Does Acupuncture Work in Physiotherapy?! | Expert Physio Reviews the Evidence

Acupuncture, one of the most controversial topics in the world of physiotherapy. If you want to find out how effective it is, including even more controversy, then keep watching. Hey everyone, Khalid here, welcome back to Clinical Physio. Acupuncture is one of the most talked about treatments in physiotherapy and it divides so much opinion. Now I actually trained myself to do acupuncture in physio about eight years ago, so in this video I'm going to my own personal opinions on how it could be used in practice. But first of all, what is acupuncture? Well it's a form of traditional Chinese medicine which was thought to have been created over 2,000 years ago. The traditional Chinese approach identifies very specific points around the body that link up to form pathways or what they call meridians where qi or energy was said to flow through the body. It was believed that pain could present itself when qi was not flowing through the meridians correctly. This is where acupuncture would come in and aim to re-establish the flow of qi so that pain was reduced. So this has been adapted in the new form western medicine acupuncture. So you know when you're a child and you bang your elbow and someone tells you to rub it and by rubbing it, oh my goodness, it seems to feel better. Well the idea there is that the brain now has to think of a different sensation, a pain inhibition stimulus, which means that it stops thinking about the pain and instead has to think about the rubbing. So the idea in western medicine acupuncture is that the needles aim to create a different sensation like a warm feeling or a deep ache or even a feeling of general relaxation in order to inhibit pain signals. We should be still using the same specific points that they used in traditional Chinese medicine but more on that later. Right so let's go through some evidence and sorry to start with the bad news but for general musculoskeletal conditions the evidence is really mixed. So to start with I've picked out this systematic review from Anya Sertal 2021 which is titled Exploring the Effectiveness of Acupuncture as an Adjunct to Physiotherapy in the Treatment of Musculoskeletal Conditions, a Systematic Review. Sounds like just what we need and I really like this review because they compared acupuncture to sham acupuncture. So you know that we said with acupuncture in the traditional Chinese medicine approach you're using very specific points along very specific pathways. Well with sham acupuncture you're still inserting needles into the body but instead of those very specific points they use random points throughout the body. So what were the results? Well the authors concluded that for the majority of musculoskeletal conditions they found very little evidence that acupuncture when combined with physiotherapy adds an additional pain relieving effect but they did find some evidence to suggest that it can be useful to add to treatment for neck disability, improving muscular strength and for shoulder dysfunction. So as a result I thought I'd do some more digging around neck pain and I found this Cochrane review from Trinh et al 2016 titled Acupuncture for Neck Disorders. Now a Cochrane review is said to be one of the top pieces of evidence in the world of medicine and this particular Cochrane review involved 27 studies including more than 10,000 patients so that is huge. So this review looked at things like whiplash associated neck pain, chronic neck pain, subacute neck pain, a real range and they concluded that there is moderate quality evidence to suggest that acupuncture was better than sham acupuncture when pain was measured at the completion of treatment and at short-term follow-up so in between sessions and they also concluded that acupuncture also had moderate evidence to be better than patients just sitting on a waiting list i.e not receiving any treatment at all. So that's really good when it comes to neck pain. Okay so we have some good evidence for the use of acupuncture with neck pain but as Agnes et al 2021 highlighted not for a lot of other musculoskeletal conditions. So I dive further into the other musculoskeletal conditions. Now in the UK we have the NICE guidelines. NICE stands for National Institute of Health and Care Excellence. This organization look at lots of different pieces of research around a specific condition and use that research to create best practice guidelines and they've created guidelines for low back pain and sciatica and osteoarthritis and I have to tell you that the NICE guidelines for both of those conditions do not support acupuncture. For low back pain it says that they do not recommend the use of acupuncture for low back pain with or without sciatica and also do not include the use of acupuncture for osteoarthritis. That's pretty clear and pretty convincing. Okay so what's the next level? Well a really important consideration is for those who have chronic pain or persistent pain. We know these individuals have very complex pain pathways that can be affected by mood, stress, anxiety, memory, family circumstances, living circumstances, so much at play and because acupuncture is a very pain-focused intervention maybe there's some substance to it when it comes to persistent pain management. So I found this systematic review and meta-analysis from Al in 2022 looking at acupuncture versus sham acupuncture and also comparing it to intravenous lidocaine which is a local anesthetic and change in diet for patients with fibromyalgia. So they included 23 randomized control trials involving over 1,400 patients and their main conclusion was that whilst intravenous lidocaine and diet did not have a significant improvement compared to placebo or sham, true acupuncture did have a significant improvement on these patients reducing pain, reducing depression and enhancing quality of life. So that's really cool and actually the NICE Institute also released their guidelines on chronic primary pain management and they concluded that practitioners should consider a single course of acupuncture whether that be a traditional Chinese or a Western medicine approach as long as it's delivered in a community setting, it's delivered by a senior healthcare professional with adequate training and that the total acupuncture treatment time doesn't exceed more than five hours over the total sessions and that's basically so that patients don't have months and months and months of acupuncture. So also a shout out for acupuncture for tension headaches, the NICE Institute released their guidelines on this highlighting that it can be useful and also a shout out to Canon, Bellow and Windsor who released their systematic review in 2022 and highlighted that acupuncture can be really useful for patients who have ongoing pain post-stroke. So those are a couple of other conditions to throw into the mix too. So that's the evidence, what about a summary of my thoughts into the use of acupuncture in practice? Well I know that lots of clinicians don't like acupuncture and from listening to them I suppose there's two key things that stand out for me. Number one is acupuncture is considered to be an inactive treatment. Lots of healthcare professionals either don't give exercises alongside the acupuncture or perhaps give patients the opinion that they don't need exercises and that the acupuncture is the key part of their treatment. That kind of feeds into the second point which is that acupuncture can be a very dependent treatment. You hear really sad stories of patients having gone back for 20, 25, 30, 40 sessions of acupuncture because they feel like they really need it to manage their condition. That can make these patients very vulnerable and you can really understand as a result why clinicians want it phased out for physiotherapy. Then you add that to the evidence. We've seen with the evidence that there's lots that acupuncture doesn't seem to have much benefit with. There's also lots of conditions that acupuncture does seem to have a benefit with and I can wholeheartedly say that that's probably the summary of my experience with acupuncture in practice. Patients that I can remember definitely didn't get better with acupuncture but I can also remember patients who had real differences with acupuncture, real differences that really enhanced their quality of life. So as a result my four tips for using acupuncture in practice. Number one, make sure it's used for the right patient. Perhaps from this review we'd consider patients with neck pain or patients with persistent pain. Number two, make sure that acupuncture is a part or an adjunct within their physiotherapy treatment. The patient still need to be active, doing exercises, understanding activity modification and therapists should be educating on other self-management strategies so that acupuncture isn't the only part of their treatment. Number three, don't be that clinician that says that patients need 30 sessions of acupuncture. If you wish, try three or four to see if it has an effect. If those three or four sessions don't have an effect, I doubt that 20 more are going to have an effect. And my fourth and final tip which is an interesting one and is a consideration for you to think about. So let's say that your patient walks into your clinic room and they're really stressed, they're really anxious and they've got persistent pain and lying down or sitting down for them with some acupuncture needles in for 20 minutes or so allows them to leave the clinic feeling very relaxed, feeling distressed, perhaps with that warm glow that acupuncture can sometimes give. Isn't that a good thing? Perhaps it's that de-stressing feeling, that relaxation effect that can have that positive effect with those patients with persistent pain or fibromyalgia. That could be a really good use case for acupuncture. As long as we act with honesty and integrity as clinicians by not promoting over-dependence, that could be one of the key things that you use your acupuncture for in practice. So guys, that's it from me. I really hope you've enjoyed this video. If you have, please support us by smashing that like button and subscribing to the channel for all our best updates. Also follow us on social media at clinicalphysio on Instagram and check out our website clinicalphysio.com. We've got loads for you. My name's Khalid. Thank you so much for watching. See you really soon here on Clinical Physio.