BMJ
BMJ 2003 (May 3);  326 (7396):   S152

Career focus

Training in acupuncture



Colin Lewis and Richard Halvorsen explain what is involved


I (CL) was frustrated that I could not do more for my patients with musculoskeletal disorders. The rheumatologists suggested non-steroidal anti-inflammatory drugs (NSAIDs) and steroid injections, and the orthopaedic surgeons said that my patients were too young for joint replacements. So I learned how to perform medical acupuncture and added a very useful skill to help me look after these patients.



Acupuncture has also proved to be a useful extra therapeutic option to clinical practice. The term literally means inserting needles into various parts of the body to treat disease. It is safe and especially useful in treating some disorders for which other treatments are ineffective. Although it arrived in the West shrouded in the mystery of meridians, Qi (energy), and yin and yang, most doctors who practise acupuncture do so by using Western scientific principles rather than those of traditional Chinese medicine. Doctors are increasingly accepting that acupuncture has much to offer patients, and a recent report from the BMA supports the use of acupuncture and its integration into the NHS.1
(Credit: TEK IMAGE/SPL)


Why learn acupuncture?

Although Western medicine has undoubtedly made huge advances during the 20th century, many (usually chronic) diseases remain for which we have little to offer. This is frustrating both for us as doctors and, even more so, for our patients, who are increasingly seeking help from complementary and alternative medicine.2 Acupuncture has been used for 5000 years and has survived as a complete system of medicine, but little proof exists of its efficacy. It was not until 1972, when US President Richard Nixon returned from a visit to China, that acupuncture started to flourish in the West.

Frustrated with the medicine that I (RH) had been taught at medical school, and having far fewer answers than I had hoped for, I studied acupuncture shortly after completing my house jobs. I learnt Chinese acupuncture, which is based on a system of looking at the body that was completely alien to me as a Western trained doctor. Over the years I have adapted my practice, and I now use acupuncture as one of several therapeutic options to treat a problem once I have made an orthodox Western diagnosis. For example, irritable bowel syndrome (IBS) has no definitive treatment. It may be treated with diet, antispasmodics, laxatives, hypnotherapy, acupuncture, peppermint, or biofeedback, all of which have some rationale, and any of which may help an individual patient. As a general practitioner (GP), I offer acupuncture in my day to day practice as an additional treatment option to my patients with IBS.

West versus East



Most doctors prefer to work in the Western medical paradigm and to treat patients on the basis of orthodox medical diagnoses. It is, of course, essential that an orthodox diagnosis be made first to ensure that acupuncture is an appropriate treatment. Many doctors will treat mainly trigger points (tender spots in tight bands of muscle) and ignore traditional Chinese medicine completely. Some of us (including RH) use a mixture of Western and Eastern methods. The eastern theories of traditional Chinese acupuncture are fascinating but can be difficult to integrate into orthodox medicine as they are based on mysticism. Most non-medical acupuncturists will practise acupuncture based on theories from traditional Chinese medicine, including tongue and pulse diagnosis.

What can be treated with acupuncture?

Most acupuncture treatment entails relieving musculoskeletal pain and dysfunction. There is evidence that acupuncture is effective in treating nausea and vomiting,3 back pain4 and migraine5; and some evidence shows that it helps the pain of osteoarthritis of the knee6 7 and hip,8 temporomandibular joint dysfunction,9 and fibromyalgia.10 Some trials, clinical experience, and anecdotal evidence show that it is probably effective (at least in some patients) in treating "tennis elbow," neck pain, dysmenorrhoea, irritative bladder, hay fever, IBS, and some drug dependencies. It is not helpful in treating tinnitus and has limited use in smoking cessation, weight loss, and asthma (where pharmaceutical agents are more effective).



One of the problems with acupuncture trials is that no reliable placebo exists.11 Also, double blinding is difficult to achieve, but acupuncture works on animals and sceptical patients.

How does it work?

No single theory explains the mechanism of acupuncture. We know that it can deactivate trigger points, leading to improvement in muscle pain and function. A wide range of neurotransmitters, including opioid peptides (such as endorphins), are released centrally (giving rise to relaxation and a feeling of wellbeing) and in the spinal cord---which slow down the transmission of pain impulses. Segmental acupuncture relies on the sensory stimulation of a spinal segment, restoring function to the muscles and autonomically innervated organs in that segment. A working central and peripheral nervous system is required for acupuncture to work, and local anaesthesia, deep general anaesthesia, and naloxone can inhibit acupuncture effects. The acupuncture needle directly stimulates A delta nerve fibres, which have an inhibitory feedback effect on pain transmission mechanisms. Functional magnetic resonance imaging shows how acupuncture stimulation can have a specific effect in the brain---for example, needling acupuncture points on the foot to treat eye conditions produces activity in the visual cortex.12 Traditionalists believe that acupuncture restores the flow of Qi and the balance of energy (see further reading list).

Safety

Despite being an invasive technique, acupuncture is remarkably safe. Two recent studies showed that adverse effects were minimal.13 14 The most serious adverse effect that can occur with acupuncture is organ puncture (especially pneumothorax and rarely haemopericardium)---which is obviously preventable with careful practice, combined with good anatomical knowledge. The risk of transmitting infections is negligible with the use of single use, sterile, disposable needles.

What specialties can include acupuncture?

Most doctors in the United Kingdom who use acupuncture are GPs who incorporate the technique in their daily practice to treat the conditions mentioned above. In secondary care, acupuncture is used predominantly for musculoskeletal problems by specialists in musculoskeletal medicine (using acupuncture as one of their preferred treatment modalities) and rheumatologists. Anyone treating painful conditions may find acupuncture helpful, as its use in most NHS pain clinics testifies. Anaesthetists sometimes use acupuncture in the management of postoperative nausea and pain as well as in specialised pain clinics. Midwives are increasingly using acupuncture antenatally and in intrapartum care. In terminal care, acupuncture can help with pain, nausea, and breathing difficulties.

The British Medical Acupuncture Society

The British Medical Acupuncture Society (BMAS) was formed in 1980 and now has over 2300 doctor members who use acupuncture in hospital or general practice. The society promotes the use of acupuncture as a treatment after orthodox medical diagnosis by suitably trained practitioners.



It also seeks to enhance the education and training of suitably qualified practitioners and to promote high standards of working practices in acupuncture among such practitioners, by tests, examinations, and accreditation procedures.



The society's house journal, Acupuncture in Medicine, is published four times a year, the Point newsletter twice a year, and a comprehensive website offers further information (see below).

Training

The most widespread training for doctors is provided by the BMAS. Their foundation courses are the ideal introduction and are regularly advertised in BMJ Careers. They are held all over the country throughout the year and usually run over two weekends (a week long course is also held, in central London). These courses provide a sound practical introduction to acupuncture, predominantly from a Western scientific perspective, which will enable doctors to start treating patients with confidence. Attending a foundation course provides participants with a year's free membership of the BMAS, allowing access to the society's many resources (including the provision of hands on clinical training at its central London acupuncture teaching clinic).
(Credit: PHANIE/REX)




Further training centres on the intermediate level course, which is spread over a three year rolling programme, and additional specialist study days.



The BMAS runs two major scientific conferences a year, giving members the opportunity to hear experts from around the world, learn the latest research results, and to network with likeminded colleagues from across the country.

Qualifications

There are no acupuncture qualifications that can be registered with the GMC, but this may change as negotiations proceed to make acupuncture a statutory regulated discipline.



The BMAS offers doctors two levels of expertise. After three months' practice you have the opportunity to obtain a certificate of basic competence. This entails answering a safety questionnaire and points checklist (both usually completed at the foundation course), presenting a logbook of 30 cases and undergoing a short clinical assessment. The advanced certificate of accreditation is for serious medical acupuncturists and requires more extensive training and practice, and in-depth case histories and clinical assessment. The successful candidates qualify with a Diploma in Medical Acupuncture (DipMedAc), which is recognised by most medical insurance companies and may be helpful if you are attempting to secure funding from your primary care trust. Reaccreditation is undertaken every five years and is dependent on ongoing acupuncture education.


Training to become a medical acupuncturist

Foundation courses are run over two weekends, about a month apart, and cost £495 for the lectures, small group practical sessions, a very comprehensive manual, starter needles, lunches and refreshments, and an initial year's membership to the BMAS. (Held at venues throughout the United Kingdom.)



Intermediate courses are for doctors who have completed a foundation course and wish to learn more about acupuncture in detail. They cost £110 per day for BMAS members and £150 per day for non-members. They are held at weekends.



Two major scientific meetings are held each year (spring and autumn) on a Saturday for £100. The accompanying Sunday hosts workshops and guest speakers and also costs £100.


Conclusion

Orthodox medicine has some, but not all, the answers to today's health problems. Learning how to use acupuncture in your daily clinical work will provide you with an additional treatment modality to treat a variety of medical problems. The equipment is not expensive---each needle costs about four pence, and on average five or six needles are used for each treatment. Training obviously costs more (see box for more details).



Learning the technique of acupuncture might even give you additional enthusiasm to ward off impending burnout and to face patients with renewed energy and interest. Watch out: more and more patients will be asking you about acupuncture, and wanting treatment.

Colin Lewis, past chairman of the British Medical Acupuncture Society, general practitioner, Honeygrove, Guildford, GU3 1DA
Drcalewis@aol.com

Richard Halvorsen, past public relations officer of the British Medical Acupuncture Society, general practitioner, Holborn Medical Centre, London WC1N 3NA
halvorsen@easynet.co.uk



Further information/reading

bullet The British Medical Acupuncture Society, 12 Marbury House, Higher Whitley, Warrington, Cheshire, WA4 4QW (tel 01925-730727, fax 01925-730492,

bullet Baldry PE. Acupuncture, trigger points and musculoskeletal pain. Edinburgh: Churchill Livingstone, 1993.

bullet Filshie J, White A. Medical acupuncture---a western scientific approach. Edinburgh: Churchill Livingstone, 1998.

bullet Ernst E, White A. Acupuncture---a scientific appraisal. Oxford: Butterworth-Heinemann, 1999.

bullet Stux G, Hammerschlag R. Clinical acupuncture---scientific basis. Berlin, Vienna, New York: Springer, 2001.

References
1. Board of Science and Education. Acupuncture: efficacy, safety and practice. London: BMA, 2000.
2. Rees L, Weil A. Integrated medicine. BMJ 2001; 322: 119-120[Free Full Text].
3. Vickers AJ. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. J Royal Soc Med 1996; 89: 303-311[Abstract].
4. Ernst E, White AR. Acupuncture for back pain, a meta-analysis of randomised controlled trials. Arch Intern Med 1998; 9: 2235-2241.
5. Melchart D, Linde K, Fischer P, White A, Allais G, Vickers A, et al. Acupuncture for recurrent headaches: a systematic review of randomized controlled trials. Cephalalgia 1999; 19: 779-786[CrossRef][ISI][Medline], 765.
6. Christensen BV, Iuhl IU, Vilbek H, Bulow HH, Dreijer NC, Rasmussen HF. Acupuncture treatment of severe knee osteoarthrosis: A long-term study. Acta Anaesthesiol Scand 1992; 36: 519-525[ISI][Medline].
7. Tokeda W, Wessel J. Acupuncture for the treatment of pain of osteoarthritic knees. Arthritis Care Res 1994; 7: 118-122[Medline].
8. McIndoe AK, Young K, Bone ME. A comparison of acupuncture with intra-articular steroid injection as analgesia for osteoarthritis of the hip. Acupuncture Med 1995; 13: 67-70.
9. Ernst E, White AR. Acupuncture as a treatment for temporomandibular joint dysfunction: a systematic review of randomized trials. Arch Otolaryngol Head Neck Surg 1999; 125: 269-272[Abstract/Free Full Text].
10. Berman BM, Ezzo J, Hadhazy V, Swyers JP. Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract 1999; 48: 213-218[ISI][Medline].
11. Nahlin RL, Straus SE. Research into complementary and alternative medicine: problems and potential. BMJ 2001; 322: 161-164[Free Full Text].
12. Cho ZH, Chung SC, Jones JP, Park JB, Park HJ, Lee HJ, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Nat Acad Sci USA 1998; 95: 2670-2673[Abstract/Free Full Text].
13. White A, Hayhoe S, Hart A, Ernst E. Adverse effects following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323: 485-486[Free Full Text].
14. MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001; 323: 486-487[Free Full Text].


© 2003 BMJ Publishing Group Ltd