The journal of the American Academy of Medical Acupuncture with acupuncture research articles, reviews, abstracts and case studies.
Volume 13 / Number 3
Of A Modern And
of Defining Acupuncture
In pharmaceutical research, the precise definition of the intervention allows other scientists to accurately reproduce the experimental design in other settings and to compare outcomes. Unless one can be precise in defining and communicating the acupuncture intervention, predicting the relationship of the acupuncture treatments to an outcome becomes problematic.
Acupuncture research has been compromised by the lack of a standard definition. It has been noted that the reporting of adverse events associated with acupuncture has also been compromised by poor definitions for acupuncture.1 The educational benefits of clear definitions are self-evident. This is true not only in training and monitoring practitioners, but also in communicating with patients.
to Clearly Defining Acupuncture
In reviewing this definition, one is struck by its lack of clarity. The procedure itself was defined broadly enough to include any stimulation of the skin anywhere on the body. Given that this definition was a product of a government-sponsored consensus conference, it is understandable that the definition would respect and emphasize the great diversity in acupuncture traditions.
A unique problem with defining acupuncture has been a reticence to define it simply in terms of a surgical procedure or a standard medical intervention. The definition arrived at by the NIH consensus conference infers that any definition of acupuncture needs to include the various approaches to diagnosis and treatment. Defining a procedure based on the diagnostic or therapeutic approach used is consistent with a traditional acupuncture paradigm.
Western medicine generally has standard algorithms for arriving at a differential diagnosis, and all practitioners are expected to use these algorithms to arrive at a final diagnosis. The Western practitioner then generally selects from a number of pharmaceuticals and/or surgical techniques that have been accepted as valid for treating the established diagnosis. In contrast, acupuncture medicine (in its broadest understanding) includes a number of approaches that can be used to make an appropriate diagnosis and treatment protocol. From a Western scientific perspective, this many seem confusing, but those familiar with acupuncture recognize that what is most interesting about acupuncture and what ultimately defines it is not the procedure of needling itself, but rather the process through which the treatment formula is derived (i.e., the selection of points). In considering an acupuncture intervention from a traditional approach, one is required to consider the context of the intervention as well as the diagnosis. This approach is in contrast to the Western approach in which the diagnostic element of the intervention is most often a separate issue from the procedure. In traditional models of providing acupuncture, the treatment and diagnosis are so intimately intertwined that providing formula treatments based on Western diagnoses is contrary to Oriental medical traditions.4
Therefore, to respect traditional concepts and definitions of acupuncture, the researcher needs to allow for an expanded definition that surpasses simply needling a set of points to include contextual issues. Nonetheless, the definition of acupuncture needs to be clear enough so that the effects of treating a condition with acupuncture can be reported to the scientific community in a manner that allows for a reliable reproduction of the treatment effect.
These contextual issues may present a barrier to researchers who wish to design clinical research studies involving acupuncture. There appears to be, particularly in the United States, perhaps biased issues associated with the diversity of acupuncture approaches which may impede a consensus on establishing a precise definition for acupuncture. There has been an unspoken, perhaps territorial battle evolving over which school of acupuncture theory has legitimate authority. For example, the Traditional Chinese Medicine (or Eight Principles system) advocates often assume their system is best and should be the basis for all clinical research designs, while those who use the Neuroanatomical approach or the Five Element system consider their system to generally be superior.
The vast majority of Western-trained medical researchers are uninformed of the fact that defining an appropriate set of points to use in an acupuncture intervention can be largely dependent on one's approach to acupuncture. In designing antibiotic research, for example, one realizes that all antibiotics are not the same. Yet many health care professionals still assume that all acupuncture therapy is the same. Thus, if one approach does not appear effective for a given condition, then it is assumed that acupuncture is ineffective to treat that condition. If clinical studies were designed using different schools of thought, the results would be profoundly different. In fact, this is repeatedly observed in the clinic where acupuncture health care professionals who are not restricted by one system of acupuncture theory observe a significant difference in outcomes based on the acupuncture approach used. For example, the use of triangular equilibration would be inappropriate as first-line treatment for a musculoskeletal injury, whereas the use of the tendinomuscular meridian system would be an ideal choice for injuries such as acute sprains and contusions. The importance of an eclectic approach to acupuncture is supported in the literature.5
The definition of acupuncture outlined below is intended to include all major approaches to acupuncture treatment design while remaining clinically practical and precise. Until there is adequate evidence to exclude an acupuncture approach, it would be a misstep to omit a priori any major style of acupuncture from this definition.
ACUPUNCTURE: Objective 1
The authors suggest that the following definition meets the objective of a precise description and at the same time, addresses the contextual issues previously discussed. Perhaps the basic, unqualified definition of acupuncture should be: Acupuncture is a therapeutic and/or preventive medical procedure performed by the insertion of 1 or more specially manufactured solid metallic needle(s) into specific location(s) on the body. The intent is to stimulate acupuncture points, with or without subsequent manual manipulation.
In the interest
of accuracy and completeness in designing and reporting clinical studies
of acupuncture, the authors have further added the following 4 qualifiers
to the basic definition of acupuncture: The 1st qualifier is the school
of thought behind the diagnosis that led to the points used (diagnostic
approach); the 2nd is the nature/type of acupuncture points used; the
3rd is adjunctive methods of needle stimulation used; and the 4th involves
the training of the practitioner.
The authors ultimately envision a numbered code that would accompany this acupuncture definition and facilitate its use (perhaps replacing the current Medical Subject Headings used by the National Library of Medicine).
OF ACUTHERAPY: Objective 2
There is accumulating evidence6,7 for nonspecific effects of needling that support acupuncture involving needles to be in a separate category. The above system separates the general category of acutherapy into divisions where needles may or may not be used in an effort to achieve precision in reporting acupuncture interventions. It recognizes that procedures such as moxibustion and cupping are separate from acupuncture and allows a basic definition of acupuncture that is not contradicted by our 4 qualifiers.
Noted earlier is that the definition for surgical procedures typically does not include all the variables necessary to precisely describe the procedure. Likewise with acupuncture, there are many technique variables that need to be described to precisely report an acupuncture intervention. These variables are discussed elsewhere in detail,8,9 but for clarity in defining acupuncture, such issues as obtaining the Qi sensation, depth of needle insertion, manual technique used, and type of needle are not to be qualifiers for acupuncture. Rather, these variables are to be reported as the specific needling techniques used.
Dr Lowell E.
Kobrin is in private practice in Coos Bay, Oregon. Dr Kobrin is a Diplomate
of the American Board of Obstetrics and Gynecology, is a founding member
of the American Academy of Medical Acupuncture (AAMA), and is on the
Board of Directors of the Medical Acupuncture Research Foundation (MARF).
His specialty is Korean Hand Therapy (KHT).