A Review of Acupuncture in Australia

Dr Marc Cohen MBBS (Hons), B Med Sci (Hons), D Ac., FAMAS.
Director, Complementary Medicine Research Unit
Faculty of Medicine Monash University
Reprinted from the Journal of the Australian Medical Acupuncture Society
12 No 1:1994, p8-15.
© Copyright 1994 Please do not reproduce without author's permission

Historical basis of acupuncture

The use of counterirritation techniques is as old as recorded history. The use of sharpened bone and stone implements has been recorded in diverse geographical locations and amongst widely separated cultures, including the Bantus in South Africa, the Singhalese in Sri Lanka, the Eskimos in Alaska as well as in China, Northern Europe and South America. In China, stone needles dating back to 1700 BC have been found at an archaeological site in Anyan, in the Honan province.

The modern day practice of acupuncture has evolved from Traditional Chinese Medicine teachings (TCM). According to legend these teachings commenced with Fu Hsi (c.2953) who is attributed with the invention of the eight Diagrams used as the basis of the I-Ching which acts as a pictorial representation of the Chinese universalistic philosophy. The elaboration of Chinese medicine was continued by the emperor Shen Nung (died 2698) who is venerated as the father of agriculture and is reputed to have undertaken systematic empirical observation of all herbs by tasting each one in order to acquaint himself with their value. By far the most renown of the legendary rulers of ancient China however, was Huang Ti, also known as the Yellow Emperor who is said to have reigned from 2696-2598.

Su-ma Ch'ien, the great historian of the second century B.C., began his Historical Records with an account of Huang Ti, whom he defined as the founder of Chinese civilisation and the first human ruler of the empire. Huang Ti has been accredited with the invention of wheeled vehicles, armour, ships, pottery, and other useful appliances, as well as the art of writing. Huang Ti is also regarded as the author of the Canon of Internal Medicine called the Nei Ching Su Wen (The Yellow Emperors Classic of Internal Medicine) which is said to be the oldest extant medical book in the world. This text remains the theoretical foundation for Chinese medicine to this day, as Ilza Veith states in the introduction to her translation of the Nei Ching Su Wen ;

"The Nei Ching, the Classic of Internal Medicine, attributed to Huang Ti, the Yellow Emperor, is indeed a very important if not the most important early Chinese medical book, particularly its first part, Su Wen, "Familiar Conversations" between the Emperor and has physician Ch'i Po. It is important because it develops in a lucid and attractive way a theory of man in health and disease and a theory of medicine. It does this in very much the same way as did the physicians of India who wrote the classic books of Yajutvedic medicine, or the Hippocratic physicians of Greece; that is by using the philosophical concepts of the time and picturing man as a microcosm that reflects the macrocosm of the universe. The theory expounded in the Nei Ching Su Wen has remained the dominating theory of Chinese indigenous medicine to the present day" [22]

Despite the authorship of the Nei Ching Su Wen being attributed to the Huang Ti, its antiquity has been questioned and most historians now date its origins to around the fourth century BC. It was at this time that the foundations of both Eastern and Western thought were first committed to writing, with Socrates, Aristotle and Plato laying the foundation for Western thought, and Lao Tzu, Confucius, and Gautama Buddha providing the basis for the development of Eastern thought. It was also around this time that the foundations of Eastern and Western medicine were being forged, with the formation of the Hippocratic writings ( Corpus Hippocraticum ) in the West, and the canonization of the Nei Ching Su Wen in the East. These medical works are significant as they mark the beginnings of modern medicine and are the first treatise to view disease as arising from interactions between the environment and constitutional factors, rather than the actions of gods or supernatural forces.

The Nei Ching Su Wen, which is still used today as the theoretical basis for Traditional Chinese Medicine, is unusual for a general medical text in that it is devoted primarily to preventative measures. Rather than defining different disease entities and attempting to treat illness, the ancient Chinese physicians emphasised the healthy state which was defined as being "at one with the Tao", and having defined a state of health, it was the aim of Chinese physicians to detect any deviation from this state and correct it before disease could develop. Placing great emphasis on the pulse, Chinese physicians aimed to detect premorbid conditions before they developed into overt pathology, and since disease was seen to arise out of disequilibrium, the basis of cure was in restoring harmony.

The duty of the traditional Chinese doctor was to instruct the patient how to remain well and accordingly, the ancient physicians were paid only while their patients remained healthy. If a patient was to unexpectedly die, the physician responsible was required to hang a lighted lantern outside his practice for a full month so that other patients would be made aware of his shortcomings. This attitude is expressed in the Nei Ching with the following passage; [8]

"The superior physician helps before the early budding of the disease. The inferior physician begins to help when the disease has already developed; he helps when destruction has set in, and since his help come when the disease has already developed, it is said of him that he is ignorant" [22]

The Eastern attitude of preventive medicine lies in stark contrast to that of the Hippocratic tradition. The Hippocratic physicians practiced in a market economy where physicians were sought only after disease had become established and a physician's worth was judged on his ability to make accurate predictions, even if powerless to alter an adverse outlook. The Hippocratic tradition thus concentrated on defining specific disease entities rather than abstract notions of health, for it was only by defining the evolution of clinical syndromes that specific prognostic features could be recognised and the likely course of disease and the effect of specific interventions be determined.

It has been suggested by some scholars that the complementary nature of Eastern and Western medicine has arisen through their respective use of language.[15] Eastern thought, which places much emphasis on the concept of flow and on symbolic representations of natural phenomena, is based on an intuitive language which uses ideograms and symbolic constructs. In contrast, Western thought emphasises the process of systematically observing nature and deriving rational explanations, and is based on rational languages (the epitome of which is mathematics), which utilise a phonetic alphabet and logical construction. Furthermore Chinese thought has remained fairly consistent throughout the ages, as has the Chinese language (even though pronunciation differs in different regions), whereas Western thought has undergone numerous additions, corrections and modifications as it has been translated into the dominant language of the time.

The development of Eastern medicine has taken an opposite but complementary approach to that of Western medicine. The Eastern way of thinking is holistic, and involves nonlinear logic and acausal relationships rather than the reductionistic theories and linear causality of Western science. These different approaches to medical knowledge can be considered to be parallels of what are commonly called the holistic and reductionistic world views and although these views appear opposite, neither view can be considered more correct or more useful than the other. Reductionism and holism are merely different (or complementary) approaches, and both views are necessary when considering the many complexities of health and disease.[3]

The Practice of Acupuncture

The practice of acupuncture usually involves needles, but may also involve low level laser, moxibustion, cupping, transcutaneous electrical neural stimulation (TENS), trigger point therapy, point injection therapy and dorsal column stimulation. [2] In Australia at present, acupuncture is offered by a variety of providers including doctors, dentists, veterinary surgeons, physiotherapists, chiropractors, and various lay practitioners. Of these groups however, medical practitioners are the only ones trained to asses patients in a primary health care setting as their training includes instruction in the basic sciences including anatomy, physiology, pharmacology, microbiology, pathology and immunology as well as in clinical diagnostic, methods and procedures. When skilled in the use of acupuncture, medical practitioners are thus able to offer acupuncture as a treatment modality in the full context of diagnosis and management. [21]

While medical practitioners are the only professional group trained to act as primary health care providers and coordinate and manage all aspects of patient care, there are other registered health professionals who may posses sufficient training to use acupuncture as an available modality and identify circumstances when other professional medical services are required. In Australia however, it is not appropriate for acupuncture to be used as a complete therapeutic modality and acupuncture is best considered as a 'complementary' rather than an 'alternative' form of medicine. Non-medical acupuncturists should therefore be encouraged to work in conjunction with the medical profession rather than in opposition to it and in this position non-medical acupuncturists should adopt the role of 'therapists' rather than 'doctors', as they are not subject to the theoretical, ethical, or legal rigorousness required of medical practitioners, nor are they bound by the medical boards advertising restrictions.

Acupuncture is a procedure involving both diagnosis and treatment and like any other procedure, acupuncture does have associated risks if used without appropriate skills and knowledge. Risks associated with acupuncture include transmission of infections such as HIV and Hepatitis B and C, etc. from contaminated needles, injury to vital structures by misguided needle placement, and the masking of symptoms preventing early detection and diagnosis. While the risk of infection can be easily prevented through the use of disposable needles or low level laser, the risk of injury can only be prevented through adequate training in anatomy and pathology. Without such training potentially serious complications may arise and death due to acupuncture has occurred in Australia in the hands of a non-medical acupuncturist.

Non medical acupuncturists who adopt the role of primary health care providers may also put their patients at risk if they withdraw medications indiscriminately, mask symptoms without performing investigations to determine a medical diagnosis, or prevent patients attending registered medical practitioners and receiving preventative screening and immunisations.

Education of acupuncturists

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In Australia at present the extent to which general practitioners practice acupuncture appears to be extremely varied ranging from a few consultations to full time practice. However, as there are no educational or legal requirements necessary for medical graduates to practice acupuncture, it is left up to each individual doctor to determine, and seek out, the level of education and expertise he/she deems adequate. This lack of guidelines for practicing acupuncture extends into the non-medical sphere and although some universities and private institutions offer degree and diploma courses in acupuncture there are no standard educational requirements for these courses nor are there established legal requirements to govern acupuncture practice.

"submissions from lay acupuncture training organisations do not indicate a content of training of standard equivalent to that of medical practitioners in the relevant subjects (anatomy, microbiology, diagnosis etc), nor has there been any independent evaluation by suitably qualified authorities in any of these disciplines of the course content and quality or the standards achieved by students."

The NH&MRC working party also suggested that;

"When acupuncture courses have been accredited it has been by administrative bodies and not by authorities able to evaluate curriculum content. Furthermore when acupuncture courses have been adopted by tertiary education institutions it has been by institutions with expertise in certain disciplines (eg. nursing, social sciences) but not in those disciplines considered by the Working party as critical to the safe and informed practice of acupuncture such as anatomy, microbiology, clinical diagnosis, therapeutics and clinical trial research. Moreover, there is no evidence that teachers of acupuncture have had adequate training in these disciplines and most significantly, there is no evidence that they have a capacity to critically evaluate existing or new knowledge in their discipline in order to determine its validity.[12]"

The AMAC fellowship is acknowledged worldwide for setting a high standard of professional knowledge and competency and fellows of the society are held in high regard by other medical colleagues both in Australia and internationally. At present however, there are no legal requirements for doctors to obtain their fellowship or other postgraduate qualifications and there are less than 200 Fellows of the Society. The AMAC however maintain that doctors need formal training to practice acupuncture effectively. To this end the AMAC suggests that medical acupuncture needs to be formally integrated into university medical undergraduate curriculums, as well as becoming an acknowledged area of special interest with established minimum qualifications for postgraduates. Acupuncturists should also be encouraged to display their qualifications in order to make the public aware of their level of training. In the absence of accepted standards, the use of acupuncture should always be on the basis of 'buyer beware', and both the AMAC and the NH&MRC advise patients to seek acupuncture treatments from suitably trained medical acupuncturists.

Uses of acupuncture

In general practice acupuncture has proven to be a cheap, safe and effective therapy, the main use of which is in treatment of pain and addictions as well as being helpful in systemic conditions. Acupuncture can be used either, in conjunction with conventional therapy, or as an alternative to pharmacotherapy when patients cannot tolerate certain medications. As many of the conditions treated by acupuncture are painful musculoskeletal conditions, acupuncture is often able to prevent the long-term use of NSAIDS and steroids and thus minimise the side effects and cost of treating these conditions. The relative safety and efficacy of acupuncture compared to other treatment modalities suggests that in many conditions, acupuncture should be used as a 'first line therapy', thus keeping with the Hippocratic ethic of "first do no harm".

In addition to treating pain, acupuncture has been shown to be effective in systemic conditions as well as in treating addictions, including addictions to narcotics, alcohol, tobacco and minor tranquillisers. Acupuncture has also been shown to be effective for surgical analgesia, [20] however its efficacy is such that there would appear no justification for the introduction of acupuncture anaesthesia in competition with orthodox anaesthetic techniques. Acupuncture analgesia however may have a role when conventional anaesthesia is either contraindicated or unavailable, and thus when discussing acupuncture anaesthesia the NH&MRC [12] advise that;

" it may be appropriate to allow such a modality, at the request of a registered medical practitioner skilled in its use, for consumers who request it."

In 1979 the World Health Organisation drew up the following provisional list of disorders that lend themselves to acupuncture treatment. This list is based on clinical experience and not necessarily on controlled clinical research.

World Health Organisation List of Indications for Acupuncture

Neurologicaldisorders
Headache and migraine
Trigeminal neuralgia
Facial paralysis
Peripheral neuropathy
Post poliomyelitis paralysis
Meniere's syndrome
Neurogenic bladder
Nocturnal enuresis
Intercostal neuralgia

Musculoskeletal disorders
Acute/ chronic muscle strains
Frozen shoulder
Tennis elbow
Lumbar pain and sciatica
Degenerative arthritis Inflammatory polyarthritis.

Mouth disorders
Toothache
Post extraction pain
Gingivitis
Acute or chronic pharyngitis

Upper respiratory tract
Acute sinusitis
Acute rhinitis
Common cold
Acute tonsillitis

Respiratory system
Acute bronchitis
Bronchial asthma

Eye disorders
Acute conjunctivitis
Central retinitis
Myopia in children
Uncomplicated cataract

Gastrointestinal disorders
Oesophageal and cardia spasm
Hiccough
Acute and chronic gastritis
Gastric hyperacidity
Uncomplicated duodenal ulcer
Acute and chronic colitis
Acute bacterial dysentery
Constipation and Diarrhoea
Paralytic ileus 

Cost of Acupuncture
At present, when acupuncture is performed by a registered medical practitioner it is covered by a Medicare rebate under item 173 which includes:

"Attendance at which acupuncture is performed by a medical practitioner by application of stimuli on or through the surface of the skin by any means, including any consultation on the same occasion and any other attendance on the same day related to the condition for which the acupuncture was performed."

  The current Medicare rebate for item 173 ($18.30) is less than that offered for a standard consultation for a vocationally registered practitioner under item 23 ($20.40). The existing rebate system thus acts as a disincentive for doctors to practice acupuncture. Despite this inequity however, in 1992 a Health Insurance Commission study revealed that over 3000 GPs (nearly 25%) claimed rebates for acupuncture. Furthermore this study showed that the costs to Medicare were much lower for doctors who had at least 50% of their income derived from acupuncture. Compared to other GPs, these doctors had one fifth as many referrals and utilised one quarter of the expenditure in radiology and pathology, as well as presumably having less prescribing. It thus appears that acupuncture offers a considerable cost saving to the community however further studies are needed to determine the extent of this saving as well as the optimal use of acupuncture in general practice.

The practice of acupuncture represents an area of special interest requiring similar training and expertise as minor surgery or psychotherapy. Furthermore as well as additional training, the practice of acupuncture requires more surgery space and more time per patient than conventional consultations. The AMAC maintain that Medicare rebates should reflect these increased demands and that the rebate for acupuncture be at least equal to that of a standard consultation. It is also suggested that for initial consultations, a consultation item be submitted along with item 173. The AMAC further suggests that Fellows of the AMAC should be recognised as Vocationally Registered and thus attract a higher rebate for their services in accord with Fellows of the RACGP. Such moves would encourage more doctors to consider using acupuncture in their practice and would act as a financial incentive for doctors to undertake advanced training in acupuncture and thus achieve a high level of clinical competency and efficacy.

Modern Theories of Acupuncture

Many theories have been proposed to explain the mechanism of action of acupuncture, these range from the theory of Traditional Chinese Medicine (TCM), couched in the terms of Chinese cosmology, to modern neuro-humoral theories invoking complex nerve pathways and neurotransmitter release, as well as theories invoking bioelectric, biomagnetic and embryological phenomena. [3, 5] So far however, all Western theories on acupuncture are incomplete and while TCM theory claims to be a complete one, its concepts have not yet been integrated into the Western scientific framework thus rendering it incomplete from a scientific viewpoint. In 1989 after investigating the scientific basis of acupuncture the executive committee of the National Health and Medical Research Council concluded that;

"that the relief of pain by acupuncture can be explained in terms of neurophysiological mechanisms. These mechanisms depend on an intact and functioning peripheral and central nervous system, can be induced without using the full range of traditional acupuncture points and are similar in mechanisms associated with narcotic analgesia. In addition to a neurophysiological effect on pain, acupuncture has a powerful placebo effect."[12]

The neurophysiological basis of acupuncture is now well established on the basis of endorphin and other neurotransmitter involvement, the diffuse noxious inhibitory control system (DNIC) and the gate control theory [3].

The reality of acupuncture points however is often questioned for no consistent structural correlates for them have been identified. Acupuncture points it seems are best considered as functional, rather than structural entities, and this is confirmed by the finding that acupuncture points can be defined electrically as points of low electrical resistance. [1,10,18] The functional nature of acupuncture points is also evident from the fact that there is an extremely high correlation between acupuncture points and musculoskeletal trigger points, which are points of focal muscle tenderness that can be identified using a pressure algometer or palpation, and which are found to have a local twitch response to mechanical stimulation. [11,16]

While functional correlates of acupuncture points have been shown to exist, sceptics often point out that the acupuncture meridians have not been objectively identified. Most acupuncturists however would maintain that acupuncture meridians are a conceptual tool, such as the lines of latitude and longitude on the earth, and thus while they are useful for navigating a specific territory, to search for anatomical correlates of the meridians would make as much sense as digging in the ground to look for the equator. Recently however there has been the suggestion of objectively defining the meridians using techniques capable of imaging functional, rather than structural relationships. Studies utilising radioactive tracers have shown that certain tracers appear to migrate along the acupuncture meridians [6] and electrical impedance studies have shown significantly lower impedance along the acupuncture meridians compared to surrounding skin. [18]

Many clinical trials on acupuncture have been published in the medical literature however, while the gold standard for clinical trial research is the double-blinded, randomised, placebo-controlled, cross-over trial with defined outcome criteria and sufficient numbers of patients to minimise type 1 and type 2 errors, none of the trials on acupuncture are able to meet this standard. [23] Clinical trials on acupuncture have many inherent methodological problems [14, 19], however they generally fall into four different groups;
1) Anecdotal or uncontrolled studies;
2) trials using a no-treatment control group;
3) trials using a alternative treatment control group;
4) placebo controlled trials which may either use a non-acupuncture placebo group such as bogus TENS, or a 'sham acupuncture' placebo group, where needles are placed in points considered to be 'non-acupuncture points'.[7, 19]

The methodological problems associated with clinical trials of acupuncture include the fact that in order to have reproducible results a standardised treatment approach is needed. Acupuncture however is a 'holistic' therapy, and most acupuncturists tailor their treatments to the needs of individual patients and may even use different points as treatment progresses. Furthermore due to the nature of the treatment, double blind conditions are virtually impossible to achieve as to perform true acupuncture requires that the therapist know the nature of the treatment. Other methodological problems include the choice of control groups, agreement as to the location of 'true' acupuncture points, the need for large numbers of patients in order to detect a statistical differences between groups, and the requirement of having objective yet multidimensional measures of outcome.[7, 19]

A review of randomised trials on acupuncture [7] has shown that successful response rates vary from 30% for placebo groups, 50% for sham acupuncture groups, and 70% for true acupuncture groups. This review suggests that sham acupuncture cannot be considered an adequate placebo, but rather a 'poor form of acupuncture' and that the use of a sham acupuncture group requires large numbers of subjects to be able to detect a significant difference between the groups (130 patients are needed in each arm of a trial for a p value of 0.05). As most trials do not employ such large numbers of subjects the authors were forced to conclude that:

"The majority of published reports have a very low power for distinguishing statistical differences between treatment groups" {and hence} "one cannot necessarily conclude from trials which produce statistically non-significant results that acupuncture (when compared with placebo for example) is ineffective."

It is generally acknowledged amongst practitioners that the main mode of action of acupuncture is through stimulating homeostasis. This no doubt involves neuronally and chemically mediated phenomena, however while the neurophysiological basis for acupuncture is well established, acupuncture has also been shown to decrease red blood cell viscosity, white cell count, carotid arterial pressure and peripheral vascular resistance, increase free fatty acids, gamma and beta globulin levels, the phagocytic index of white blood cells and the blood glucose level as well as enhancing the release of serotonin, histamine and kinin components. Acupuncture also affects the autonomic nervous system and skin temperature as well as electroencephalograph, electrocardiograph and electromyograph readings. Furthermore acupuncture has also been shown to produces multiple effects on defence and immune mechanisms including raising the titre of a variety of specific and nonspecific immune substances such as bacteriolysins, agglutinins, opsonins, antibodies and complement components.[21]

While the above findings are indeed significant, these findings merely take the form of evidence of how acupuncture may act through the actions of particular nerve pathways and central mechanisms or through the release of humoral agents and although this evidence suggests how acupuncture works, it does not explain why acupuncture works.

Traditional theories of acupuncture

Traditional Chinese Medical theory provides a comprehensive explanation of why acupuncture works, this theory however is couched in the conceptual language of Chinese cosmology and philosophy [4] which employs such concepts as; "Tao " (universal order), " Chi " (vital energy), "Wusieng " (five evolutive phases), "ko " and "sheng " cycles (constructive and controlling cycles) and "Yin " and " Yang " (complementary opposites). When expressed in Chinese terminology it is difficult for Western minds to appreciate their significance, however these concepts can all be found to have parallels in Western science.

When investigating the theoretical basis of acupuncture much remains to be learned from scientific inquiry however there is also much valuable knowledge contained in the ancient Chinese texts and traditional practices. When attempting to translate traditional Chinese practices into a modern day scientific setting however there are many pitfalls, and as the renowned historian Joseph Needham states;

"In evaluating acupuncture through the works of representatives of the present day practitioners in the western World some reserve should be exercised for the following reasons;
(a) very few of them have had reliable linguistic access to the voluminous Chinese sources of many different periods, (b) it is often not quite clear how far their training has given them direct continuity with the living Chinese clinical traditions,
(c) the history in their works is liable to be minimal or unscholarly,
(d) their familiarity of theory are generally very inadequate,
(e) they tend to adopt a too simplistic assimilation of classical Chinese disease entities to those of modern western medicine,
(f) the cardinal importance of sphygmology [pulse diagnosis] in Chinese differential diagnosis is almost ignored, and
(g) their works are naturally so much influenced by modern western concepts of disease aetiology and pathology that they seem not to practice the classical Chinese methods of holistic classification and diagnosis. Not everyone with a modern Western medical training can immediately perform all the traditional-Chinese therapeutic feats. Pulse diagnosis, for example, as well as a very organistic psychosomatic approach, is a fundamental feature of this traditional art, which after all depends on much subtle theorising, not of course in the modern style, but not nonsense either." [13]

The future of Acupuncture

Acupuncture has over the past 5000 years proven to be a safe and effective therapy which is currently used by nearly 25% of Australian GPs, however much research remains to be done at both a basic science and clinical level to come to an understanding of its mechanisms of action. In order to perform such research people must be trained in both acupuncture and research methodology. Recently important steps toward this end have recently been made with the recognition of the academic basis of general practice, involving the training of GPs in research methods, and the introduction of formal training in acupuncture to medical undergraduates (at Monash University). These measures insure that in future there will be a growing number of well-trained people able to perform high quality research into the scientific basis of acupuncture.

It is generally recognised that just as there are two sides to the brain, there are two approaches to knowledge; -rational and intuitive, subjective and objective, holism and reductionism. Neither of these views has a more privileged position than the other and a balanced worldview requires input from both. The approaches of Eastern and Western medicine represent two such views and thus by combining these views a more balanced and coherent medicine results. Thus just as Western-trained medical acupuncturists are able to combine the best elements of both Eastern and Western medicine in their practice, modern research has been able to blend ancient wisdom with modern technology to produce new effective therapies. Already there are hundreds of thousands of patients world-wide who have benefited from the new techniques of acupuncture anaesthesia, TENS, laser acupuncture, auricular therapy, and electroacupuncture, and as research continues these techniques will no doubt be refined and perhaps others developed. This ability to integrate Eastern and Western ideas has been explored at a theoretical level by Capra who suggests;

"We are heading towards a new synthesis, a new naturalism. Perhaps we will eventually be able to combine the Western tradition, with its emphasis on experimentation and quantitative formulations, with a tradition such as the Chinese one, with its view of a spontaneous, self organising world." [3]
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