Legend has it that benefits of acupuncture were discovered on the battlefield more than 5,000 years ago. A Chinese soldier felled by an arrow intrigued the physician attending him. He said stomach pain unrelated to his wound had gone away after the arrow pierced him.
The physician examined the point of penetration and wondered how pressure at one place might relieve pain somewhere else. He decided to investigate. The rest, as they say, is history;Chinese history for the most part.
It wasn't until 1971, when New York Times writer James Reston reported on his emergency appendectomy in Peking, that acupuncture got much visibility
in the U.S. One of the first Western journalists invited to China under Mao's rule, Reston wrote about how the needles relieved his postoperative pain, and the Times ran the story on the front page.
By the early 1990s, however, Americans were spending more than $13 billion a year on acupuncture and many other alternative therapies, most of it out of their own pockets. And in 1992, the National Institutes of Health established an Office of Alternative Medicine to conduct clinical trials on some of them. Ten sites were funded, including The Kessler Institute for Rehabilitation/ UMDNJ-New Jersey Medical School Center.
Samuel Shiflett, PhD, who holds appointments in the school's psychiatry department and in physical medicine and rehabilitation, is directing the center's three-year study. He says it is assessing complementary and alternative medicine techniques for patients with neurological disorders caused by stroke and brain or spinal cord injuries. One aspect is to evaluate acupuncture for stroke victims who have difficulty swallowing, a debilitating condition know as dysphagia.
The basis of acupuncture is the concept that energy flows along pathways called meridians, and that each one affects different parts of the body. The Chinese contend that pain and disease are caused by blocked energy and that by inserting very fine needles at specific points along the meridians, the energy is released.
Noel Nowicki, MD, studied the technique at UCLA in 1994 and 1995. An internal medicine specialist on the Kessler staff, he says his interest in alternative therapies stems from the failure of traditional treatment for conditions like unexplained fatigue, fibromyalgia and irritable bowel syndrome.
"Acupuncture needles are conical in shape and push tissue aside, so there's very little trauma. They don't have the cutting edge of needles used for drawing blood or giving injections." Noel Nowicki, MD
"I don't look at it from a Western perspective," he notes, "which just masks pain in many cases and manages symptoms. I see them as autoimmune disorders, but closer to chronic fatigue than to classic autoimmune diseases like scleroderma or lupus.
He is not claiming to cure patients. "Most people's symptoms abate and then don't recur for a while. When they do recur, it's a matter of how many trigger points I can find that will help them move with less difficulty, sleep better and have a better quality of life with less pain medication and sometimes with no medication."
Jean Albert, of Glen Ridge, became a patient of Nowicki's two years ago, after she had been diagnosed with fibromyalgia. "The pain comes and goes, and it moves around your body," she says. "No test shows anything;that's typical of this disease. Years ago they would have told you it was in your head."
A plucky, outspoken woman, who is familiar with the world of medicine from her years as director of social work at Mountainside Hospital, Albert knew there wasn't anything she could do for the disorder except take analgesics. But she had become interested in acupuncture when it helped a friend with a bad knee. As her pain became more constant than intermittent, she decided to try it.
"I had a very long interview with Dr. Nowicki the first time I went," Albert recalls. "The first part was a typical Western medical history, and then he asked questions that were more in harmony with Chinese medicine;whether I preferred sweet or sour things, what my favorite time of year was. And when I said autumn, whether I liked it better when the leaves were on the trees, or off. I felt like I'd had a session with a psychoanalyst."
Nowicki says her reaction is not far off. "Certain types of people are prone to certain illnesses," he observes. "The Chinese link personalities to fire, water, earth, metal and wood, while Westerners categorize them as Type A or B." Type A is more likely to display explosive anger and resentment and may have headaches or back problems, he adds. "Knowing a person's likes and dislikes is a way of establishing these patterns."
In line with Chinese medicine, Nowicki always takes a patient's pulse at three positions in each wrist. "There are superficial and deep pulses that correspond to the meridians," he explains. "They help narrow the search for areas of weakness or imbalance."
Albert began with one session a week for about two months, then every other week, and now usually goes every six weeks. "I call if I start having pain," she says. In March, after she helped someone move a desk and began having leg pain that she felt was unrelated to fibromyalgia, she saw Nowicki.
His questions for her included: "Are you sleeping okay? How about walking the dog? Is the pain worse when you first get up out of a chair?" Then he said he thought she had injured her back, and he would treat it like sciatica. He first inserted eight needles into the upper and mid-back for fibromyalgia pain, then eight in the lower back and sacrum to relieve the leg pain, and finally in the ankles and legs.
Electrodes were attached to the needles. "They stimulate electrons in the needles, which excite ions in the meridians," he notes. To alleviate the leg pain, Nowicki used frequencies of two and four herz levels at which endorphins are released. He says spinal synapses occur where the peripheral nerves meet the nerve cells in the central nervous system, and that's where the endorphins are secreted.
"Once in a while I feel a needle go in," Albert says, "but it doesn't hurt;you don't bleed." That's because acupuncture needles are conical in shape and sort of push tissue aside, Nowicki notes, so there's very little trauma. They don't have the cutting edge of needles used for drawing blood or giving injections.
In the United States, acupuncture, herbal remedies and relaxation techniques fall under the rubric "alternative medicine." For the medical establishment the phrase has long been pejorative, smacking of sham concoctions and quackery. One accepted description uses negative terms: It isn't used conventionally, isn't taught in medical schools, isn't reimbursed by insurers and there's no research on it.
By 1992, however, when the National Institutes of Health established an Office of Alternative Medicine, it was clear that despite official sanction, the public had embraced these therapies.
A study by researchers at Harvard Medical School, published in the New England Journal of Medicine (Jan. 28, 1993), reported a 1990 telephone survey of 1,539 adults. Thirty-four percent said they had used at least one of 16 unconventional therapies in the previous year, and a third of that group saw these practitioners an average of 19 times during that year.
The study found the highest use to be among those 29 to 45 years of age, who had relatively more education and higher incomes. People tried the therapies for conditions ranging from low-back pain, insomnia and headaches to cancer and AIDS. Eighty-three percent of those seeking treatment for serious disorders also saw conventional physicians, but 72 percent did not tell these doctors about their alternative therapies.
Based on the data, the research-ers estimated that: Americans spent about $13.7 billion for such services in 1990, 75 percent of the cost was totally unreimbursed, and the frequency of visits to such practitioners translated to more than were made to all primary care providers in the U.S. that year.
Given the growing acceptance, it's not surprising that medical school students are pushing for courses on alternative medicine and that NIH-sponsored clinical studies are under way.
UMDNJ-New Jersey Medical School instituted a non-credit elective in alternative medicine in 1996, and UMDNJ-Robert Wood Johnson Medical School will offer one next fall. The impetus for both came from students.
The UMDNJ-School of Osteopathic Medicine has had a course for second-year students for three years, according to Marvin E. Herring, MD, who directs it. He says students team up to do research on acupuncture, herbal therapy, homeopathy, and vitamins and antioxidants. They use the Web and library databases to search the literature and then present their findings to the class.
The Association of American Medical Colleges says it does not yet have statistics on how many schools have such courses, but will begin to gather them. The number may be as high as 40.
Albert says that she hasn't taken a Tylenol since she began acupuncture and that she feels energized after each session. "We've had great things happen in Western medicine," she observes, "and they'll continue to happen. But my feeling is that alternative medicine doctors spend more time with you and get to know you better."
Nowicki first did acupuncture on a stroke victim when a Kessler patient's daughter insisted on it. She had arranged to bring in her own acupuncturist, not knowing anyone on the staff was qualified.
"I was addressing his paralysis, speech problems and dysphagia," Nowicki says, "and his responses after three sessions were dramatic." Patients are scored both before and after therapy on their mobility, balance and speech. Videotapes document their progress.
Because of acupuncture's beneficial effect on the man's dysphagia, Nowicki began searching the literature for information. "I consulted my teacher and found translations of Chinese texts on the Internet," he says. "For thousands of years they have made notations; observations on effects relating to particular acupuncture points -; but I didn't find anything specific to swallowing."
That sparked the dysphagia study. "It is a horrible disability," Nowicki observes. "The problem has been researched and speech pathologists have been doing therapy for years, but mainly it amounts to teaching people to compensate for loss of motor control." They learn to tilt their heads, take small amounts and thicken liquids. Thinner ones are harder to swallow, he explains: "They tend to go down the wrong pipe and because there's paralysis the patient doesn't realize it."
When asked how they can measure acupuncture's effects objectively, Shiflett, the project director, replies: "We'll follow the rules of good science to the best of our ability. The most scientifically sound study is a randomized, placebo-controlled, double-blind trial." This trial will be randomized and placebo-controlled, but it can't be double-blind since the acupuncturist will know whether or not the needles are inserted in the appropriate places. But the patients will not know, nor will those evaluating the outcomes.
He adds that speech pathologists use fluids and solids of varying consistencies and video fluoroscopy to measure dysphagia, so there will be hard data to gauge efficacy.
The acupuncture study at Kessler, which began last fall, will include about 40 patients. Insurers usually pay for only two or three weeks at a rehab center, so acupuncture treatments will be limited to about six for each patient, which should be enough to determine its effectiveness.
Wen-hsien Wu, MD, who directs the Pain Management Center at New Jersey Medical School in Newark, has used acupuncture since 1981 to treat patients with chronic pain caused by neurological disorders, and arthritis and low back pain, particularly when it is muscular in origin. He says the therapy brings only temporary relief in these cases: "Patients also have to work with a physical therapist when the pain lessens to stretch and strengthen the muscles;acupuncture is just one aspect of integrated treatment."
A professor of anesthesiology at the school, Wu thinks it will take a long time for acupuncture to be accepted in the U.S. "The Chinese are in tune with Einstein's concept of the universe; that matter and energy can be exchanged," he observes. "U.S. medicine follows the Newtonian scientific concept, which promotes measurable evidence."
Western scientists who have conducted animal studies report that acupuncture releases natural opiates that dull pain and a hormone that reduces inflammation.
"The Chinese are in tune with Einstein's concept of the universe;that matter and energy can be exchanged. U.S. medicine follows the Newtonian scientific concept, which promotes measurable evidence." Wen-hsien Wu, MD
A Swedish study published in the journal Neurology (November 1993) found that stroke patients who received acupuncture, in addition to physical therapy, scored significantly higher on tests measuring balance, mobility and quality of life than those who did not have it. It would also decrease health costs, Nowicki points out, because it means a patient can return home sooner.
The Harvard Women's Health Watch (September 1995) reported that controlled clinical trials demonstrated that acupuncture could be effective in treating menstrual cramps, chronic low back pain, neck pain and substance abuse.
Perhaps because of such research more American physicians are learning acupuncture. A spokesman for the American Academy of Medical Acupuncture says it has 977 members and the number is growing by 15 to 20 percent a year. He adds that many physician-acupuncturists do not belong to the organization.
To practice the therapy in New Jersey, licensed physicians and dentists are required to have completed a course of study at a U.S. or foreign school, or complete at least 300 hours of training;150 hours of theory and 150 of clinical. But they cannot call themselves certified acupuncturists. That category is reserved for non-doctor practitioners licensed by the Acupuncture Examining Board. There are some 7,000 licensed acupuncturists in the U.S., according to the American Association of Oriental Medicine.
A spokesperson for the New Jersey Board of Medical Examiners says acupuncturists trained in this country must have an undergraduate degree in the sciences and three years of advanced training at a recognized school in order to be certified in the state. The board is working to develop such guidelines for those trained outside the U.S. It has contacted the governments of China, North and South Korea, Japan and the United Kingdom to gather information about the curricula of their recognized schools in order to evaluate credentials.
Alan Lichtbroun, MD, a clinical assistant professor of rheumatology at UMDNJ-Robert Wood Johnson Medical School, learned acupuncture in China last summer. He uses it to treat back, neck and shoulder pain, knee pain from arthritis, and fibromyalgia. Lichtbroun recommends other alternative therapies, too.
The Chinese were pioneers in the use of medicinal herbs, the root of pharmacology in all countries. Lately they have flourished in the U.S., too. General Nutrition Centers, one of the largest marketers of herbals and vitamin supplements, reported earnings of nearly $846 million in 1996.
Health professionals are concerned about the craze because many people equate "natural" with safe. Yet the potent chemicals; ephedra, yohimbine, chaparral, comfrey, licorice; that make these plants effective can be dangerous if taken in large doses, particularly when combined with other medications people may be taking regularly.
Because herbals are not classified as drugs, they are marketed without the rigorous testing and approval process required of pharmaceuticals. And they don't contain warnings about possible side effects or conditions that should preclude people from taking them.
But there is extensive European scientific literature on herbs, particularly in Germany where an FDA equivalent has been studying them for some 20 years, notes Samuel Shiflett, PhD, who has appointments in the psychiatry department and in physical medicine and rehabilitation at UMDNJ-New Jersey Medical School. An extract from leaves of the Ginkgo biloba is an example, he says, and studies have included randomized, double-blind, placebo-controlled trials on humans.
Ginkgo extracts have been used to treat ischemia (obstruction of arterial blood flow), memory problems in elderly patients, edema and depression. Shiflett, who is directing an NIH-sponsored trial of alternative therapies, says his group will study ginkgo's effects on the cognitive function of stroke patients.
He suggests that some patients try a combination of glucosamine and chrondroitin sulfates, natural building blocks of cartilage that are sold in health food stores. "I don't tell people it works," he says. "I say it may possibly work." Lichtbroun adds that fish oil and fatty acids have shown good results in patients with inflammatory arthritis, "so I recommend them for patients, too. Some do dramatically better."
Despite his keen interest, Lichtbroun says: "I'll never be a great practitioner of alternative medicine. It will take another generation to have doctors open-minded enough. Medical schools should take the lead in evaluating alternative medicine because their patients are using it."
With the NIH grants, that is finally happening.