RESTRUCTURING AMERICAN ACUPUNCTURE PRACTICES
Four times each year, I receive an issue of the Journal of Traditional Chinese Medicine, and each issue has several acupuncture articles. The articles include clinical reports of acupuncture therapies given to patients in China. In virtually every report (see Appendix), acupuncture therapy is administered daily, for several days in a row, typically 5-10 days consecutively, followed by a short break of 1-3 days, and then another course of 5-10 days of therapy, as needed until the symptoms have been alleviated. In some cases, acupuncture is administered every other day rather than daily. I do not recall seeing any report where acupuncture is administered once per week (other than a follow-up to a successful treatment where acupuncture had previously been done every day or every other day). There are quite a few protocols where two sets of acupuncture points are chosen, with one set given one day, the next set the next day, and then continuing this alternating pattern. This is a means of addressing two sets of therapeutic concerns or two approaches to the same basic therapy without losing momentum in the treatment of either pattern. The alternating treatments also reduce the possibility of irritating the patient by repeating the same pattern each day.
By contrast, most American practitioners I have spoken with-many hundreds of such practitioners over the years-routinely recommend to their patients a schedule of once per week acupuncture. Further, they have become accustomed to having patients miss a weekly appointment here or there, so that a course of 10 acupuncture treatments can easily take 3 months, compared to 10-20 days in China. In many instances, the weekly acupuncture appears adequate to address the patient's needs. However, it is frequently reported to me that an acupuncture treatment helps the patient notably, but the apparent effects wear off in a day or two. If I point out the therapeutic method used in China, with daily acupuncture rather than weekly acupuncture, the response is uniformly that patients cannot afford to get acupuncture daily; additionally, daily or every-other-day acupuncture may be restricted by either the patients' or practitioners' schedules. As a result, the concept of weekly acupuncture has become entrenched here.
In a survey conducted among practitioners who applied for inclusion in ITM's Practitioner Reference Guide, it is clear that many, if not most, American acupuncturists work less than 5 days per week, may spend an hour during each standard patient visit (initial visits are typically longer), and may see fewer than 30 patients per week. Thus, even if patients had the time and money for daily or every other day acupuncture visits, the way practices are set up now, it would be almost impossible for them to schedule it. On average, with current schedules, a practitioner might be able to treat about 7 patients daily for four days per week, limiting the number of patients far too much.
In this proposal, I would first like to point out the reasons for promoting the use of daily (or nearly daily) acupuncture (at least for some patients), and then indicate how such a situation could be attained by practitioners who are willing to provide this kind of service. It is my proposal that by restructuring acupuncture practices, many patients could avail themselves of frequent acupuncture in an affordable manner. In making this proposal, I recognize that there are many styles of providing Chinese medical services, and many personal factors that a practitioner may face influencing what they can offer. However, I believe the model offered here needs to be elucidated so that practitioners can consider it as an option.
It has been reported to me informally that many acupuncture patients seen here (in the U.S.) will note an improvement in their condition after about 5-6 weekly acupuncture treatments. Further treatments may then be needed to gain the full effect of acupuncture. A course of 10-15 treatments in total is not unusual. Some patients opt for prolonged treatment over several months or even years, but for those attempting to address a particular health problem and then move on, such a course of therapy appears typical. This is not unlike the Chinese experience, in terms of number of treatments, in which patients are given a "course of therapy" that is typically 10 treatments, followed by another course if necessary. However, as pointed out above, the Chinese approach suggests that resolution of the disorder is then accomplished in 10-20 days, rather than 10-15 weeks.
The ideal frequency for acupuncture therapy (assuming both patients and practitioners have the option to adjust to it) depends on one's concept of the function of acupuncture therapy. Consider a few examples of other therapies. Would you, or specialists in their respective fields, recommend that a patient:
I think you will find it obvious that once per week doesn't work for any of these things. There are some cancer therapies that are given once per week, but they are severely toxic and long-lasting, and not comparable to the experience of natural therapies. But, diet, exercise, sleep, herbs, vitamins, and common drug therapies are more like acupuncture treatments in their regulatory and recuperative effects, and a person should be doing them daily or almost every day.
According to the theoretical underpinning of acupuncture therapy, the treatment adjusts the flow of qi and blood in the meridians, which then influences the functions of all the organs. What is it that prevents the organ system dysfunctions and imbalances and the blockages and irregularities in flow of qi and blood in the meridians from returning to their former unhealthy state? Two things: one is the natural process of healing that functions to restore and then maintain the body in a state of balance, and the other is the next application of acupuncture. At the beginning of a course of therapy, especially for a disorder that is severe or one that has been present for many months or years, it is unusual (not impossible) for a single treatment to trigger a complete healing, where the body once eased towards balance by the treatment simply keeps moving that way and rights itself thoroughly. Instead, the treatment produces a notable impact (not always on the first try) that typically reverts after a day or two. This reversion is a result of the continued presence of deficiencies and excesses, of severe blockages (such as blood stasis), of pathogens (such as chronic viruses), emotions, and unhealthy habits, to name a few. In other words, forces acting to counteract the therapeutic benefits remain active.
When a push towards balance and health is accomplished with one acupuncture treatment, to make real progress, it is best to give a second push in that direction before the first push has completely worn off, thus making a cumulative impact. If a person has a severe disease due to bacterial infection and one dose of ordinary antibiotic is given, the bacteria will be inhibited by that dose, but will then likely grow back if another dose is not given the next day. If one were to wait a week to administer the next dose, the infection can simply progress (especially if this is not a self-limiting type of infection). The dose given the next week, will again push back the bacteria, but it will continue its progress again after a couple of days without more antibiotic. In like manner, the pathology of the body can simply resume after a day or two without acupuncture. This doesn't happen all the time; even if symptoms revert after a couple of days, there may still be some internal momentum in the right direction, something that accumulates over several treatments, giving the observed benefit after 5-6 weekly sessions. No doubt, each patient is different in their responses, and some may, while others may not, be able to get a cumulative benefit over several once-per-week treatments. For those who do not, it may only be the low frequency of acupuncture that is the basis of failure, not the practice of acupuncture itself.
One of the roles of herb therapy for acupuncturists in the West who rely on once-per-week acupuncture is to prolong the effect of the treatment. That is, if the herbs can accomplish the same kind of push in the direction of health as the acupuncture treatment, then there can be continual progress by daily use of herbs. This approach is most viable in cases where acupuncture and herbs have a close correspondence in their therapeutic effects on underlying disorders and where the acupuncturist is well-trained in herb therapies.
However, in many cases, acupuncture and herb therapies differ sufficiently that-though they are both of benefit-they inadequately reinforce one another. Moreover, it is common for Western patients to utilize relatively low doses of the herbs, so that the impact is far less than that of the acupuncture treatment, and fails to be an adequate substitute. Therefore, some cases are not amenable to having herbs carry over the effect of acupuncture for a full week; in cases where weekly acupuncture seems appropriate, it is important to assure proper dosing of the herbs.
From the modern interpretation of acupuncture therapy, where it is understood to cause the release of various biochemicals (such as endorphins), the theoretical problem of applying acupuncture weekly remains the same. These biochemicals are released by the acupuncture treatment, they have their effects, but they are metabolized and gone soon after the acupuncture session and the effects wear off over the next several hours. In a sense, acupuncture (in this model) works like taking a complex drug of neurotransmitters and immune response modifiers, but taking the drug only once per week instead of daily.
It is my understanding that many acupuncturists, especially those fresh out of college, are surprised at the lack of effectiveness of acupuncture therapy for many patients. They then become susceptible to the claims of numerous proponents of alternative therapies (alternative to traditional Chinese medicine) that they are encouraged to practice in their clinics. It is easy for practitioners to hear the message that such therapies "work better" than acupuncture, and, in light of the apparent poor performance of acupuncture, they are willing to try all sorts of things, some of them without any basis outside of the informal claims of effectiveness. If practitioners were alerted to the potential need for frequent acupuncture, at least for some patients, then their view of what to offer and what results to expect from acupuncture might be shifted.
Imagine that you have a patient who comes to you for daily acupuncture (for sake of discussion, I will mean by this that they come in 3-5 days per week, not on the weekends). How much discussion do you need to have during each of the return visits?
I raise this question, because I've had a chance to listen in on many patient visits when the schedule of treatment is once per week. Several minutes are spent talking about how things went since the last treatment: what things improved or got worse, what stressful situations might explain the lack of progress, the downturn, the new symptoms, or the improvement. Having not visited for a week, the patient might like to tell you about their latest vacation plans, or other chit-chat, and you might well want to comply by relaying your own personal messages. After all, you don't want to seem to brusque about getting down to business after a week's break, especially when the business at hand is sticking needles into the person, then walking away and letting them sit quietly.
Often, a large part of those 45-60 minute return visits devolve into dealing with things other than administration of treatment. In fact, a significant portion of the discussion may well be taken up by the failings of not performing daily acupuncture and of not getting into a routine of treatment. The whole strategy of therapy that could be logically determined at the outset can be lost, because this week the patient is different from last week, with these new areas of focus and concern; thus, the changes have become the focus of attention. So, rather than having a consistent strategy of treatment, as would occur with daily acupuncture, an ad hoc therapy may be given each time. "Today, I want to work on...." Even more of the office visit time may be taken up when the patient misses a week and hasn't been by for two weeks.
With daily acupuncture, after the initial visit in which discussion of the medical situation and treatment method and strategy takes place, the practitioner can focus almost the full duration of the sessions on the administering the treatment itself. There is a plan and you are going to follow it, making only slight adjustments based on brief reports (of what happened only since yesterday or a day or two before, not during the prior week or two). There is less sense that one needs to spend time chatting in order to break the ice of the office visit, which becomes, instead, a routine visit. Since acupuncture therapy typically lasts for 20-30 minutes, that is about the length of a return visit, not 45-60 minutes or longer. It is possible to give two return daily visits in place of one prolonged hour for a weekly visit.
In the first several years when acupuncture became a recognized profession in the U.S. (basically from 1979-1990), most acupuncturists were not young people who grew up wanting to be a doctor, and decided on acupuncture as their medical specialty. Rather, the profession was populated almost exclusively by people who had other professions and decided to go into acupuncture as an alternative to what they were doing. The attraction may have been experience of an acupuncture treatment that was helpful, interest in Chinese culture, health problems unresolved my modern medicine, or discomfort with more standard professions. As such, practices were often not set up on the model of a medical profession. Medical doctors, for example, after many years of expensive and grueling studies at medical school usually work long hours, typically five or six days per week during their early years, and then this becomes routine. Acupuncturists frequently set up practices that reflected their place as a secondary profession that initially required only 2 years of part-time schooling (now 3 years), with work schedules of 2-4 days per week. They might see their offering of Chinese medicine, being such a unique field, as something that would draw certain people to seek them out, regardless of their location or limited work hours. Medical doctors are usually trained to think of themselves as offering a critical service for which they have to be available at almost any hour.
More recently, acupuncture has been established as a primary professional goal. A student graduating from college at the age of about 22 might go on to training in acupuncture immediately afterward and be a young practitioner who has decided to devote his or her life to providing this medical service. Yet, their teachers (whether at colleges or in seminars) are usually of the prior group, who may inadvertently convey a very different idea about the nature and potential of acupuncture as a medical profession.
If a practitioner truly believes that Chinese medicine offers medical solutions, and not just an interesting and pleasant experience, then it is reasonable for that practitioner to establish a practice in a manner that serves the public best. As with most medical facilities, easy access is a critical feature. Imagine calling your physician to deal with a serious health problem and being told that you can only see the doctor on Tuesdays or Thursdays. Already, due to heavy reliance on medicine, it can take too long to see a medical doctor for an extremely short visit, and that is with the doctors working long hours and long work weeks.
Setting up an office in a location where many people can gain easy access, and offering services five days a week (a typical work week for the American worker and for most medical professionals) indicates that a practitioner is offering a medical service and not just an interesting cultural experience. Easy access also means that people can come frequently if necessary. Ultimately, a large number of clinics serving many local communities will reduce the current difficulty with getting to a service provider. In addition, when acupuncture clinics can be established within a large modern medicine facility, patients who are getting other medical services can have easy referral and access to acupuncture as an adjunct therapy.
Here is a potential situation, assuming that patients could come for daily acupuncture:
a practitioner works just 35 hours per week (5 days, 7 hours per day);
allows for five new patients each week (at one hour per visit), and 10 other patient-visits for prolonged repeat treatments of an hour (perhaps for the second or third visits in a series);
40 patient-visits for return treatments of half an hour each week;
5 hours per week are reserved for paperwork and other maintenance activities during unfilled available treatment slots.
This sample schedule is minimalist by most standards of work in modern America, yet allows 50 return treatments in a week (40 at half an hour, 10 at an hour). That is a reasonably good practice. As mentioned earlier, many practitioners have only about 30 patients coming regularly, once per week.
If a patient gets treated once per week at a cost of $50 per treatment (with $75 the first visit), the cost for 10 treatments over a three month period is $525 (not including costs of herbs). If a patient, instead, came for a course of 10 treatments over three weeks (average of 3 treatments per week), and paid $60 for each of the first two treatments but $30 for the follow-up treatments, the cost would be $360. This is not only less cost, but, I would argue, potentially far more effective treatment, and more convenient for the patient, who visits for only half an hour during most of the treatments. Either the therapy is working or not by the end of 10 treatments and, if it is not, the patient can move on, instead of waiting three months to find out.
Practitioner income, on average, would be higher with this model of treatment than the current weekly method (though more hours worked). At the same time, the patient gets potentially more effective treatment and acupuncture gets a better reputation. Importantly, the practitioner gets more experience, and becomes a better practitioner of acupuncture.
Increasingly, practitioners of acupuncture work in group settings rather than in individual private practices. Currently, this occurs most often where the acupuncturist in an office with chiropractors and massage therapists, but not other acupuncturists. To effectively offer daily acupuncture, it would be important for at least two practitioners of acupuncture to work together, so that when one is off on vacation or out sick, the other can help cover critical cases for their daily acupuncture.
At this time, it is reported that there are more than 15,000 acupuncture licenses outstanding, though quite a few of the licenses are retained by people who are not actively practicing, or have very little activity in their practice (perhaps 10 treatments or less per week). In actuality, there are about 12,000 active practitioners, which is sufficient for 6,000 practices comprised of 2 practitioners each. That could provide coverage for most major cities in America, where acupuncture services can be applied to adjunct cancer therapy, HIV/AIDS, drug withdrawal, back pain and other pain syndromes, diabetes, hepatitis, and other diseases for which Chinese medicine has gained a good reputation. As the field grows in numbers of practitioners, the web of services across the country can expand.
Practitioners working together can offer services where a patient can be treated by two practitioners over a course of several days of therapy. This might occur, for example, as a means to assure that the patient can come at a convenient time every day; perhaps one practitioner is busy at a time and day that the patient has available; the other practitioner might provide the service at that time. When practitioners see patients once per week for an hour, the service becomes highly personalized. There is a significant requirement for having the practitioner's "bedside manner" mesh well with the patient. This is because, as outlined above, there is considerable time spent discussing what went on during the past week, rather than merely performing yet another treatment in a sequence. If daily acupuncture is offered, so long as the two practitioners have a similar needling style, they can offer their services as a package to the patient.
Many Americans, maybe most Americans, have very full schedules that make it difficult to add an office visit daily. Yet, just as Americans can arrange a vacation or other change in their daily schedule for a limited period of time, most people can arrange a two to three week period of incorporating into their schedule an acupuncture office visit. The key element of the proposal is that daily acupuncture is undertaken for a limited period of days or weeks, not over many weeks or months, as occurs with weekly acupuncture.
For many people, work schedules and childcare schedules dominate the availability of time for making such appointments. Some may be able to come before work, others after work, others during a lunch period. If two or more practitioners are available at a site (as discussed above), it may be possible to have availability of appointment times early and late and during traditional lunch hours, by having one practitioner start early and end early, and the other practitioner start late and end late. Employers may be able to let workers go at a specified time of day if the number of days that these absences occur is limited (e.g., 2-3 weeks).
Daily acupuncture may simply be too much to expect from most patients, but every other day acupuncture (Monday, Wednesday, Friday) is a reasonable next best situation that still avoids the problem of having to catch up each time from a prolonged absence. Twice-per-week acupuncture (e.g., Monday and Thursday or Tuesday and Friday) may be satisfactory for some patients, but doesn't match the method used in China today.
A clinic can set up a schedule to maximize opportunities for frequent acupuncture. For example, Monday, Wednesday, and Friday can be reserved almost exclusively for those who can manage three-times-per week acupuncture, daily acupuncture, or other frequent acupuncture treatments. Tuesdays and Thursdays may be ideal days to schedule new patient visits (that require longer time), for those who can only manage twice per week acupuncture, and for those patients who have already done their high frequency acupuncture and are now using weekly visits or for maintenance purposes.
Acupuncture in China is traced back more than 2,000 years. The historical documents that we use as a fundamental starting point, such as the Neijing that comes down to us today, are traced back to the Han Dynasty and have an approximate date of 100 A.D., just about 2,000 years ago.
Numerous records of acupuncture have been produced since that time. Prior to the modern era, there was little mention of the actual procedures involved in acupuncture. For example, there are very few references to duration of needling and frequency of treatments, with most attention paid to the point to be needled, the type of needle, and the specific stimulus (e.g., needle movement and depth, use of moxa or blood-drawing). The impression obtained from the literature is that acupuncture was mainly utilized to treat critical cases, where a single treatment or just a few consecutive treatments were administered in an effort to turn a disease from one that is worsening, and perhaps threatening death, to one that is improving. There are few, if any, references that clearly indicate a prolonged course of treatment by acupuncture.
Chinese medicine had suffered a significant decline at the end of the 19th Century and into the early 20th Century, for a number of reasons, including certain attractive features of Western medicine. However, after the revolution of 1949, Chinese medicine was given formal government backing in a desperate effort to bring health care to hundreds of millions of people who had access to virtually none. At the time of the revolution, traditional Chinese medicine was in disarray, and there were only a few thousand trained Western doctors. One attempt that was made-and ultimately failed-was to rapidly train a million secondary health care workers, the so-called barefoot doctors (indicating their peasant background). With a few months indoctrination, they learned the basics of "new acupuncture" (simplified acupuncture), limited herb prescribing, and use of a few key drugs. Insufficient medical knowledge and training given to too many people not well attuned to the personal requirements for offering medical assistance doomed the program.
The medical system that eventually emerged relied on construction and staffing of large colleges, hospitals, research centers, and other facilities to produce a massive city-centered health care system that provided both traditional Chinese medicine and Western medicine. It was within this system that the treatment of numerous diseases, including chronic illnesses, came to involve daily acupuncture. The medical treatments were either free or low cost, and involved daily visits to the hospital (or inpatient care on a daily basis). Workers could readily get time off from work for treatments, as there were too many workers on the job: maintaining full employment, not industry efficiency, was the goal of the central government. A prolonged absence was often needed to travel, by bicycle or bus, to the facility, wait in line to get treatment, stay through the treatment, and return home (or to work).
The hospitals and other clinics were staffed by large numbers of medical professionals and assistants, and it was common for acupuncture to be administered in large rooms with many patients, a dozen or more being treated at the same time in plain sight of each other. The doctors usually performed a cursory interview, and then either treated the patient directly or read off the acupoints to be treated by another medical worker. Assistants would help in stimulating needles, removing needles, and escorting patients in and out. The patient did not get a personal relationship with any one practitioner: they came in for the treatment and got it from whomever was on duty. It was in these settings that clinical data were accumulated and relayed in research reports that have informed practitioners in the West about the success of acupuncture.
Research reports were originally generated (and often still are) by simply compiling information from records of numerous patients over a period of years. Because many different doctors were treating patients, the lead doctors at the hospital would set out basic sets of points that were to be treated. This might include one set of points for the defined disease (or several sets for the disease, based on differential diagnosis, such as one point set for qi and yin deficiency, one set for qi stagnation), and then certain auxiliary points to be selected based on particular symptoms. Since certain point formulations were commonly used to treat individual diseases at a facility, one could retroactively go through the case reports and find, for example, about 100 patients who had a particular disease and were treated with a particular main set of points and a certain range of adjunctive points. Then a report would emerge about treating that disease with acupuncture, using a specific basic protocol, with so many patients having complete remission of symptoms, so many "markedly effective," so many somewhat effective, and so many ineffective. The same was done with herb prescribing, where there was a basic formula with certain modifications, and then a retroactive investigation of case reports. The impression gotten from cursory reading of the report might be that this was a research project set-up in advance to track patients when, in fact, it is merely a retrospective review of what was done. Western researchers and doctors remain skeptical of the claims made under these circumstances.
Still, for acupuncturists, evidence that the therapy has a positive outcome for certain syndromes may be based on these cumulative case reports, in which sets of acupuncture points were treated daily. Some Western studies have been conducted on acupuncture in recent years, but many of them have very limited applications, such as treating nausea or back pain or aiding withdrawal from drugs. By contrast, Chinese medical reports involve treatment of a wide range of cardiovascular diseases, cancers, autoimmune disorders, digestive system disorders, and infectious diseases. If one is to rely on the claims of success made in the Chinese medical journals, even if one assumes a certain exaggeration of benefits, one should rely on the method of treatment reported, which is frequent acupuncture.
It might be argued that the Chinese model in the post-revolution period leans too heavily towards treating Western defined diseases and using established point formulas, rather than holistically treating the person with individualized prescriptions. It may appear, then, that acupuncture in China is simply not appropriate for the American situation, where patients may seek a more fluid and holistic model. However, one can equally argue that acupuncture in America has been side-tracked into a very limited area, partly related to the use of weekly acupuncture.
In the collection of information from practitioners who sign up for ITM's Practitioner Reference Guide, questions are asked about areas of specialization. Remarkably, a huge proportion of practitioners have focused in on certain types of disorders, particularly chronic allergies, fibromyalgia, chronic fatigue syndrome, and various stress syndromes. Typically, these patients return repeatedly for their weekly visits, and display their ups and downs from week to week, giving the practitioner much to think about in terms of causation, treatment strategy, and recommendations to give. None of these are major subjects of the practice of Chinese medicine in China.
I would postulate that these ailments commonly seen at acupuncture clinics are ones that give the patient and practitioner plenty to mull over during a one hour appointment each week. They can contemplate how progress had been good until the food that causes reactions was consumed; how the symptoms were better on these days and worse on other days, and how it is postulated that certain events and substances contributed to the improvements and worsening. Rather than trying to make a complete turn-around in the disease condition by several days of consecutive acupuncture therapy, the process becomes long and drawn out. The patient is better over time, but still coming in with most of the same complaints (or a slightly different set).
The situation I am depicting here is one that establishes a significant limitation for acupuncture therapy. It takes it away from participation in the treatment of serious diseases and meanders into the realm of managing the distress of patients who have disorders that are largely outside the realm of modern medical treatment. For those patients who come for treatment of life-threatening and debilitating diseases, the services offered under the model currently prevalent may be inadequate.
Based on observations of how acupuncture therapy was administered in China, and a clinic that used a similar approach in Portland (now called PAHC, for Portland Acupuncture Health Center), ITM established the Immune Enhancement Program (IEP) in Portland. The features carried over are: the group clinic setting (less privacy than the one-on-one appointments in closed rooms), the treatment of patients by more than one practitioner, and the offer of acupuncture at a recommended frequency based on the disease condition rather than an automatic weekly appointment schedule. Thus, for example, cancer patients undergoing chemotherapy might come in 3-4 times per week to alleviate side effects and attempt to improve the therapeutic outcomes, while others who were in more stable condition might come in only once per week for maintenance purposes.
Costs are kept low, and a staff of 5 part-time acupuncturists provide an average of 110 treatments each week. Treatment times, half an hour each, are posted on a sign-up schedule, with new patient intakes utilizing two consecutive treatment time slots, for one hour total. At any given time, there are two practitioners working (for selected times, there are three practitioners working), for a total of about 65 hours per week of cumulative practitioner time. The schedule is typically about 85% filled; during scheduled time when there is not a patient to be treated, practitioners are encouraged to review patient charts and improve them, and to read relevant TCM information. Patients come to the clinic from the local neighborhood by walking or bicycling, and from more distant sites by car or bus. A non-medical staff member helps keep the clinic running smoothly. The clinic space itself is just 750 square feet, including bathroom, but some office space next door is used, so that a total of about 900 square feet is relied upon.
ITM operates another clinic (called An Hao Natural Health Care Center) that follows the more typical American model, where there are acupuncturists along with a chiropractor, massage therapist, and medical doctor. Most patients come once per week, and the cost of treatment is typical for private practices in the city. The facility is nearly 4 times the size of IEP and its operating costs are also far higher. Patients who require daily or near daily treatments are referred to IEP.
While both clinical models are functional and in demand, the IEP model is especially well suited to people with serious diseases requiring intensive treatment. The other, more standard clinic, is suitable for busy people who can only come in weekly who wish to rely on natural therapies as much as possible, but who plan to visit the clinic from time to time over an extended period, perhaps years, for health problems as they arise rather than rapidly resolving serious health problems. It is more suited to people who want to place their trust for long-term health care in an individual practitioner, and see them in a private setting. Having the IEP also available is a valuable service for situations where daily acupuncture is important.
The An Hao Clinic, while offering acupuncture as a routine service, tends to rely much more on other therapies overall. Of four practitioners who are licensed to provide acupuncture, one does not use acupuncture at all, and two others are additionally licensed as naturopathic physicians and rely heavily on therapies derived from that training. Only one practitioner is primarily serving an acupuncturist, maintaining a relatively small practice. It may well be said that the weekly acupuncture is being made up for by other therapies, such as naturopathy (which includes prescription of some modern drugs as well as numerous supplements), chiropractic, and massage therapy. So long as patients avail themselves of these multiple treatment methods, the lack of daily acupuncture may be compensated for, but if not, then the problems associated with infrequent use of acupuncture (as outlined in this article) remain.
Acupuncture performed once per week or less frequently has no known precedent in the long history of Chinese medicine, and, particularly, in the current practice of acupuncture in China. Less than ideal results may derive from delaying the subsequent treatments by such a long interval, and acupuncture sessions may become unfavorably molded by the fact that there is such a delay. For some patients, in place of resolving disorders, delayed administration of subsequent acupuncture therapies may lead to a prolonged course of treatment with modest outcomes, involving an expense as high or higher than a short-term set of consecutive treatments. Weekly acupuncture is a model that may have been established inadvertently, as the result of initial introduction of acupuncture as a secondary career choice, as opposed to being purposefully selected as the most appropriate treatment methodology.
Acupuncture sessions at high frequency (several times per week) can be accomplished without loss of income to the practitioner if the appropriate model for treatment is established. Ideal configuration includes locating the clinic at a site that is easily accessible, having more than one acupuncturist working at the site at any given time, having most treatment sessions last only half an hour, and adjusting treatment fees to fit this approach. Treatment protocols may be shared between two or more practitioners to assure that a patient has access to the treatment each visit at a convenient time.
A mix of acupuncture offerings, some focusing on weekly acupuncture, others on frequent acupuncture, would be suitable for most communities. This would reflect the diversity in the interests and personal approaches of different practitioners and the variety of requirements and expectations of potential patients. However, when a model of once per week acupuncture dominates a community, it may well set the standard for both patient and practitioner undertaking of this therapy, and thus, force acupuncture into a more limited and less successful role than it deserves.
Therefore, my proposal is to encourage acupuncture schools and seminar speakers to convey the theoretical and practical aspects of frequent acupuncture and, in turn, promote the use of this method as an option for graduating students to consider. Practitioners, especially those who are setting up a new practice, should take into consideration factors of location, access, sharing office space, scheduling, and practice promotion that provide for the option of frequent acupuncture. Patients should be made aware of the possibility that a short course of frequent acupuncture may be appropriate for their condition, and may provide faster relief at an overall lower cost than a prolonged course of therapy with low frequency of acupuncture. Students and practitioners of acupuncture should be taught the methods of integrating acupuncture and herb therapies effectively, both for those patients who will undertake a short course of frequent acupuncture and for those who will have infrequent acupuncture over a longer period.
Reports from the three most recent issues of the Journal of Traditional Chinese Medicine (as of the writing this article) involving acupuncture treatment strategies, in which treatment frequency was specifically stated or evident, are presented here in table form. In 9 of the 14 reports, acupuncture was administered daily, in the other 5, it was administered every other day. Most treatments involved at least 2 courses of therapy, sometimes 3-4 courses, and there was usually a break between courses (duration not always specified). Duration of needling was often specified, and did not exceed 30 minutes in these reports.
|Disorder (Reference)||Main Points Treated||Needling Duration||Treatment Frequency|
|Piriformis syndrome (1)||GB-30 (huantiao), GB-34 (yanglingquan), GB-39 (xuanzhong)||30 minutes; manipulation beginning, midpoint, end of treatment||Every day for 12 sessions is one course; 3-day break between courses.|
|Facial paralysis (2)||Set 1: LI-4 (hegu), LV-3 (taichong), GB-14 (yangbai), SI-18 (quanliao), TB-17 (yifeng), LI-20 (yingxiang) Set 2: GB-20 (fengchi), TB-5 (waiguan), GB-14 (yangbai), ST-6 (jiache), CV-24 (chengjiang), extra point qianzheng||20-30 minutes, manipulated beginning and then every 5 minutes (note some points are treated by penetrating from one acupoint to another)||Every day, alternating between set 1 and set 2, for 10 days; 3 days break between courses.|
|Sciatica (3)||BL-2 (zanzhu), GB-20 (fengchi)||30 minutes; stimulation at the beginning to get deqi and transmit sensation to shoulder||Every day for 10 days; interval of 2-3 days between courses.|
|Neuropathic incontinence (4)||BL-32 (ciliao), BL-35 (huiyang)||30 minutes; stimulate to get deqi and radiating sensation to vulva; apply electrostimulation||Every day for 5 days; interval of 2 days between courses.|
|Anxiety neurosis (5)||GV-20 (baihui), PC-6 (neiguan), GV-26 (renzhong), SP-6 (sanyinjiao); other points added, such as BL-44 (shentang)||not specified||Every day for 6 days; interval 1 day break, with 30 sessions as one course.|
|Insomnia (6)||GV-20 (baihui), GV-24 (shenting), extra (sishencong), HT-7 (shenmen), PC-6 (neiguan), CV-12 (zhongwan), ST-40 (fenglong), SP-4 (gongsun)||not specified||Every day for 10 days as a course.|
|Depressive syndrome (7)||GV-26 (renzhong), PC-6 (neiguan), LV-3 (taichong), HT-7 (shenmen)||not specified||Every day for 10 days as a course.|
|Gonitis (8)||SP-10 (xuehai), ST-34 (liangqu), extra (xiyan), ST-36 (zusanli), BL-40 (weizhong)||30 minutes; needle with moxa on needle; follow acupuncture with blood letting at BL-40||Every other day for 10 sessions as one course; interval of one week between courses.|
|Dysmenorrhea (9)||ear points: tingzhong, pizhixia, neifenmi, jiaogan, and neisheng zhiqi||not specified||Every other day, 4 treatments each menstrual cycle; 3 cycles is one course.|
|Obesity (10)||ST-25 (tianshu), ST-24 (huaroumen), ST-26 (wailing), CV-10 (xiawan), CV-5 (shimen)||30 minutes; manipulation to get deqi and, if possible, sense of contraction of abdominal muscles||Every other day, 15 sessions is one course.|
|Headache (11)||scalp acupuncture zones shenting (near GV-24), baihui (near GV-20), benshen (near GV-13), shaigu (near GB-8), wangu (near GB-12)||30 minutes; manipulation for 2 minutes at beginning, middle, and end of treatment.||Every day for 7 days as one course.|
|Senile insomnia (12)||scalp acupuncture ezhongxian and epangxian zones; body acupuncture by differential diagnosis||15-20 minutes; manipulated at the start of treatment||Every day for 10 days as one course.|
|Cervical spondylopathy (13)||GB-20 (fengzhi), GV-20 (baihui; by scalp acupuncture technique), TB-5 (waiguan), cervical Huatuo points||30 minutes; manipulation beginning, midpoint, end||Every day for 10 days, interval of 5 days between courses.|
|Post-stroke paralysis (14)||GV-14 (dazhui), LI-15 (jianyu), LI-11 (quchi), LI-4 (hegu), GV-4 (mingmen), ST-31 (biguan), SP-10 (xuehai), ST-36 (zusanli), etc.||not specified; needling through to another point used; manipulation every 5 minutes or electro-stimulation||Every other day for 10 sessions is one course.|
In these and other clinical reports of acupuncture therapy, satisfactory to excellent results are described. The authors often mention, in the discussion section, the rapidity with which positive results are attained, so that even when the total treatment time is several courses of therapy over a period of one to two months, the changes are already seen within the first course for most patients. Repetition of courses of daily or every other day acupuncture sessions are applied either to complete the therapy or to attempt to gain success in patients who showed little response during the first course. It appears evident, based on these reports, that a portion of patients require more than a course of 5-10 sessions to begin to show significant benefits from the treatments.
Even if one were to assume that less frequent acupuncture is as effective as daily or every other day acupuncture, but requires the same number of treatments, it is clear that weekly acupuncture therapy will require many months to attain the desired results for a large proportion of the patients, based on the examples displayed in the table. Therefore, a reasonable objective is to shrink the total duration of the therapeutic activity, by encouraging and making available frequent acupuncture.