Acupuncture 1

Running Head: ACUPUNCTURE AN OPTION FOR PAIN MANAGEMENT

Acupuncture: An Option for Pain Management in Primary Care

Anna E. Marshall and Miriam C. Slaugh

Washburn University, School of Nursing

For NU 504 Integrative Healing Modalities

April 27, 2009

Acupuncture 2

Acupuncture: An Option for Pain Management in Primary Care

Introduction

Many patients seek care in the primary care setting for complaints of pain. It is estimated

that “50 million Americans live with chronic pain caused by disease, disorder, or accident”

(Weiner, 2001). From back pain, headaches, arthritis, irritable bowel syndrome, and other

chronic pain syndromes such as fibromyalgia are being treated with pain medications. In addition

to the use of pain medications, patients seek complementary and alternative medicine (CAM) for

further options to help manage the pain. According to a 2007 National Health Interview Survey,

approximately 38% of adults aged 18 and older and nearly 12% of children in the United States

used some form of CAM (Biomedicine, 2008). One of these CAM options used is acupuncture.

In the 2002 National Health Interview Survey, the largest and most comprehensive survey of

CAM use by American adults to date, an estimated 8.2 million U.S. adults had used acupuncture

before and an estimated 2.1 million U.S. adults had used acupuncture in the previous year

(http://nccam.nih.gov/health/acupuncture/introduction.htm).

Acupuncture has been used since 3000 BC (Barbaso-Schwartz, 2004). Acupuncture is

used to treat disease, prevent disease, and to balance an individual’s health. The basis of

acupuncture is the qi, the vital energy force. Qi is accessed in the human body through

acupuncture points to regulate or smooth the flow of the body’s motivating energy (Shan, 2007).

The balance is determined by yin (cold) and yang (hot). Acupuncture is a holistic philosophy that

aims to primarily restore balance and harmony between an individual’s physical, emotional, and

spiritual aspects. An acupuncture practitioner uses small, sterile needles to manipulate the

communication network of meridians that provide a circulation system for electrical energy

throughout the body. Acupuncture increases the circulation of congested qi, moisture, and blood

resulting in better flow and correcting obstructions in the network (Leddy, 2006). The needles

Acupuncture 3

are placed and left for 20 to 45 minutes. The number of needles is determined by the degree of

disharmony. It can take up to ten weeks to treat a long-standing condition with appointments

lasting about 40 minutes or less (Barbaso-Schwartz, 2004). “Acupuncture is believed to work by

stimulating the nerves in the skin and the muscles in the regions of the acupoints” (Shan, 2007, p.

27).

This paper will review acupuncture studies found in literature, the theoretical framework

that best supports the use of acupuncture, cultural/ethical/legal aspects of using acupuncture, and

incorporating acupuncture in the advanced nursing practice.

Review of Literature

Introduction

CINAHL and Proquest databases were searched for the key word acupuncture.

Acupuncture resulted in 5,333 hits using CINAHL and 1,240 hits using Proquest. The authors

narrowed the search by adding pain management which resulted with 83 hits using CINAHL and

52 hits using Proquest. Reviewing the literature, eight studies were found and analyzed.

Critique of Studies

Martin, Sletten, Williams, and Berger (2006) conducted a partially blinded, controlled,

randomized clinical trial of 50 fibromyalgia patients with 25 in the treatment and 25 in the

control group who received simulated acupuncture treatment. Patients with previous acupuncture

experience were excluded from the study. The Fibromyalgia Impact Questionnaire (FIQ), a 20-

item questionnaire used to assess the current health status of patients with fibromyalgia,

evaluating physical functioning, work status, depression, anxiety, sleep, pain, stiffness, fatigue,

and well-being on a 0 to 10 scale, was used. The Multidisciplinary Pain Inventory (MPI), a scale

Acupuncture 4

specifically designed for chronic pain, was utilized as well. Each participant completed the FIQ

and MPI initially, after each treatment, and at one month and seven months. After the

participants completed the initial FIQ and MPI, they were randomly assigned to be a member of

treatment or control group. The participants were scheduled on different days and times to avoid

participants talking and comparing experiences. Martin, Sletten, Williams, and Berger selected

six bilateral points at large intestine 4, stomach 36, liver 2, spleen 6, pericardium 6, and heart 7

(2006). The axial paramedian points along the bladder meridian at the cervical spine were used

during the first three sessions and at the lumbar spine during the last three sessions. At each

point, the skin was wiped with alcohol, and an adhesive bandaid was placed over the point. The

needle was inserted through the bandage to the acupuncture point. Electrical stimulation was

applied between the large intestine 4 and the stomach 365. Eighteen needles were used during

the first three sessions and 20 needles were used during the final three sessions. With the control

group, the same points were wiped with alcohol, skin was indented with a dull surgical

instrument, bandaid rigged with acupuncture needle was taped to the skin. The control group and

the treatment group couldn’t watch the procedure. Electrical stimulation was applied to the same

points. After each treatment, the patients relaxed for twenty minutes in a darkened room while

quiet music played.

The FIQ scores were significantly improved in the acupuncture group compared with the

control group during the study period with p = .01. The largest difference in the mean FIQ total

score was observed at the one month interval with 42.2 in the control group and 34.8 in the

acupuncture group with p = .007 (Martin, Sletten, Williams, & Berger, 2006). During this study,

acupuncture improved symptoms of fibromyalgia significantly more than control group. “Pain

trended closely toward statistical significance in THE FIQ (p = .07) and MPI (p = .05)”

Acupuncture 5

(Martin,Sletten, Williams, & Berger, 2006, p. 756). The authors of this study reported that the

acupuncture treatments were well tolerated, the most clinical improvement in scores were with

the fatigue and anxiety scales. Martin, Sletten, William, & Berger (2006) concluded that

acupuncture may have a role in symptomatic relief with fibromyalgia patients.

Spira (2008) conducted a study with 500 sailors deployed to Iraq from September 2006

through March 2007 offering acupuncture along with medical treatments. A total of 132 different

patients opted for the acupuncture treatment and more than 80% of those 132 patients did not

take pain medications. Nineteen sprains and fractures were treated with acupuncture and it was

found that these troops returned to duty an average of two days sooner than other groups of

troops using conventional therapy. Patients averaged 3.3 visits with 2.3 treatments per condition

and an average of 7.9 needles per treatment were used. Each needle had the average cost of $0.10

making the total average cost per treatment $0.79. One patient refused acupuncture treatment for

a stiff knee, chose to take ibuprofen instead and ended up hospitalized with a gastro-intestinal

bleed, costing the Department of Defense $3958.00. Spira (2008) pointed out that acupuncture

treatment was actually cheaper than the weekly cost of ibuprofen for the treatment of mild to

moderate pain syndromes and avoids the potential gastric complications and renal damage. The

United States government paid $375 for the entire study. Spira (2008) concluded that

acupuncture is a safe treatment that avoids unnecessary complications and can decrease lost man

days, but further studies should be done.

Tam, Leung, Li, Zhang, and Li (2007) recruited 36 patients from the 80 that met their

eligibility requirements from the Prince of Wales Hospital between June 2005 and May 2006 to

participate in a randomized double-blind placebo-controlled trial analyzing the effects of

electroacupuncture (EA), traditional Chinese acupuncture (TCA), and sham or placebo

Acupuncture 6

acupuncture on pain associated with rheumatoid arthritis. All patients received two 40-minute

sessions weekly for a total of ten weeks from a registered acupuncturist with at least ten years

experience. The 36 patients were divided into three control groups and were analyzed using the

visual analog scale (VAS) for pain, the number of swollen and tender joints, the Chinese health

assessment questionnaire (HAQ) and global assessments by the patient and physician. There

were no significant differences in pain scores between the three groups at week 10, but a

significant reduction in the physicians’ global assessment score (p = 0.04) and the number of

tender joints (p = 0.03) in the EA group was noted (Tam, Leung, Li, Zhang, and Li, 2007). For

the TCA group, significant reduction in patients’ global assessment score and number of tender

joints at week 10 was (p = 0.01). Although no definite anti-inflammatory effects were

demonstrated, the acupuncture treatments were found to be safe and may be effective as an

adjunct in reducing the number of tender joints (Tam, Leung, Li, Zhang, and Li, 2007).

Prady, Thomas, Esmonde, Crouch and MacPherson (2007) conducted a follow-up study

of the York Acupuncture for back pain trial (conducted 5.5 to 7 years previously); they attempted

to contact the 239 original participants with the Mosby Short Form 36 item quality of life

questionnaire which addresses pain, with higher scores indicating better health status. A five

point difference between current score and original score indicates minimal clinical important

change and a ten point change indicates a moderate difference. 105 of the original 239 (43.9%)

participants responded to the follow-up questionnaire and eighty-two percent had experienced at

least one episode of back pain within the last 12 months. Comparing the acupuncture group to

the control group, there were no statistically significant differences to report after seven years;

however, about a quarter of patients from both groups chose acupuncture after the original study,

paying for it out-of-pocket and 90.8% of the treatment group and 62.1% of the control group,

Acupuncture 7

reportedly, would recommend acupuncture as a treatment (Prady, Thomas, Esmonde, Crouch

and MacPherson, 2007). This study was limited by some inconsistencies in the statistical data; it

is unclear whether it is related to the low response rates or the diminished effectiveness of

acupuncture as a long-term treatment.

White, Foster, Cummings, and Barlas (2007) conducted a meta-analysis of 13

randomized control studies involving 2362 patients in which the effect of acupuncture on chronic

knee pain was studied. The number of participants in each of the thirteen studies ranged from 8

to 330 participants. This meta-analysis showed that acupuncture is superior to sham treatment

for chronic knee pain, but suggested the need for more large, high quality clinical trials in order

to reach definitive conclusions about acupuncture’s long-term effectiveness.

Vas, Aguilar, Perea-Miller, & Mendez (2007) conducted a retrospective review of 5981

electronically stored case histories of patient seeking treatments at the Pain Treatment Unit in

Spain from June 1997 to July 2006. They reviewed a total of 45,395 treatment sessions for non-

oncological pain and tried to analyze the effectiveness of acupuncture in treating a wide variety

of common complaints where the main symptom is pain and evaluate the contribution that an

acupuncture service could make if offered. The patients mean age was 58.2 years, 84.5%

patients were female, 88.8% had pain lasting longer than three months (Vas, Aguilar, Perea-

Miller, & Menez, 2007). The main reason for the consultations were neck pain (28.3%), low

back pain (25.7%), knee pain (16.9%), shoulder pain (8%), back pain (4.8%), hip pain (3.1%),

cephalgia (2.5%) and other pain (10.7%). The mean number of sessions per patient was 7.7 (SD

2.4) with a range of 2-15. 95.1% of the patients that completed the treatment program, with

transportation barriers being the highest cited reason for dropping. A total of 1594 adverse events

were recorded out of all 45, 395 treatments and included bruising (2.02%), residual pain (1.2%),

Acupuncture 8

cephalgia (0.1%), forgetting needles (.12%), and orthostatic problems (0.05%) (Vas, Aguilar,

Perea-Miller, & Mendez, 2007). The audit showed an overall favorable response rate from

patients, most of them less than 65 years old with acute or sub-acute pain issues, the absence of

severe adverse events, and a reduction in the consumption of analgesic and anti-inflammatory

drugs. The study was limited by the lack of clear statistical data to support these claims and was

also limited by the use of participants from a single clinic and in only one geographical region.

Conclusion

Theoretical Framework

Parse’s Human becoming theory best supports the use of acupuncture. Parse’s theory

views “human being as co-participants in life and co-authors of health and quality of life”

(Welch, 2007). Parse viewed health as a process of being and becoming which is reflective of a

person’s life choices and patterns of living. Parse promotes being in true presence with a client

by honoring their personal choices and valued priorities. Parse’s theory also focuses on the

human-universe health process which is “the wholeness or health of human beings, recognizing

that they are in continuous interaction with their environments” (Fawcett, 2000, p. 575). With

chronic pain patients, they seek medical treatment in hopes of improving the quality and comfort

of living. Using Parse’s theory, the healthcare provider would provide a holistic approach that

embraces the potential healing as a collaborative work by the provider, client, and family. This

theory also empowers the client to have ownership and make decisions regarding their health

care plan. In regards to acupuncture, the client would decide if this is a modality that they would

like to include in their plan. The healthcare provider, being in true presence, would listen to the

Acupuncture 9

individual and use co-creating rhythmical patterns of relating. Parse’s theory and assumptions

are listed in Appendix A and the model is found in Appendix B.

Cultural, Legal, and Ethical Issues

Cultural issues with acupuncture would include communication between the healthcare

provider and the client. Healthcare provider needs to have an open mind toward the health beliefs

of other cultures and understanding patients’ culture improves patient care (Freeman & Dobbie,

2007). In discussing acupuncture as adjunctive therapy for pain control, the healthcare provider

needs to listen to the individual’s needs and be able to clearly communicate the scope of the

acupuncture may play in the patient’s pain control. It is therapeutic communication and

establishing a relationship that is necessary. Some individuals may not want to pursue

acupuncture. Others will ask the healthcare providers opinion on the use of acupuncture. The

healthcare provider needs to be cognitive of the individual’s cultural needs and be sensitive to

the individuals’ requests. Pain is highly subjective and sometimes difficult to alleviate, and

understanding an individual’s culture and beliefs about pain is helpful (Shan, 2007).

A major legal issue confronting healthcare providers in the clinic setting is the extent to

which they have a duty to discuss CAM with their clients (Cohen, 2004). So far, United States

court has not held a physician liable for not discussing CAM alternatives with a patient. In 1993,

a federal appeals court case concluded that a physician who failed to disclose the possibility of

using chelating therapy rather than bypass surgery to treat carotid artery disease wasn’t required

to give this option to the patient because it wasn’t a generally acceptable treatment in the medical

community (Cohen, 2004). The other question that arises is there liability connected with

referring patients to CAM providers. According to Cohen, a medical specialist generally is not

Acupuncture 10

liable for a specialist negligence unless there is a delay of necessary medical treatment resulting

in patient harm, referring to a CAM provider that the referring healthcare provider knew or

should have known might be incompetent, or there is a joint treatment of the patient such as

when the healthcare provider and the CAM provider share information by telephone or email as

part of the treatment plan (2004). In regards to acupuncture, a healthcare provider should be

familiar with the acupuncture treatments and the evidenced-based medical diagnosis and

problems acupuncture is proven to treat. If a healthcare provider is referring an individual to a

selected acupuncture specialist, the healthcare provider should know that the individual has a

naturopathic acupuncture specialty certification issued by the Kansas State board of healing arts.

This certification is issued to “an individual who has submitted an application and paid the $20

certification fee, completed basic oriental medicine philosophy from a college or university

approved by the board, and completed 500 hours of supervised clinical training under a trained

naturopathic acupuncturist’s supervision” (KS Statutes, 2002).

Ethical Issues that healthcare provider face is balancing beneficence and patient

autonomy (Cohen, 2004). The healthcare provider is responsible to diagnosis and provide

treatments for acute and chronic illnesses and communicating to the client the severity or the

urgency in seeking treatment. The healthcare provider should include the client in discussing and

planning the treatments. When a client doesn’t want to pursue western medicine and only wants

to use CAM therapy, the situation becomes very sticky. An example of an ethical dilemma

would be an individual who has low back pain with left leg radiculopathy and leg weakness.

With the nerve impingement in the lower back, neurosurgery is recommended to release the

pressure on the nerve. The longer the nerve has the pressure and impingement the more damage

the nerve will have and the lasting pain may become permanent. If the patient refuses the surgery

Acupuncture 11

and states that “I am going to try acupuncture. I don’t want the surgery.” The healthcare provider

would need to document the patient’s decision and allow the individual to try a CAM therapy

while monitoring the situation. The healthcare provider should attempt to persuade the individual

to return to the office in one to two weeks to re-evaluate the leg weakness. At the next

appointment if the patient’s leg weakness is worse, the healthcare provider should try to persuade

the patient to pursue the neurosurgery to prevent lasting effects of the nerve impingement.

Incorporation into Advanced Nursing Practice

Acupuncture can be incorporated into the family nurse practitioner practice by referring

individuals who haven’t obtained the quality of life they would like using western approach of

medicine using pain medications, surgeries, and physical therapies with their chronic or acute

pain conditions. Acupuncture is a complementary treatment that has been shown to be helpful in

many conditions (see Appendix C). As a nurse practitioner, being aware of the conditions for

which acupuncture has been approved will be essential to make appropriate referrals. A

healthcare provider should not refer a patient on anticoagulant therapy for acupuncture due to the

risk of bleeding. The limitations of using acupuncture in one’s own practice would be limited by

the individual states’ legal requirements to become licensed to perform acupuncture. A nurse

practitioner in Kansas would need to study acupuncture from an approved university, complete

500 clinical hours working under a certified acupuncture provider to be able to provide this

modality within the practice, and complete the application and paying a small fee. Because of

this, most nurse practitioners will not perform acupuncture in their clinical practice but rather

refer them to an acupuncture specialist.

Acupuncture 12

Using an integrative approach to practice, allows the nurse practitioner to provide a

holistic approach to each individual they treat. Each individual has unique needs and problems.

The use of alternative and complementary modalities allows the nurse practitioner to use more

creative and personal means to find solutions to increase the client’s quality of life. Most

acupuncture treatments are not covered by insurance, resulting in the patients paying cash for

services rendered. Therefore, acupuncture would be pursued mainly by individuals with more

economical means.

Potential nursing research studies using acupuncture could include fibromyalgia, drug

addiction, and Raynaud’s syndrome. These three medical diagnoses are very problematic and

involve a certain amount of pain and discomfort. The study could use a treatment group and a

control group. The treatment group would consists of western medication and acupuncture

treatment 2 times a week for 10 weeks, evaluating quality of life and pain scores at the beginning

of the study, after each visit, and the end of the study. The control group would consist of the

same western medications and no acupuncture. Before starting a study, collaborating with the

International National Council of Nurses (ICN) and the World Health Organization (WHO)

would be advisable. Contacting these two organizations, may uncover possible grants available

to help with the cost of the study, allow for collaborating with other professionals that may

already know that a similar study is in progress, and networking with other individuals to

brainstorm, share ideas, and solutions that may prove to be beneficial.

Conclusion

Acupuncture 13

References

According to a new government survey, 38 percent of adults and 12 percent of children use

complementary and alternative medicine. (2008). Retrieved February 22, 2009, from

http://www.bio-medicine.org/medicinenews-1/According-to-a-New-Government-Survey.

Barbaso-Schwartz, A. (2004), Traditional Chinese medicine: ancient holistic healing. Home

Healthcare Management &Practice, 16, 494-498.

Cohen, M.K. (2004). Legal and ethical issues in complementary medicine: a United States

perspective. MJA, 181, 168-169.

Kansas Statute 65-7213. (2002). Naturopathic acupuncture specialty certification. Retrieved

March 17, 2009, from http://www.kslegislature.org/legsrv-statutes/getStaturesFile.do?

number=/65-7213.html

Fawcett, J. (2000) Analysis and evaluation of contemporary nursing knowledge: nursing models

and theories. Philadelphia: F. A. Davis Company.

Freeman, J. & Dobbie, A. A gain in cultural competence through an international acupuncture

elective. Innovations in Family Medicine Education, 39, 16-18.

Leddy, S.K. (2006). Integrative health promotion. Sudbury: Jones and Bartlett.

Martin, D.P., Sletten, C.D., Williams, B.A., & Berger, I.H. (2006). Improvement in fibromyalgia

symptoms with acupuncture:results of a randomized controlled trial. Mayo Clincal

Proceedings, 81, 749-757.

Parse, R. R. (1998). The human becoming school of thought . Thousand Oaks, CA: Sage.

Retrieved on March 17, 2009 from http://www.discoveryinternationalonline.com/site/ihb-

home.html

Prady, S.L., Thomas, K., Esmonde, L., Crouch, S., & MacPherson, H. (2007). The natural

Acupuncture 14

history of back pain after a randomized controlled trial of acupuncture vs usual care.

Acupuncture in Medicine, 25, 121-129.

Shan, Y. Using acupuncture to manage pain. Primary Heath Care, 17, 25-29.

Spira, A. (2008). Acupuncture: a useful tool for health care in an operational medicine

environment. Military Medicine, 173, 629-634.

Tam, L., Leung, P., Li, T.K., Zhang, L., & Li, E.K. (2007). Acupuncture in the treatment of

rheumatoid arthritis: a double-blind controlled pilot study. BMC Complementary and

Alternative Medicine, 7, 1-8.

Vas, J., Aguilar, I., Perea-Milla, E. & Mendez, C. (2007). Effectiveness of acupuncture and

related techniques in treating non-oncological pain in primary healthcare. Acupuncture in

Medicine, 25, 41-46.

Weiner,K. (2001). Pain issues: pain is an epidemic. Retrieved March 17, 2009, from American

Academy of Pain Management, http://www.aapainmanage.org.

Welch, A.J. (2007). The phenomenon of taking life day-by-day: using Parse’s research method.

Nursing Science Quarterly, 20, 265-272.

White, A., Foster, N.E., Cummings, M., & Barlas, P. (2007). Acupuncture treatement for chronic

knee pain: a systematic review. Rheumatology, 46, 384-390.

Acupuncture 15

Appendix A

The Human Becoming School of ThoughtRosemarie Rizzo Parse, RN; PhD; FAAN

The human becoming school of thought is a unique paradigm explicating the human-universe process. The ontology of the human becoming school of thought is specified in its philosophical assumptions and principles. In this ontology, the human-universe process is mutual; the human structures personal meaning from multidimensional options; the human is free to choose in situation; the human lives paradoxical patterns of relating; and, the human moves beyond with possibles (see table below). The epistemology and methodologies congruent with human becoming all evolve from the ontology.

Assumptions About the

Human and Becoming

Assumptions About

Human Becoming

Principles of Human

Becoming

The human is coexisting while coconstituting rhythmical patterns with the universe.

The human is open, freely choosing meaning in situation, bearing responsibility for decisions.

The human is unitary, continuously coconstituting patterns of relating.

The human is transcending multidimensionally with the possibles.

Becoming is unitary human-living-health.

Becoming is a rhythmically coconstituting human-universe process.

Becoming is the human=s patterns of relating value priorities.

Becoming is an intersubjective process of transcending with the possibles.

Becoming is unitary human is emerging.

Human becoming is freely choosing personal meaning in situation in the intersubjective process of living value priorities.

Human becoming is cocreating rhythmical patterns of relating in mutual process with the universe.

Human becoming is cotranscending multidimensionally with emerging possibles.

Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging.

Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing-concealing and enabling-limiting while connecting-separating.

Cotranscending with the possibles is powering unique ways of originating in the process of transforming.

Acupuncture 16

From: Parse, R. R. (1998). The human becoming school of thought. Thousand Oaks, CA: Sage. Retrieved on March 17, 2009 from http://www.discoveryinternationalonline.com/site/ihb-home.html.

Acupuncture 17

Appendix B

The symbol of human becoming was

inspired by Dr. Parse and originally designed in

black, white, and green by Alj Mary for the

cover of Man-Living- Health: A Theory of

Nursing.

The black and white colors were chosen to

represent apparent opposites-paradox-which

is significant to the ontology of human becoming. The green is the color of hope, representing

ongoing human-universe emergence. The center joining of the swirling ribbons represents the

cocreated mutual human-universe process at the ontological level and the nurse-person process

and researcher-participant process at the methodological level. The combination of green and

black swirls intertwining represents human-universe cocreation as an ongoing process of

becoming.

Retrieved March 17, 2009 from http://www.humanbecoming.org/index.html

Acupuncture 18

Appendix C

Table 1. WHO List of Indications for Acupuncture which have been Proven through Clinical

Trials to be an Effective Treatment.

Type* Indication

Respiratory Allergic rhinitis

Gastorointestinal Biliary colic, dysentery, epigastralgia (in peptic

ulcer, acute and chronic gastritis and

gastrospasm

Pain Facial Pain, headache, knee pain, low back

pain, neck pain, dental and TMJ pain,

periarthritis of the shoulder, postoperative pain,

rheumatoid arthritis, sciatica, sprain, tennis

elbow

Gynecological and Renal Renal colic, primary dysmenorhhea, induction

of labor, correction of malposition of fetus

Cardiovascular Hypertension, hypotension, stroke

General Adverse reactions to radiotherapy and/or

chemotherapy, depression (including

depressive neurosis and depression following

stroke), leukopenia, morning sickness, nausea

and vomiting

Retrieved March 17, 2009 from http://www.rep.bham.ac.uk/2006/Mapping_Acupunture.pdf.

Acupuncture 19