Why Acupuncture Is More Than Just Needling,and the Implications for Research

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When researchers are considering the evaluation of acupuncture, a key question is, what exactly does the acupuncture comprise? One could take the view that acupuncture, as the name suggests, is only about puncturing the skin with needles, based on a prescription of appropriate points. However, if acupuncture practitioners are involved in this question as to what comprises acupuncture, a different perspective is likely to emerge. For most acupuncturists, acupuncture is a complex multicomponent intervention that includes needling but incorporates additional components provided they are drawn from the same acupuncture-based theoretical framework that underlies the tradition. From this perspective, acupuncture is more than simply the insertion of needles at specified points.

From the literature, it is known that the practice of acupuncture comprises a range of non-needle-related components, including palpation, explanation of an East Asian medicine-based diagnosis, advice about lifestyle and self-care, eliciting the active involvement of the patient in their recovery, and supporting behavior change. Take for example advice to patients about self-care, a survey exploring practice characteristics in European countries and China found that dietary advice and advice about exercise was routinely provided by around 50% and 70% of acupuncture practitioners. ¹ Further evidence comes from a U.K. survey that found that lifestyle advice relevant to an acupuncture diagnosis was provided for 56% of patients for a range of conditions. ² It has been shown in a qualitative study that advice given by an acupuncturist is informed by, and relevant to, each patient's individual traditional acupuncture diagnosis. ³

When acupuncture involves multiple components, it can be described as a complex intervention. But where does one draw the line between advice that is part of the acupuncture and advice that is not. For example, advice could be generic, such as suggesting to an obese patient to lose weight or engage in more exercise. Or the advice could be driven by traditional acupuncture theory. In an article on designing randomized controlled trials of complex interventions, Hawe et al. focus on how to define interventions in such trials. ⁴ Drawing on their approach, it can be argued that what is specific to the intervention are components that are integral to treatment, driven by underlying theory, and designed to impact on outcome. By this definition, acupuncture-theory-related advice should be considered characteristic or specific to the intervention, whereas generic advice that is independent of theory with incidental effects can be described as nonspecific or contextual. ⁵ Likewise the therapeutic relationship can be considered both specific when, for example, explaining to a patient the relevance of the acupuncture diagnosis, as well as nonspecific and contextual, for example, providing background emotional support and empathy.

There are many implications for research. Appropriate methods are needed to evaluate the impact of components of acupuncture beyond needling. Explanatory trials are useful for identifying cause and effect, but they have a limited role in assessing acupuncture that also involves diagnosis-specific advice, as a placebo control for advice, for instance, is not feasible. More appropriate are pragmatic trials, which are particularly suited to complex interventions, and can model the delivery of acupuncture as it is routinely provided. An exemplar pragmatic trial is of acupuncture for chronic neck pain, which had a primary focus on evaluating clinical and cost-effectiveness. ⁶ By collecting additional data on advice it was possible to evaluate the impact of advice in a secondary analysis. ⁷ A key aspect of this study was the identification of the underlying theoretical frameworks used and the clear link between advice and these frameworks. Then the link between advice and its impact on changes made by patients was captured by assessing self-efficacy and pain. The authors found that improvements in self-efficacy in acupuncture patients were associated with reductions in neck pain over the longer term.

There are many other research challenges once the researcher considers the complexity of the actual practice of clinical acupuncturists. In what ways do touch and palpation engage the patient's senses and regulatory systems, bringing together mind and body simultaneously as a starting point in a treatment? What ways do practitioners use palpation to help make individualized treatment decisions? How best can practitioners describe the diagnosis/treatment to a particular patient—whether East Asian medical theory, Western biomedical language, or some combination? Can the imagery drawn from acupuncture theory be used to help patients perceive and feel their bodies differently and promote a shift toward balance? How best can diagnosis-specific advice about self-care be given? What factors help patients act on this advice? What aspects of the therapeutic relationship are important to improve the uptake of self-care? In an integrative or functional acupuncture practice, what are the distinctive features and to what extent do they relate to traditional acupuncture theories? There are more. Qualitative methods have a useful role to play when exploring these types of questions, as was illustrated by the study on different forms of communication between patient and practitioner in acupuncture consultations as documented by Evans et al. ³

To conclude, acupuncture as it is routinely practiced is a complex multicomponent intervention, which commonly incorporates more than just the needling process. Advice relevant to acupuncture theory can be an example of such a component that needs to be considered “specific” to the intervention. Aspects of the therapeutic relationship might also be considered specific, such as the explanations of the acupuncture diagnosis, and the ongoing support for acting on the relevant advice and self-care. There are wide-ranging implications for research. Pragmatic trials are particularly suited to evaluating the impact of complex interventions, and by collecting additional data on the non-needling components, and the extent to which they are driven by theory, secondary analysis can be used to explore whether there are clear associations between these non-needling components and clinical outcomes. Qualitative methods also have a useful and important role, and could begin to unpack the potential impact of non-needling components of acupuncture.