This special issue of Physical Therapy Reviews brings together articles predominantly on acupuncture but with a flavour of complementary medicine as a whole. The presented papers range from a clinical case study to a systematic review of the literature and encompass material on the education of physiotherapists in the use of acupuncture as a treatment modality, the biopsychosocial model of treatment and adverse events. It is reported that Complementary and Alternative Medicine (CAM) is becoming increasingly popular (Smith et al.,Citation1 Bleakley and Stinson,Citation2 this issue), with increasing consumer demands for this type of healthcare. Acupuncture as one aspect of CAM intervention is becoming increasingly popular as a physiotherapeutic treatment modality. Indeed, the Acupuncture Association of Chartered Physiotherapists in the United Kingdom is one of the biggest special interest groups with over 6,000 members currently registered.
The last few years have seen an increased acceptance of acupuncture in mainstream clinical practice with the National Institute of Clinical Excellence (NICE, 2009)Citation3 recommending its use in the treatment of persistent non-specific low back pain. Similarly the use of acupuncture has been advocated as a treatment modality in the management of chronic low back pain by the American Pain Society.Citation4 This increasing acceptance, however, does not negate the need for future research in this area but is encouragement for researchers to continue to investigate the benefits of acupuncture.
With the increased acceptance of acupuncture into mainstream physiotherapeutic practice it is as important as ever to ensure that minimum standards for training have been established. One aspect of this involves the use of evidence to support training; for example, in this issue of the journal, Kohut et al.Citation5 describe how in New Zealand physiotherapists are encouraged to base their interventions on best available evidence. Although the expansion of the evidence base remains a challenge it is clear that research findings are being used in the development of acupuncture education programmes for physiotherapists. The two papers on acupuncture education (Kohut et al.Citation5 and Rittig–RasmussenCitation6) give the reader a taste of acupuncture education in physiotherapy in two different countries. In both papers there is a heavy emphasis on education based on the available evidence and a leaning towards a Western approach to acupuncture therapy. The paper by Kohut et al.Citation5 advocates the integration of the theories of Traditional Chinese Medicine (TCM) however the Danish experience is somewhat different in that there is a clear leaning away from the perceived ‘mysticism’ associated with the traditional theories towards an education programme with a neuro-physiological basis.
Indeed this neuro-physiological aspect is reiterated in the paper by McDowell et al.Citation7 in their discussion of the classification of adverse events in acupuncture therapy (another really key aspect of any acupuncture training programme). This paper highlights the need for consistent reporting of events associated with acupuncture therapy and the need for agreement on what should be classed as an adverse event and not an expected reaction to acupuncture therapy. The paper by McCutcheon and YellandCitation8 identifies the need for therapists to be adequately educated and skilled in the application of needles before they attempt to needle around areas that are particularly vulnerable (e.g. thorax and cervical regions, where there is a risk of pneumothorax). The identification of various techniques to avoid involvement of the pleura and lungs is particularly useful for practitioners. Indeed, as the use of acupuncture in physiotherapy becomes more widely accepted in the treatment of non-musculoskeletal pain conditions, it is increasingly important that training and education is at an optimum level supported by thorough research activity through both the use of randomised controlled trials, and less rigorous evidence from cohort studies and case studies. The use of the case study methodology is often advocated in complementary research as it affords the researcher the flexibility to examine the intervention in what purists describe as its original TCM form e.g. the use of acupuncture for the management of post-herpetic itch (ImrieCitation9) in the current issue.
Another key area highlighted in this special issue is the importance of reporting of specific treatment approaches (whether they be TCM or Western). Adoption of the Standards of Reporting in Controlled Trials of Acupuncture (STRICTA) guidelines (MacPherson et al.Citation10) by authors may improve the reporting of intervention details in acupuncture studies, allowing the reader to make an informed judgement on the content and implications of the published articles. Researchers still have to deal with the dilemma of individualised treatment according to traditional teaching versus prescribed treatments which allow an element of control within randomised controlled trials. Rittig-RasmussenCitation6 takes this argument further, questioning the specificity of acupuncture points and the possible benefits of a series of non-specific stimulations as a way to desensitise the nervous systems. This debate between the use of TCM acupuncture and a more Western approach based on a neuro-physiology background will continue. However, the TCM approach of individualised patient management is in essence what we, as physiotherapists, attempt to do in our day-to-day clinical practice. Adopting a biopsychosocial approach leads us to adapting our treatment interventions based on the patient we see before us and not on a set protocol of treatment for a particular condition. This ability to adjust treatment according to the patient allows us as clinicians to offer the best care for the patient following Sackett’sCitation11 description of evidence-based medicine; a combination of both clinical expertise and best available evidence. Clinicians should make judicious use of evidence-based clinical guidelines in conjunction with their clinical expertise to develop individual patient-centred practice.
The adoption of the biopsychosocial model in our clinical reasoning in Western-style acupuncture (Bradnam)Citation12 is advocated in this issue. Those physiotherapists who have undergone traditional training in acupuncture will recognise that what is being advocated is not unlike that which traditional practitioners would use in their clinical practice. Traditional acupuncturists would see the patient as an integral part of their surroundings and affected by many other influences, not only the physiological condition that they are suffering from but also their psychological condition, and accept that it would be unwise to attempt to address one and not the other for a successful outcome. Perhaps future research should address the issue of appropriate outcome measures in acupuncture research which encapsulate all that we expect from successful patient management.
Development of the evidence base for acupuncture has been an arduous task for researchers. The investigation of acupuncture as a treatment modality in the traditional gold-standard fashion in an RCT remains difficult even with the advent of placebo needles and sham devices. There is still no agreement regarding a true placebo intervention in acupuncture trials and the inability to blind therapists to the treatment only increases the potential risk of bias. The systematic review by Tough and White,Citation13 included in this issue, confirms again what most acupuncture research has reported in the past; there remains a need for good quality, adequately powered, placebo controlled trials. The question remains as to whether this type of trial can ever be carried out given the nature of acupuncture and as yet the inability to define an adequate placebo. The NICE guidelines (2009)Citation3 suggest that acupuncture (along with other modalities for which evidence is limited) should be tested in a pragmatic fashion. It is suggested that perhaps acupuncture should be investigated as an intervention were other treatments have failed or as part of a combination of treatments, much as it would be used in clinical practice.
In conclusion, the articles included in this special issue demonstrate that the practice of acupuncture in physiotherapy is one that appears to be continuing. The increasing numbers of chartered physiotherapists in the UK and physiotherapists in other countries such as Denmark (Rittig-RasmussenCitation6) who use the modality and the increasing postgraduate training activity such as that in Auckland University of Technology (KohutCitation5) as well as the number of countries included in the International Acupuncture Association of Physical Therapists (IAAPT, 2011)Citation14 are testament to this. There is evidence that acupuncture education is based on a growing research evidence base and that the use of acupuncture is expanding beyond the remit of treating musculoskeletal pain. This is highlighted by the case study report by Imrie. More recently acupuncture has been used by physiotherapists in women’s health, the treatment of infertility and there is a widening body of evidence for its use in neurological conditions. Indeed the review by Bleakley and StinsonCitation2 highlights that many women diagnosed with breast cancer are turning to CAM to improve their quality of life. Given these developments it is important that this growth and development increases and that the practice of acupuncture and other CAM interventions continue to be supported by robust research activity in its many forms.
Daniel Kerr
University of Ulster
School of Health Sciences
Shore Road, Newtonabbey
County Antrim BT37 0QB, UK
References
- Smith JM, Sullivan JS, Baxter GD. Complementary and alternative medicine: contemporary trends and issues. Phys Ther Rev 2011;16(2):91–5.
- Bleakley and Stinson. Complementary and alternative therapies: do they improve quality of life for women with breast cancer? Phys Ther Rev2011;16(2):96–105.
- NICE Guidelines 2009 Low back pain. Early management of persistent non-specific low back pain Accessed 19 April 2011 http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf.
- Chou R, Qaseem A, Snow V, Casey D, Cross T, Shekelle P, Owens DK. 2007 Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine 147(7):478–91.
- Kohut SH, Larmer PJ, Johnson G. Western acupuncture education for New Zealand physiotherapists. Phys Ther Rev 2011;16(2):106–12.
- Rittig-Rasmussen B. Physiotherapy and acupuncture practice in Denmark. Phys Ther Rev 2011;16(2):113–7.
- McDowell JM, Johnson GM, Bradnam LV. Towards a neurophysiological mechanisms-based classification of adverse reactions to acupuncture. Phys Ther Rev 2011;16(2):118–25.
- McCutcheon L, Yelland M. Iatrogenic pneumothorax: safety concerns when using acupuncture or dry needling in the thoracic region. Phys Ther Rev 2011;16(2):126–32.
- Imrie AD. Acupuncture treatment of facial postherpetic itch. Phys Ther Rev 2011;16(2):133–7.
- MacPherson H, White A, Cummings M, Jobst K, Rose K, Niemtzow R. Standards for reporting interventions in controlled trials of acupuncture: the STRICTA recommendations. Complement Ther Med 2001;9(4):2469.
- Sackett DL. Evidence based medicine. Semin Perinatol 1997;21(1):3–5.
- Bradnam LVA biopsychosocial clinical reasoning model for western acupuncture. Phys Ther Rev 2011;16(2):138–46.
- Tough E, White AR. Effectiveness of acupuncture/dry needling for myofascial trigger point pain. Phys Ther Rev 2011;16(2):147–55.
- International Acupuncture Association of Physical Therapists. Accessed 19th April 2011 http://www.wcpt.org/iaapt/members.