Abstract
Sandro Graca, MSc, Lic TCM, FABORM
Claudia Citkovitz, PhD, LAc
—John Weeks, Contributing Editor, Special Projects and Collaborations, JICM (
By volume, acupuncture research is currently at a high-water mark. Over the past two decades, the number of randomized controlled trials of acupuncture has grown at a twofold higher rate than biomedicine overall, as has the number of publications in higher impact factor journals. 1 Over that same period, guidelines for reporting of interventions within clinical trials of acupuncture have meaningfully improved the reporting quality of journals that endorse them. 2 Consistent with the stronger evidence basis, Birch et al 3 found a total of 1311 publications between 1991 and 2017 with recommendations for the use of acupuncture made by government health institutions, national guideline panels, and medical specialty groups, largely in North America, Europe, and Australasia. 3
Nonetheless, a recent high impact overview of acupuncture research by Lu et al 4 found that, despite this rapid increase in the evidence base, both “clinical practice and health policy underuse beneficial acupuncture therapies for which rigorous systematic reviews have documented high or moderate certainty evidence.” 4 Birch et al also reaffirmed a previous finding that recommendations for use of acupuncture are not well known or widely implemented, either by acupuncture practitioners or within mainstream medical systems. 3,5
Economic and cultural barriers to mainstream integration of acupuncture therapies are considerable; a growing body of acupuncture implementation research explores these challenges and possible solutions. 6 Here the dissemination of acupuncture research to practitioners is discussed, along with several recent developments that, in the authors' opinion, may narrow the procedural, educational, and communicative gaps found to undermine interest in evidence-informed practice (EIP) among acupuncturists.
Recent studies of practitioner attitudes to research in Australia and New Zealand reaffirm previous findings from the early 2000s: practitioners surveyed do not generally perceive acupuncture research as relevant to their clinical work, and thus are not using it to inform their practice. The reason most commonly cited for this perception is that clinical trials do not reflect the personal, relational spirit at the core of their clinical practice. 7 –12 This practitioner sentiment is not unique to acupuncture: substantive biomedical literature addresses discrepancies between research-based guidelines and real-life medical care of individual patients, with proposed solutions including use of observational, naturalistic, and whole-person, patient-centered study designs alongside conventional efficacy research. 13 –16
These and other methods to improve external validity in clinical research, such as manualization 17,18 and pragmatic designs, 19 –21 have been proposed and used by acupuncture practitioner-researchers over the past two decades. Nevertheless, efficacy research prioritizing internal validity remains a critical element of clinical knowledge construction for many funders and institutional consumers of research. This impasse between acupuncture research and practice is longstanding and well documented. 17,22 –24 However it may be shifting, at least in some regions, as in recent years a number of independent initiatives have sought to promote acupuncturists' understanding of, and fluency in, EIP.
Acupuncture Research Dissemination: Advocacy Initiative for Literacy
Acupuncture Research Dissemination: Advocacy Initiative for Literacy is a 1-year research dissemination initiative funded by the David and Lura Lovell Foundation. This survey project grew out of a stakeholder panel held at the 2019 meeting of the Society for Acupuncture Research (SAR) in conjunction with the Patient-Centered Outcomes Research Institute (PCORI). Its purpose was to provide research literacy training to acupuncturists and disseminate acupuncture research to acupuncturists to encourage access to and utilization of research and evidence. Seventy-two industry leaders were recruited to assist in survey development and dissemination.
An introduction and 15-question data collection instrument were deployed to members and affiliates of American acupuncture societies to assess research literacy skills. Baseline results informed development of a 90-min research literacy education module and supplements that will be deployed to the group over 12 months. The group also received free scholarly content alerts from medical acupuncture. The 15-question survey will be redeployed at the end of the project to assess impact.
Evidence Based Acupuncture
Evidence Based Acupuncture (EBA) is a nonprofit organization founded by Dr. Bartosz Chmielnicki MD, with the core principle of using the language of science to highlight the state of knowledge about acupuncture and communicate effectively with the public, other clinicians, and health care policymakers. 25 Current EBA directorship remains focused on synthesizing evidence through producing evidence summaries, educating acupuncturists in research literacy using educational videos, and dissemination using plain language in stylish sharable format on social media platforms.
EBA helps acupuncturists to describe the use of acupuncture for specific conditions using research information 26 and, crucially, to negotiate prohibitions established in some regions against making therapeutic claims when advertising their services. 27,28 The goal is to increase the general public outreach and address the question “the research is out there, but who is reading it?”
The SAR Webinar Series
The SAR Webinar Series began in late 2020 as it became clear that the COVID-19 pandemic would disrupt in-person meetings. Subsequent practitioner surveys have reported that online education is a preferred source of continuing professional education. 11,12 The series includes free livestream events, and also paid on-demand webinars that carry continuing education credit for acupuncture practitioners certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM).
Upcoming livestream events feature the “Styles of Acupuncture” series, curated by Dr. Ari Moré, in which experts discuss styles of acupuncture commonly practiced in Western clinics and the epistemic approaches taken to studying them with conventional research methods. Continuing education webinars for practitioners use lectures, guided reading, and specific discussions to introduce key topics to practitioners, including new research in interception and the relationship of complex adaptive systems science to acupuncture research and practice.
The SAR Model Curriculum for Acupuncture Research
The SAR Model Curriculum for acupuncture research grew out of a preconference seminar at the 2019 SAR conference. Fourteen members from East Asian medicine (EAM) schools across the United States and Brazil collaboratively contributed to a draft model curriculum that was then circulated to subject matter experts and stakeholders for further comment.
The goals of the new curriculum are to (1) present the basic/translational science to inform the mechanisms of acupuncture, (2) discuss the strengths/limitations of clinical research using the framework of evidence-based medicine, (3) teach students to effectively communicate the mechanisms and clinical evidence of acupuncture to patients and other health care providers, and (4) provide an experiential component to give students a sense of research activities.
Importantly, development of the SAR Model Curriculum was preceded by a change in acupuncture degree programs in the United States: a new professional doctorate degree was phased in between 2013 and 2018, whose standards and criteria for accreditation include evidence-based medicine/EIP, as well as patient care systems and collaborative care. 29 As the new degree increasingly replaces or supplements the master's degree, the professional and cultural impact of widespread systematic instruction in EIP may be considerable.
It will be observed that the four initiatives already described approach the research–practice gap by helping practitioners of acupuncture and EAM to achieve fluency in the language of research and EIP. By understanding and speaking this lingua franca of contemporary medical care, acupuncturists open new possibilities for interprofessional collaboration as well as patient care. The ramifications of clear and uniform acupuncture language and terminology extend beyond benefits for the therapeutic relationship 30,31 and will consequently have implications for implementation 32,33 and acupuncture research 31,32 as a result of bridging the communication gap between practitioners, researchers, and policymakers.
Reciprocally, acupuncture clinicians can then use those skills to relay back knowledge from their clinical expertise to inform future design trial toward “practice-informed research.” Basic research now shows that a single needling encounter comprises multiple active principles based on widely divergent conceptual models, any of which would have strained scientific credibility until experimentally demonstrated. (These include somato-vagal-adrenal reflexes, 34 mechanical signaling through fascial tissue, 35 enhanced neuroplasticity, 36 and patient–practitioner brain-to-brain concordance. 37 )
Careful efficacy research has begun to substantiate the clinical impact of these mechanisms individually. 38 However, it is difficult to envision a pathway from bench to bedside that meaningfully integrates them, without iterative feedback from acupuncture practice as to how they are implemented, separately or in combination, in the clinic. Such research has been undertaken in the field of contemplative neuroscience, a comparable field where biomedical research methods are used to study clinical effects of a non-Western discipline that has self-identified as a science since before the European Renaissance.
A widely cited 2015 article by Dahl et al 39 proposes a preliminary taxonomy of cognitive mechanisms in meditation practice, “crosswalking” historically established categories with best available evidence regarding their underlying neural mechanisms; the framework has since been used in the validation of multiple psychometric scales for use in assessing specific effects of individual meditation practices 37,40,41 (rather than nonspecific effects of mindfulness generally).
In effect, this integrated taxonomy has broadened the bandwidth of communication between research and practice by creating a transparent protocol for the simultaneous application of both biomedical and historical/cultural epistemologies in a single research question, rather than enforcing a cultural hierarchy. A critical question for acupuncture research is whether a similar epistemic protocol can be constructed, allowing for the transparent and scientifically rigorous juxtaposition of biomedical and clinical epistemic categories. Below are described three projects in which this kind of work is underway.
The National Institute for Complementary Medicine Acupuncture Network Scale
The National Institute for Complementary Medicine Acupuncture Network (NICMAN) scale was designed to be used in conjunction with STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines. 42,43 The NICMAN scale extends the STRICTA checklist and highlights the relevance of incorporating differential diagnosis, justifying point selection and the minimum number of treatments required, as well as disclosing the qualifications of the practitioner performing the intervention. 43
Including the NICMAN scale in the quality analysis of acupuncture interventions puts the spotlight on pragmatic aspects of clinical practice and can further increase the quality of reporting already noticeable through the use of STRICTA guidelines. 2,44 In time, this can have a positive impact in addressing concerns of acupuncture trial design misalignment with methods practiced in the community.
Convergent Points: An East–West Case Report Journal
Convergent Points: An East–West Case Report Journal is a new online open access peer-reviewed publication founded in 2021 and dedicated to describing practices and outcomes within acupuncture and EAM. 45 The journal aims to inspire practitioners to collect data accurately reflecting the scope of acupuncture and EAM, as well as social and environmental factors affecting patients' health. It provides a platform for leaders and emerging scholars to share knowledge and experience, and creates a library and database for high-quality scientifically rigorous case reports. It is hoped such database can help generate more complex analyses in the future.
ACU-Track
ACU-Track is a new subscription-based research organization providing web-based infrastructure for individual and organizational collection and analysis of patient data using validated outcome measures. 46 They are currently developing a large-scale observational study of acupuncture usage for symptoms of long COVID.
Conclusion
These initiatives are modest, but they may be significant leading indicators of progress in a longstanding deadlock. The timing is crucial, given the opportunity presented by the National Center for Complementary and Integrative Health strategy to develop research methods for studying whole person health. 47,48 The initiatives presented here can help capturing the nature of acupuncture as a complex intervention incorporating more than just needling, 31,49,50 and reiterate how the holistic model of acupuncture treatment along with the therapeutic encounter has implications for both clinical practice and research design. 31,49
To continue the metaphor of data bandwidth in connecting bench and bedside, the first four initiatives increase practitioners' capability to “download” research results for application in clinical practice, whereas the latter three build capacity for “uploading.” Development of an integrative taxonomy of acupuncture's multiple mechanisms of effect could greatly increase capabilities for bidirectional communication between research and whole person care.