncture for their patients

• Almost half the acupuncture arranged was providedin the GP surgery

• 15% of GPs who had arranged acupuncture,provided it themselves. 57% used another doctor.24% had used a physiotherapist and only 5% hadused a TCM practitioner

• Acupuncture was most commonly arranged for painrelief and musculoskeletal disorders

• 97% of GPs who arranged acupuncture said theyreceived feedback from their patients. Only 18%said that they always liaised with the acupuncturistfollowing a referral

• Whether they had used acupuncture or not,responding GPs believed that doctors andphysiotherapists were the most appropriateproviders of acupuncture in primary care. However,almost half of all responding GPs believed that TCMacupuncturists were suitable providers

• GPs not using acupuncture cited lack of patientdemand, lack of knowledge or information aboutservices available, lack of guidelines to assesscompetency of acupuncturists, and lack of financialresources as the most common reasons for not doingso

• 16% of responding GPs said that they had“considerable knowledge” of acupuncture or “knewa lot about the subject”


• 46% of responding GPs said that they would like toreceive further training in acupuncture in order totreat their own patients in the future

• 79% of responding GPs would like to seeacupuncture provided in the NHS.

The survey has confirmed the findings of a previousstudy of general practitioners’ use of CAM in England(Thomas et al., 1995), indicating that a large proportionof general medical practitioners nationally are likely tobe using CAM therapies in their treatment options,particularly acupuncture. The number of overallrespondents is small, although compared to otherstudies that have investigated doctors’ use of CAM,this number is relatively large. There is a possibilitythat there was response bias, since those GPs who useacupuncture in their treatment options may haveperceived the subject as more salient than those GPswho did not, and hence had greater motivation torespond. This might, therefore, have influenced thefindings for the GP group as a whole, although it isunlikely that it will have affected the results from theselective group of GPs arranging acupuncture.

As has been found previously, knowledge andtraining in CAM and acupuncture among the GPpopulation was found to be low overall, while thedesire for training for acupuncture was found to begenerally high. This discrepancy needs to be addressed,perhaps through GP educational initiatives orcontinuing professional development, detailingconditions that can be treated with acupuncture, theevidence base of acupuncture, details of courses,qualifications, and so forth.

The NHS Confederation (1997) found that patientsview NHS health professionals as an informationsource about CAM, although they did not view them as


the providers of the treatment. However, only a smallproportion of GPs in this study reported their patientsinitiating the discussion on acupuncture, and a largeproportion of the GPs who gave reasons for notarranging acupuncture for their patients, stated therewas no patient demand. With an estimated one in fivepeople in the UK using some form of CAM (Ernst andWhite, 2000), their demand must be finding a differentoutlet. Those referrals and delegations documentedhere might very well be mainly professionally ledrather than patient-led. It is possible that this situationhas arisen because patients are concerned about theirGPs’ opinions of CAM and if this is found to be thecase in any future research, ways to alleviate thisconcern should be sought. Mills and Budd (2000)speculate that if there was evidence that professionalsfrom across the healthcare spectrum were engaging in“constructive debate about their relative roles”, greatercommunication might be encouraged between patientsand individual practitioners.

Communication between the GPs and their patients’acupuncturists was found to be mixed, with only asmall proportion of GPs reporting that they alwayscommunicate with the acupuncturist. With no adviceto guide GPs on choosing an acupuncturist and liasingwith them, it is likely that this situation will remainthe same. The opportunity to exchange details of theirpatients’ medical histories, and hence inform eachother in the event of an adverse event, may be missed.

The survey has revealed a discrepancy between theresponding GPs’ attitudes about which type ofhealthcare professional should in theory provideacupuncture treatment for their patients, and whichtype they recommend in practice. Almost half of thosearranging acupuncture treatment felt TraditionalChinese Medicine practitioners should provide the


treatment, but only 5% used such a practitioner inpractice. A greater number of GPs were found to referto medically qualified practitioners, rather than toother types of therapist, as has been found in previousstudies. This could be due to the divide betweenWestern and Traditional Chinese Medicineacupuncture itself. Most medically qualifiedacupuncturists practise Western acupuncture. Thesplit between the Western approach to acupunctureand the traditional approach is one that tends to dividethe medical profession and practitioners ofacupuncture alike, and may prove difficult to resolvein a regulatory system. Future high quality researchinto both styles of practice may prove beneficial in thisdebate.

On the other hand, the discrepancy between thetheory and practice of referral/delegation by the GPscould be due to the local level of service provision andthe GPs’ level of knowledge about it. One of theprincipal reasons GPs gave for not wishing to arrangeacupuncture treatment for their patients was their lackof knowledge and information of services available.Considering that most GPs choose their acupuncturistsby word of mouth, it perhaps isn’t surprising that thevast majority arranged for treatment to be provided bytheir medical colleagues. Finally, one furtherconsideration for this discrepancy is that when GPsrefer to medically qualified acupuncturists, they are notrequired to assess their competence since theirregistration with the GMC is taken as evidence of that.However, in delegating to a non-medically qualifiedacupuncturist, the GP is responsible for assessing thetraining, qualifications and experience of thatindividual, a responsibility the GP might feel unable tofulfil adequately.


Regardless of whether they had ever arrangedacupuncture treatment for their patients in the past,the majority of GPs believed that acupuncture shouldbe available on the NHS. The principal reason givenfor this belief was that acupuncture has provenefficacy. However, as has been discussed inchapter two, so far evidence in favour of acupuncturehas been found for only a small number of conditions.There is no strong evidence in favour of usingacupuncture for smoking cessation, but a significantnumber of the GPs reported arranging acupuncture fortheir patients for this reason. There is therefore a needfor dissemination of information to GPs. Other reasonsgiven by the GPs for making acupuncture available onthe NHS included increased choice for both patientsand doctors, and a reduction in the use of prescriptiondrugs. With such support for the move to makeacupuncture available on the NHS, and such highnumbers of GPs already using it in their treatmentoptions, consideration should be given to ways ofmaking it more easily accessible.

The 1986 BMA report Alternative Therapycommented, “Time, touch and compassion are allfeatures of good medical practice. Alternativetherapists do not have a unique claim on these aspectsof healing, or a monopoly on their use”. However, thepressures of a busy general practice may tend to limitthe extent to which a medical practitioner can applyappropriate time-consuming skills, when on averageonly seven minutes of consultation time per doctor areavailable for each patient (Venning et al., 2000).Further research into efficacy, safety and cost-effectiveness is crucial therefore, to the futuredevelopment of CAM practice within primary care.


6Future developments

Introduction

This report has confirmed that the provision of patientaccess to complementary medicine via primary care iswidespread in the United Kingdom. Our surveyreflects that over half of GPs nationally will considerarranging CAM treatment for their patients, andacupuncture is the most widely used therapy.

Efficacy, safety and training

Randomised controlled trials have demonstrated thatacupuncture is more effective than sham acupuncture(or other experimental control interventions) fornausea and vomiting, back pain, dental pain andmigraine. For other conditions, the evidence isuncertain. In terms of safety, few major adversereactions to acupuncture treatment are reported incomparison to adverse reactions to orthodoxinterventions. For example, non-steroidal anti-inflammatory drugs (NSAIDs) prescribed for back painand arthritis have been estimated to cause one death inevery 1,200 patients who take them orally for atleast2 months. Extrapolated to an annual estimate,approximately 2,000 deaths occur in the UK which

would not otherwise have taken place had the patientsnot taken the NSAIDs (Tramer et al., 2000).

Opportunities for training in acupuncture, both formedically qualified and non-medically qualifiedindividuals, have increased in recent years. Theadvent of validated degree courses and the emergenceof CAM (elective) modules in the medical curriculumare evidence of greater acceptance, where previouslyattitudes may have been radically different. Allacupuncture courses (eg undergraduate courses,weekend courses) should contain basic anatomy andphysiology modules, with particular emphasis on thelocation and depth of major organs, and first aid skills.

Survey of GPs

Our snapshot survey of attitudes to CAM in generalpractice in the UK in 1999 has confirmed the findingsof a previous study of general practitioners in England(Thomas et al., 1995), indicating that large numbers ofGPs are arranging CAM treatment for their patients.However, more GPs are now arranging acupuncturetreatment (47% in 1999 versus 22% in 1995), with apreference for practitioners who are healthcareprofessionals, such as doctors or physiotherapists.

Overall levels of knowledge of acupuncture amongGPs are low, although almost half of the BMA postalsurvey respondents indicated they would like toreceive further training in the therapy in order to treattheir patients in the future, regardless of whether theyhad ever arranged acupuncture treatment. Both thesefactors could be addressed by continuing professionaldevelopment (CPD) opportunities. Those GPs whohave not arranged acupuncture treatment for theirpatients cited reasons including lack of knowledge of


local services, lack of guidelines and lack of patientdemand.

The Medical Care Research Unit, in a major study ofprimary care CAM provision (Luff and Thomas, 1999),identified two key issues that underpin perceptions ofthe sustainability of complementary therapy services;credibility (cost-effectiveness and science base) andfunding.

Funding

The provision of acupuncture treatment has flourisheddespite lack of widespread knowledge of its efficacy,lack of comprehensive guidelines for either GPs orpatients, and without national regulatory and safetystandards being in place for the practitionersthemselves. One fundamental issue concerns funding,both for research and for service provision. In aprimary care-led NHS, 86% of all health problems aremanaged entirely within primary care (DoH, 1999).The Government’s current primary care research anddevelopment (R&D) strategy is summarised in R&D inPrimary Care National Working Group Report (DoH,1997), and was accompanied by a ministerialcommitment to increase R&D spending on primary careresearch to £50 million by 2002–3. Figures show thatonly 0.08% of the NHS R&D funds were used incomplementary medicine in 1996 (Ernst, 1996).Funding for service provision in the NHS based onevidence-based medicine depends on the availability ofevidence of efficacy of the treatment. Large-scale trialsare the best way to obtain this data, but are expensiveto undertake. Research funds are urgently needed.

Sources of funding could include the NHS, MedicalResearch Council (MRC), via independent or jointinitiatives, the Wellcome Trust, King’s Fund, or

FUTURE DEVELOPMENTS 85

perhaps The National Lottery. In fact, in February thisyear, the King’s Fund awarded the Foundation forIntegrated Medicine a substantial grant of £1 million tosupport their work on regulation. The EuropeanCommission’s analysis of unconventional medicine(EC, 1998) recommended that those agencies, whethergovernmental or voluntary, who currently make fundsavailable for research should be encouraged to allow forsubmissions from those working in unconventionalmedicine. Equally, CAM practitioners should ensurethat their methodologies are in accordance withstandards of good quality research. In the last fiveyears the MRC has received six applications for grantsupport from researchers of CAM therapies,for relaxation techniques, herbal medicine,chiropractic, acupuncture, homoeopathy andhypnosis. All but one (a trial of chiropractic treatmentfor back pain in primary care) has failed to reach thecompetitive standard required for funding. Support isgiven to potential applicants in the form of advice ondeveloping successful applications, which mayinclude guidance from the Clinical Trials Manager ontrial design, or in some cases, practical statistical help.The MRC have been involved in meetings with theFoundation for Integrated Medicine and also have aplace on the Homoeopathic Trust Research Committee.The MRC and DoH have a joint initiative for researchin primary care.

The NHS research and development budget for2000–2001 will be over £448 million. There are nodedicated funds for research into CAM. Two grantshave recently been awarded to researchers ofacupuncture in the NHS Health TechnologyAssessment Programme (HTA). Both studies arepragmatic RCTs which also examine cost-effectiveness;one will evaluate the offer of acupuncture to patients


with low back pain assessed as suitable for primarycare management (mentioned in chapter 2), the otherwill evaluate acupuncture delivered byphysiotherapists to patients with chronic migraine.The HTA programme aims to identify the mostimportant gaps in the current knowledge that the NHShas about health technologies by soundings from keypeople and organisations, extracting researchrecommendations from high quality systematicreviews of research evidence, and using the HorizonScanning Centre in the University of Birmingham.Criteria used in assessing research priorities include:what the benefits are from research in terms of reduceduncertainty, how long it might be before any benefitscould be realised, and whether the assessment wouldbe likely to offer value for money.

A separate NHS R&D programme, the ServiceDelivery and Organisation Programme, aims to“produce and promote the use of research evidenceabout how organisation and delivery of services can beimproved to increase the quality of patient care, ensurebetter strategic outcomes and contribute to improvedhealth” (DoH, May 2000). Such a programme couldpossibly provide funding for suitable research into theprovision of acupuncture in primary care.

Further sources of funding for research includemedical charities which spent 0.05% of their totalresearch budget on CAM in 1999 (Ernst, 1999), andinstitutions which provide funding solely for CAM—the Blackie Foundation Trust, The HomoeopathicTrust, and the Foundation for Integrated Medicine. The1993 BMA report suggested that many CAM therapistsand organisations may not have the resources todevelop adequate research infrastructure, and sofunding from grant awarding medical researchorganisations appears essential to enable this


development; as such funding has not been substantivein recent years the prospect of monies dedicated toencouraging and supporting high quality researchshould be considered. This would ensure funds aredirected appropriately and would assist targeting andmeasurement of funding levels.

Cost-effectiveness

Cost-effectiveness will be an important issue for thepotential future integration of acupuncture into theNHS. Very little is known about this issue (vanHaselen, 1999), and there are few robust studies whichhave tackled it. Due to the lack of high technology inmost CAM therapies, it is a common assumption thatthey will be less expensive than orthodox medicine.However, CAM consultations may take on average sixtimes longer than GP consultations (Fulder andMunro, 1985). White et al. (1996) outlined four areaswhere cost savings might be made by using CAM: costof drugs, visits to GP, secondary referrals and reducingadverse events of orthodox therapy. The analysis usedto evaluate these savings can use the same factors thatare used within orthodox medicine for economicevaluation; cost-comparison, cost-utility analysis,cost- effectiveness analysis, cost descriptions, and costbenefit analysis (White and Ernst, 2000). However,research conducted into the cost-effectiveness of CAMhas tended not to follow such strong theoretical bases.

A systematic review of studies addressing the issueof economic analysis in CAM concluded that there is alack of experimentally robust studies from which todraw conclusive evidence of differences between thecosts and outcomes between complementary therapiesand orthodox medicine (White and Ernst, 2000). Themajority of studies which report evidence in favour of


the CAM therapies, that is, evidence of reducedreferral and treatment costs, are retrospective, whilemore rigorous and prospective studies suggest CAM is“an additional expense and does not substitute fororthodox care”.

Economic analysis of acupuncture has suggestedsavings in reduced drug expenditure (Myers, 1991),reduced length of stay in hospital (Johansson, 1993)and reduced need for surgery for osteoarthritis of theknee (Christenssen et al., 1992). Lindall (1999)concluded from a study of 65 patients suffering pain,that for selected patients, and when used by anappropriately qualified practitioner, acupunctureappeared to be a cost effective therapy for use ingeneral practice, reducing the need for more expensivehospital referrals. An average minimum total saving foreach patient was estimated at £232. However, due tomethodological limitations the findings of thesestudies are not conclusive (White and Ernst, 2000).There is a need for high quality research into both thecosts and benefits of acupuncture, particularly asprimary care groups and trusts outline their healthimprovement plans in line with a remit to provide acost-effective service.

Integration into the NHS

Over the last decade or so there have been majororganisational and structural changes within primarycare in the NHS. The late 1980s brought theintroduction of fundholding (1989), and more recentlyprimary care groups (PCGs) have been introduced inEngland (Local Health Groups in Wales, and LocalHealth Care Co-operatives in Scotland and NorthernIreland) (1999), which will eventually develop intoprimary care trusts (PCTs). One of the aims of


fundholding was to give GPs greater awareness of, andresponsibility for, their use of secondary care services,and the change was intended to lead to improved costcontainment, cost-effectiveness, quality of care, patientchoice and empowerment. There is consistentevidence that fundholding practices provided betteraccess to secondary services, greater development ofnew practice-based services for patients, and reducedwaiting lists (Samuel, 1992; Dowling, 1997). Theprovision of CAM was also facilitated by GPfundholding, since those fundholding practices wereable to use the staff element of their budget to employCAM practitioners. Non-fundholding GPs, on the otherhand, were able to use their ancillary staff budget forthis purpose, but at the expense of another member ofstaff. Local health commissions and authorities havesometimes used money for R&D or for waiting listinitiatives to finance CAM provision (Zollman andVickers, 1999).

With the NHS reforms in April 1999, uncertaintyregarding the position of CAM in the NHS has emerged.PCGs are subcommittees of Health Authorities (HAs)and are dependent on them for some commissioningsupport. Their responsibilities include (NHSE 1998):

• to improve the health of, and address healthinequalities in, their communities

• to develop primary care and community services(with an emphasis on reducing variability ofservices, developing clinical governance andincreasing integration of primary and communitycare services)

• to advise on, or commission directly, a range ofhospital services.


The introduction of the Health ImprovementProgramme (HImP) process will further assist PCGsand PCTs in strategic planning, taking account oflocally determined needs, as well as nationalpriorities. Concerns have been raised over whetherCAM will be identified as a priority by significantnumbers of GPs in individual PCGs; there is a risk thatin the changeover from fundholding practices to PCGs,some established CAM services may be lost (Zollmanand Vickers, 1999). With renewed emphasis on financeand efficiency, CAM therapies could be the firstservice to go.

Eventually PCGs will progress to Primary Care Truststatus, which will be statutory bodies rather thansubcommittees of Health Authorities. Being the solecommissioning bodies in the NHS, PCTs will beresponsible for the commissioning of both primary andsecondary care, and for the provision of primary care.

Models of provision of acupuncture inprimary care

In order to facilitate the potential integration ofacupuncture, and other CAM services, into the NHS, agreater understanding is required of possible models ofprovision. The Foundation for Integrated Medicine(1997), the Scottish Office Department of Health (1996)and the Medical Care Research Unit in Sheffield (Luffand Thomas, 1999) have examined methods used ingeneral practice within England, Wales and Scotland.These include on-site provision by healthcareprofessionals, on-site provision by privatepractitioners, referral to NHS hospitals orcomplementary medicine referral centres, delegationsto off-site private practitioners, and the use ofnetworks of experienced medically qualified


complementary practitioners (as has been establishedfor homoeopathy at the Glasgow HomoeopathicHospital). With the first Primary Care Trusts ‘goinglive’ this year, priority should be given to investigatingnationally the optimum method of service provision.

Concerns have been raised about the limitations ofCAM service provision on the NHS (Worth, 1995), andpoints have been highlighted which could possiblydilute the true potential of CAM when it is integrated.For example, Worth (1995) has warned that:

• The use of CAM therapies may be restricted tominor ailments or, at the other end of the scale, tochronic and incurable diseases where CAM is oftenviewed as the last resort

• CAM therapies sometimes may not show benefits asrapidly as conventional medicine, and doctors mayresort too quickly to orthodox drugs if a conditiondoes not improve within set time limits

• In addition, if CAM is subsumed withinconventional medicine the opportunity to be“different” could be lost.

However, if the integration is accompanied bysufficient information and training opportunities forall involved, these risks may never materialise.

Guidance for Primary Care Groupsand Trusts

GPs face potentially confusing guidance regardingtheir role in arranging for their patients to see CAMpractitioners. Those GPs in our survey who did notbelieve it appropriate for acupuncture to be madeavailable on the NHS (21%) cited reasons ranging fromthere being no proven efficacy and safety concerns, tothere being no local services and a lack of information


about acupuncture. The NHS Confederation report(1997) Complementary Medicine in the NHS:managing the issues, discovered four barriers tofurthering complementary medicine usage which wereconsistently identified by healthcare purchasers,similar to the reasons GPs in our survey gave for notarranging acupuncture treatment for their patients.These were: lack of knowledge about therapists whoshould treat referred patients, lack of available funds,concern about the competence of practitioners, andlack of evidence. The doctors surveyed in the NHSConfederation report (1997) found an increase in thenumbers of patients requesting information aboutCAM, although the patients did not necessarily viewthe NHS as their provider of CAM, but rather viewedthe healthcare professionals as an information source.This patient perception adds to the importance ofproviding comprehensive information and guidancefor general practitioners, particularly in light of ourfindings that 58% are arranging some form of CAM fortheir patients.

Guidelines for GPs should cover the following:

• Definition of acupuncture• Where to find a local practitioner• Details of what qualifications are expected of

practitioners• Details of GPs’ medico-legal position• Which conditions are likely to benefit from

acupuncture• Responsibilities in employing an acupuncturist—

West Yorkshire Health Authority (1995) producedguidelines for GPs for the employment ofcomplementary therapists in the NHS. Updated,nationally available guidance should now be drawnup

• Where to obtain further information, contacts, etc


• Codes of practice and ethics one should expecttherapists to follow.

There is a need for greater consensus on the part of theGovernment, Department of Health, NHS Executive,the medical profession, and acupuncture organisationsto provide guidelines and agree how acupuncture andother CAM services can be integrated into the UKhealthcare system.

Recommendations

Integration of acupuncture into theNHS

1. Guidelines and recommendations on CAM use forGPs, practitioners, and patients are urgentlyneeded, and the Department of Health shouldselect key CAM therapies, including acupuncture,for appraisal by the National Institute for ClinicalExcellence, for its third review programme in2001–2002.

2. A general list of all acupuncturists, medically andnon-medically qualified, should be produced andmaintained by the NHS Executive, in order tofacilitate the referral process for NHS doctors.

3. In light of the evidence supporting the use ofacupuncture for back pain, dental pain, migraine,nausea and vomiting in appropriate patients,consideration should be given to the need for apolicy, guidelines, and flexible mechanisms ofmaking this treatment available to NHS patients.Health Authorities and Primary Care Groups/Trusts should give consideration to includingacupuncture services in their Health ImprovementProgrammes.


Research and funding

4. Further research should be conducted into keyissues including:

• Investigating those other medical conditions thatmay be usefully treated by acupuncture, toensure that patients who could gain the mostbenefit have access to acupuncture on the NHS

• Investigating the cost-effectiveness ofacupuncture treatment, with particular emphasison the conditions that have so far been identifiedas possibly benefiting from the treatment (backpain, dental pain, migraine, nausea andvomiting).

5. Centrally provided research monies dedicated toCAM should be made available to grant-awardingmedical research organisations. The establishmentof groups who could help CAM researchers who donot have a research background should beencouraged. Established research groups shouldconsider undertaking more collaborative work withCAM practitioners.

Regulation

6. The BMA commends the moves towardsimproving self-regulation made by the acupunctureorganisations, and recommends that carefulconsideration should be given to the establishmentof a single regulatory body, requiring theregistration of all practitioners not currentlysubject to statutory regulation.

7. Acupuncture organisations should collaborate increating a national surveillance system for thereporting of adverse events.


Communication

8. Strategies are needed to foster the relationship andcommunication between doctors, acupuncturists,and patients, such as:

• An atmosphere of mutual respect between GPsand their patients regarding the use ofacupuncture as a treatment option should bepromoted to facilitate patients communicatingthe use of the therapy to their GPs

• Doctors should ask about their patients’ use ofacupuncture and other CAM therapies wheneverthey obtain a medical history, and acupuncturistsshould recommend that their patients informtheir GPs of their treatment

• Acupuncturists should not alter the instructionsor prescriptions given by a patient’s medicalpractitioner without prior consultation oragreement with that doctor.

Training

9. Acupuncture should be included in anyfamiliarisation course on CAM provided within themedical undergraduate curriculum.

10. Accredited postgraduate courses should beprovided to inform GPs and other clinicians aboutacupuncture and the possible benefits for patients.

11. All acupuncture courses should have a corecurriculum, with components including researchmethodology, information technology, statistics,fundamentals of orthodox medical diagnosis,ethics, and human anatomy and physiology, andshould be subject to external validation, with anexamination board and external examiners.


12. All acupuncturists should be fully trained ininfection control procedures, and immunisationagainst hepatitis B should be considered for theprotection of themselves and their patients.


Appendix I

Glossary

Acupressure Similar to acupuncture, but instead ofusing needles, pressure is applied to the meridianpoints with fingers.

Acupuncture There are two main systems ofacupuncture used—Western and Chineseacupuncture. The ancient Chinese system ofmedicine works on the theoretical belief thatmeridians, or energy channels, link inner organs andexternal points of the body. The acupuncturistapplies fine steel needles at external points alongthese meridians (or sometimes burns tiny cones ofherbal material over these points) to stimulatehealing. In the Western system a non-traditionalapproach, based on modern concepts ofneuroanatomy and physiology, is used.

Bach Flower Remedies Infusions made from extracts offlowers or wild plants diluted according tohomoeopathic principles, which are taken internallyto cure subtle emotional roots of disease.

Blinding The “blinding procedure” involves some ofthe people involved in a trial not knowing whetherplacebo or active treatment is being given—usuallymembers of the study group. In a double-blind trial,both the patients and the researchers are ‘blinded’:In particular, the researchers do not know if they aregiving an active treatment or a placebo. This is to

avoid any subtle differences caused bytheir knowledge between the way they deal withpatients in the active treatment group and thepatients in the control group, and that could bedetected by the recipients of the treatment. Blindingis removed only after the trial has run its course, andindividual responses have been analysed.

Control A control group is used to establish whetheror not a given intervention is the reason for anobserved difference following treatment. This groupis treated identically to the study group with thesingle exception that individuals do not receive theintervention.

Discrete clinical disciplines—homoeopathy,osteopathy, chiropractic, herbal medicine,acupuncture These are distinguished from othertherapies by having more established foundations oftraining and have to differing degrees, establishedcriteria of competence and professional standardsand perhaps have the greatest potential for use inconjunction with orthodox structures of health care.

Ear acupuncture (Auricular therapy) Acupuncturesolely applied to some of the many points in andaround the ear, in order to affect other parts of thebody.

Electroacupuncture A variation of acupuncture inwhich small electrical currents are applied toneedles inserted into acupuncture points.

Endogenous An effect occurring without an obviouscause external to the body, and believed to originatefrom an internal cause.

The Five Elements This ascribes the qualities of Metal,Water, Wood, Fire and Earth to Qi in differentprocesses of change associated with a particularseason of the year. There are correspondencesbetween one element and another, and energy flowsbetween them in cycles. Each element represents adifferent human quality and different organs areassociated with specific elements, as are senses andemotions.


Formula approach A standard formula is used to treatdisorders based on a Western medical diagnosis.However, the points used are classical ones, and theformula may originally be derived from traditionalChinese ideas.

Healing May refer specifically to spiritual or psychichealing; spiritual healers lay their hands on thepatient or may simply place their hands over thepatient’s body without touching it, in order tochannel healing energies. Distance healing may beachieved through prayer or other kinds of thoughtprocesses and does not even require the presence ofthe recipient.

Hypnotherapy The therapeutic use of hypnoticsuggestion, widely used to control or changeundesirable behaviour patterns, and promotepositive attitudes. Can also be used in the treatmentsof organic disorders and in pain relief.

Kinesiology A technique which studies the physics ofbody movement, in which muscular strength andbalance at distant points of the body are used todetermine the site and nature of a local impairment.

Laser acupuncture Low-level laser therapy is used tostimulate acupuncture points instead of needles. Itis painless and therefore useful in children andthose intolerant to needle insertion.

Massage Rubbing and kneading of areas of the body,normally using the hands.

Moxibustion A technique for applying heat by burningrolled cones of dried Artemisia (mugwort) overacupuncture points in order to affect the flow ofenergy (Qi) at those points, to prevent and treatdiseases and disabilities.

Meridians In traditional Chinese medicine, these areconsidered to be invisible channels or pathwaysthrough the body along which energy (Qi) flows.There are said to be 14 main meridian channels thatrun to and from the hands and feet, and to the bodyand head, and along these the acupuncture pointsare found.

APPENDIX 1 101

Neurotransmitters/neuromodulators Chemicalmessengers from nerve endings which mediate ormodulate the transmission of impulses in thenervous system. These include noradrenaline,dopamine, serotonin, acetylcholine, GABA (gammaaminobutyric acid), NMDA (N-methyl-D-aspartate),endogenous opioids and many others.

Placebo Latin term meaning, ‘I will please’—placebo isan inert substance or a non-effective treatment, butthe person receiving it does not know this. Forexample, in drug trials all subjects receive a pill, butonly in the study group does the pill contain theactive substance. Placebo control is important inresearch, because when any form of therapy isoffered, a large proportion of patients will reportimprovement based on the belief that the treatmentwill benefit them.

Qi Chinese term for the universal energy underlyingthe physical universe. The philosophy considers thatbodies are made up of Qi, animated by it, needing afree flow of Qi for good health; acupunctureenhances the Qi of a meridian and restores andmaintains health.

Randomisation All subjects in a trial should have anequal chance of being assigned to any groups thatexist, and so must be allocated at random.

Reflexology Considers that different areas of the feetare held to correspond to other parts of the bodythrough a system of internal connections. Massageof the appropriate area of the foot is believed tostimulate healing in the corresponding organ or partof the body.

Sham acupuncture Includes a range of controltechniques such as needling at non-acupuncturepoints or inappropriate points, or in using non-invasive needling techniques.

TENS (transcutaneous electric nerve stimulation)Stimulation of body tissue with pulses of low-voltage electricity for pain relief.


Trigger points These tender points (or myofascialtrigger points) are important in the causation ofmusculoskeletal pain.

Yin and Yang Negative and positive polarisations oflife energy (Qi), considered by practitioners ofTraditional Chinese Medicine to be containedwithin everything in varying proportions.

APPENDIX 1 103

Appendix II

Acupuncture organisations

British Academy of Western Acupuncture12 Poulton Green CloseSpitalWirral CH63 9FSTel. 0151 608 0753 or 0151 343 9168

The British Acupuncture Council63 Jeddo RoadLondonW12 9HQTel. 020 8735 0400

European Federation of Modern Acupuncture59 Telford CrescentLeighLancs WN7 5LYTel. 01942 678 092

Fook Sang Acupuncture and Chinese HerbalPractitioners Association590 Wokingham RoadEarleyReadingBerks RG6 7HNTel. 0118 966 5454

The Modern Acupuncture Association106 Higher LaneRainfordSt HelensMerseyside WAll 8AZTel. 01744 883 737

Acupuncture Association of CharteredPhysiotherapists18 Woodlands CloseDibden PurlieuSouthampton S045 4JGTel. 023 8084 5901

British Medical Acupuncture SocietyNewton House12 Marbury HouseWhitleyWarringtonCheshire WA4 4QWTel. 01925 730 727


Appendix III

The following report on the current position ofacupuncture in the UK is reproduced withpermission from Professional Organisation ofComplementary and Alternative Medicine in theUnited Kingdom 2000, published by the Centrefor Complementary Health Studies at theUniversity of Exeter.

Further details of the Centre’s work and copiesof the report are available from:

Simon Mills, Director,The Centre for Complementary Health Studies,University of Exeter, Amory Building, RennesDrive,Exeter, EX4 4RJTel: 01392 264 498

Acupuncture

There are two broad groups of practitioners ofacupuncture in the UK, those who work as statutoryhealth professionals and those who work primarily asspecialist acupuncturists. The former include mainly

doctors or physiotherapists: as well as differentregulatory concerns they sometimes take the viewthat acupuncture is a technique to complement theirconventional practice rather than anautonomous therapy (this is reflected in theireducational requirements).

Of those whose members are primarily specialistacupuncturists, by far the largest group is the BritishAcupuncture Council (BAcC) which represents aunification of five professional groups established fromthe early 1960s. The BAcC has led the way amongcomplementary professions in establishing verifiablestandards of education for their profession. They areassociated with the British Acupuncture AccreditationBoard which, under an independent chair, works withthe relevant training colleges to set and audit standardsof education and training. The accreditation process isinclusive and other organisations may becomeinvolved in the future.

Of the other groups, calculations for the whole sectorhave had to leave out the position of the Fook SangAssociation, which has a policy of not providingdetails about its membership. The EFMA has beenestablished recently as an umbrella organisation withthe Society of Electrotherapists and the AuricularAssociation of Great Britain as members; these practisemodern techniques rather than traditionalacupuncture.

In the case of the acupuncture professions, there islikely to be a relatively clear demarcation between thedifferent professional groups. Overlap in membershipis likely to be minimal.


Respondent Organisations were asfollows:

Year Established Number ofPractitioners

OrganisationsComplementarypractitionersModernAcupunctureAssociation (MAA)

1981 30

Fook SangAcupuncture &Chinese HerbalPractitionersAssociation(FSACHPA)

1983 not provided

BritishAcupunctureCouncil (BAcC)

1995 2020

EuropeanFederation ofModernAcupuncture(EFMA)

1995 not provided

Subtotal 2050Statutory healthpractitionersBritish Academy ofWesternAcupuncture(BAWA)

1976 250

British MedicalAcupunctureSociety (BMAS)

1980 1680

AcupunctureAssoc of CharteredPhysiotherapists(AACP)

1984 1600

Subtotal 3530

APPENDIX III 109

Year Established Number ofPractitioners

TOTAL practisingacupuncture

5580

Growth inprevious two yearsComplementarypractitioners 36%

Statutory health practitioners 51%

Proportion of acupuncturists inorganisations made up largely of

complementary practitioners that:

• are registering bodies the great majority• obtain funding mainly through

subscriptionsALL

• have an elected council ALL• have paid administrative staff the great majority• use a formal accreditation process

to screen membershipthe great majority

• require members to graduate from arecognised college

ALL

• require continuing professionaleducation

a small minority

• publish a professional register ALL• publish codes of ethics/practice ALL• publish formal complaints

procedures freely available to thepublic

the great majority

• publish disciplinary codes andsanctions

the great majority

• require/provide professionalindemnity and public liabilityinsurance

ALL

Education requirements formembership

1200 hours (BAcC)


Update 1997–99The BAcC has a new professional Chief Executive, anew core curriculum and is revising its codes of ethicsand practice; it has set up a university-basedAcupuncture Research Resource Centre to encourageundergraduate and postgraduate research.

Disciplinary sanctions 1997–99

There have been at least three practitioners struckoff their register and more than ten warnings issued.

Summary responses from theorganisations to other questions:

• Willingness to increase disclosure of administrativeaffairs to the publicGreat majority willing

• Willingness to increase public representation onexecutive councilsGreat majority willing

• Likelihood of members proceeding in treatmentswithout a doctor having seen the patient for thosesymptomsLikely

• Consider treatments combine well with conventionalmedical treatmentThere were a range of opinions with a tendency toagreement

• Views about regulationThe BAcC is due to have a referendum of itsmembership in May 2000; until it has that result, it willnot formally take a position; the FSACHPA considersthat a system of voluntary self-regulation would bepreferable to a statutory route; MAA contains otherpractitioners among its membership and has no singleposition for acupuncture.

APPENDIX III 111

Proportion of acupuncturists inorganisations with membership madeup largely of statutorily registered

practitioners that:

• are registering bodies ALL• obtain funding mainly through subscriptions ALL• have an elected council ALL• have paid administrative staff ALL• use a formal accreditation process to screen

membershipALL

• require members to graduate from a recognisedcollege

ALL

• require continuing professional education ALL• publish a professional register ALL• publish codes of ethics/practice ALL• publish formal complaints procedures freely

available to the publicBMAS

• publish disciplinary codes and sanctions NONE• require/provide professional indemnity and

public liability insuranceALL

Education requirements for membershipHours: 200(BAWA), 100(BMAS), 80(AACP)

Update 1997–99

The BMAS has a new Chief Executive Officer and anew accreditation procedure for entry intomembership; the AACP has increased its entryrequirement to 80 hours specialist acupuncturetraining and has developed an MSc degree programme.

Disciplinary sanctions 1997–99

There have been at least two struck off, onesuspension and imposed conditions of practice; atleast two letters of warning.


Summary responses from the organisations to otherquestions:

• Willingness to increase disclosure of administrativeaffairs to the publicBMAS: “already full disclosure”; BAWA and AACP:willing

• Willingness to increase public representation onexecutive councilsBMAS: conditionally willing; BAWA and AACP:willing

• Likelihood of members proceeding in treatmentswithout a doctor having seen the patient for thosesymptomsMostly unlikely

• Consider treatments combine well with conventionalmedical treatmentIn all cases

• Views about regulationMembers already statutorily registered; however for theviews of the BMAS, see below.

A common standard for acupuncture?Moves towards consensus

The formation of the BAcC continues to lead the agendafor complementary acupuncture practitioners. Therehave been occasional meetings between the BAcC andthe BMAS and AACP The MAA and FSACHPA remainseparate. The BMAS sees a formal separation of“medical” and “traditional” acupuncturists and somedistinction, therefore, in the regulatory development ofthe two streams; however, it has affiliated with theAACP and BAWA.

APPENDIX III 113

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Index

accreditation see underregulation

acupressure 97nausea in pregnancy17–18

acupuncturesee also complementaryand alternative medicine(CAM)BMA policy 4education 50, 53–3clinical trials 11–21contraindications 42–7costs 6, 88education 47, 53–6evidence base 6–35general practice 66–81NHS integration 2, 88–90recommendations 94organisations 57–9,103–4, 108GP attitudes to selectionof type of acupuncturist70–2research 85–6schools 6university courses 56US 53

Acupuncture Association ofCharteredPhysiotherapists 41, 111address 106courses 57membership 108

Acupuncture ExaminingCommittee (US) 53

Acupuncture ResearchResource Centre 110

adverse effectssee alsocontraindications 36–46,78comparison with drugs23, 45–8, 81, 87difficulties withevaluation of reports 43–7GP attitudes 75incidence 36, 45–8recommendations 94

age groups, general practiceCAM provision 67–8

Alexander technique 68American National Institutes

of Health, consensusstatement 11

127

anaesthesiology, GPattitudes to selection oftype of acupuncturist 70–2

anosmia 68antibiotics 50anticoagulants 42aromatherapy 60artemisia 101arthritis 81asthma 21

GP referral 64systematic reviews 31

Auricular Association ofGreat Britain 108

auricular therapy 58, 100

Bach flower remedies 97general practiceprovision 67–8

back pain 14–16, 21, 25–7,81controlled clinical trials26–9research 86recommendations 94, 94

Bell’s Palsy 68bioresonance 58Blackie Foundation Trust 87bleeding 40, 43, 46blinding 11–12, 97–8blood pressure 41Board of Science (BMA) xii,

5Bowen technique 67–8British Academy of Western

Acupuncture 111address 103courses 57–8membership 108

British AcupunctureAccreditation Board(BAAB) 54–5, 56, 108

British AcupunctureCouncil (BAcC) 39, 45, 54,108address 103courses 57educational requirements110membership 108

British Committee of Safetyof Medicines 45

British MedicalAcupuncture Society 111address 106courses 57membership 108

British Medical Association(BMA)acupuncture in primarycare survey 66–81Annual RepresentativeMeeting 1998 policy 5ComplementaryMedicine:New Approaches toGood Practice 3 , 3–4,41, 50

education 50, 54–3, 55,56

bruising 40

CAM see complementaryand alternative medicine(CAM)

Canada 65cardiovascular traumas 38case studies 24Centre for Complementary

Health Studies,


ProfessionalOrganisation ofComplementary andAlternative Medicine inthe United Kingdom 200059, 106–11

charities 87children 100Chinese medicine see

Traditional ChineseMedicine (TCM)

chiropractic 100BMA policy 4general practiceprovision 68General PractitionerCommittee (BMA)referrals guidance 4MRC research funding85–6NHS and 2

clinical ecology 67–8clinical kinesiology see

kinesiologyclinical trials see under

randomisedcontrolled trials (RCTs)

communicationsee also patient-doctorrelationship 75, 77–9, 93recommendations 95

complementary andalternative medicine(CAM)see also acupuncture;specific therapieseducation 50expenditure on xii–2GP provision 64–5growth xii–3

NHS integration,recommendations 94number of practitioners 2professional organisation106–11researchdifficulties 22–3funding 85–7recommendations 94

complementary research 24consultations 2, 6

time availableCAM 87general practice 81

continuous professionaldevelopment see undereducation

contraindicationssee also adverse effects42–7

cost effectiveness 5–6,12–13, 23future trends 87–8GP attitudes 75NHS 89research needs 24

Council for Acupuncture 54courses 55–6

GP acupuncture training73–4, 77

Creutzfeldt-Jakob disease(CJD) 39–2

curriculum 50, 61, 84BAAB 55recommendations 95database for acupunctureadverse reactions 45

deep vein thrombosis 38dental pain 20, 21, 25–7, 81

INDEX 129

controlled clinical trials32–5recommendations 94, 94

dentists, GP attitudes toselection of type ofacupuncturist 70–2

depression 40diet 47driving 40–3, 43drowsiness 40–3, 42drug clinics, GP attitudes to

selection of type ofacupuncturist 70–2

drug withdrawal, generalpractice acupunctureprovision 68

drugs, concurrent withacupuncture 42

ear acupuncture seeauricular therapy

earth, five elements 100education 47–61

future trends 84acupuncture training 73–4, 77recommendations 95

effectiveness 25funding for research 85–7future developments 81research needs 24

electroacupuncture 42, 58,100

elements 100endogenous opioids 47energy 10, 97ethics 41, 93European Commission, Co-

operation in Science andTechnology Action B410–11, 85

European Federation ofModern Acupunctureaddress 103courses 58membership 108

evidence-based medicine9–10

fainting 40feet 102fibromyalgia 21

systematic reviews 31fire 100five elements 100Fook Sang Acupuncture and

Chinese HerbalPractitioners Association108address 103courses 58membership 108

formula approach 100Foundation for Integrated

MedicineCAM integration 90CAM research funding85, 86, 87

Foundation for TraditionalChinese Medicine 45

fundholding 89

gender, general practiceCAM provision 62, 67–8

General Medical Council 4professional misconduct55–6Tomorrow’s Doctors 3

general practiceacupuncture provision67–9, 89, 90–1


BMA acupuncture survey66–81CAM provision 3recommendations 95

General PractitionerCommittee (BMA),guidance on referrals 4

general practitioners (GPs)with acupuncturetraining 65–6attitudes to NHSacupuncture provision75attitudes to selection oftype of acupuncturist70–2, 78–80CAM and 62, 64–5knowledge ofacupuncture 65–6, 73–4,77, 84, 93–3reasons for not arrangingacupuncture 72–3

Glasgow HomoeopathicHospital 90

guidelines 93–3

hayfever 68headache see also migraine

17, 21GP referral 64systematic reviews 31

healing 10, 100general practiceprovision 67–8

health authorities 89recommendations 94

Health ImprovementProgrammes 90recommendations 94

health inequalities 89

health status measurement24

Health TechnologyAssessment Programme(NHS) 86

Healthwork UK 60heart valves 42hepatitis 38–1

recommendations 96herbal medicine 100

BMA policy 4general practiceprovision 68MRC research funding85–6NHS and 2in TCM 14, 47, 97

history taking 42, 55recommendations 95

HIV infections 38–1holistic medicine 36, 53

GP attitudes 75The Homoeopathic Trust 87Homoeopathic Trust

Research Committee 86homoeopathy 100

BMA policy 4general practiceprovision 67–8, 90hospitals 2, 90MRC research funding85–6NHS and 2occupational standards60

Horizon Scanning Centre,University of Birmingham86

hospices 2, 68hypnotherapy 100

INDEX 131

general practiceprovision 67–8MRC research funding85–6NHS and 2occupational standards60

immunosuppression 43infection control 38–2, 46

recommendations 95insomnia 40irritable bowel syndrome 68

kinesiology 58, 100King’s Fund 85

laser acupuncture 100law of the five elements 53life force 10limits of competence 53low back pain see back pain

massage 47, 101feet 102general practiceprovision 67–8

Medical Care Research Unit90

medical history taking seehistory taking

Medical Research Council(MRC) 85–6, 87

medical schoolsfuture trends 84GP acupuncture training73recommendations 95

medico-legal aspects 93meridians, 101metal 100

midwifery, GP attitudes toselection of type ofacupuncturist 70–2

migrainesee also headache 17, 21,81general practiceacupuncture provision68research 86recommendations 94, 94

mis-diagnosis 41Modern Acupuncture

Association 106courses 58membership 108

morning sickness, generalpractice acupunctureprovision 68

motion sickness 18–19moxibustion 40, 47, 101mugwort 101musculoskeletal disorders

102general practiceacupuncture provision68

National Commission for theCertification ofAcupuncturists (US) 53

National Health Service(NHS)CAM integration with 92,92–2GP attitudes toacupuncture provision75, 80Health TechnologyAssessment Programme86


research budget 86Service Delivery andOrganisation Programme86–7

National Institute of ClinicalExcellence (NICE) 25recommendations 94

National Lottery 85nausea 17–19, 21, 81

general practiceacupuncture provision68systematic reviews 31recommendations 94, 94

neck pain 16, 21, 25–7controlled clinical trials28–1

nerve damage 38neurological disorders,

general practiceacupuncture provision 68

neurotransmitters 47, 53,101

New Zealand 65NHS Confederation,

Complementary Medicinein the NHS: Managing the Issues 92–2

NHS Executive, list ofacupuncturists,recommendations 94

non-steroidal anti-inflammatory drugs(NSAIDs) 81

nursing 56, 58GP attitudes to selectionof type of acupuncturist70–2

obesity see under weight lossobservational studies 24

occupational standards 60–1Office of Health Economics

(OHE) xiiOkibari 38osteoarthritis 16–17, 21, 25–

7controlled clinical trials30–3

osteopathy 100BMA policy 4general practiceprovision 67–8General PractitionerCommittee (BMA)referrals guidance 4NHS and 2

P6 stimulation 18–19pain clinics

CAM consultations 2general practiceacupuncture provision68, 68GP attitudes to selectionof type of acupuncturist70–2

patient-doctor relationshipsee also communication2–3neck pain 16stroke 19–20recommendations 95

phantom limb syndrome 68pharmacology 50physical injuries from

acupuncture 36–38physiotherapy 56, 58

general practiceprovision 67

INDEX 133

GP attitudes to selectionof type of acupuncturist70–2research 86

placebos 12, 16, 97, 101effect 10difficulties in CAMresearch 22, 23value 22–3

pneumothorax 36–38postoperative nausea 17–19,

21systematic reviews 31

potentisation 10pragmatic randomised

controlled trials 12, 23, 86pregnancy

acupressure for nausea17–18acupuncture for nausea18–19systematic reviews 31contraindications 42

primary care groups 89, 90recommendations 94

primary care trusts 89, 90,90–1recommendations 94

primary health care seeunder general practice

private practice 5–6general practiceacupuncture provision68, 90

psychological disorders 68

Qi 10, 47, 100, 101, 102five elements 100

randomised controlled trials(RCTs) 11–12, 23, 101

difficulties in CAM 22recommendations 94–6recurrent headache see

headachereferrals

BMA guidance 53General PractitionerCommittee (BMA)guidance 4GP attitudes to selectionof type of acupuncturist70–2, 78–80GPs and 62, 64, 90recommendations 94

reflexology 102general practiceprovision 67–8occupational standardsregulation 111accreditation 50, 56, 108recommendations 94, 95

relaxation techniques, MRCresearch funding 85–6

researchdifficulties 22–3funding 85–7future needs 23–46recommendations 94

respiratory disorders 68rheumatic diseases 21, 81

GP attitudes to selectionof type of acupuncturist70–2systematic reviews 31

Royal College of Physiciansof London 3

Royal LondonHomoeopathic Hospital(RLHH) 9–10

Royal Society 10


Scottish Office Departmentof Health, CAMintegration 90

septicaemia 38–1Service Delivery and

Organisation Programme(NHS) 86–7

sham acupuncture 12, 16,21, 23, 81, 102

skin disorders 40, 42, 68smoking cessation 19, 21,

25–7controlled clinical trials32–5general practiceacupuncture provision68GP referral 64NHS acupunctureprovision 80–1

Society of Electrotherapists108

spinal cord injuries 38spontaneous reporting 44stainless steel needles 40standards 54, 112sterilisation 39, 40, 43, 55 55stress 68stroke 19–20, 21, 25–7

controlled clinical trials32–5

syllabus see curriculumsystematic reviews 31

temperomandibular jointdysfunction 21systematic reviews 31

tenosynovitis 64tension headache see under

headachethorax 43

tinnitus 21systematic reviews 31

Traditional ChineseMedicine (TCM) 8GP attitudes to selectionof type of acupuncturist70–2, 78–80

training see educationtranscutaneous electric

nerve stimulation (TENS)102

trigger points 9, 102twelve pulses 53

United States (US) 53universities, acupuncture

courses 56University of Birmingham,

Horizon Scanning Centre86

University of Exeter,Professional Organisationof Complementary andAlternative Medicine inthe United Kingdom 200059, 106–11

urinary infections 68

variant Creutzfeldt-Jakobdisease (vCJD) 39–2

vomiting see under nausea

water 100weight loss 19, 21, 25–7

GP referral 64Wellcome Trust, CAM

research funding 85West Yorkshire Health

Authority 93Western acupuncture 9wood 100

INDEX 135

World Health Organizationguidelines 10, 40, 42Guidelines on BasicTraining and Safety inAcupuncture in 199959–60

wristbands 18

yin-yang energy 8, 47, 102


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