Issues Magazine

Integrating Acupuncture with the Australian Healthcare System

By Charlie Xue, Tony Zhang, Angela Yang, Zhen Zheng and Brian May

Acupuncture is gaining significant acceptance in Australia, but further research and review will aid its integration with the broader healthcare system.

Acupuncture is not new in Australia. Since at least the 1840s it has been one of the methods used by practitioners of Chinese medicine for treating a range of disorders, and was used by some medical practitioners during the 19th century for pain management.

Interest in acupuncture escalated in post-war Europe with the establishment of an acupuncture society in France in 1945 and England in the 1960s.

In the 1970s acupuncture received considerable attention in the Australian press, and this was associated with the development of training courses and associations.

The 1980s saw rapid expansion in both acupuncture and other aspects of Chinese medicine including herbal medicine, tui na (therapeutic massage) and exercise systems such as tai chi and qi gong.

During the 1990s courses proliferated, standards of practice were developed and calls for regulation culminated in the registration of practitioners of acupuncture and Chinese herbal medicine in Victoria in 2000. However, acupuncture remains unregulated in other states and territories in Australia.

How Common Is Acupuncture in Australia?

A nationwide survey about the use of 17 forms of complementary and alternative medicine (CAM) in Australia was conducted in 2005 by Charlie Xue and colleagues. The survey estimated that nearly one in 10 (9.2%) Australians used acupuncture over a 12-month period and over 10 million visits were made to acupuncturists nationally each year. Most of the acupuncture users were born in Australia, had completed post-secondary education, were covered by private health insurance and lived in the states of New South Wales, Victoria and Queensland.

In the past several decades, acupuncture has become a formal part of the healthcare systems of a number of Asian countries and, more recently, it has been gaining acceptance in western countries as a therapeutic alternative to conventional western medicine. In recent years, the integration of acupuncture into conventional medical settings in the western countries has become increasingly common. For example, through an integrative health-care approach and in collaboration with the Northern Hospital in Melbourne, RMIT University has introduced an acupuncture program in a public hospital setting since 2005.

In Victoria, more than 900 acupuncture practitioners are registered with the Chinese Medicine Registration Board.

Acupuncture has been widely accepted by Australians as well as general medical doctors. Marc Cohen and colleagues (2005) found that acupuncture was considered one of the three most popular forms of complementary medicine used by medical doctors personally (12%), and nearly one in five (18%) of them practised acupuncture. In addition, over three-quarters (76%) of medical doctors referred their patients to acupuncturists at least once a month.

Overall, the evidence suggests that acupuncture has been a growing practice and has a considerable degree of community acceptance.

Acupuncture Education in Australia

In the early 1970s, acupuncture colleges were established in Sydney, Brisbane and Melbourne, and acupuncture entered the tertiary education system in the 1990s. In 1992, Victoria University of Technology (currently Victoria University) began its Bachelor of Health Science (Acupuncture) program, and in 1994 the University of Technology, Sydney (UTS) College of Acupuncture was founded.

In the same year, RMIT University introduced the first postgraduate acupuncture program, a Master of Applied Science (Acupuncture) for healthcare practitioners such as medical doctors, dentists, nurses and physiotherapists, in response to the growing acceptance and use of acupuncture in Australia and the need to provide a standard of education at a level expected by the community. In 1996 RMIT introduced the first comprehensive double-degree undergraduate program in Chinese medicine, which included training in both acupuncture and Chinese herbal medicine. This trend was followed with the set-up of Chinese medicine programs in several other educational institutions, including the University of Western Sydney (UWS).

In 2008, seven institutions in Australia provided degree- or diploma-level education in Chinese medicine, including acupuncture. Of these, four publicly funded Australian universities offered degree programs. The length of full-time study is 4 years for a single bachelor degree (UWS and UTS) and 5 years for a double bachelor degree (RMIT University, Bachelor of Human Biology and Bachelor of Chinese Medicine). These programs accept both local and international students and provide opportunities for clinical internships in affiliated teaching hospitals in China.

Currently, to be eligible for registration in Victoria, applicants must have completed a degree-level course that has been approved by the Chinese Medicine Registration Board of Victoria. Three courses have been approved (www.cmrb.vic.gov.au/

registration/approvedcourses.html), and all include substantial studies in medical sciences and are informed by the results of scientific studies into acupuncture as well as by clinical knowledge amassed over generations of recorded experience.

How Does Acupuncture Work?

Chinese medicine theory suggests that acupuncture unblocks energy channels in the body to restore the physiological functions of the related organs, thus alleviating a range of disorders, particularly those that involve pain.

From a modern biomedical science perspective, the mechanisms of action of acupuncture are yet to be fully understood. When acupuncture was first gaining popularity in western countries in the 1970s, some clinicians thought its effects were just due to non-specific and placebo effects (the effect produced by taking a sugar pill instead of a real medication). However, this view has been largely dismissed due to subsequent findings from numerous studies on animals and humans.

These studies demonstrated that the nervous system needs to be intact for the effects of acupuncture to be evident. Such studies offer an understanding of the physiological effects of acupuncture in the management of various painful conditions.

It appears that the insertion of an acupuncture needle activates specific structures, known as receptors, and this results in a cascade of activities within the human body. These processes induce the release of a number of chemicals such as endorphins, which can reduce the feeling of pain and increase pain threshold, thus alleviating the suffering due to pain. Further research has revealed that acupuncture affects other chemicals such as serotonin, norepinephrine, dopamine and a series of neurotransmitters. These actions can at least partly explain the analgesic effect of acupuncture in pain management and how it assists in drug withdrawal.

Using modern technologies such as functional magnetic resonance imaging (fMRI), researchers have found that acupuncture can affect the activities of the limbic system in the brain, which is associated with emotions such as fear and anger. This may help explain its effect on insomnia, depression and anxiety.

Other research indicates that acupuncture can regulate the function of internal organs such as the stomach and intestines, and this may be why acupuncture can be used to treat stomach pain, constipation and diarrhoea. There remains much that is unknown about the physiological effects of acupuncture, but continuing efforts in research will not only further our understanding of acupuncture but also learn how complex bodily systems operate.

State of Acupuncture Research in Australia

A number of Chinese medicine research centres and groups have been established in Australia to investigate the efficacy and safety of acupuncture, such as the Chinese Medicine Research Group at RMIT University (CMRG) and the Centre for Complementary Medicine Research at UWS. In 2007, a new Australian national initiative, a Collaborative Centre for Traditional Chinese Medicine, was established under the National Institute of Complementary Medicine (NICM).

The recent shift from mechanistic studies to clinical trials of acupuncture has produced exciting findings that offer critical clinical evidence on acupuncture for a number of clinical conditions such as pain, women’s health and allergic rhinitis. To investigate the efficacy and safety of acupuncture, a series of randomised controlled trials (RCTs) following rigorous methodology have been conducted in a number of parts of Australia over the past few years. Findings have been published in high-quality international peer-reviewed journals.

The CMRG commenced its research in acupuncture in 1994. Ten acupuncture clinical studies have been completed or are currently ongoing. These include RCTs for allergic rhinitis, headache, migraine and chronic pain as well as studies conducted to better understand the mechanisms of acupuncture and the effects of acupuncture analgesia.

For example, an RCT by Charlie Xue and associates (2002) on seasonal allergic rhinitis indicated that a significant improvement was observed in the real acupuncture group in terms of nasal and non-nasal symptoms using a five-point scale. In a subsequent RCT the same research group randomised 80 patients with persistent allergic rhinitis into two groups. After 8 weeks of treatment, the symptom score in the real acupuncture group decreased significantly compared with the sham acupuncture group, and this effect lasted at least 3 months after the completion of the treatment period. No severe adverse effects were observed in either of these studies. These results suggest that acupuncture may be an effective and safe treatment for the symptomatic relief of seasonal and persistent allergic rhinitis.

The effect of acupuncture on pain has also been investigated. CMRG has conducted an RCT to examine the efficacy of electro-acupuncture, applied only to acupuncture points remote from the site of the pain, for tension-type headache. This study indicated that electro-acupuncture was effective for short-term symptomatic relief of tension-type headache by needling acupuncture points on the limbs below the elbows and knees. In addition, a pilot RCT in a hospital in Victoria by Zhen Zheng and associates (2007) demonstrated that electro-acupuncture has a promising effect for the short-term reduction of opioid-like medication consumption in patients with chronic non-malignant pain.

Women’s health is another acupuncture research focus in Australia. Studies completed by researchers at the University of Adelaide suggested that acupuncture is generally safe in early pregnancy. An RCT by Caroline Smith and associates (2002) involved 593 women with nausea and vomiting in early pregnancy, and showed that women receiving acupuncture had less nausea throughout the trial and less dry retching from the second week compared with women who did not receive acupuncture treatment.

Recently, this group completed another RCT to evaluate the effects of acupuncture on pregnancy rates for women undergoing embryo transfer. Based on the outcome of 228 patients, the pregnancy rate was 31% in the acupuncture group, compared with 23% in the control group. In addition, the ongoing pregnancy rate at 18 weeks was higher in the treatment group (28%) than in the control group (18%).

As an alternative to traditional acupuncture, laser acupuncture (without needling) has been investigated by some researchers. Joo Im Quah-Smith and colleagues (2005) investigated 30 patients with mild to moderate depression and found that the active laser acupuncture group showed a significantly lower depression score than the inactive laser acupuncture group at the end of the treatment period and after 12 weeks of follow-up.

These acupuncture RCTs followed rigorous methodologies that are internationally recognised. Most Australian clinical trials are now registered with the Australian Therapeutic Goods Administration and the Australian New Zealand Clinical Trial Registry. With the introduction of the Consolidated Standards of Reporting Trials (CONSORT Statement), trials conducted in Australia have followed this international standard. Therefore, Australian researchers have already made scientifically sound contributions to our understanding of the clinical effects of acupuncture, and this work is ongoing. Such activities require appropriately qualified individuals to join the research teams to enhance the capability and capacity of acupuncture research in Australia.

Systematic Reviews of Acupuncture Trials

A systematic review is a review of the research literature that aims to answer specific research questions. It uses a standard methodology to identify, critically appraise, select and synthesise high-quality original evidence. Systematic reviews are an evidence-based medicine approach. Conclusions from systematic reviews are considered the highest level of medical evidence, and these findings should be used in clinical decision-making. It is becoming increasingly important for health professionals to understand the systematic review process and to apply the results of systematic reviews in their clinical practice.

Australia is one of the foundation member countries in the development of Cochrane Database Systematic Reviews. In 1994, the Australasian Cochrane Collaboration Centre was established and it was, at that time, one of only a small number of Cochrane centres worldwide. Since then Cochrane centres have been established in many countries.

In line with the increasing focus on evidence-based complementary medicine, Australian researchers have made considerable contributions to the generation of acupuncture evidence, in the form of systematic reviews. These include reviews on the effectiveness of acupuncture for a number of clinical conditions such as depression, induction of labour, lateral elbow pain, shoulder pain and fibromyalgia. All these reviews are available to the public via the Cochrane Library. Even though the number of clinical studies on one condition remains, in most cases, too small to allow conclusive recommendations, some of the reviews provide promising evidence for the effectiveness of acupuncture for specific conditions such as pain caused by tennis elbow.

Other systematic reviews of acupuncture have also been conducted in Australia. In 2006, a systematic review by researchers from the CMRG concluded, after a number of well-designed clinical trials, that there is evidence to support the use of acupuncture for the symptomatic treatment of allergic rhinitis.

Also in 2006, based on 25 studies with a total of 3004 patients, Sean Scott from the Gold Coast Hospital in Southport, Queensland, found that acupuncture was significantly better than waiting list (no treatment) and at least as good as the effect of several routinely used drugs for the treatment and prevention of migraine. Consistent with these findings, Yanyi Wang and colleagues (2008) conducted a systematic review of 17 studies conducted in China with a total of 2097 participants, and found that there was moderate evidence that acupuncture is more effective for migraine than western pharmacotherapy.

Acupuncture is commonly used for women’s health, and a systematic review by Caroline Smith and associates (2007) found that acupuncture and acupressure to be beneficial in the management of pain during labour.

As the number of clinical trials for acupuncture and associated methods increases internationally, Australian researchers can pool the results of these trials to determine what the total body of evidence tells us about the efficacy of acupuncture to enable clinicians to make better informed decisions on whether or how to use acupuncture for certain health conditions.

Future Issues for Acupuncture

In June 2008, Victoria’s Department of Human Services funded a project to evaluate the effectiveness of acupuncture for acute pain management at an emergency department. This project, led by the Division of Chinese Medicine at RMIT University, exemplifies an effective collaboration between western medical emergency physicians and Chinese medicine (acupuncture) practitioners.

Upon successful completion, this project may offer a model for the integration of acupuncture into the healthcare system in Australia and other western countries for pain management. Such integration requires not only further research evidence but also a well-trained workforce consisting of registered acupuncture practitioners who are able to provide good-quality clinical acupuncture services to the community and who are sufficiently well-educated in biomedical sciences to be able to effectively communicate with mainstream medical professionals.

In Victoria, due the effect of statutory registration of practitioners and the establishment of uniform educational standards at degree level, the main preconditions for the greater integration of acupuncture already exist. However, although similar developments are progressing in other states, a nationally uniform system is not yet in place.

In addition to further research into the efficacy and safety of acupuncture, the cost-effectiveness of acupuncture in clinical practice needs to be evaluated. Since acupuncture does not involve the use of drugs, acupuncture may be able to reduce the use of medications such as pain medications with a resultant saving to the health insurance system.

Traditionally, acupuncture has been used as an important aspect of health maintenance and not just in the treatment of disease. As the cost of the burden of disease rapidly rises, acupuncture may be an effective alternative in the prevention of certain disorders as well as an effective therapy for the treatment of a range of chronic diseases.

Setting up pilot programs, such as the one mentioned above, is the logical next step in evaluating the most appropriate roles for acupuncture as an integral part of the broader healthcare system. This will require effective collaboration between academics, researchers, healthcare professionals and members of local communities, as well as positive political leadership.

References will be provided on request. Email Professor Charlie Xue, Head, Division of Chinese Medicine, RMIT University (charlie.xue@rmit.edu.au).