Understanding the Challenges of U.S. Acupuncture Practice (Pt. 5)

Editor’s Note: Part 1 of this eight-part series appeared in the June issue. Note: Pt. 3 (August issue) ran as a web exclusive due to space restrictions in the print issue.

In the past, many health professionals viewed CAM as not related to science and not a substitute for modern medicine.¹ The majority of physicians felt awkward in discussing CAM treatments with patients, although most physicians admitted there were benefits of CAM therapy for certain illnesses.²

If CAM therapies could provide evidence through well-designed scientific experiments such as randomized, controlled trials (RCTs), most physicians suggested they would think about bringing some CAM options into their practices.² Many, though, were still not comfortable with such recommendations.

Considering some studies with RCTs design as examples, a study conducted by Liu, et al., adopted a RCT design to demonstrate the evidence of the effectiveness of electroacupuncture for women with stress urinary incontinence, which was published in the prestigious Journal of the American Medical Association.³

Lesi, et al., conducted a pragmatic RCT to determine the effectiveness of acupuncture for women who had breast cancer with hot flashes, showing that acupuncture, along with enhanced self-care, is an effective integrative intervention in improving the patients’ quality of life.⁴

Another RCT study conducted by Ratmansky, et al., regarding the effects of acupuncture on post-stroke patients showed acupuncture could significantly influence the cerebral blood-flow velocity at both healthy and damaged hemispheres.⁵

A systematic review including 67 RCTs studies by Liu, et al., regarding the effectiveness and safety of electroacupuncture (EA) for acute ischemic stroke (AIS) showed EA had a significant effect in improving AIS compared with conventional Western treatments.⁶

All these studies adopted a randomized clinical trial design and can demonstrate the evidence for physicians to employ acupuncture into their practice.

This section of our discussion (parts 5 and 6) will discuss the mesosystem that includes evidence-based medicine, insufficient awareness by mainstream professionals, lack of consistent professional competencies, and the influence of capitalism.

Evidence-Based Medicine

A survey of selected physician views on acupuncture in pain management by Chen, et al., indicated that the lack of research evidence for the effectiveness of acupuncture became one of the barriers that discouraged physicians from referring patients to acupuncture treatment.⁷

Similarly, a study by Garland, et al., stated that whether CAM causes benefits after a cancer diagnosis, including better psychosocial health, requires that more evidence-based research must exist before reporting the causal relationship between CAM use, benefit finding, and better psychosocial well-being.⁸

In a qualitative study conducted by Chan, et al,. regarding the perception of acupuncture among users and nonusers, the nonusers labeled acupuncture as lacking clinical evidence, hazardous, and disorganized.⁹ All these studies demonstrate that evidence for acupuncture efficacy is necessary.

One of the most common voices of opposition toward acupuncture being integrated into mainstream medicine is from scientific standpoints. Baran, et al., argued that “various pseudosciences maintain their popularity in our society: acupuncture, astrology, homeopathy, etc.”¹⁰

Good proposed: “Believing in something like chiropractic or acupuncture really can help relieve pain to a small degree and for a short period of time, but many related claims of medical cures by these pseudosciences are bogus.”¹¹ Furthermore, Ernst argued that the majority of research suggested that acupuncture’s effects were mainly due to the placebo effect, even though some research results suggested acupuncture could alleviate pain.^12-15

A systematic review of acupuncture with RCTs by Madsen, et al., concluded acupuncture had a small analgesic effect, but still is lacking sufficient clinical relevance.¹⁶ Another systematic review regarding the electrical properties of acupuncture points and meridians by Ahn, et al., indicated that prior studies were poor in quality and could not provide powerful evidence to verify that acupuncture points or meridians are electrically identifiable.¹⁷

In addition, mainstream medical practitioners do not advocate the existence of qi or energy within acupuncture points because there is a lack of solid research evidence.^18-19

Overall, there is insufficient research-based evidence to support the use of acupuncture as a means of medical therapy compared to mainstream medical treatments.²⁰

Insufficient Awareness of Reliable Evidence-Based CAM Treatments by Mainstream

Continuing the discussion about evidence-based information and strategies, Shim, Koh, and Ahn stated that medical schools should provide students with CAM courses by employing evidence-based strategies to ensure students to grasp the useful CAM therapies, which aims to educate students to understand and practice both medicines correctly.²¹

Evidence-based CAM practices not only capture the interest of medical practitioners, but also provide a bridge connecting CAM with mainstream medicine and further advance CAM in biomedicine education.²²

A survey of 233 physicians in the Mayo Clinic conducted by Wahner-Roedler, et al., revealed that 70% of respondents believed patients should have the opportunity to receive proven CAM therapies, but 62% could not find reliable sources about CAM treatments.²

Eight years later, Wahner-Roedler, et al., conducted a new survey to follow up on the 2006 study at the same academic medical center.²³ The new survey indicated that the attitudes of physicians toward CAM had become much more positive. However, the knowledge and experience of physicians on many CAM treatments did not change.

For example, 43% of physicians in the 2014 study, compared to 45% of physicians in the 2006 study, felt uncomfortable counseling patients about acupuncture treatment because they were not familiar with CAM treatments or techniques.

Acupuncture research has grown significantly in the past two decades. According to Ma, et al., who researched publication trends in 13,320 acupuncture-related publications, the proportion of acupuncture research with RCTs increased from 7.4% in 1995 to 20.3% by 2014.²⁴ Despite this, the mainstream medical community actively questions the credibility of acupuncture and specific therapeutic applications.²⁵

Therefore, insufficient awareness of reliable, evidence-based acupuncture research within mainstream medical practice might be an underlying factor in the inability to mainstream acupuncture.

References

1. Highfield ES, McLellan MC, Kemper KJ, et al. Integration of complementary and alternative medicine in a major pediatric teaching hospital: an initial overview. J Alt Compl Med, 2005;11(2):373-380.
2. Wahner-Roedler DL, Vincent A, Elkin PL, et al. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies: a survey at an academic medical center. Evid-Based Compl Alt Med, 2006;3:495-501.
3. Liu Z, Liu Y, Xu H, et al. Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: a randomized clinical trial. JAMA, 2017;317:2493-2501.
4. Lesi G, Razzini G, Musti MA, et al. Acupuncture as an integrative approach for the treatment of hot flashes in women with breast cancer: a prospective multicenter randomized controlled trial (AcCliMaT). J Clin Oncol, 2016;34:1795-1802.
5. Ratmansky M, Levy A, Messinger A, et al. The effects of acupuncture on cerebral blood flow in post-stroke patients: a randomized controlled trial. J Alt Compl Med, 2016;22:33-37.
6. Liu AJ, Li JH, Li HQ, et al. Electroacupuncture for acute ischemic stroke: a meta-analysis of randomized controlled trials. Am J Chin Med, 2015;43:1541-1566.
7. Chen L, Houghton M, Seefeld L, et al. A survey of selected physician views on acupuncture in pain management. Pain Med, 2010;11:530-534.
8. Garland SN, Valentine D, Desai K, et al. Complementary and alternative medicine use and benefit finding among cancer patients. J Alt Compl Med, 2013;19:876-881.
9. Chan K, Siu J YM, Fung TK. Perception of acupuncture among users and nonusers: a qualitative study. Health Mark Q, 2016;33:78-93.
10. Baran GR., Kiana MF, Samuel SP. Chapter 2: Science, Pseudoscience, and Not Science: How Do They Differ? Healthcare and Biomedical Technology in the 21st Century. New York, NY: Springer, 2014: p.p. 19-57.doi:10.1007/978-1-4614-8541-4_2
11. Good R. Why the Study of Pseudoscience Should Be Included in Nature of Science Studies. In: Advances in Nature of Science Research. Netherlands: Springer, 2012: p.p. 97-106.
12. Ernst E. Acupuncture - a critical analysis. J Intern Med, 2006;259:125-137.
13. Birch S, Hesselink JK, Jonkman FA, et al. Clinical research on acupuncture: part 1. What have reviews of the efficacy and safety of acupuncture told us so far? J Alt Compl Med, 2004;10:468-480.
14. Lee H, Ernst E. Acupuncture for GI endoscopy: a systematic review. Gastroint Endosc, 2004;60:784-789.
15. Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med, 2005;142:651-663.
16. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. Brit Med J, 2009;338:a3115.
17. Ahn AC, Colbert AP, Anderson BJ, et al. Electrical properties of acupuncture points and meridians: a systematic review. Bioelectromagnetics, 2008;29:245-256.
18. Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. London: Elsevier Health Sciences, 2000.
19. Williams WF. Encyclopedia of Pseudoscience: From Alien Abductions to Zone Therapy. Abingdon, UK: Routledge, 2013.
20. Goldman L, Schafer AI. Goldman’s Cecil Medicine. London: Elsevier Health Sciences, 2011.
21. Shim BS, Koh BH, Ahn KS. Education in Oriental medicine in Kyung Hee University. Evid-Based Compl Alt Med, 2004;1:331-334.
22. Ghassemi J. Finding the evidence in CAM: a student’s perspective. Evid-Based Compl Alt Med, 2005;2:395-397.
23. Wahner-Roedler DL, Lee MC, Chon TY, et al. Physicians’ attitudes toward complementary and alternative medicine and their knowledge of specific therapies: 8-year follow-up at an academic medical center. Compl Ther Clin Pract, 2014;20:54-60.
24. Ma Y, Dong M, Zhou K, et al. Publication trends in acupuncture research: a 20-year bibliometric analysis based on PubMed. PloS One, 2016;11(12).
25. Salehi A, Marzban M, Imanieh MH. The evaluation of curative effect of acupuncture: a review of systematic and meta-analysis studies. J Evid-Based Compl Alt Med, 2016;21:202-214.

Editor’s Note: Part 6 (November issue) discusses lack of consistent professional competencies and the influence of capitalism. Complete references supporting citations in pt. 5 accompany the web version.