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The current debate in the USA over professional ‘ownership’ of acupuncture, as detailed in the linked paper by Zhou et al1 and reflected by the recent position paper from the American Academy of Medical Acupuncture (http://www.medicalacupuncture.org/ForPhysicians/AbouttheAAMA/AAMAPositionStatement), is in stark contrast to the diverse, multidisciplinary approach that is flourishing in the UK. Dispelling the myths of physiotherapy (physical therapy) led acupuncture is a task that is long overdue. Perhaps the argument “why physiotherapists should not deliver acupuncture” should be reframed “why not physiotherapists (or other healthcare professionals who are not physicians)?”. Chartered physiotherapists are placed at the forefront of modern healthcare, with >55 000 currently practising in the UK.2 As professionally regulated and autonomous healthcare professionals, there is huge opportunity for physiotherapists to deliver acupuncture as part of mainstream healthcare for patient benefit.
Acupuncture in physiotherapy
Western medical acupuncture (WMA) practice by physiotherapists and other healthcare professionals in the UK and internationally has substantially increased in the last decade. The Acupuncture Association of Chartered Physiotherapists (AACP) was established in 1984 and membership is currently >6500,3 double that of any other UK acupuncture organisation. Physiotherapists also contribute to the membership of the British Medical Acupuncture Society. Collectively, physiotherapists are the largest professional group of acupuncture providers in the UK and are arguably leading the way in bringing acupuncture into mainstream healthcare.
Physiotherapists have typically completed 3–4-year professional degrees, including extensive training in anatomy, physiology, pathology, and diagnostics. This provides an excellent foundation for learning acupuncture at an advanced level. Physiotherapy uses a holistic approach to patient care, which complements theories underpinning acupuncture. Most UK physiotherapists choose to study/practise WMA. Some complete masters degrees in acupuncture and a small proportion choose to study dry needling (DN) only.
As one example, AACP education/training of physiotherapists in WMA is provided at an advanced (masters degree) level. Courses are mapped against an educational framework of 300 h (in line with WHO recommendations) and include extensive assessment. AACP training includes evidence-based WMA (including a component of DN or trigger point acupuncture) blended with some Traditional Chinese Medicine (TCM) theories and ideologies, providing a comprehensive education and a high standard of training.4 The rationale behind teaching/practice of WMA is in part due to the statutory requirement for regulated health professionals to use evidence-based practice. Furthermore, the rigorous evidence base from Europe is predominantly based on WMA and not TCM diagnostic theories.
Autonomous practice within the UK allows physiotherapists to develop their scope of practice into areas in which they are trained and competent, allowing specialism. Some choose to study DN for use in a limited form within their practice, but are equally aware of their limitations and safety. These practitioners, like all physiotherapists, are regulated by the Health and Care Professionals Council and are required to remain within scope of practice in their delivery of all techniques. Using invasive techniques such as ‘needling’ requires competence, formal training and safety certification. Short CPD (continuing professional development) courses with no formal assessment component would be questionable for any UK practitioner; however, the principle of professional autonomy means that it is the responsibility of the individual to decide whether their education in DN constitutes sufficient training to achieve competence and extend their scope of practice. The same principle applies when attending CPD courses to maintain competence in a current area of clinical practice (http://www.csp.org.uk/professional-union/professionalism/scope-of-practice/introduction).
Internationally, DN has evolved to provide a solution in countries where traditional acupuncture (TA) is not permitted for scientific reasons or where there is restriction on acupuncture provision; for example, in Italy, only medical doctors are legally permitted to deliver acupuncture.5 Society and healthcare will always adapt, often for financially driven reasons. As professionals we either adapt, or lose out to others who are willing to do so. Historically, physiotherapists have seen other professions learning/embracing their skills (eg, professional masseurs, sports and exercise therapists) and this is true across many professions. It is important to embrace change and professional collaboration for the benefit of patients.
The National Institute for Health and Care Excellence (NICE) estimated the cost of implementing acupuncture for low back pain in the UK National Health Service (NHS) to be £24 366 000 (∼€33 200 000, ∼US$37 600 000)—a seemingly impossible spend for a cash-strapped NHS.6 However, through utilisation of physiotherapists already in NHS posts, acupuncture is currently being provided across the country at a fraction of the cost. Patients benefit from the combination of physiotherapy treatment with evidence-based WMA, effectively receiving two interventions ‘for the price of one’.7 Respecting professional boundaries is important, but patient care needs to remain the priority.
A protectionist argument by traditional acupuncturists is the allegation that WMA or DN may not represent acupuncture in its ‘true form’, but in no other area of medicine would it be acceptable/justifiable to use 2000-year-old theories on patients. Historical aspects help us respect the foundation/roots of TA, but whether they should inform current clinical practice is highly debatable. If acupuncture is to become an accepted treatment modality in modern medicine, those delivering it have a responsibility to use evidence-based medicine and current biomedical/scientific knowledge to inform their practice. Physiotherapists are well placed to lead the way in the delivery of evidence-based WMA.
The word acupuncture simply means “the practice of inserting fine needles into specific parts of the body for therapeutic reason”,8 therefore all forms of needling described in the article by Zhou et al1 are technically acupuncture. There is negligible scientific evidence to suggest one method of acupuncture delivery is more effective than another, and research should focus on demonstrating efficacy/effectiveness, not which style to use. Regarding TA (ie, TCM or Japanese, Korean or Five Element acupuncture) there are many schools claiming their traditional theory is most effective, but no evidence to substantiate such claims. UK colleges providing TA training use different acupuncture styles without agreement on which is most effective, which is mirrored internationally. Research has shown it is needling per se that stimulates physiological responses within the body, not the philosophy behind it. Style of acupuncture and practitioner experience have been shown to have no influence on outcome in chronic pain trials.9
Placing an acupuncture needle into the body, regardless of the underlying principle, stimulates the central and peripheral nervous systems, eliciting release of serotonin, melatonin, and endorphins—the body's natural pain-relieving chemicals.10 Acupuncture also influences connective tissue11 and induces analgesia by deactivation of the limbic system (demonstrated by functional MRI studies) and releasing endogenous opioids.12 More recently, electroacupuncture has been shown to modulate systemic inflammation by vagal activation.13 Such physiological responses are likely to occur regardless of therapist, training or diagnostic principle. Research has also shown that acupuncture is synergistic with conventional therapies,14 which is highly relevant for physiotherapists as they already combine various interventions. If integration of treatments reduces cost and enhances effects for patients, this should be embraced.
Rigorous, evidence-based training is imperative to ensure safe delivery of acupuncture, and all providers should be regulated and follow strict codes of conduct to ensure patient safety. Acupuncture in the hands of chartered physiotherapists and other regulated healthcare practitioners is very safe.15 Collaboration across professional groups will help normalise acupuncture to make it more acceptable within society, rather than simply complementary/alternative. UK patients often report receiving a limited number of acupuncture sessions from their NHS physiotherapist before seeking further treatment by an independent physiotherapist or traditional acupuncturist. Collaboration aids patient care by allowing referral between practitioners, which is important in the current climate of commissioning so that patients receive the best possible care. Patient choice is also an important and topical consideration. If we are practising healthcare for the benefit of patients, our priority should be to ensure safe and appropriate treatment in an inclusive healthcare system, not to debate how their treatment is delivered and by whom.
In response to the ongoing debate outlined by Zhou et al,1 I would question why traditional acupuncturists are limiting themselves to ancient philosophies, when these principles were developed at a time when there was no possibility to prove or disprove their theory. With advances in modern medicine and technology, we can better demonstrate the effects of acupuncture and are learning more and more about how our amazing bodies work. As caring healthcare professionals we have a responsibility to update our practices constantly for the safety and benefit of our patients. Theories and ideologies are just principles to be explored until fact is demonstrated. Traditional treatments may be effective, but not necessarily for the reasons that underlie their principles. The past is for us to learn from, to lead the way into a new future, but not to restrict our present.
Twitter Follow Vivienne Dascanio at @VCDascanio
Competing interests VCD is a doctoral student, director and past chairman of the Acupuncture Association of Chartered Physiotherapists (AACP). The opinions expressed are those of VCD and not those of the University of York or the AACP.
Disclaimer The opinions expressed are those of VCD and not those of the University of York or the AACP.
Provenance and peer review Commissioned; internally peer reviewed.
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