Vol. 11 •Issue 2 • Page 81
Acupuncture Essential for Nurse Practitioners
Interest in complementary and alternative medicine (CAM) is rising dramatically, and acupuncture is one of the modalities your patients may seek your advice about. In the United States, regulation of acupuncture practice varies markedly from state to state. To make safe and informed decisions about referring patients for acupuncture treatments, nurse practitioners must understand the basic theory, applications and training requirements for acupuncturists.
What is Acupuncture?
Acupuncture is a form of traditional Chinese medicine (TCM) that has been practiced for more than 2,000 years. It is based on the belief that health is determined by a balanced flow of energy or chi (qi). Chi regulates the balance among the mind, body and spirit. It flows along energy channels or meridians. TCM states that when the normal flow of energy is blocked, an excess or deficient condition results in specific organs. In TCM, organs are not congruent with allopathic anatomy and physiology; instead, organs are abstract with energetic qualities.1 Acupuncture treatments are aimed at manipulating the flow of energy by restoring balance and harmony in the body. At specific acupuncture points just beneath the skin surface and along meridians, the acupuncturist inserts ultra-thin, hair-like needles (0.22 mm to 0.25 mm in diameter) of varying lengths (0.5 inches to 3.0 inches) to correct the flow of chi.2
In Western societies, acupuncture has evolved into a hybrid called medical acupuncture that has developed from TCM and biomedical practices.3 Medical acupuncture combines a neurohumoral approach with the classical paradigm of needling along meridians to stimulate the flow of chi.3 Specific point locations are needled to treat various conditions. A standard prescriptive combination of acupuncture points is generally used to treat specific conditions. For example, a headache is generally treated by needling colon 4, an acupuncture point located on the radial side of the wrist and between the extensor pollicis longus and brevis tendons.4
In contrast, point selection in TCM acupuncture is individualized and based on a comprehensive analysis of information collected through inspection, auscultation, olfaction, inquiry and palpation. For example, two different patients complaining of a headache would not likely receive the same acupuncture treatment. Several pathologies can cause headaches in TCM diagnosis, and the acupuncturist considers individual constitutions when selecting an appropriate treatment plan.
Several techniques are used to stimulate the flow of chi to impaired organs, including electroacupuncture, moxibustion, cupping and auricular acupuncture. These techniques can be used as an alternative to needling acupuncture points or adjunctively.
In electroacupuncture, which is often used for musculoskeletal problems such as arthritis, low back pain and sciatica, the acupuncturist inserts pairs of needles into acupuncture points. The needles are connected to a battery-operated device that delivers a fine, direct, electric current.5 Frequency and strength of the electric current can be adjusted, based on the patient’s tolerance and condition. Most patients feel a heightened sense of pulsation at the point where needles are connected to the electric current. Electroacupuncture is contraindicated in patients with pacemakers because the current from the electroacupuncture device may interfere with the function of a pacemaker.6 Other contraindications to electroacupuncture can include pregnancy; decreased or impaired sensation and circulation, as in severe arterial disease; undiagnosed fever; or severe skin lesions.7
In moxibustion, the acupuncturist applies the dried herb Artemisia vulgaris indirectly or directly onto the skin. In indirect moxibustion, he or she rolls the herb into a cigar shape (moxa stick) and burns it. When lit, the moxa stick can be applied over an area of skin or above an inserted needle. When applied directly, the acupuncturist stacks and shapes the herb into the form of a cone and places it on the skin surface. He or she lights the top of the cone and extinguishes it before the skin is burned. The heat produced from the lit moxa is hypothesized to penetrate the meridians and influence the flow of chi. Moxa emits a strong, musky odor when burned. The burned moxa leaves a temporary erythema at the site of application.8 Moxibustion is generally used to treat conditions with edema and pain, such as shoulder and back pain. Moxa is contraindicated on the face and over major vessels and nerves.8 In addition, special care is needed for patients with reduced levels of consciousness, sensory disturbance, psychotic disorders, purulent dermatitis or impaired circulation.7
In cupping, the acupuncturist places glass cups varying in size (from a shot glass to a highball glass) over acupuncture points. He or she holds a cotton ball with forceps, dips it into alcohol and lights it. The practitioner then holds the cup upside down near the patient and heats the inside briefly with the burning cotton ball. This technique reduces the air pressure inside the cup and creates a strong suction. He or she then leaves the cup on the skin for approximately 15 minutes to 20 minutes. Cupping is often used to treat conditions such as arthritis and ecchymosis.
Auricular acupuncture involves using 1Ú2-inch needles, special needles such as press needles (tiny needles placed on a small adhesive patch) or ear seeds (mustard seeds placed on a small adhesive patch) to provide a form of acupressure. The ear represents a micro-version of acupuncture points that, when stimulated, can affect the flow of chi in other organs.5 Auricular acupuncture is used to manage pain and to treat addiction to alcohol, cigarettes and drugs.9
Indications for Acupuncture
Although acupuncture has been practiced for thousands of years in China, research about it is limited. At this time, clinical trials indicate that acupuncture is effective for the treatment of post-operative and chemotherapy-induced nausea and vomiting.10,11 Additional evidence suggests that acupuncture is also helpful in reducing pain associated with osteoarthritis and dental surgery.12,13 A National Institutes of Health (NIH) panel has also determined that acupuncture may be useful in the treatment of alcohol addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, low back pain, carpal tunnel syndrome and asthma.11 For other health conditions, there is little evidence about whether acupuncture is effective or ineffective. However, many clinical trials funded through the National Center for Complementary and Alternative Medicine at the NIH are in progress to test acupuncture’s effectiveness.
Needle insertion with skin penetration is the most common form of acupuncture, and it is comparable to a subcutaneous injection. In general, acupuncture is a safe treatment modality with few contraindications and complications.7 Adverse events are uncommon when acupuncturists are properly trained and adhere to sterile needle techniques.14
Nonetheless, adverse events have been reported, such as cardiac tamponade, pneumothorax, transverse myelopathy, and infection.6,8,14,15 Such complications could be avoided, however, with better knowledge of anatomy relevant to acupuncture and appropriate needling techniques. For example, a needle should be inserted obliquely to the sternum to prevent cardiac tamponade. Acupuncture is contraindicated in certain circumstances: in the presence of hemophilia, pregnancy or psychosis, and when a patient is fasting or has recently ingested alcohol. In addition, acupuncture is contraindicated in medical emergencies. First aid should be administered immediately or the patient should be transported to the closest emergency room. Furthermore, acupuncture should not be the primary therapy for the treatment of cancers or tumors. In these cases, it should be used as an adjunct to conventional medical care to alleviate side effects associated with treatment to improve quality of life.
What to Expect
Although the theories governing acupuncture differ from conventional Western medicine, both systems utilize patient histories and physical assessments to formulate diagnoses. In TCM acupuncture, the diagnosis is based on the pathogenic factors of TCM, called syndrome analysis. Syndrome analysis can be classified in three categories: external, internal and other (neither internal nor external). There are six external factors: wind, cold, summer heat, dampness, dryness and fire. These factors are normal and not harmful to the body, unless they become excessive or when chi declines. If this occurs, the six factors can cause disease and symptoms. The internal factors refer to seven emotions: joy, anger, melancholy, worry, grief, fear and fright. If any of the emotions are expressed too strongly or frequently, disease can result. Other factors include dietary irregularities, obsessive sexual activity, fatigue, trauma and parasites.2 An acupuncturist typically utilizes four diagnostic methods to evaluate a patient’s syndrome: inspection, auscultation or olfaction, inquiry and palpation.2
Inspection involves assessing the patient’s posture, complexion, color, facial expression and the nature of their secretions and excretions. Another important component of inspection includes observation of the tongue for markings, color, shape and coating. For example, a deep red tongue with a yellow coating would indicate a heat syndrome.
Auscultation involves listening to the patient’s voice for volume, strength, clarity and rate of speech. In olfaction, the acupuncturist evaluates the patient for odors that emanate from the mouth, body and excreta. For example, a sour odor from the mouth is often associated with a digestive disorder.
Inquiry involves taking an extensive history to evaluate the chief complaint, such as the onset of the illness, the course of the disease, the location of symptoms, and past medical history.2 The interview also inquires about the patient’s quality of life, including:
• appetite and diet
• bowel movements (color, consistency, frequency, odor)
• thirst (frequency, preference for cold vs. hot vs. warm fluids)
• urination (frequency, color, odor)
• sleep and dreams (hours of sleep per night, type of sleep [restful or restless], vivid or violent dreams)
• body temperature (chill or fever)
• conditions of the head, eyes, nose, ears and throat
• conditions of the trunk (chest, abdomen, back)
• condition of the limbs
• spirit or emotion
• pain (location, quality, duration)
• menstruation (cycle, duration, amount, color, quality, cramps, leukorrhea)
• pregnancy, abortions or miscarriages
• energy level (self-rated on a scale of 1 to 10).
During palpation, the acupuncturist looks for areas of coldness, heat, softness, hardness, tenderness, masses or other abnormal conditions of the skin, hands, feet and abdomen. For pulse palpation, the acupuncturist places three fingers (index, middle and ring fingers) on the radial arteries of the wrists. Each hand has three pulse locations corresponding to particular organs. Each pulse is assessed for speed, depth, strength, fluency, size, shape, tension and rhythm. A normal pulse is smooth, even and forceful, with approximately four beats per breath.2
An acupuncture session may last from 30 to 60 minutes. The number of sessions required varies with each condition and person. Typically, at least six treatment sessions are needed to evaluate changes in condition. Treatment sessions are typically given weekly or twice weekly. Some conditions may require periodic treatment follow-up (i.e., monthly or every few months). It is advisable for patients to eat well-balanced meals and to exercise regularly during acupuncture treatment.
When advising patients about acupuncture or another complementary therapy, safety and shared decision-making are essential.16 Conduct a complete medical evaluation and make any appropriate specialist referrals. Advise the patient about all conventional therapeutic options. If a patient refuses conventional approaches, document this refusal in the chart.16 Discuss with the patient his or her expectations about acupuncture treatment and the rationale for selecting the therapy. Review the appropriateness of acupuncture for treatment of the principle symptom. If the medical literature shows that acupuncture is a safe and suitable treatment, determine whether the chosen acupuncturist is licensed, has had the appropriate training, and maintains malpractice insurance. Review the acupuncturist’s credentials and document them in the patient’s record. If possible, suggest that the patient interview the acupuncturist before scheduling a visit.
The patient should ask the acupuncturist about the effectiveness of the therapy and how the outcome will be measured.16 Patients should also ask about herbal preparations that may be prescribed, and their potential risks and side effects. In addition, patients should request that the acupuncturist communicate their findings and plans with you. You should schedule two visits with such a patient, the first to follow up and review the treatment plan prescribed by the acupuncturist, and the second to review the response to acupuncture. Clinical encounters and discussions should be well-documented. If a patient’s request for an acupuncture referral is inappropriate, explain why.
There are various avenues to becoming an acupuncturist in the United States. In many parts of the country, physicians, chiropractors and dentists are allowed to practice the modality with little or no training. In contrast, acupuncturists who attend a full-time, 3-year acupuncture program but who are not physicians may not be permitted to practice in some states, despite a more rigorous and intensive educational curriculum and credentialing process (Table 1).
The National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine (NACSCAOM) has approved more than 50 schools and colleges of acupuncture and oriental medicine. The national minimum is 1,725 hours of training, with 360 hours devoted to Western biomedical coursework (which may be waived for health care professionals with evidence of passing those courses during prior study) and 1,365 hours devoted to acupuncture theory, technique and clinical practice.17 These guidelines comprise the formal educational standard for eligibility to sit for certification by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). Formal education entails graduating from a full-time acupuncture program accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). Candidates must document at least 1,725 hours of entry-level acupuncture education, consisting of 1,000 didactic and 500 clinical hours.18 World Health Organization (WHO) guidelines recommend 2,500 hours of study with no fewer than 1,000 hours of practical and clinical work.7 Most professional acupuncture programs exceed WHO standards and are about 2,700 hours in length.17
Alternatively, allied health or medical professionals may choose the apprenticeship route to prepare for NCCAOM eligibility and certification. This training consists of at least 4,000 contact hours over 3 to 6 years. Preceptors must have a minimum of 5 years of experience performing acupuncture. The preceptor’s practice must have a minimum of 500 acupuncture patient visits each year, with at least 100 different patients seen during each year of the apprenticeship.
The NCCAOM mission is to promote nationally recognized standards of competency and safety in acupuncture, Chinese herbology and Oriental bodywork therapy.18 Eligibility for certification requires successful completion of a clean needle technique course approved by the NCCAOM, agreement to be bound by the NCCAOM’s code of ethics, and a passing score on the organization’s exam. The exam includes a written comprehensive examination and a point location assessment.
People who have graduated from an acupuncture program, meet the NCCAOM requirements and successfully pass the exam are credentialed as diplomates in acupuncture or “Dipl. Ac.” However, depending on a medical professional’s state scope of practice, passage of the NCCAOM examination may not be required to practice acupuncture.
Because not every state has the same requirements to practice acupuncture, the degree of education and training of medical professionals performing acupuncture varies. Thirty-five states permit physicians to practice acupuncture without regulation, since it is considered within the scope of their medical or osteopathic licenses. In Alaska and Iowa, podiatrists and dentists may practice acupuncture under their scopes of practice. Connecticut allows nurses to perform acupuncture under the orders of a physician without any specified training. Some states also allow chiropractors to practice acupuncture after 100 hours of instruction. Kansas permits physician assistants to needle patients if authorized by a physician.19 The other 11 states require physicians to register evidence of formal training or participation in 200 to 300 hours of training (Table 2).19
An MD, DO or dentist can prepare to practice acupuncture by attending continuing education programs or completing a formal education program or apprenticeship.20 Physicians who do not meet the NCCAOM requirements and wish to practice acupuncture may seek certification from the American Board of Medical Acupuncture (ABMA). Again, state requirements for physician practice of acupuncture vary and certification may not be necessary. The ABMA evaluates the acupuncture training of physicians seeking certification. Once ABMA has approved the program of study and the physician completes the clinical experience requirements and passes the examination, a certificate is issued acknowledging the applicant as a diplomate of the American Board of Medical Acupuncture.
The ABMA standards include a minimum of 200 hours of acupuncture training post-medical school, of which 100 hours must be clinical. The guidelines are based on standards recommended by WHO and the World Federation of Acupuncture and Moxibustion Societies (WFAS).8 WHO suggests that “basic training” for physicians should be undertaken to become competent in acupuncture as a form of therapy in modern clinical practice or for the purpose of scientific research.8 For example, the scope of acupuncture practice for this type of training can include a physician or dentist who acquires proficiency in specific applications of acupuncture such as pain management, or for dental or obstetric analgesia.8 WHO guidelines recommend 1,500 hours of formal training, including 1,000 hours of practical and clinical work, “for qualified physicians who want to independently practice acupuncture.”8
Acupuncture is an important addition to the health care repertoire. However, major concerns about the lack of standard training regulations must be addressed. Without standardization, the benefits of acupuncture may never be fully recognized or understood. Of greater concern is that patient safety is jeopardized without appropriate education in anatomy relevant to acupuncture and needling. Physicians and allied health professionals are unlikely to have been taught this information in traditional health science curriculums.15 Notably, the currently accepted training methods for physicians consisting of approximately 200 to 300 hours (many are home study programs) do not meet the guidelines established by WHO to practice acupuncture independently.7,20 WHO recommends that providers who are not physicians undergo at least 2,500 hours of training with direct clinical supervision, while physicians should receive at least 1,500 hours of education and direct clinical supervision.7 At this time, the 200- to 300-hour programs are only for use by physicians who want to become competent in acupuncture to conduct clinical research or to learn about specific acupuncture points to treat specific conditions such as pain.7
State regulators must address the lack of training so that consumers are protected. Currently, Hawaii applies the highest standards and regulations to the practice of acupuncture. Any person who wishes to practice acupuncture in that state must graduate from an accredited acupuncture program consisting of at least 2,175 academic and clinical training hours in TCM and pass the NCCAOM examination.19 Other states would do well to follow this model. Poorly trained acupuncturists will negatively influence patient assessment and treatment outcomes, thus inaccurately reflecting the risk and benefits of acupuncture. More serious, however, is that referring patients to acupuncturists with limited training places patients at great risk for injury or inappropriate treatment. In sum, nurse practitioners must understand the importance of the proper training of acupuncturists before they can make safe and informed referrals for patients.
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17. Gaeta M. Acupuncture law & certification. The Acupuncture Society of New York Web Site. Available at: http://www.asny.org/testim2.asp.
18. National Certification Commission for Acupuncture and Oriental Medicine. Eligibility: Acupuncture. Available at: http://www.nccaom.org/certify.html.
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Bernadette Capili is a nurse practitioner with a doctorate who is the clinical manager at Mount Sinai Medical Center’s General Clinical Research Center. Amy Weinberg is a family nurse practitioner who is the Nicholas Rango HIV Clinical Scholar at SUNY Downstate Medical Center in Brooklyn.