Acupuncture in an Outpatient Clinic in China.

ABSTRACT

A Comparison With the Use of Acupuncture in North America 

Background. The National Institutes of Health Consensus Panel on Acupuncture has listed as a priority the study comparing indications and patterns of use of acupuncture in different countries.

Methods. I visited an outpatient acupuncture clinic in China and reviewed the clinical files. A MEDLINE search was done to compare the use of acupuncture in North America and China.

Results. The most common disorder treated in the clinic was musculoskeletal pain. Less common indications included stroke rehabilitation, Bell's palsy, cholelithiasis, tinnitus, insomnia, migraine, and visceral pain. In North America, acupuncture is primarily for pain relief. Other uses include stroke rehabilitation, various emetic problems, migraine, and various addictions.

Conclusions. Acupuncture is most frequently used in China and North America for pain relief. Other common indications include peripheral nerve palsy, peripheral nerve neuralgia, stroke rehabilitation, psychoemotional disorders, migraine, visceral pain, emesis, asthma, and tinnitus. Acupuncture for cholelithiasis in China but not in the United States suggests a novel use of this modality.

ACUPUNCTURE as therapy for a variety of diseases has gained greater acceptance among the medical community and the public. However, doubt and rejection can be expected if the basis of treatment is stated to be correlated with ancient Chinese philosophy, which is rather difficult to understand because of the complicated relationship between religious thought, ancient philosophical reasoning, and a naturalistic Yin-Yang principle. The situation is not helped by the fact that often unwarranted and unsubstantiated claims are made in studies that lack useful scientific design with proper controls. [1-3] Nevertheless, one study indicates that in 1990 Americans made an estimated 425 million visits to providers of unconventional therapy. [4] There are more than 10,000 acupuncture practitioners in the United States, [5] and there were an estimated 5 million acupuncture visits in 1997. [6] Recently, the National Institutes of Health held a consensus conference on acupuncture to address the increased use of this interve ntion and reviewed the current scientific literature on the efficacy of acupuncture for many disorders. The consensus statement concludes that "... there is sufficient evidence, however, of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value." [7] As guidance for future research, the statement lists as a priority studies comparing indications and patterns of use of acupuncture in various countries.

To compare the patterns of use of acupuncture in various countries and regions, this study reviews the literature on the use of acupuncture in China, Taiwan, and the United States. A site visit was made to an outpatient acupuncture clinic in China to catalog the frequency and indications of acupuncture. The data obtained were compared with data on acupuncture practice in North America. The study provides helpful clues for identification of effective and novel uses of acupuncture in the United States.

METHODS

I spent 3 weeks in the Acupuncture Clinic of Jinan Central Metropolitan Hospital, Jinan, Shandong, China. This university-based hospital is affiliated with Shandong Medical University. The hospital is a metropolitan teaching hospital with 611 beds in a city of about 2 million people. The clinic is typical of outpatient acupuncture clinics and has two physician-acupuncturists. I interviewed the patients and physicians in the clinic, witnessed the application of acupuncture in their daily operations, and reviewed the clinical files accumulated during a 1-year period (June 1995 to June 1996). The number of cases for each complaint was calculated and analyzed. The efficacy of the treatment was evaluated according to the subjective feelings of the patients and objective findings by the physicians.

To identify the pattern of use of acupuncture in China, Taiwan, and the United States, the literature was searched via MEDLINE and reviewed. Only publications in English were included in this study. Since many more patients were using acupuncture in China than in the United States, the relative frequency of acupuncture therapy for each disorder was used as the basis for comparison.

RESULTS

The Jinan Clinic

Musculoskeletal pain management accounts for 58% of the total visits, making it the disorder most commonly treated by acupuncture (Table 1). Peripheral nerve diseases including Bell's palsy and trigeminal nerve pain take 17.1% of the total. Cerebrovascular accident, mainly stroke rehabilitation, accounts for 11%. Other acupuncture uses include neck pain, cholelithiasis, tinnitus, insomnia, migraine, and visceral pain. Among the uses of acupuncture for these disorders, pain management (musculoskeletal pain, neck pain, trigeninal pain, and migraine) clearly plays a dominant role. Acupuncture is used only for adults, and no pediatric patients are seen in the clinic. Female patients who sought acupuncture therapy for musculoskeletal pain significantly outnumbered the male patients (Table 1), making the total number of number of women almost double that of men (M/F = 128/245). More male patients were treated with acupuncture for cerebrovascular accident (M/F = 25/16) and more female patients for cholelithiasis (M /F = 3/12), consistent with the higher incidence of each disorder in the corresponding sex. When acupuncture is used to treat cholelithiasis, the diagnosis is based on clinical symptoms and signs and confirmed by ultrasonography. Efficacy is determined by collection of the passed stones in the stool and by relief of the symptoms. The number of acupuncture sessions in a complete regimen generally ranges from 3 to 20 (average of 12), depending on the type of indications and seventy of the disorders.

Patterns of Acupuncture in China, Taiwan, and the United States

The biomedical literature in English was searched with MEDLINE to identify studies on the use of acupuncture in China, Taiwan, and the United States. A few studies examined the pattern of acupuncture use in these regions, but none compared the use between these regions. Table 2 summarizes the use of acupuncture in the Jinan Clinic, China, Taiwan, and the United States. Since most of the studies are done in teaching hospitals, universities, or research institutes and are primarily based on data obtained from patients visiting these large clinic settings, by no means will these studies cover every sector of acupuncture therapy in a particular region. Comparison of the relative frequency of use of acupuncture in a particular area clearly shows that musculoskeletal disorders are the major clinical indications for acupuncture in China, Taiwan, and the United States. Neurologic disorders including peripheral nerve palsy, peripheral nerve neuralgia, and cerebrovascular accident are also common indications in these regions. Other indications for acupuncture in China, Taiwan, and the United States include psychoemotional disorders (drug addiction, alcoholism, tension-type headache, psychogenic impotence, depression), migraine, visceral pain (cancer, peptic ulcer), emesis, asthma, and tinnitus. Disorders that have been commonly treated with acupuncture in China and Taiwan but not in the United States are cholelithiasis, diabetes, hypertension, insomnia, and skin diseases. Interestingly, one of the studies showed a higher percentage (72%) of women receiving acupuncture than men in the United States) [5] This ratio is comparable with the 66% female patients in Jinan Clinic (Table 1).

DISCUSSION

The current study clearly shows that musculoskeletal disorders are the most common indication for acupuncture in China, Taiwan, and the United States, suggesting that it is the number one indication worldwide. As shown by the Jinan data and other studies, [8,9] most of the musculoskeletal disorders treated by acupuncture are pain-related disorders. Other pain-related disorders treated by acupuncture are migraine, visceral pain, neck pain, and peripheral nerve neuralgia. These data coincide with those in many publications showing strong evidence of effective use of acupuncture for pain management. [10,11] Although the mechanism by which acupuncture relieves pain or other disorders is not fully understood, studies show that acupuncture promotes release of neurotransmitters and neuromodulators locally and in the central nervous system. [12,13] A strong correlation between the acupuncture analgesia and stimulated release of endogenous opioid peptides, such as [beta] endorphin and enkephalins, has been well estab lished. [14] In addition, acupuncture appears to activate the body's pain modulatory system, thereby changing the processing and perception of noxious information at various levels of the central nervous system. Serotonin and norepinephrine seem to play an important role in these processes. [15, 16] These and other unidentified mechanisms could explain the effect of acupuncture on pain relief. Theoretically, the process of other disorders treated by acupuncture in all three regions for this study such as peripheral nerve palsy, cerebrovascular accident rehabilitation, and emetic and psychoemotional disorders could conceivably be affected by procedures that alter peripheral and central nervous system activities.

This study also has identified certain disorders such as cholelithiasis, diabetes, hypertension, insomnia, and skin diseases that are commonly treated by acupuncture in China and Taiwan but not in the United States. Most intriguing of these indications is cholelithiasis, particularly among elderly patients who have severe colic pain not relieved by other approaches and who are poor surgical candidates. Some data suggest that acupuncture could prove to be an attractive alternative approach to cholelithiasis if future studies with well-controlled scientific design show the efficacy of acupuncture for the disorder. [17,18]

Use of acupuncture as a treatment for certain types of diseases has begun to catch the attention of the mainstream of medical society only in recent years. As more well-controlled quality studies of acupuncture are conducted, the accumulated data will allow more reliable evaluation of its effectiveness or ineffectiveness so that we can better understand the use and mechanisms of acupuncture as a therapeutic modality.

From the Department of Family Practice, Catholic Medical Center, Jamaica, NY.

Reprint requests to Xinqi Xu, MD, St. Vincent-Catholic Medical Center, Department of Family Practice, 88-25 153rd St, Jamaica, NY 11432.

References

(1.) Ishida Y: Acupuncture today South Med J 1988; 81:885-887

(2.) Ishida Y: A theoretical analysis of oriental medicine, 1: Acupunture. Med Hypotheses 1997; 49:327-335

(3.) Mayer DJ: Acupuncture: an evidence-based review of the clinical literature. Annu Rev Med 2000; 51:49-63

(4.) Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States. prevalence, costs, and patterns of use. N Engl J Med 1993; 328:246-252

(5.) Cassidy CM: Chinese medicine users in the United States. Part I: Utilization, satisfaction, medical plurality. J Altern Complement Med 1998; 4:17-27

(6.) Eisenberg DM, Davis RB, Ettner SL, et al: Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998; 280:1569-1575

(7.) Acupuncture. NIH Consensus Statement. 1997;15:1-34

(8.) Bullock ML, Pheley AM, Lenz SK, et al: Short-term outcomes of treatment for musculoskeletal disorders in a hospital-based alternative and complementary medicine clinic. J Altern Complement Med 1999;5:253-260

(9.) Davis AB: Primary care management of chronic musculoskeletal pain. Nurse Pract 1996;21:72,75,79-82

(10.) ter Riet G, Kleijnen J, Knipschild P: Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol 1990;43:1191-1199

(11.) Patel M, Gutzwiller F, Paccaud F, et al: A meta-analysis of acupuncture for chronic pain. Int J Epidemiol 1989;18:900-906

(12.) Ulett GA, Han S, Han JS: Electroacupuncture: mechanisms and clinical application. Biol Psychiatry 1998;15:129-138

(13.) Jin HO, Zhou L, Lee K, et al: Inhibition of acid secretion by electrical acupuncture is mediated via beta-endorphin and somatostatin. Am J Physiol 1996;271 (3 Pt 1):G524-G530

(14.) Adams ML, Brase DA, Welch SP, et al; The role of endogenous peptides in the action of opioid analgesics. Ann Emerg Med 1986;15:1030-1035

(15.) Janssens LA, Rogers PA, Schoen AM: Acupuncture analgesia: a review. Vet Rec 1988;122:355-358

(16.) Takagi J, Yonehara N: Serotonin receptor subtypes involved in modulation of electrical acupuncture. Jpn J Pharmacol 1998;78:511-514

(17.) Zhang Y, Zhang L, Yang H, et al: 1291 cases of cholelithiasis treated with electric shock on otoacupoints. J Tradit Chin Med 1991;11:101-109

(18.) Liu J, Zhou X, Zeng X, et al: Effects of acupuncture on myoelectric activity of Oddi's sphincter in humans. J Tradit Chin Med 1993;13:189-190

Suggested Reading

(1.) Bonica JJ: Therapeutic acupuncture in the People's Republic of China, implications for American medicine. JAMA 1974;228:1544-1551

(2.) Wang XT: An introduction to the study of acupuncture and moxibustion in China (Part I) J. Tradit Chin Med 1984;4:85-90

(3.) Chou P, Lai MY, Chung C, et al: Acupuncture utilization in Taiwan. Chung Ha I Hsueh Tsa Chili (Taipei) 1998;61:151-158

KEY POINTS

* Pain relief is the primary indication for acupuncture in China and North America.

* Other indications in North America include stroke rehabilitation, various emetic problems, migraine headaches, and drug addictions.

* Common use of acupuncture for cholelithiasis in China suggests a potential alternative approach for this disorder in North America.

TABLE 1.
Use of Acupuncture at Jinan Clinic, China (June 1995 to June 1996)
                            Sex     Age   Average     No.
        Disease            (M/F)   Range    Age       (%)
Musculoskeletal pain       74/142  20-75    52     216 (58.0)
Peripheral nerve disease   33/31   25-50    33      64 (17.1)
Cerebrovascular accident   25/16   25-70    61      41 (11.0)
Neck pain                   5/12   37-57    48      17 (4.5)
Cholelithiasis              3/12   37-51    42      15 (4.0)
Tinnitus                    9/1    55-70    61      10 (2.7)
Migraine                    2/4    30-60    51       6 (1.6)
Insomnia                    2/2    21-40    32       4 (1.1)
   Totals                 128/245                  373 (100)
TABLE 2.
Relative frequency of Acupuncture use in China, Taiwan,
and the United States
                               Jinan Clinic
Disease                          (China)     China  Taiwan
Musculoskeletal                +++++         +++++  +++++
Neurologic                     ++++          ++++   +++
Psychoemotional                              ++     ++
Migraine                       ++            +++    +++
Visceral pain                  ++            +++    ++
Insomnia                       ++            ++     +
Tinnitus                       ++            ++     ++
Asthma                                       ++     +
Diabetes (type I and type II)                ++     +
Cholelithiasis                 ++            ++     +
Hypertension                                 ++     +
Skin disorders                               ++     +
Antiemetic                                   ++     ++
Disease                        United States
Musculoskeletal                +++++
Neurologic                     +++
Psychoemotional                ++
Migraine                       +
Visceral pain                  +
Insomnia
Tinnitus                       +
Asthma                         +
Diabetes (type I and type II)
Cholelithiasis
Hypertension
Skin disorders
Antiemetic                     +
(+)Denotes relative frequency of acupuncture use from the most
frequent use (+++++, [greater than]35% of total visits
in most surveys) to rare use (+, [less than]2%).
Data from references 5, 19, 20, and 21.