MARK GREENER
Freelance medical writer, journalist and editor
Mark, a former research pharmacologist, is now an award-winning medical writer and journalist. He has also published numerous medical economic papers in peer-review journals and is the author of 10 books on health-related issues
Traditional Chinese healers started practising acupuncture, initially using stone needles, at least 2,500 years ago. Despite some scepticism among Western clinicians, there is no doubt that acupuncture alleviates the pain, discomfort and impaired function arising from several conditions. For example, a Cochrane review concluded that acupuncture relieves pain and improves function over three months in patients with chronic low-back pain.(1)
Indeed, acupuncture recently received the National Institute of Health and Clinical Excellence’s (NICE) seal of approval for low-back pain.(2) NICE suggests offering sufferers a course of exercise, manual therapy or acupuncture depending on patient preference. If the chosen treatment does not produce a satisfactory improvement, primary care trusts (PCTs) should offer one of the remaining options.(2)
Evidence base
Dr Mike Cummings, Medical Director of the British Medical Acupuncture Society (BMAS) and a former GP in the Royal Air Force, told Management in Practice that NICE considered large randomised controlled trials (RCTs) and an economic assessment published since the Cochrane review that bolster the evidence base supporting acupuncture.
The economic analysis estimated that offering 10 individualised acupuncture sessions over three months would cost the NHS £460 per patient, compared with £345 for usual care, over two years. The cost per quality adjusted life year gain (QALY) was just £4,241, well within NICE’s usual threshold of around £20,000 per QALY.(3)
The NICE guidelines suggest restricting acupuncture to a maximum of 10 sessions over 12 weeks or less. Dr Cummings, who advised the NICE guideline development group about acupuncture, would have preferred a “less didactic recommendation”. He notes that NICE derived the recommendation from the recent large RCTs.
“Clinical practice is not the same as an RCT,” he points out. “I would have preferred to see more clinical judgement applied in this decision, but I understand the need to put an upper limit on provision”.
Treatment approach
Dr Cummings suggests treating patients for between three and six sessions, and then moving to exercise or manual therapy if patients do not benefit. Most patients who benefit should continue for between eight to 12 sessions. Clinicians should review patients who relapse after a month to decide on whether or not to offer maintenance acupuncture treatment. However, Dr Cummings stresses that he bases his suggestions on clinical experience, rather than rigorous RCTs.
Patients, depending on their preference, can either use acupuncture as their first course of treatment, or try needling after manual therapy or exercise if these options fail. NICE suggests offering a maximum of nine sessions of manual therapy, including spinal manipulation, over 12 weeks or less.
The tailored, structured exercise should comprise a maximum of eight sessions over 12 weeks or less, usually in a supervised group of up to 10 people. However, if groups are not suitable for a particular person, NICE advocates offering one-to-one supervised exercise programmes. All patients should also receive advice and information that encourage self-management.
GPs should consider referring people who received at least one of these less intensive treatments and who endure “high disability”, significant psychological distress or both for a combined physical and psychological programme. This comprises around 100 hours over a maximum of eight weeks.
Practice service implication
Against this background, Dr Cummings would like to see all PCTs develop acupuncture services with a “strong focus on high-volume, group acupuncture clinics”. The approach proved successful in initial results from an ongoing UK study.(4)
“I think it is possible for all practices to have one or more GP, nurse or physiotherapist with acupuncture skills,” he says. “The BMAS trains regulated healthcare professionals in short and inexpensive courses in Western medical acupuncture. There is also room for the development of more central PCT-run clinics, perhaps associated with a musculoskeletal clinical assessment treatment and support service”.
Despite acupuncture’s long history, several questions remain. According to Dr Cummings, further studies should investigate: the most effective acupuncture techniques and regimes; how to select patient subgroups that respond well; and the most cost-effective approach to implementation. In the meantime, after two-and-a-half millennia the NICE guidelines firmly establish acupuncture in the medical mainstream.
References
1. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005:CD001351.
2. National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain. London: RCGP; 2009. Available from: http://www.nice.org.uk/nicemedia/pdf/CG88fullguideline.pdf
3. Ratcliffe J, Thomas KJ, MacPherson H, et al. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. BMJ 2006;333:626.
4. Berkovitz S, Cummings M, Perrin C, et al. High volume acupuncture clinic (HVAC) for chronic knee pain – audit of a possible model for delivery of acupuncture in the National Health Service. Acupunct Med 2008;26:46-50.
