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Commissioning Guidance for Acupuncture

Scope of this guidance

This guidance is intended for use by clinical commissioning groups to support them in commissioning acupuncture services for their local population. It may also be useful for those interested in introducing acupuncture services in their organisation or region.

This document outlines:

  • What is acupuncture?
  • How does acupuncture work?
  • What is the evidence for the efficacy of acupuncture?
  • Is acupuncture safe?
  • Who can perform acupuncture?
  • Is acupuncture cost effective?
  • How can acupuncture be incorporated into conventional healthcare?
  • How do you plan a course of acupuncture for chronic pain?

The guidance also provides resources through links to evidence on the efficacy of acupuncture and training organisations.

Download this guidance as a pdf document here.

A book of BMAS recommended protocols for chronic pain is available here. This is intended for acupuncture practitioners.

This guidance will be reviewed in April 2023.

 

Who produced this guidance?

Dr Amer Sheikh MBChB MRCGP MSc (Pain Management)

I am GP with a special interest in musculoskeletal and chronic pain. Between 2013 and 2019, I was the Musculoskeletal Clinical Lead for North-West Surrey Clinical Commissioning Group. During this time, I was responsible for the design and oversight of the Surrey Integrated Musculoskeletal Service. I have been a lecturer in acupuncture for several years and am current President of the British Medical Acupuncture Society.

Dr Mike Cummings MB ChB Dip Med Ac

I am Medical Director of the British Medical Acupuncture Society and a former military GP with a principal interest in musculoskeletal medicine. I have been teaching acupuncture techniques to GPs and other healthcare professionals for the British Medical Acupuncture Society for 25 years. I am an author and editor of the principal textbooks in the field of Western medical acupuncture.

Mr Duncan Lawler BPhysio, DipHSM, MA, Dip Med Ac

I am a physiotherapist specialising in acupuncture and pain management. I have written several books on men's health, back pain (Back to Brilliant) and positive thinking (Be the Best You).  These books feature on the recommended reading lists for a number of degree courses. I have been a lecturer and assessor in acupuncture for several years and am the current Chair of Professional Services of the British Medical Acupuncture Society.

 

Key messages

Acupuncture is an effective treatment for a range of pain-related conditions

Acupuncture is a safe practice in the hands of trained staff

Acupuncture is a cost-effective intervention

Acupuncture can be easily incorporated into standard NHS care


NICE guidelines recommend acupuncture for the treatment for tension-type headache and migraine,[1] and chronic pain.[2]

The International Association for the Study of Pain states:

Chronic pain treatment strategies that focus on improving the quality of life, especially those integrating behavioral and physical treatments, are preferred.[3] 

 

What is acupuncture?

‘Acupuncture’ refers to the insertion of a solid needle into any part of the human body for disease prevention or treatment. Techniques in which any substance is injected through a hollow needle are not considered to be acupuncture, nor are treatments that do not include piercing the skin.[4]

There are various forms of acupuncture:

Traditional acupuncture: this is based on Traditional Chinese Medicine in which illness is seen as an imbalance of the body, and acupuncture is used to restore the equilibrium.

Western medical acupuncture: this makes diagnoses in conventional medical terms and uses needles to influence the physiology of the body according to current scientific understanding. It regards needling as a conventional treatment alongside drugs and surgery, and practice changes as evidence emerges.

Dry needling: this is used mostly to treat painful conditions by inserting needles into tender areas of the body. It contrasts with ‘wet needling’ in which substances are injected and these are thought to achieve a therapeutic effect as opposed to the needle itself.

Trigger-point acupuncture: as the name implies, this is needling done over myofascial (muscles and its fascia) trigger points in order to treat pain and dysfunction. This is synonymous with most uses of dry needling.

 

How does acupuncture work?

The effects of acupuncture can be divided into the specific effects of the needling itself and non-specific effects related to the clinical encounter and ritualistic aspects of a hands-on technique.

The specific effects of acupuncture include:[5]

Local effects

Stimulation of sensory nerves (A-delta fibres) in skin and muscle; and increasing local blood flow and promoting healing through release of neuropeptides.

Segmental effects

This is similar to the ‘gate-theory’ of pain. Needling the same neurological segment in skin or muscle around the site of the pain affects the dorsal horn of the spinal cord at the same segmental level, causing suppression of painful stimuli, ‘closing the gate’ at that level.

General effects

Needling triggers the release of opioid peptides and activates the descending modulatory pain systems. Beta-endorphin is released in the brain and bloodstream, and enkephalin in the spinal cord. Serotonin and noradrenaline are released in the descending modulatory pain systems. Very strong acupuncture stimulation can also cause widespread pain inhibition involving the descending systems: this is referred to variously as Diffuse Noxious Inhibitory Control (DNIC), Heterotopic Noxious Conditioning Stimulation (HCNS) and most recently as Conditioned Pain Modulation (CPM). However, this level of stimulation is rarely used in clinical practice.

Acupuncture reduces the affective component of pain by deactivating limbic system activity and producing a feeling of wellbeing. This can result in emotional calming, euphoria and relaxation. It can also modulate autonomic tone which can be useful in treating both musculoskeletal conditions as well as functional visceral disorders, such as overactive bladder.

 

What is the evidence for the efficacy of acupuncture?

Acupuncture has been found to be effective for a range of medical problems, most of which are pain-related complaints.[6] These include headaches and chronic pain. A full list can be found in the document titled Clinical evidence for acupuncture on this webpage. As a result, they also feature in NICE guidelines.

NICE guideline for headaches in over 12s (CG150): last updated 25th November 2015 [1]

Tension-type headache

1.3.9    Consider a course of up to 10 sessions of acupuncture over 5-8 weeks for the prophylactic treatment of chronic tension-type headache.

Migraine with or without aura

1.3.20  If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5-8 weeks according to the person’s preference, comorbidities and risk of adverse events.

NICE guideline for chronic pain (primary and secondary) in over 16s (NG193) 2021 [2]

Acupuncture for chronic primary pain

1.2.5    Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:

is delivered in the community setting andis delivered by a band 7 (equivalent or lower) healthcare professional with appropriate training and is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries) or is delivered by anther healthcare professional with appropriate training and/or in another setting for equivalent or lower cost.

 

Is acupuncture safe?

Acupuncture is a generally very safe and well-tolerated treatment when performed by competent individuals.

At the same time, there are inherent risks related to inserting needles into the human body such as unintended puncturing of body parts. Acupuncture needles generally have a fine diameter; are solid as opposed hollow injection needles; and have a sharp point. They cause much less injury as compared to the thicker, hollow needles used for injections. Spread of blood-borne diseases such as HIV and hepatitis B has been reported but is thankfully rare after the advent of disposable needles. Good training and regulation of acupuncture practitioners is vital in maintaining the safety of this practice.

The biggest safety study so far involved over 220 000 patients and concluded that acupuncture is relatively safe [7]. Of the 220 000 patients, 8% had an adverse event but only 2% required any treatment. These included:

  • Minor bleeding and haematoma: 6.1% of patients – the most common adverse event
  • Pain: 1.7%
  • Vegetative symptoms (eg sleepiness, change in appetite): 0.7%
  • 2 patients suffered a pneumothorax: one of them needed hospital treatment, the other needed observation only
  • The longest duration of an adverse event was 180 days for a nerve lesion of the lower limb.

 

Who can perform acupuncture?

The 3 largest groups of trained and regulated acupuncturists are:

  • British Medical Acupuncture Society (BMAS): Western medical acupuncture (WMA)
  • Acupuncture Association of Chartered Physiotherapists (AACP): WMA
  • British Acupuncture Council (BAcC): Traditional Chinese Medicine (TCM) Acupuncture

 

Is acupuncture cost-effective?

Chronic pain comes at a great cost to the individual, their family and friends, and society as a whole. Part of this cost is related to healthcare including time spent with a range of healthcare professionals, diagnostics, procedures and long-term use of medication with risk of addiction and side-effects. The risks of opiates and gabapentinoids have become very clear in recent years and NICE guidelines for chronic pain are a step towards rectifying the disservice done to patients over the past few decades.

Acupuncture has been shown to be cost-effective when compared to standard treatments for a range of chronic pain conditions including headaches.[8–10] Economic evaluations undertaken by NICE underpin their guidelines for these conditions. Acupuncture treatment offers the upside of efficacy without the greater downsides of addiction, side-effects and disability that are features of standard medical treatments and that carry their own costs.

 

How can acupuncture be integrated into conventional healthcare?

Setting

Community-based acupuncture services are more cost-effective than secondary care settings. This is the primary reason for the recommendation for community-based acupuncture in the NICE guidelines for chronic primary pain. This also make sense in terms of availability and access to acupuncture practitioners and waiting times.

Trained staff

Acupuncture can be performed by appropriately trained healthcare staff. One route is to train existing staff to do acupuncture as part of their role instead of hiring new staff members to do only acupuncture. Having healthcare staff trained in more than one skill adds to the holistic biopsychosocial approach to chronic pain.

Certain healthcare staff may be more amenable to adding acupuncture to their repertoire of therapies that they offer. This would include First Contact Physiotherapists who work in community settings, nursing staff, paramedics and primary care pharmacists. The latter are often put in the position of deprescribing opioids in general practice and the ability to practise acupuncture can empower them to do this more effectively.

Physicians practising acupuncture are unlikely to be a cost-effective solution in the current healthcare environment. However, NICE have allowed for this alternative as long as it is delivered at equivalent or lower cost.

Indications

Acupuncture can be practised for any of the conditions that the evidence base supports. However, commissioners may want to limit its use to indications that are backed by NICE guidelines. At the present time, this means tension-type headache, migraine and chronic pain.

Access

Commissioners may be concerned about the potential demand for acupuncture by patients, for both appropriate and inappropriate medical conditions. Direct access to acupuncture by patients is unlikely to be a consideration. Instead, acupuncture as a modality should be embedded in local clinical pathways and offered to patients at the appropriate point in the patient journey. This is much easier to do in an integrated healthcare environment in contrast to the use of the Any Qualified Provider system.

Context

Acupuncture is not a magic bullet as it is often viewed by lay people. It should also not be offered as the sole modality in chronic pain conditions. Instead, it should be offered as part of a biopsychosocial management plan.

 

How do you plan a course of acupuncture for chronic pain?

Acupuncture treatments can be brief and short, particularly when the intervention is used opportunistically in primary care. However, whilst such an approach can give meaningful benefit to some patients with chronic pain conditions, for most you will need to plan a course of treatment and be able to provide top up sessions after that to maintain optimal benefit.

a minimum course is
6 to 8 sessions

The minimum treatment course to achieve the best effects in chronic pain is 6 to 8 sessions separated initially by no more than a week, and an optimum course is likely to be 12 to 15 sessions. Following this, some patients will require top ups on a long-term basis every 4 to 6 weeks.

12 to 15 sessions
plus top ups
is more optimal

To achieve this in most circumstances group clinics are to be recommended, and such clinics have been successfully set up in both secondary care and in primary care.[11–13] It is recommended that such clinics are organised to provide electroacupuncture (EA) sessions of 20 to 30 minutes treatment duration,[14] since this is likely to be both most effective and most efficient in terms of practitioner time. Whilst there is little data to suggest EA is more effective than manual acupuncture (MA), the comparisons have always used MA with frequent needle manipulation by the practitioner, essentially meaning the practitioner must be close to the patient for the entire session.

The optimum frequency of sessions is probably 2 to 3 times per week,[15] and not more; however, one session a week still achieves an amplification of the effect and is likely to be easier to provide logistically in public healthcare systems. If treatment sessions twice per week are feasible then this only needs to be for the first couple of weeks.

combine acupuncture with other therapies in complex cases

Whilst acupuncture can be used successfully as a single intervention in chronic pain, the more complex cases will likely benefit from a multidisciplinary approach, combining acupuncture with exercise and psychological therapies.

EA is synergistic with TCADs and SNRIs

In terms of prescribed drugs for patients with chronic pain, preliminary laboratory data seems to indicate that both tricyclic antidepressants (TCADs; specifically low dose amitriptyline) and serotonin and noradrenalin reuptake inhibitors (SNRIs; specifically milnacipran) combine well with EA to enhance analgesic effects.[16–18]

consider the treatment environment

The treatment environment can have measurable effects on treatment outcomes, so it is worth taking some time to consider this when planning a course of treatment.[19] Sunlight, windows, odour and seating arrangements generally produce positive effects in clinical trials,[20] and music has also been associated with positive effects.[21]

The perceived length of consultation rather than the actual length has been associated with satisfaction, so creating an unhurried environment in a group setting may be advantageous overall.

SOFTEN

The treatment context is also affected by attributes and behaviour of the practitioner. Although all of us are warm, friendly people, in a busy working environment, those few seconds where a smile can allay a nervous patient’s fears might easily be missed. The non-specific effects of acupuncture are magnified with a Smile, Open gesture, Forward lean, Touch (handshake if appropriate), Eye contact and a friendly Nod – SOFTEN.

 

Contact Information

Authors

Dr Amer Sheikh
amer.sheikh@nhs.net

Dr Mike Cummings
london@thebmas.com

Duncan Lawler
duncantheolawler@hotmail.com

 

Organisations

British Medical Acupuncture Society
https://www.medical-acupuncture.co.uk/

Acupuncture Association of Chartered Physiotherapists
https://www.aacp.org.uk/

British Acupuncture Council
https://www.acupuncture.org.uk/

 

References

  1. Recommendations | Headaches in over 12s: diagnosis and management | Guidance | NICE. https://www.nice.org.uk/guidance/cg150/chapter/Recommendations (accessed 9 Jan 2021).
  2. Recommendations | Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain | Guidance | NICE. https://www.nice.org.uk/guidance/ng193/chapter/Recommendations (accessed 7 Apr 2021).
  3. IASP Statement on Opioids - IASP. https://www.iasp-pain.org/Advocacy/OpioidPositionStatement (accessed 7 May 2021).
  4. Acupuncture Regulatory Working Group. The statutory regulation of the acupuncture profession - the report of the Acupuncture Regulatory Working Group. The Prince of Wales’s Foundation for Integrated Health 2003.
  5. White A, Cummings M, Filshie J. An Introduction to Western Medical Acupuncture. 2nd ed. London: Elsevier 2018.
  6. Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain 2018;19:455–74. doi:10.1016/j.jpain.2017.11.005Witt CM, Pach D, Brinkhaus B, et al.
  7. Safety of acupuncture: Results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementarmed 2009;16:91–7. doi:10.1159/000209315
  8. 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. doi:10.1136/bmj.38932.806134.7C
  9. Whitehurst DGT, Bryan S, Hay EM, et al. Cost-effectiveness of acupuncture care as an adjunct to exercise-based physical therapy for osteoarthritis of the knee. Phys Ther 2011;91:630–41. doi:10.2522/ptj.20100239
  10. Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27:26–30. doi:10.1136/aim.2008.000281
  11. 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. doi:10.1136/aim.26.1.46
  12. Freedman J, Richardson M. Setting up an acupuncture knee clinic under Practice Based Commissioning. Acupunct Med 2008;26:183–7. doi:10.1136/aim.26.3.183
  13. White A, Richardson M, Richmond P, et al. Group Acupuncture for Knee Pain: Evaluation of a Cost-Saving Initiative in the Health Service. Acupunct Med 2012;30:170–5. doi:10.1136/acupmed-2012-010151
  14. Cummings M. The Development of Group Acupuncture for Chronic Knee Pain Was All about Providing Frequent Electroacupuncture. Acupunct Med 2012;30:363–4. doi:10.1136/acupmed-2012-010260
  15. Harris RE, Tian X, Williams DA, et al. Treatment of Fibromyalgia with Formula Acupuncture: Investigation of Needle Placement, Needle Stimulation, and Treatment Frequency. J Altern Complement Med 2005;11:663–71. doi:10.1089/acm.2005.11.663
  16. Fais RS, Reis GM, Silveira JWS, et al. Amitriptyline prolongs the antihyperalgesic effect of 2- or 100-Hz electro-acupuncture in a rat model of post-incision pain. Eur J Pain 2012;16:666–75. doi:10.1002/j.1532-2149.2011.00034.x
  17. Fais RS, Reis GM, Rossaneis AC, et al. Amitriptyline converts non-responders into responders to low-frequency electroacupuncture-induced analgesia in rats. Life Sci 2012;91:14–9. doi:10.1016/j.lfs.2012.05.009
  18. Li C, Ji BU, Kim Y, et al. Electroacupuncture Enhances the Antiallodynic and Antihyperalgesic Effects of Milnacipran in Neuropathic Rats. Anesth Analg 2016;122:1654–62. doi:10.1213/ANE.0000000000001212
  19. Cummings M. Western Medical Acupuncture – The Approach to Treatment. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture – A Western Scientific Approach. London: : Elsevier 2016. 100–24.
  20. Dijkstra K, Pieterse M, Pruyn A. Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review. J Adv Nurs 2006;56:166–81. doi:10.1111/j.1365-2648.2006.03990.x
  21. Biley F. The effects on patient well‐being of music listening as a nursing intervention: a review of the literature. J Clin Nurs 2000;:668–77.