AFPA ACUPUNCTURE AWARENESS WEEK 2018
Acupuncture for Occupational Health & Wellbeing
Deirdre Murphy, AFPA Chairperson.
Prevalence of Absenteeism in Ireland
According to an IBEC survey in 2010, the average number of days work lost per employee averaged at 5.98 days. When we extrapolate this figure to the economy generally, the total cost to the economy of days lost through absence was around 11 million days (IBEC, 2011). More recent figures from a 2014 Small Firms Association (SFA) survey report 4,052,222 work days lost in 2014. For large businesses the average absenteeism rate is 2.34% or 5.4 days per employee whereas in businesses with less than 50 employees the rate is 2.06% or 4.7 days per employee. The Public Service Sick Leave Statistics for 2016 show the rate of sick leave is 4.1% and on average 8.9 working days were taken per Full-Time Equivalent (FTE) in the Public Service during that year (Department of Public Expenditure and Reform, 2016).
This IBEC survey of over 600 companies, carried out during 2010, conservatively estimates the cost of absence in Ireland per year to be in the region of €1.5 billion. The 2014 Small Firms Association Absenteeism Report shows that absenteeism is costing small businesses over €490 million per annum. “The direct cost to small business with sick pay schemes is over €490 million. When you include additional direct costs, the overall cost is close to €1 billion," said SFA’s Alan Sherlock (SFA, 2017). The overall cost of sick leave in the Public Service is estimated at €337.4 million for 2016 (Department of Public Expenditure and Reform, 2016).
Back pain and anxiety/depression are the biggest contributors to absenteeism (SFA). This is seen also in claims from health assurance companies. Friends First reported that back issues accounted for 28% of the €34m in income protection claims last year (Charlie Weston, 2016). This was the highest category for claims, followed by psychological issues. Aviva Life & Pensions reported that Musculoskeletal and mental health conditions contributed to over 60% of total claims in 2017 (Aviva, 2018).
Musculoskeletal conditions comprise over 150 diseases and syndromes, which are usually associated with pain of varying severity. They can broadly be categorized as joint diseases, physical disability, spinal disorders, and conditions resulting from trauma. Common areas affected include the hands, wrists, elbows, neck, shoulders, lower back, hips, ankles and feet (European Commission). It is the leading cause of temporary work disability amongst Ireland’s working age population and costs Ireland €750m each year and 7 million days in absenteeism (FFW, 2013).
Acupuncture has been used within Chinese medicine for thousands of years. Modern approaches have allowed us to establish that it is safe in the hands of well-trained practitioners, it is also effective, evidence-based and cost-effective (MacPherson et al., 2001; Zhang et al., 2010; Mcdonald & Janz, 2017). For these reasons it is well placed to play a significant role in solving the current opioid crisis (Fan et al., 2017)
Research trials often compare “real-acupuncture” to “sham-acupuncture” which potentially underestimates the effect of ‘real’ acupuncture as ‘sham’ interventions are not inert placebos (Lundeberg et al., 2011).
The evidence for the efficacy and effectiveness of acupuncture is demonstrated in The Acupuncture Evidence Project, published in January 2017, which provides the most up to date comprehensive review of evidence regarding acupuncture (Mcdonald & Janz, 2017). There are over 8,000 acupuncture clinical trials published and the efficacy of acupuncture in 117 conditions has been confirmed from studies using the highest levels of rigorous scientific methods i.e. systematic reviews and meta-analyses thus confirming the place of acupuncture as an evidence-based therapy. Acupuncture is recognised by the World Health Organisation, recommended internationally in hundreds of clinical practice guidelines(Birch et al., 2016), and used by traditional Chinese medicine (TCM) trained practitioners in hospitals throughout the world including the UK and USA (WHO, 2003).
Effectiveness of Acupuncture Compared To Conventional Medicine
Figure 1 highlights the gaps in conventional care as identifird by UK GPs in a 2004 survey. The right hand side of the table shows how acupuncture has been shown to be more effective than usual care for these conditions and cost effective for most of them (Thomas et al., 2006; Macpherson et al., 2012; MacPherson et al., 2013; Macpherson et al., 2013; Mcdonald & Janz, 2017).
Figure 1. Gaps in conventional medicine can be filled by acupuncture.
How Does Acupuncture Work?
Traditional Chinese Acupuncture treatments are based on an individual diagnosis and work by treating the underlying root cause of any condition as well as the symptoms. Acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules and the resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being. A 2010 study, using fMRI to monitor the effects of several classical acupuncture points on the human brain, indicated that acupuncture modulates the limbic network, an important intrinsic regulatory system of the human brain (Hui, Napadow, et al., 2010). A more recent paper suggests that increasing evidence supports the role of connective tissue in the mechanism of acupuncture (Langevin & Schnyer, 2017).
Acupuncture correlates with decreases in blood flow in the frontal cortex.
Kick Ass Miracles, BBC3 Episode 5, 2006
ACUPUNCTURE FOR CONDITIONS RELATED TO ABSENTEEISM
In Jan 2013, the results of a study which examined “Why Patients Visit Their Doctor” were published. This study included 142,377 patients and found that four of the top ten conditions that result in a GP visit have a strong pain involvement. These include chronic neurological disorders and headaches & migraines. However just over one third of all visits are related to joint disorders including osteoarthritis (33.6%) and slightly less than one quarter of all visits are related to back problems (23.9%). These two categories combine to give a total of 57.5%.
A similar study conducted in Finland and published in January 2001 concluded that pain was responsible for 40% of Primary Healthcare interactions
WHAT CAN ACUPUNCTURE DO FOR PAIN?
Chinese Medicine has a saying: “通则不痛，不通则痛” “When there is free flow, there is no pain. When there is no free flow, there is pain”.
This statement underpins the treatment of pain with Acupuncture, which recognises pain as an obstruction of the free flow of the body’s Qi, Blood and other body substances. This can be seen as swelling, inflammation, bruising and abnormal coloration of the skin and underlying tissues, as well as being felt by the patient as pain.
The aim of Acupuncture is to restore the free flow and thereby relieve the pain. Using the body’s channel system, an acupuncturist will insert an average of 6 to 8 sterile acupuncture needles into acupuncture points on the patient’s body to relieve the pain. Treatment can be exclusively in the local area of pain or can be exclusively distal to the area of pain or a combination of both local and distal needling can be used. Acupuncture works by treating the underlying root cause of the condition causing the pain as well as the symptoms.
ACUPUNCTURE PAIN RESEARCH STUDIES
The Journal of the American Medical Association (JAMA) published the results of Dr. Andrew Vickers study “Acupuncture for Chronic Pain - Individual patient data Meta-analysis” in September 2012. This study analysed a total of 17,922 patients, took Dr. Vickers and his team about 6 years to complete and concluded that “Acupuncture is effective for the treatment of chronic pain……..in analysis of patient level data…..we found statistically significant differences between both acupuncture vs sham acupuncture and acupuncture vs no acupuncture control for all pain types studied.” He further states “we believe that our findings are both clinically and scientifically important”. In the New York Times on Sept 11th 2012, Dr. Vickers stated “They’re not just getting some placebo effect”.(Vickers et al., 2012)
A comprehensive 2014 review of non-invasive and alternative management of chronic low back pain (efficacy and outcomes) concluded that the strongest evidence in the literature for good efficacy and outcomes included acupuncture (Wellington, 2014). According to Acupuncture For Chronic Pain And Depression In Primary Care: A Programme Of Research (NHS: National Institute For Health Research), acupuncture is significantly better than sham & usual care for low back pain (MacPherson et al., 2017)
In a study of 517 patients with neck pain of a median duration of 6 years, acupuncture treatment led to significant reductions in neck pain and associated disability compared with usual care at 12 months (MacPherson et al., 2013).
Acupuncture was shown to be significantly better than sham & usual care for neck pain in Acupuncture For Chronic Pain And Depression In Primary Care: A Programme Of Research (MacPherson et al., 2017).
Frozen shoulder (adhesive capsulitis) is a common, painful and sometimes disabling condition that can last for months or years. The pragmatic German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) showed that Chinese acupuncture is more effective than conventional standard therapy with NSAIDs and physiotherapy (Molsberger et al., 2010). In their 2015 high quality publication, Treatments For Shoulder Impingement Syndrome: A PRISMA Systematic Review And Network Meta-Analysis, Dong et al. found that exercise, exercise-based therapies and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended.(Dong et al., 2015)
Headache & Migraine
NICE UK recommends up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.(NICE, 2012)
Acupuncture has also been found to be significantly better than sham & usual care for migraine. (MacPherson et al., 2017)
Fibromyalgia, Low Back Pain & Osteoarthritis
According to the 2013 report from Arthritis Research UK, acupuncture is the most effective form of complementary therapy for treating osteoarthritis, low back pain and fibromyalgia (Arthritis Research, 2013).
In a study to compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis, acupuncture treatment was found to be significantly better than standard care (Corbett et al., 2013). Acupuncture For Chronic Pain And Depression In Primary Care: A Programme Of Research, found acupuncture to be cost-effective and significantly better than sham & usual care for osteoarthritis of the knee (MacPherson et al., 2017).
Carpal tunnel syndrome
This affects 1 in 10 people and involves potentially disabling sensory and/or motor symptoms in the hand. Researchers in a 2010 RCT concluded that acupuncture was as effective as orthodox treatment of night splinting in terms of overall symptoms and function, and superior to it for pain control (Kumnerddee & Kaewtong, 2010).
A systematic review of RCTs of acupuncture and moxabustion for lateral elbow pain showed that the acupuncture group had a significantly higher cured rate than conventional therapy, including prednisolone injection, triamcinolone acetonide, lidocaine injection and oral administration of meloxicam tablets (Gadau et al., 2014).
Researchers concluded that the results of a 2011 RCT showed that acupuncture can provide pain relief to patient with plantar fasciitis (Zhang et al., 2011).
STRESS, ANXIETY & DEPRESSION
Stress is the feeling of being under too much mental or emotional pressure and can have a significant impact on a person's mental and physical well-being. Many of life's demands can cause stress, such as work, relationships, illness, major life events and money problems and it can manifest as symptoms such as insomnia, anxiety, depression and physical pain. Mental health issues, including stress, anxiety and depression, are the reason for one-in-five visits to a GP (“Causes of stress”), and, according to the 2014 Small Firms Association Report, stress, anxiety and depression account for over 20% of absenteeism from work in Ireland thereby costing small business €98 million per annum (“Small Firms Association”).
WHAT CAN ACUPUNCTURE DO FOR STRESS, ANXIETY & DEPRESSION?
The Chinese characters 紧张 (stress or tension) and 精神紧张 (nervous tension) convey a sense of tightness or tautness, of something stretched really tight, which is exactly what happens in a body under stress. Traditional acupuncture treatments are based on an individual diagnosis and work by treating the underlying root cause of any condition as well as the symptoms.
A 2011 randomised controlled trial (RCT) (Huang et al., 2011) suggested that acupuncture might be successful in treating the symptoms of chronic stress (Huang 2011) while a crossover study with healthy individuals subjected to stress testing found that acupuncture was more effective than a 'control' point (Fassoulaki et al., 2003).
More recently, in 2014 Sparrow et al, found that some patients' HRV increased over weeks to months during the course of acupuncture treatment for hypertension as evidenced by a decrease in their LF/HF ratio, indicating a relative decrease in their physiologic stress (Sparrow & Golianu, 2014).
According to research, acupuncture may specifically benefit anxiety disorders and symptoms of anxiety by acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the 'analytical' brain, which is responsible for anxiety and worry(Hui, Marina, et al., 2010; Hui et al., 2009); improving stress induced memory impairment (Kim et al., 2011); reducing serum levels of corticosterone and the number of tyrosine hydroxylase-immunoreactive cells (Park et al., 2010); and reversing stress-induced changes in behaviour and biochemistry (Kim et al., 2009).
Studies indicate that acupuncture can have a specific positive effect on depression by altering the brain's mood chemistry, increasing production of serotonin (Sprott et al., 1998) and endorphins (Wang & Wang, 2010).
In the first randomised trial of acupuncture and counselling for patients continuing to experience depression in primary care, researchers found statistically significant benefits at 3 months associated with both interventions when provided alongside usual care. (Macpherson et al., 2013)
A 2014 study by Spackman et al., Cost-Effectiveness Analysis of Acupuncture, Counselling and Usual Care in Treating Patients with Depression, found that, at 3 months, patients treated with acupuncture or counselling were less likely than patients treated with usual care to report that they were moderately or extremely anxious or depressed rather than not anxious or depressed. The 3-month improvement in anxiety and depression was sustained over the trial period to 12 months (Spackman et al., 2014). The NIHR study, Acupuncture for Chronic Pain and Depression in Primary Care: A Programme of Research, found acupuncture to be clinically effective and cost-effective for treating depression. (MacPherson et al., 2017)
PROFESSIONAL ACUPUNCTURISTS in IRELAND
Acupuncture as practiced by Professional Traditional Acupuncturists is widely used in mainstream hospitals throughout the World, including the Whittington Hospital in London which has a dedicated Pain Clinic run entirely by TCM practitioners. The therapeutic benefits of acupuncture have been embraced internationally due to its proven effectiveness not only in respect of the management of chronic and acute conditions but also in the treatment of their underlying causes. It is now the largest drug-free healthcare therapy in the World whilst being compatible with and therefore capable of being used alongside Western (Orthodox) Medicine. In Ireland acupuncture is becoming increasingly acknowledged within mainstream healthcare as a treatment option for many conditions and is included in many private health insurance plans. This potential of acupuncture to deliver timely, cost effective, safe and clinically effective management of a range of conditions has yet to be fully exploited and referrals to acupuncture clinics are likely to become more commonplace as happens in other countries.
Established in 1987, the Acupuncture Foundation Professional Association (AFPA) is the longest established independent professional register of acupuncturists and practitioners of Traditional Chinese Medicine in Ireland. Members work within the guidelines set out in 2006 by the Department of Health and Children. They are graduates from many Colleges in Ireland and abroad and all are bound by a Code of Ethics and Practice which is strictly enforced by the AFPA.
We are active members of the European TCM Association (ETCMA) and collaborate with our international colleagues in achieving the best outcomes for our patients.
Our practitioners are professionals who are required by virtue of their training and adherence to codes of ethics and practice, to refer patients to other more appropriate healthcare providers when warranted. Patients attending an Acupuncturist registered with the AFPA are assured that their practitioner:
• Highest level of training in Ireland
• Is subject to Professional oversight
• Possesses professional indemnity insurance
• Adheres to a code of ethics and practice
• Undertakes Continuous Professional Development
• Has 3 years training in Traditional Chinese Acupuncture
• Uses single-use sterile needles
• Is recognised by private health insurers
Acupuncture is considered very safe in the hands of well-trained practitioners. Ensure that you receive the highest standard and most effective acupuncture treatment by attending a Registered Acupuncturist who is suitably qualified with a minimum of three years training in this specialised field. In Ireland practitioners should be a registered member of a Professional Association such as the AFPA which oversees excellence in training, safe practice and professional conduct. Find a registered professional acupuncturist on www.afpa.ie.
Diseases & Disorders That Can Be Treated With Acupuncture
The following is a list of diseases or disorders from the World Health Organisation for which acupuncture therapy has been tested in controlled clinical trials reported in the recent literature can be classified into four categories as shown below.
1. Diseases, symptoms or conditions for which acupuncture has been proved-through controlled trials-to be an effective treatment:
Adverse reactions to radiotherapy and/or chemotherapy Allergic rhinitis (including hay fever) Biliary colic Depression (including depressive neurosis and depression following stroke) Dysentery, acute bacillary Dysmenorrhoea, primary Epigastralgia, acute (in peptic ulcer, acute and chronic gastritis, and gastrospasm) Facial pain (including craniomandibular disorders) Headache Hypertension, essential Hypotension, primary Induction of labour Knee pain Leukopenia Low back pain Malposition of foetus, correction of Morning sickness Nausea and vomiting Neck pain Pain in dentistry (including dental pain and temporomandibular dysfunction) Periarthritis of shoulder Postoperative pain Renal colic Rheumatoid arthritis Sciatica Sprain Stroke Tennis elbow
2. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which further proof is needed:
Abdominal pain (in acute gastroenteritis or due to gastrointestinal spasm) Acne vulgaris Alcohol dependence and detoxification Bell’s palsy Bronchial asthma Cancer pain Cardiac neurosis Cholecystitis, chronic, with acute exacerbation Cholelithiasis Competition stress syndrome Craniocerebral injury, closed Diabetes mellitus, non-insulin-dependent Earache Epidemic haemorrhagic fever Epistaxis, simple (without generalized or local disease) Eye pain due to subconjunctival injection Female infertility Facial spasm Female urethral syndrome Fibromyalgia and fasciitis Gastrokinetic disturbance Gouty arthritis Hepatitis B virus carrier status Herpes zoster (human (alpha) herpesvirus 3) Hyperlipaemia Hypo-ovarianism
Insomnia Labour pain Lactation, deficiency Male sexual dysfunction, non-organic Ménière disease Neuralgia, post-herpetic Neurodermatitis Obesity Opium, cocaine and heroin dependence Osteoarthritis Pain due to endoscopic examination Pain in thromboangiitis obliterans Polycystic ovary syndrome (Stein-Leventhal syndrome) Postextubation in children Postoperative convalescence Premenstrual syndrome Prostatitis, chronic Pruritus Radicular and pseudoradicular pain syndrome Raynaud syndrome, primary Recurrent lower urinary-tract infection Reflex sympathetic dystrophy Retention of urine, traumatic Schizophrenia Sialism, drug-induced Sjögren syndrome Sore throat (including tonsillitis) Spine pain, acute Stiff neck Temporomandibular joint dysfunction Tietze syndrome Tobacco dependence Tourette syndrome Ulcerative colitis, chronic Urolithiasis Vascular dementia Whooping cough (pertussis)
3. Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult:
Chloasma Choroidopathy, central serous Colour blindness Deafness Hypophrenia Irritable colon syndrome Neuropathic bladder in spinal cord injury Pulmonary heart disease, chronic Small airway obstruction
4. Diseases, symptoms or conditions for which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment:
Breathlessness in chronic obstructive pulmonary disease Coma Convulsions in infants Coronary heart disease (angina pectoris) Diarrhoea in infants and young children Encephalitis, viral, in children, late stage Paralysis, progressive bulbar and pseudobulbar
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