electroacupuncture의 효과

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acupuncture의 효과

아주 기초적인 개념부터 다시 공부해야겠다.

panic bird......

Electroacupuncture in the Treatment of Obesity.pdf

Differential endogenous pain modulation in complex regional.pdf

Electroacupuncture suppresses hyperalgesia and spinal Fos.pdf

1: Prog Neurobiol. 2008 Aug;85(4):355-75. Epub 2008 Jun 5. Links

Neural mechanism underlying acupuncture analgesia.

Zhao ZQ.

Institute of Neurobiology, Institutes of Brain Science and State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China. zqzhao@fudan.edu.cn

Acupuncture has been accepted to effectively treat chronic pain by inserting needles into the specific "acupuncture points" (acupoints) on the patient's body. During the last decades, our understanding of how the brain processes acupuncture analgesia has undergone considerable development. Acupuncture analgesia is manifested only when the intricate feeling (soreness, numbness, heaviness and distension) of acupuncture in patients occurs following acupuncture manipulation. Manual acupuncture (MA) is the insertion of an acupuncture needle into acupoint followed by the twisting of the needle up and down by hand. In MA, all types of afferent fibers (Abeta, Adelta and C) are activated. In electrical acupuncture (EA), a stimulating current via the inserted needle is delivered to acupoints. Electrical current intense enough to excite Abeta- and part of Adelta-fibers can induce an analgesic effect. Acupuncture signals ascend mainly through the spinal ventrolateral funiculus to the brain. Many brain nuclei composing a complicated network are involved in processing acupuncture analgesia, including the nucleus raphe magnus (NRM), periaqueductal grey (PAG), locus coeruleus, arcuate nucleus (Arc), preoptic area, nucleus submedius, habenular nucleus, accumbens nucleus, caudate nucleus, septal area, amygdale, etc. Acupuncture analgesia is essentially a manifestation of integrative processes at different levels in the CNS between afferent impulses from pain regions and impulses from acupoints. In the last decade, profound studies on neural mechanisms underlying acupuncture analgesia predominately focus on cellular and molecular substrate and functional brain imaging and have developed rapidly. Diverse signal molecules contribute to mediating acupuncture analgesia, such as opioid peptides (mu-, delta- and kappa-receptors), glutamate (NMDA and AMPA/KA receptors), 5-hydroxytryptamine, and cholecystokinin octapeptide. Among these, the opioid peptides and their receptors in Arc-PAG-NRM-spinal dorsal horn pathway play a pivotal role in mediating acupuncture analgesia. The release of opioid peptides evoked by electroacupuncture is frequency-dependent. EA at 2 and 100Hz produces release of enkephalin and dynorphin in the spinal cord, respectively. CCK-8 antagonizes acupuncture analgesia. The individual differences of acupuncture analgesia are associated with inherited genetic factors and the density of CCK receptors. The brain regions associated with acupuncture analgesia identified in animal experiments were confirmed and further explored in the human brain by means of functional imaging. EA analgesia is likely associated with its counter-regulation to spinal glial activation. PTX-sesntive Gi/o protein- and MAP kinase-mediated signal pathways as well as the downstream events NF-kappaB, c-fos and c-jun play important roles in EA analgesia.

1: Brain Res. 2007 Dec;1186:171-9. Epub 2007 Oct 22. Links

Electroacupuncture suppresses hyperalgesia and spinal Fos expression‎ by activating the descending inhibitory system.

Li A, Wang Y, Xin J, Lao L, Ren K, Berman BM, Zhang RX.

Center For Integrative Medicine, School of Medicine, University of Maryland, 20 Penn Street, Baltimore, MD 21201, USA.

Although electroacupuncture (EA) is widely used to treat pain, its mechanisms have not been completely understood. The present study investigated the descending inhibitory system involvement in EA action. Inflammatory pain was induced by injecting complete Freund's adjuvant subcutaneously into one hind paw of rats with dorsolateral funiculus lesions and sham-operated rats. EA treatment, 10 Hz at 3 mA, was given twice for 20 min each, once immediately post- and again 2 h post-Freund's adjuvant at GB 30, at the junction of the lateral 1/3 and medial 2/3 of the distance between the greater trochanter and sacral hiatus. For sham EA control, acupuncture needles were inserted bilaterally into GB 30 without electrical or manual stimulation. Paw withdrawal latency to a noxious thermal stimulus was measured at baseline and 20 min after EA treatment. Compared to sham EA, EA significantly (P<0.05, n=9) increased withdrawal latency of the inflamed hind paws in the sham-operated rats but not in those with dorsolateral funiculus lesions, indicating that lesioning blocked EA-produced anti-hyperalgesia. EA, compared to sham EA, also significantly inhibited Fos expression‎ in laminae I-II of the spinal cord in the sham-operated rats (58.4+/-6.5 vs. 35.2+/-5.4 per section) but not in those with dorsolateral funiculus lesions. Further, EA activated serotonin- and catecholamine-containing neurons in the nucleus raphe magnus and locus coeruleus that project to the spinal cord. The results demonstrate that EA inhibits transmission of noxious messages and hyperalgesia by activating supraspinal neurons that project to the spinal cord.

1: Neurochem Res. 2008 Oct;33(10):2023-7. Epub 2008 Aug 22. Links

Electroacupuncture in the treatment of obesity.

Wang F, Tian DR, Han JS.

Neuroscience Research Institute, Peking University, Beijing 100083, People's Republic of China. wuling51@263.net

Obesity is becoming one of the most common health problems in the world. Many other disorders, such as hypertension and diabetes are considered as the consequences of obesity. Since effective remedies are rare (only two drugs, Orlistat and Sibutramine, were officially approved by the US Food and Drug Administration for long-term obesity treatment so far), researchers are trying to discover new therapies for obesity, and acupuncture is among the most popular alternative approaches. To facilitate weight reduction, one can use manual acupuncture, electroacupuncture (EA) or transcutaneous electrical acupoint stimulation (TEAS). As the parameters of the EA or TEAS can be precisely characterized and the results are more or less reproducible, this review will focus on EA as a treatment modality for obesity. Results obtained in this laboratory in recent five years will be summarized in some detail.

 

 

1: Brain. 2009 Mar;132(Pt 3):788-800. Epub 2009 Jan 19. Links

Differential endogenous pain modulation in complex-regional pain syndrome.

Seifert F, Kiefer G, DeCol R, Schmelz M, Maihöfner C.

Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.

Endogenous pain modulation may provide facilitation or inhibition of nociceptive input by three main mechanisms. Firstly, modification of synaptic strength in the spinal dorsal horn may increase or decrease transmission of nociceptive signals to the brain. Secondly, local dorsal horn interneurons provide both feed-forward and feed-back modulation to spinothalamic and spinobulbar projection neurons. Thirdly, descending systems originating in the brainstem exert top-down modulation of nociceptive input at the spinal level. Not much is known on the activity of these systems in complex regional pain syndrome (CRPS). CRPS is a chronic pain condition characterized by burning pain and abnormalities in the sensory, motor and autonomous nervous system. In the present study, we tested changes in endogenous pain modulation in 27 CRPS patients compared with age-matched healthy controls. We applied repetitive noxious electrical stimuli (stimulation frequency 1 Hz) at the dorsal aspect of affected and unaffected hands in patients and to corresponding hands in controls. As known from previous studies this protocol simultaneously activates inhibitory and facilitatory pain modulating systems. This results in adaptation to the repetitive noxious stimulus, and simultaneously and at the same site, in development of an area of pinprick hyperalgesia. We measured (i) pain adaptation during the course of stimulation and (ii) the provoked area of pinprick hyperalgesia. These parameters were used as activity measures of pain inhibitory and pain facilitatory systems. As both measures result from gross inhibitory and gross facilitatory activity in pain modulatory systems, pain adaptation reflects net pain inhibition and area of pinprick hyperalgesia net pain facilitation. We found (i) decreased adaptation to painful electrical stimuli on both affected and unaffected hands of CRPS patients compared to healthy controls and (ii) increased areas of hyperalgesia on affected hands of CRPS patients compared to unaffected hands of CRPS patients and healthy controls. These findings imply a shift from inhibition towards facilitation of nociceptive input in CRPS patients, based on differential activation of subcomponents of the endogenous pain modulatory system. The differences were not correlated with duration of the disease, pain intensity, autonomic or motor function scores, presence or degree of evoked pain. However, significant correlation was found with the extent of adaptation and hyperalgesia on the unaffected hand. Thus, we hypothesize that differential activity in endogenous pain modulating systems may be not only a result of CRPS, but a potential risk factor for its development.

 

MAJOR RECOMMENDATIONS

Definitions for the quality of the evidence (Levels I-IV) and the strength of recommendations (Grades A-E) are found at the end of the "Major Recommendations" field.

Electroacupuncture (EA)

General Operational Guidelines

The physiological features of the body allow the use of simple, rational, repeatable rules for the application of EA. This includes proper placement of the output leads to achieve the best therapeutic effect while at the same avoiding unwanted current paths in the body. Perhaps the most important consideration in the use of EA, and acupuncture in general, is the selection of candidate neurovascular nodes (acupoints) to be employed to achieve the best clinical outcome for the patient's condition. Duration of treatment, output amplitude, output frequency, and selection of proper operating mode also need to be considered. (Details are provided in the original guideline document.)

When to Consider Using EA

Generally the application of EA stimulation greatly enhances the effect of needling therapy and can increase level of analgesia and significantly extends the period of treatment effectiveness. Many practitioners apply EA as a primary modality for acute and chronic pain and musculoskeletal problems because of its ability to produce a strong analgesic effect. The application of EA is a primary consideration for pain, muscle spasms, numbness, treating nerve dysfunction, paralysis, and atrophy. EA can also be employed in surgical or dental procedures an adjuvant to normal anesthetics. EA is very effective in treating withdrawal symptoms of individuals quitting the use of addictive substances such as nicotine, alcohol, cocaine, opiates, and some prescription drugs. EA can also be used to enhance cervical dilatation and uterine contractions to induce labor. Stimulation promotes tissue repair, healing and regenerating of nerve fibers essential to treat many chronic disorders.

Placement of Leads

Physiological organization of the body that is critical to afferent and efferent processes affecting the vessels, viscera, muscles, and peripheral nerves is basically longitudinal and ipsilateral in nature. The ipsilateral nature of the ascending afferent signals dictates placing the positive and negative leads of one particular output channel of the EA/PENS device along vertical pathways on the same side of the body. One principal goal in lead placement is to conform to the segmental and axial organization of the body while making certain to prevent cross currents. Cross currents are to be avoided especially in preventing transcranial current pathways.

This is accomplished by placing the positive and negative leads of one particular output channel of the EA/PENS device along vertical pathways on the same side of the body. If the presenting problem is ipsilateral in nature, such as pain in one shoulder, the positive and negative leads are placed at appropriate locations along the affected muscular pathway. If the problem is bilateral, such as low back pain, then one set of positive and negative leads, are placed on one side of the back, and another set placed at the same relative locations on the other side. However, there is about a 40% crossover on the descending control restorative signals. This crossover features allows treatment of the opposite side to the one containing a problem to benefit the affected side, especially where the patient cannot tolerate direct treatment of the affected side.

Duration of Stimulation

Typical duration of EA application is 15 to 30 minutes. In cases of dental or surgical analgesia, the duration may by longer. In treatment of withdrawal from a powerful opiate, the duration may be increased to 45 minutes and applied twice a day for 3 to 4 days.

Amplitude (Strength of Current)

Under most conditions, amplitude of the output signal is only adjusted to the level that the patient can detect a slight sensation that feels like tapping on the skin. In many cases of trauma and pain there may be a deficit in sensory perception. These patients may not feel the electrical signal even though strong muscular contractions are activated. Thus, amplitude is adjusted only to the level where either the patient feels a slight sensation or the practitioner observes small movements of the needle or perhaps very slight muscular contractions. Excess strength of stimulation can induce a stress response. After several minutes of stimulation, control signals generated in the body, reduce the response to the stimulus and the patient no longer feels the EA stimulus. Thus, the amplitude is periodically readjusted to maintain an awareness of a slight tapping sensation. The control response generated by the body is mediated by descending neural pathways in the spinal cord. This is the prime effect that is sought in the treatment of all problems, including musculoskeletal and viscera conditions.

Frequency and Operating Mode

Care needs to be taken not to induce stress by either excess amplitude or using frequencies that are too high.

Low frequency application (2 hertz [Hz].) always invokes the analgesic and restorative processes of acupuncture. This frequency (2 Hz.) is suitable for use in treating all pain conditions, substance abuse, osteoarthritis, rheumatoid arthritis, vascular or blood distribution problems and organ dysfunction. Higher frequencies (25 to 50 Hz.) are selected where nerve dysfunction or paralysis is involved and this is usually in conjunction with a low frequency (mixed mode). Frequencies of 25 Hz. and above can produce tonic contraction of muscles and is useful in treating certain muscular conditions when applied in discontinuous or mixed mode. General considerations of mode selection involve the following:

• Continuous mode: Used for most conditions, especially in treating pain, substance withdrawal symptoms, visceral problems, inducing labor, and using EA/PENS for surgical analgesia. Normal treatment duration is about 20-35 minutes and there is little risk of developing tolerance even if this is applied several times a day. When used for surgical or dental analgesia, the duration may be extended. Tolerance can be produced after many hours of continuous application or in several days with a few hours of daily EA/PENS stimulation
• Mixed mode: Is considered when a clinical condition involves paralysis, atrophy, and impairment due to loss of nerve function. Mixed mode can also be applied to enhance segmental levels with the higher frequency component as well as activating axial effects with the lower frequency component.
• Discontinuous mode: Employed where a longer period of stimulation is needed and also where stimulation is directed to strengthen particular muscular areas or to treat problems such as scoliosis. In situations of long duration EA/PENS, use of discontinuous mode (about 3 seconds on and 3 seconds off) can be considered to reduce potential of developing tolerance

General Precautions and Contraindications for EA

• Profound analgesia induced by EA puts patient at risk of self injury, therefore the patient must be advised or restricted from strenuous physical activity after treatment.
• Contraindicated in left chest region for patients with cardiac pacemakers, or for areas with imbedded neural stimulators and other electrical devices.
• Not to be used on lower abdomen in pregnant women.
• High frequency or high amplitude application may induce stress, which is contraindicated in cases of hypertension.
• High amplitude EA that causes muscle fiber recruitment (twitching) can irritate or re-injure acute local strains and sprains.
• EA can sedate older or fatigued patients, causing drowsiness after treatment; hence some patients should arrange for others to drive them home after an EA treatment.

Treatment Guidelines

Acupuncture and electroacupuncture therapy have been utilized to treat a broad spectrum of illnesses and injuries, and have proven particularly effective at treating anatomically localized neuromusculoskeletal (NMS) injuries caused by repetitive stress or trauma. The anatomical NMS injuries that are most typically treated by acupuncture and electroacupuncture are due to trauma, sports injuries, auto accidents, and work-related repetitive stress injuries of the tendon, ligament, and bursa, and injuries in and around joint areas and the soft tissues (muscles, ligaments, etc) surrounding the spine. Acupuncture and electroacupuncture are also commonly used to treat chronic or post-operative pain, headaches, nausea, menstrual-related pain, and other conditions that may be anatomically, neurologically, or physiologically based.

Severity and Duration of Conditions

Conditions of illness and injury are generally classified into three or more categories, depending upon severity and duration. The commonly used descriptions of the stages of illness and injuries are acute, sub-acute, chronic, and recurrent.

• Acute - Having rapid onset, relatively brief duration, and severe symptoms; which have duration within four weeks of onset.
• Sub-Acute - Somewhat less than acute in severity, intermediate in character between acute and chronic symptoms within three months duration from onset of symptoms.
• Chronic - Injury of long duration and/or frequent recurrence of longer than three months duration.
• Recurrent/Flare-Up - Return of symptoms of original injury at intervals or as a result of aggravating factors.

Treatment Frequency and Duration

The effects of acupuncture are generally cumulative. Acupuncture initiates physiologic tissue restorative and regenerative mechanisms. (See Physiological Mechanisms of Action in the original guideline document.) Frequency and duration of treatment are based on several factors including severity of condition, chronicity (duration of condition), previous episodes, pre-existing conditions, and other complicating factors. Such complicating factors present inherent difficulties in recovery, therefore, extra time and treatment is appropriate in order to observe a therapeutic response. The therapeutic effects of treatment should be assessed by subjective and objective assessments after each course of treatment. (See Measurable Outcomes in the original guideline document.)

Normally an initial course of treatment consists of 12 to 18 treatments over a 4 to 6 week period, depending on complicating factors. For acute conditions, fewer treatments may be necessary to observe a therapeutic effect and to obtain complete recovery. For chronic conditions, and conditions with complicating factors, extended treatment is recommended to observe response to treatment. As in most types of therapy, the earlier the patient receives treatment, the greater the probability of recovery, and the shorter the time to recovery.

Acupuncture is commonly utilized in chronic conditions because of effectiveness in pain management and limited treatment options. However, it should be noted that acupuncture and electroacupuncture can lead to complete recovery in many NMS conditions when it is offered in the acute and sub-acute stages of injury, particularly when used in conjunction with other therapeutic interventions, such as range of motion (ROM) and strengthening exercises and manual manipulation of the soft tissue.

Acupuncture or electroacupuncture are rarely performed as a single treatment, but are usually prescribed and performed as a series, or "course of treatments." Thus, treatment planning requires a recommendation for the number, frequency, and duration of treatments that is appropriately based upon the nature and extent of the injuries and the prognosis for a progressive and timely recovery from those injuries. Severe injuries, multiple injuries, metabolic disorders, and other complicating factors may require more frequent treatments over a longer duration of time. For example, while some multiple injuries can be treated simultaneously, others must be treated independently and sequentially, requiring increased treatment frequency.

The following recommendations for the frequency and duration of treatment are based upon moderate to severe injuries in an otherwise healthy patient. Individual case recommendations should be scaled accordingly.

• Acute - 3 treatments per week, decreasing frequency as symptoms resolve and are reduced.
• Sub-Acute - 3 treatments per week for up to four weeks. 2 treatments per week thereafter. This is also the time when a rehabilitation exercise program is usually introduced.
• Chronic - 2 to 3 treatments per week for up to eight weeks as an initial course of treatment, and 1 to 2 treatment per week thereafter.
• Recurrent/Flare-Up - 8 to 12 visits as needed over a 2 month period

Initial Course of Treatments

Frequency and Duration for Initial (Trial) Course of Treatments

Stage of Condition	Frequency	Duration	Re-eval‎uate after:
Acute	3x weekly	4 weeks	12 treatments
Sub-Acute	3x weekly	4 weeks	12 treatments
Chronic	2 to 3x weekly	6 to 8 weeks	12 treatments
Recurrent/Flare-up	2 to 3x weekly	4 to 8 weeks	12 treatments

A detailed or focused re-eval‎uation designed to determine the patient's progress and response to treatment should be conducted at the end of each course of treatment. Additionally, a brief assessment of the patients response to each treatment should be noted after each treatment is completed, and again before the next one is started, and recorded in progress notes (e.g., SOAP notes). When a patient's condition is not responding to treatment for a period of 2 to 3 weeks, a more thorough re-eval‎uation should be conducted immediately to determine if the condition is different or more serious than the initial diagnosis had indicated and/or whether the condition requires further diagnostic testing and/or referral to other diagnostic or treatment specialists.

Re-Eval‎uation and Re-examination

After an initial course of treatment has been concluded, the detailed or focused re-eval‎uation should determine whether the objectives of the initial treatment plan have been fulfilled, and the extent to which they have been fulfilled by the documentation of subjective and objective assessments. A determination and recommendation must be made as to whether an additional course of treatment would continue to contribute to the patient's recovery or not. In general, if the patient is showing improvement in subjective and objective assessments from the previous eval‎uation, then continued therapy is indicated. (See Measurable Outcomes in the original guideline document). Additionally, if the goals of the treatment are reached, and there is documentation of subjective and objective outcomes in the patient's condition, it is appropriate to continue the therapy. (See Outcome Expectations in the original guideline document). If not, the patient should be referred for an alternative treatment or re-eval‎uation by a specialist after showing no response to the initial course of treatment.

Course of Continuing Treatments

Follow-up courses of treatment may be similar in frequency and duration to the initial course of treatment. However, one of the goals of any treatment plan should be to reduce the frequency of treatments to the point where maximum therapeutic benefit continues to be achieved while encouraging more active self-therapy, such as strengthening and range-of-motion (ROM) exercises, and rehabilitative exercises. The frequency of continued treatment generally depends upon the severity and duration of the condition; treatment benefits are generally stronger and last longer as a condition moves from acute towards complete resolution and as the patient takes a more active role in his or her recovery.

Frequency and Duration for Continuing Courses of Treatments

Stage of Condition	Frequency	Duration	Re-eval‎uate after:
Acute	2 to 3x weekly	4 weeks	12 treatments
Sub-Acute	2 to 3x weekly	4 weeks	12 treatments
Chronic	1 to 2x weekly	6 to 8 weeks	12 treatments
Recurrent/Flare-up	1 to 2x weekly	4 to 8 weeks	12 treatments

When the patient's condition stabilizes, or no longer shows improvement from the therapy, a decision must be made on whether to continue treatment in order to stabilize and maintain the patient's progress, or to discontinue therapy. In some cases of chronic pain, it may be appropriate to utilize acupuncture for pain management, for example, for patients who have adverse reactions to pain medications or when the prescribed pain medications are not sufficient to manage the patient's chronic pain. This decision is based on a number of factors, including the potential benefit of the therapy and the potential risks involved in that therapy.

Duration and Frequency for Courses of Treatments for Neuromusculoskeletal Conditions

Stage of Condition	Initial Course		Follow-up Course(s)		Re-eval‎uate after:
	Frequency	Duration	Frequency	Duration
Acute	3x weekly	4 weeks	2 to 3x weekly	4 weeks	12 treatments
Sub-Acute	3x weekly	4 weeks	2 to 3x weekly	4 weeks	12 treatments
Chronic	2 to 3x weekly	6 to 8 weeks	1 to 2x weekly	6 to 8 weeks	12 treatments
Recurrent/Flare-up	2 to 3x weekly	4 to 8 weeks	1 to 2x weekly	4 to 8 weeks	12 treatments

Patient Health and Safety

Identification and diagnosis of a condition/disorder is substantiated through historical data related to the chief complaint, onset of the condition, type of symptoms and their character, and previous history related to the condition. In addition, findings from the physical examination assist in defining the severity of involvement and the specific diagnosis.

In order to protect the health and safety of patients, quality of care strategies for reducing clinical errors and improving patient safety should be observed. These strategies include encouraging practitioners to adopt evidence-based health care approaches to patient care, maintain their clinical skills at or above broadly accepted professional standards of care, and follow applicable case management guidelines.

Evidence based healthcare, provided by properly trained providers, is one of the most conservative, least invasive, and safest types of health care. This being said, it is important to note that all forms of treatment carry some risk of harm to the patient and acupuncture and electroacupuncture are no exception. Therefore, implementing basic risk management procedures that recognize, avoid, and manage actual or alleged adverse outcomes, can help clinicians minimize the risk of harm or injury to patients.

Improving Patient Health and Safety

The following goals are useful in improving patient health and safety:

1. Identify types and causes of adverse outcomes
2. Educate oneself regarding patient safety standards
3. Decrease the incidence of adverse events through the identification of preventable events and risk factors
4. Facilitate the reporting of adverse outcomes
5. Support or participate in studies to improve patient safety-related clinical outcomes

Cautions and Contraindications

Besides conditions for which acupuncture and electroacupuncture may not be appropriate or medically necessary, there are also certain clinical situations where acupuncture or electroacupuncture are contraindicated, or where a patient's condition must be co-managed by multiple healthcare specialists.

Conditions Contraindicating Acupuncture:

Acupuncture is contraindicated in patients or areas of the body when certain complicating conditions are present, such as:

• Open wound or burn
• Prolonged bleeding time/hemophilia
• Artificial joint implants
• Pacemaker

Conditions Requiring Co-management

Acupuncture should only be used as an adjunct to another form of standard medical intervention, under co-managed care with other health care personnel for certain conditions, such as:

• Cancer pain
• Chemotherapy-induced nausea
• Post-operative surgical pain
• Multiple sclerosis related pain
• Labor inducement for pregnancy

Conditions Requiring Referral

Patients should be referred to another specialty health care practitioner or to emergency care in certain instances, such as:

• The patient's condition is not responding to the treatment rendered.
• The patient's condition is worsening with treatment.
• The patient has an unmanaged progressive infectious condition.
• The patient experiences a medical emergency (e.g., heart attack, laceration, pneumothorax).
• A broken needle requires surgical removal.

Conditions Requiring Special Care

Conditions for which acupuncture may be contraindicated, or must be modified, due to individual circumstances:

• Pregnancy (avoid strong stimulation of acupoints LI 4, Sp 6, UB 60, UB 67, except to induce labor; avoid low back and abdominal points during last trimester)

Informed Consent

The provider of the medical procedure should explain the procedure in writing and verbally, including potential benefits and risks. The patient must be given the opportunity to ask questions and the medical provider should discuss treatment alternatives.

Head and Neck

1. Head

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of head conditions:

   Tension Headache
   Migraine Headache
   Cluster Headache
   Sinus Headache
   Hypertensive Headache
   Cervicogenic Headache
   Head Trauma
   Temporomandibular Dysfunction
   Facial Pain

   Quality of Evidence: Level I

   Recommendation Grade: Grade A

   (References supporting the recommendation: Vickers et al., 2004; Allais et al., 2002; Liguori et al., 2000; Wonderling et al., 2004; Xue et al., 2004; Ahonen et al., 1983; Allais et al., 2003; Hansen & Hansen, 1985; Karakurum et al., 2001; Karst et al., 2001; Ghoname, Craig, & White, 1999; British Medical Association Board of Science & Education, 2000; Kaptchuk, 2002; "Acupuncture," 1997; World Health Organization (WHO), 1999)

2. Neck

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of neck conditions:

   Injuries to the Cervical Spine
   Cervical Strain and Whiplash
   Cervical Radiculopathy
   Cervical Stenosis and Spondylosis
   Herniated Cervical Disc
   Torticolis
   Unspecified Neck Pain
   Cervical Arthritis
   Degenerative Disc Disease
   Muscle Spasm

   Quality of Evidence: Level I

   Recommendation Grade: Grade A

   (References supporting the recommendation: Birch & Jamison, 1998; He et al., 2004; Irnich et al., 2001; Irnich et al., 2002; Coan, Wong, & Coan, 1980; David et al., 1998; Konig et al., 2003; Loy, 1983; Nabeta & Kawakita, 2002; Petrie & Langley, 1983; Sator-Katzenschlager et al., 2003; Yue, 1978; Zhu & Polus, 2002; British Medical Association Board of Science & Education, 2000; "Acupuncture," 1997; WHO, 1999; Kaptchuk, 2002; Ernst, 1999; Linde et al., 2001).

Upper Extremity

1. Shoulder

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of shoulder conditions:

   Injuries to the Shoulder – General
   Acromioclavicular Joint
   Separation/Compression
   Rotator Cuff Tear
   Biceps Tendon Injury
   Adhesive Capsulitis (Frozen Shoulder)
   Shoulder Tendinitis/Bursitis
   Thoracic Outlet Syndrome
   Muscle Spasm

   Quality of Evidence: Level II

   Recommendation Grade: Grade A

   (References supporting the recommendation: Sun et al., 2001; Kleinhenz et al., 1999; Dyson-Hudson et al., 2001; Kaptchuk, 2002; "Acupuncture," 1997; WHO, 1999)

2. Elbow

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of elbow conditions:

   Lateral Epicondylitis
   Medial Epicondylitis
   Olecranon Bursitis
   Ulnar Neuritis

   In general, the application of acupuncture is recommended in the first 4 weeks of treatment as a part of an overall, initial, conservative, treatment plan. Specifically 3 to 6 acupuncture treatments over 7 to 21 days are listed as one Official Disability Guideline "Return-To-Work Pathway" for lateral epicondylitis (Work Loss Data Institute, 2003).

   Quality of Evidence: Level I

   Recommendation Grade: Grade A

   (References supporting the recommendation: Trinh et al., 2004; Fink et al., "Acupuncture," 2002; Fink et al., "Chronic epicondylitis," 2002; Tsui & Leung, 2002; Brattberg, 1983; British Medical Association Board of Science & Education, 2000; WHO, 1999)

3. Forearm, Hand and Wrist

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of forearm, hand, and wrist conditions:

   Forearm Sprain/Strain
   Carpal Tunnel Syndrome
   DeQuervains Syndrome
   Trigger Finger
   Wrist/Finger Sprain/Strain
   Tendinitis of Forearm/Wrist
   Arthritis

   Quality of Evidence: Level II

   Recommendation Grade: Grade B

   (References supporting the recommendation: Kaptchuk, 2002; "Acupuncture," 1997; WHO, 1999; Naeser et al., 2002)

Torso and Low Back

The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of thorax and low back conditions:

Thoracolumbar Area

Injuries to the Costals
Low Back Sprain/Strain
Lumbar Facet Syndrome
Lumbar Disc Herniation
Sciatic Neuralgia
Sacroiliac Sprain/Strain
Spondylolisthesis
Spondylosis
Muscle Spasms
Lumbar Radiculopathy
Degenerative Disc Disease

Quality of Evidence: Level I

Recommendation Grade: Grade A

(References supporting the recommendation: Carlsson & Sjolund, 2001; Meng et al. 2003; Molsberger et al. 2002; Ceccherelli et al. 2002; Lehmann et al. 1986; Leibing et al. 2002; Thomas & Lundberg 1994; Tsukayama et al. 2002; Wang & Tronnier, 2000; Yeung, Leung, & Chow, 2003; Coan et al. 1980; Grant et al., 1999; Kerr, Walsh, & Baxter, 2003; Kvorning et al. 2004; Leung, 1973; Mendelson et al., 1983; Sator-Katzenschlager et al. 2004; Condon et al., 2002; Ernst & White, 1998; Ghoname et al., "Percutaneous electrical nerve," 1999; Ghoname et al., "Acupuncture & sciatica," 1999; Ghoname et al, "The effect of stimulus," 1999; Guerreiro et al., 2004; Hamza et al. 1999; Ernst & White, 1998; Tait, Brooks, & Harstall, 2002; Kaptchuk, 2002; "Acupuncture," 1997; WHO, 1999; Linde et al., 2001)

Lower Extremity

1. Hip and Thigh

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of hip and thigh conditions:

   Osteoarthritis
   Muscle Spasm
   Tendinitis/Bursitis
   Piriformis Syndrome
   Capsulitis
   Avascular Necrosis
   Post-Operative Fractures & Hip Replacements

   Quality of Evidence: Level II

   Recommendation Grade: Grade A

   (References supporting the recommendation: Fink, Wipperman, & Gehrke, 2001; Haslam, 2001; Stener-Victorin, Kruse-Smidje, & Jung, 2004; "Acupuncture," 1997; WHO, 1999)

2. Knee

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of knee conditions:

   Osteoarthritis
   Tendinitis
   Ligament Injuries
   Meniscus Injuries
   Patellofemoral Pain
   Post-Operative Pain
   Bakers Cyst

   Quality of Evidence: Level I

   Recommendation Grade: Grade A

   (References supporting the recommendation: Berman et al. 1999; Tukmachi et al. 2004; Jensen et al., 1999; Ng, Leung, & Poon, 2003; Vas, Perea-Milla, & Mendez, 2004; Naslund et al., 2002; Singh et al., 2001; Ezzo et al., 2001; "Acupuncture," 1997; WHO, 1999)

3. Ankle and Foot

   The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of ankle and foot conditions:

   Ankle Sprain
   Achilles Tendinitis
   Plantar Fascitis
   Tarsal Tunnel Syndrome
   Diabetic Neuropathy
   Reflex Sympathetic Dystrophy
   Osteoarthritis
   Post-Operative Pain

   Quality of Evidence: Level IV

   Recommendation Grade: Grade B

   (References supporting the recommendation: Hamza et al., 2000; "Acupuncture," 1997; WHO, 1999)

14. Chronic and Postoperative Pain

    The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of chronic and postoperative pain conditions:

    "Acupuncture, in combination with pharmacological interventions, may lower the need for medication and reduce the risk for side effects from these drugs (NIH, 2001)."

    "Acupuncture may reduce nausea and vomiting if used in early postoperative period ("Acupuncture," 1997)."

    Quality of Evidence: Level II

    Recommendation Grade: Grade A

    (References supporting the recommendation: Martelete & Fiori, 1985; Ghia et al., 1976; Junnila, 1987; WHO, 1999; Eshkevari, 2003; Tait, Brooks, & Harstall, 2002; Kaptchuk, 2002; "Acupuncture," 1997; WHO, 1999)

15. Systemic and Non-Regional Conditions
    1. Fibromyalgia

       The use of acupuncture and electroacupuncture is appropriate for, but not limited to, the following types of systemic and non-regional conditions:

       Fibromyalgia

       Quality of Evidence: Level II

       Recommendation Grade: Grade A

       (References supporting the recommendation: Berman et al, 1999; Deluze et al. 1992; British Medical Association Board of Science & Education, 2000; Tait, Brooks, & Harstall, 2002; Kaptchuk, 2002; "Acupuncture," 1997; WHO, 1999)

Definitions:

1. Quality of Evidence
   1. Multiple well-designed, randomized controlled trials, directly relevant to the recommendation, yielded a consistent pattern of findings.
   2. Evidence was obtained from at least one properly well-designed randomized controlled trial (RCT).
   3. Evidence was obtained from well-designed controlled trials without randomization.
   4. Evidence consisted of the opinions of respected authorities, based on clinical experience, descriptive studies in case reports, or reports of expert committees.

2. Recommendation Grades
   1. A strong recommendation, based on an eval‎uation of the available evidence and general consensus of the expert panel, that acupuncture and electroacupuncture treatment is effective, always acceptable, and indicated
   2. A recommendation that was based on an eval‎uation of the available evidence and general consensus of the expert panel that acupuncture and electroacupuncture treatment should be considered acceptable, effective, and indicated.
   3. A recommendation that is not well established by evidence, or for which there is conflicting evidence regarding usefulness or efficacy, but which the expert panel has determined that acupuncture and electroacupuncture treatment may be acceptable, effective, and indicated.
   4. A recommendation, based on evidence or general agreement, that acupuncture and electroacupuncture treatment may be considered not useful or effective.
   5. A strong recommendation, based on evidence or general agreement, that a given procedure or treatment is not useful or effective, or in some cases may be harmful, and should be excluded from consideration.