A cura della Fondazione Internazionale Fatebenefratelli di Roma.
È in preparazione la traduzione in italiano.

Ringraziamenti

Ringraziamenti

L'organizzazione riconosce di essere in credito con i molti esperti che hanno fornito osservazioni e  consigli durante la preparazione di queste Linee Guida di Riferimento sulla Formazione di Base e la Sicurezza in Agopuntura, inclusi coloro che hanno presentato le osservazioni agli Uffici Regionali dell'OMS ed alla Federazione Mondiale delle Società di Agopuntura e Moxibustion (WFAS).

In particolare, i ringraziamenti sono dovuto coloro che ha rivisto le copie al Congresso sulla Consultazione in Agopuntura dell'OMS di Cervia, Italia, nel 1996, al professor Thu-Fan Xie, Direttore Onorario dell'Istituto di Medicina Integrata, Primo Ospedale dell'Università Medica di Beijing, Cina, che ha redatto la prima stesura della Guida   ed al Dott Gordon Scott che ha stampato la versione definitiva.

L'apprezzamento è egualmente esteso al Ministero della Sanità Italiano ed al Centro diRicerca in Bioclimatologia, in Biotecnologie e Medicina Naturale dell'Università di Stato di Milano (centro di collaborazione OMS per la Medicina Tradizionale), per il loro supporto ed all'Associazione Giapponese di Hyogo di Agopuntura e Moxibustione ed all'Associazione Norvegese di Agopuntura, per il contributo finanziario per la pubblicazione.

© World Health Organization 1999

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commerciai purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.

Introduction   Indice

Acupuncture is an important element of traditionai Chinese medicine. It began to be used more than 2500 years ago, and its theory was already well developed at a very early time, as is shown in many of the Chinese classics. It was introduced to neighbouring countries in Asia in the 6th Century, being readily accepted, and by the early l6th Century it had reached Europe. Over the past two decades acupuncture has spread worldwide, whìch has encouraged the further development of this therapy, particuiarly through studies from modem medicai perspecfives and research methodologies.

Many elements of traditionai medicine are beneficial, and WHO encourages and supports countries to identify safe and effective remedies and pracfices for use in public and private health services. It has paid particuiar attenfion to supporting research in and the proper application of acupuncture and, in 1991, the Fortyfourth World Heaith Assembly urged Member States to introduce measures for its reguiation and control (Resolution WHA44.34).

With the increasing use of acupuncture, the need for a common language to facilitate communication in teaching, research, clinicai practice and exchange of information had become pressing and, in 1989~ WHO convened a Scientific Group which approved a Standard Internationai Acupuncture Nomenclature which is being widely disseminated and applied.

The Scientific Group also recommended that the Organization develop a series of statements and guidelines on acupuncture relating to basic training, safety in clinicai practice, indications and contraindications, and clinicai research. Guidelìnes for clinicai research on acupuncture were issued by the WHO Regionai Office for the Western Pacific in 1995.

The present document consists of guidelines on basic training and safety in acupuncture. More than 50 internationai experts shared their knowledge and experience in their preparation.

The increasing popularity in recent years of acupuncture as a forin of therapy and the interest of some countries in introducing it into primary health care mean that nationai health authorities must ensure safety and competence in its use.

In countries with a formai system of educafion in traditionai medicine, and where acupuncture is firmiy established as a normai component of health care, training may extend over severai years at college levei, and suitable mechanisms for supervision of its practitioners have been created.

However, for other countries, where "modem Western medicine" forms the oniy basis of the nationai health system, the position is different and there may be no educationai, professionai or legislative framework to govem the practice of acupuncture.

Making use of acupuncture in modem medicai care means taking it out of its traditionai context and applying it as a therapeutic technique for a lùnited number of condìtions for which it has been shown to be effecfive, without having to reconcile the underlying theories of modem and traditionai medicine.

In this type of situation, lengthy periods of instruction in traditionai medicine as a background to acupuncture are neither feasible nor necessary, and shorter training must suffice.

Furthermore, in many countries, acupuncture is not yet officially recognized and reguiations and registration requirements, where they exist, vary considerably. in some, only qualified physicians may practice acupuncture, while in others, practitioners trained in traditionai medicine may also do so.

It seems usefui, therefore, to provide guidelines for relatively short periods of theoretical and practical training in acupuncture whìch, with well designed curricula and skilled instructors, wouid be sufficient to ensure the safety and competence of those so trained.

In recent decades, the theoreticai and practical aspects of acupuncture have been developed in various countries, particularly in those where modem Westem medicai perspectives and research methodologies have been applied to studies of this traditionai therapy. The achìevements of these studies shouid be included in the training. However, since a new theoretical system has not yet been established, traditionai Chinese medicai theory is stili taken as the basis of the Core Syllabus.

These guidelines will, it is hoped, assist nationai heaith authorities in countries where modem Westem medicine forms the basis of health care to establish regulations conceming:

• general requirements for basic training in and the practice of acupuncture;

• the knowledge and experience of modem Western medicine required of acupuncture practitioners employed as such in the nationai heaith care system; and the knowledge and experience of acupuncture required of physidans and other health staff wishing to include acupuncture in their professionai work in modem Westem medicine.

A decision by the Mìnistry of Health to incorporate acupuncture in primary health care (or at any offier levei of govemment health services) in a system based on modem Westem medicine raises a number of important issues which would need to be taken into account.

 

2.1 Administrative and academic considerations

The trarning of health personnei in acupuncture involves certain achunistrative and academic considerations, for example:

e Which types of personnei shouid be trained?

e What wouid be thefr flinctions and responsibilities? What wouid be the content of training, in each case? Where wouid such trarning be given and by whom?

· Are suitably qualified instructors available or wouid they also have to be trained?

· What would be the mechanisms for officiai recognifion of training courses, instructors and institutions?

 

2.2 Examinations and licensing

A system of examination and licensing would be needed to ensure the competence of those trained, and to prevent unauthorized practice of acupuncture.
This would bring under control the situation, current in certain industrialized and developing countries, where commercial exploitation of acupuncture trarning and practice is not uricommon, with all the harmùil consequences that may ensue.

 

2.3 Supervision, monitoring and evaluation

The introduction of one or more new categories of personnel in the health system wouid probably make it necessary to provide for:

• a period of supervised practice after training;

• monitoring of performance of the trainees individualiy and as a group; and

• evaluation of the benefits (or otherwise) of including acupuncture in primary health care (and at other levels) where it was not previously available, and of its cost-effectiveness compared with other forms of treatment for common conditions.

 

 

2.4 Further education and career possibilities

Possibilìties to be envisaged, and perhaps encouraged, are that some acupuncture pracfitioners may wish to increase their knowledge of modem Westem medicine, while other health personnel who have not received the basic trairùng may wish to acquire a knowledge of acupuncture and later apply it. Ultimately, a blending of the two disciplines must, to some extent, take place.

The guidelines address four levels of trarning in acupuncture, namely:

• full training for those with littie or no prior medical education or experience, who wish to qualify as recognized acupuncture pracfifioners licensed to practise independently, subject to the lirnitations ùnposed by the Ministry of Health;

• full training of qualified physicians (modem Westem medicine) in acupuncture;

• training of qualified physicians (and certain other medicai graduates) from schools of modem Westem medicine, who wish to include acupuncture as a techuique in their clinical work; and

• limited training of other health personnel (modem Westem medicine) working in the primary health care system of their country.

The basic training of the four groups is different. For traditional acupuncture practitioners, a complete course extending over two years is recommended. For physidans and medically trained non-physicians, trarning would be adapted to their specific requirements and cohfined to the clinical applications of acupuncture. An indicafion of the period of training to be desired in each case is given in Table 1 below.

Table 1

Basic training in acupuncture

1) State exammation in acupuncture and modem Western medicine (at appropriate level).

5.6 Core syllabus in modern Western medicine

1. Approach to training

By the end of the course the student should have:

· a sound understanding of the essenfials of anatomy (including the anatomical location of acupuncture points), physiology, and the basic mechanisms of disease;

· an understanding of the principles of hygiene, the common forms disease and ill-health in the community, and their causafive factors;

· proficiency in making a simple but competent examination of a patient, and in arriving at a tentafive diagnosis and a reasonable assessment of the gravity of symptoms and signs;

· the ability to decide whether a patient may safely and suitably treated by acupuncture, or shouid be referred to a health professionai or facility; and

· training in first aid, cardiopulmonary resuscitafion, and the acfion to take in emergencies.

2. Scope and depth of training

These must be defined by the national health authorities, according to the duties and responsibilities the acupuncture practifioners will have in the national health system; including whether these will also involve the use of modern Western medicine (alone or in combination with acupuncture), and the degree of supervision under which the pracfitioner will work.

 

5.7 Other related fields of health care

As future personnel in the nafional health system, student non-physician acupuncturists shouid also have adequate knowledge of the orgarrn:afion of health services in the country, relevant regulations and procedures, the disposition of health staff and facilities, ethical considerafions, and insurance requirements.

 

5.8 Examination

On completion of the fuli period of training, the student's theoretical knowledge of and proficiency in acupuncture, and knowledge of modern Western medicine (at the appropriate level), should be evaluated by an official examination, recognized by national health authorities as evidence of the suitabilìty of the trainee to be licensed to practise.

This training programme is designed for qualified physicians (modem Westem medicine) who wish to practise acupuncture independenfly, treating the various conditions for which patients are commonly treated by acupuncture practitioners.

Qualified physicians who already have adequate knowledge and skilis in modem Westem medicine, wouid orily need to follow the Core Syllabus for acupuncture. The theoretical course couid be shortened, as qualified physicians can leam traditional medicine more easily flian those with no prior medical education. The course shouid comprise at least 1500 hours of formal training, including 1000 hours of pracfical and clinicai work.

On completion of the course and after passing an officiai examination, participants shouid be entiiled to practise acupuncture in various fields of medicine where it is indicated.

7.Limited training in acupuncture for qualified physicians   Indice

7.1 Basic training

Shorter training courses wouid be suitable for qualified physicians (and certain other graduates) who wish to become competent in acupuncture as a form of therapy in modem Westem clmical practice (or as a subject for scienfific research).

For them, a brief introduction to traditional acupuncture (derived from the Core Syllabus) would probably suffice, and the training would then be largely orientated to the use of acupuncture in modem Westem medicine.

The course should comprise at least 200 hours of formal training, and should include the following components:

1. Introduction to traditionai Chinese acupuncture

2. Acupuncture points

• Location of the 361 classical points on the 14 meridians and the 48 extraordinary points.

• Alphanurneric codes and names, classifications of points, depth of inserfion of needles, actions and indications of the Commonly Used Points selected for Basic Training.

3. Applications of acupuncture in modern Western medicine

• Principal clinical conditions in which acupuncture has been shown to be beneficial.

• Selection of patients and evaluafion of progress/benefit.

• Planning of treatment, selecfion of points and methods of needle manipuiation, and use of medication or other forms of therapy concurrently with acupuncture.

4. Guidelines on safety in acupuncture

5. Treatment techniques

• General principles.

• Specific clinical

On completion of the course and after passing an official examination, participants shouid be able to integrate acupuncture into their clinicai work or speciality.

 

7.2 Special courses

Some physicians or dental surgeons might wish to acquire proficiency in certain specific applications of acupuncture (for example, pain relief, or dental or obstetric analgesia) and for them flexibìlity wouid be needed in designing special courses adapted to their parficuiar areas of interest.

 

7.3 Advanced training

Physicians or other health personnei who have satisfactorily completed a "short" course of basic training might wish to pursue their training at an advanced level, in which case suitable courses wouid have to be "tailor-made" to meet thefr needs.

The introduction of "acupuncture" into primary health care at community level wouid require the training of a considerable number of personnel over a short period, if it is to have a demonstrable effect. mis wouid probably strain the teaching and supervision resources of the country concerned.

It wouid seem wiser, in such cases, to train such personnei in acupressure (zhi-ya) rather than in acupuncture itseìf. Training in acupressure wouid make no great demands, couid be incorporated into the general training of primary health care personnel, and wouid carry no risk to the patient. The use of acupressure in primary health care wouid have to be evaluated after a suitable trial period. Some personnei who show particuiar aptitude might be chosen for basic training in acupuncture, a training programme being arranged according to the applications envisaged.

Participants at the WHO Consultation on Acupuncture at Cervia, Italy in 1996 drew up a list of Commorily Used Points suitable for inclusion in basic training courses. These were selected from the document A Proposed Standard Internationai Acupuncture Nomenclature: Report of a WHO Scientzfic Group (WHO, Geneva, 1991).

As may be seen from the table below, the selection includes 187 of the 361 classical points, and 14 of the 48 extra points. Thus, the basic training courses for the categories of personnei described lay emphasis on the use of only 201 of a totai of 409 points.

The guidelines on safety, which follow, mention certain points as being potentially dangerous and requiring speciai skill and experience in their use. Some of these are included in the selection of Commonly Used Points, and attention is drawn to this fact.

2 Standard Internationai Acupuncture Nomenclature, Report of a WHO Scientific Group (WHO, Geneva, 1991).
3 Selected by participants at the WHO Corsultation on Acupuncture, Cervia, Italy, 1996.

Selected from:

LU 1 zhongfu              LU 7 kongzui              LU 10 Yuji

LU5 chize                    LU9 taiyuan               LU11 shaoshang

2. Large intestine meridian (LI)

LI1 shangyang         LI 7 weniiu                 LI 14 binao

L13 sanjian             LI 6 pianli                    LI15 jianyu

L14 hegu                  LI 10 shousanli          LI18 futu

L15 yangxi                LI11 quchi                  L120 yingxiang

3. Stomach meridian (ST)

ST1 chengqi         ST 21 liangmen         ST 36 zusanLi

ST 2 sibai           ST25 tianshu             ST37 shangjuxu

ST 3 juiiao         ST27 daju                  ST38 tiaokou

ST 4 dicang        ST29 guilai                ST40 fenglong

ST 5 daying        ST31 biguan              ST41 jiexie

ST 6 jiache         ST32 futu                  ST42 chongyang

ST 7 xiaguan     ST34 liangqiu            ST44 neiting

ST 8 touwei       ST35 dubi                  ST45 lidui

ST18 rugen

4. Spleen meridian (SP)

SP1 yinbai         SP 5 shangqiu      SP 10 xuehai

SP 2 dadu         SP6 sanyinjiao     SP11 jimen

5P3 taibai         SP 8 diji                 SP 15 daheng

SP4 gongsun     SP9 yinLingquan

5. Heart meridian (HT)

HT3 shaohai         HT7 shenmen          HT 9 shaochong

HTS tongli             HT 8 shaofu

6. Smali intestine meridian (SI)

SI 1 shaoze         SI 9 jiarnthen          SI17 tianrong

SI 3 houxi           SI 10 naoshu          SI18 quanliao

SI4 wangu          SI11 tianzong         SI19 tinggong

SI5 yanggu         SI12 bingfeng

SI6 yanglao         SI14 jianwaishu

NOTA: I punti in grassetto e sottolineati sono citati nelle Linee Guida sulla Sicurezza come potenzialmente pericolosi e richiedono una speciale attenzione ed esperienza nel loro uso: LU 9, ST 1, SP11, BL 1, GV15, GVI6, CV 22.

BL1 jingming            BL 21 weishu                  BL 52 zhishi

BL 2 cuanzhu         BL22 sanjiaoshu              BL54 zhibian

BL 7 tongtian          BL 23 shenshu                BL57 chengshan

BL1O tiarnthu        BL 25 dachangshu          BL 58 feiyang

BLu dazhu               BL 28 pangguangshu     BL 60 kunlun

BL 12 fengmen        BL31 shangliao               BL 62 shenmai

BL13 feishu             BL 32 ciliao                     BL64 jinggu

BL15 xinshu            BL 33 zhongliao             BL 65 shugu

BL17 geshu             BL34 xialiao                    BL66 zutonggu

BL18 ganshu           BL 36 chengfu                 BL 67 zhiyin

BL19 danshu           BL4O weiyang

BL2O pishu             BL43 gaohuang

8. Kidney meridian (KI)

KI1 yongquan         KI5 shuiquan              KI9 zhubin

KI2 rangu                 KI6 zhaohai                KIlO yingu

KI3 taixi                     KI7 fuliu

9. Pericardium meridian (PC)

PC3 quze              PC6 neiguan          PC 9 zhongchong

PC4 ximen           PC7 daling

PC5 jianshi          PC8 laogong

10. Triple energizer meridian (TE)

TE 1 guanchong         TE 5 waiguan         TE 14 jianliao

TE 2 yemen                  TE 6 zhigou         TE 17 yifeng

TE 3 zhongzhu            TE 9 sidu             TE 21 ermen

TE 4 yangchi                 TE 13 naohui     TE 23 sizhukong

11. Gallbladder Meridian (GB)

GB 1 tongziliao             GB 24 riyue               GB 37 guangming

GB 2 tinghui                 GB 25 jingmen          GB 39 xuanzhong

GB 8 shuaigu               GB 29 juiiao              GB 40 qiuxu

GB 12 wangu               GB 30 huantiao         GB41 zuiinqi

GB 14 yangbai            GB31 fengshi             GB 43 xiaxi

GB 20 fengchi              GB 33 xiyangguan      GB44 zuqiaoyin

GB 21 jianjing              GB34 yanglingquan

12. Liver meridian (LR)

LR1 dadun                  LR4 zhongfeng         LR13 zhangmen

LR2 xingjian                LR5 ligou                  LR14 qimen

LR3 taichong               LR8 ququan

GV 1 changqiang                  GV13 taodao         GV2O bainui

GV 3 yaoyangguan              GV14 dazhui           GV23 shangding

GV 4 mingmen                     GV15 yamen           GV25 suiiao

GV 9 zhiyang                       GVI6 fengfu             GV26 shuigou

GV12 shenzhu

14. Conception vessei (CV)

CV3 zhongji               CV 10 xiawan              CV17 danzhong

CV4 guanyuan         CV 12 zhongwan          CV22 tiantu

CV6 qihai                  CV 13 shangwan         CV23 lianquan

CV8 shenque            CV 14 juque                 CV24 chengjiang

CV9 shuifen

15. Extra points

EX-HN 1 sishencong        EX-HN 4 yuyao              EX-B 1 dingchuan

EX-HN 3 yintang              EX-HN 5 taiyang             EX-B 2 jiaji

EX-UE 7 yaotongdian     EX-LE 4 nekiyan

EX-UE 9 baxie                 EX-LE 6 dannang

EX-UE 10 sifeng              EX-LE 7 lanwei

EX-UE 11 shixuan         EX-LE 10 bafeng

* HN Head and neck; B Back; UE Upper extremities; LE Lower extremities.

In mani competenti l'Agopuntura è generalmente una tecnica sicura con poche controindicazioni. La sua forma più comunemente utilizzata comprende l'infissione dell'ago e la sua profondità di penetrazione nei tessuti attraverso la pelle, che può essere equiparata ad una iniezione sottocutanea o intramuscolo.  Tuttavia, vi è sempre un rischio potenziale, fortunatamente molto lieve, di trasmissione di infezioni da un paziente all'altro (per es. HIV o HBV, HBC), oppure di introdurre organismi patogeni. La Sicurezza in Agopuntura richiede tuttavia una costante vigilanza nel mantenimento di alti standards di Igiene Ambientale, strerilizzazione ed tecniche di asepsi.

Inoltre vi sono altri rischi che non possono essere prevedibili o prevenute, ma per le quali l'agopuntore deve essere preparato. Essi sono: rottura degli aghi, reazioni sgradevoli, dolore o disagio, lesioni involontarie ad importanti organi (es. pneumotorace) e, certi rischi associati alle altre forme di terapia⁵ classificate sotto la rubrica "Agopuntura".

In ultimo, vi sono rischi connessi alla formazione inadeguata dell'agopuntore. Questo include la lselezione non appropriata del paziente, errori di tecnica, ed errori nel riconoscere controindicazioni e complicazioni, o far fronte alle emergenze quando si presentano (lipotimie, mioclonie, reazioni ansiose, etc...).

 

5 Acupunture treatment is not limited to needling, but may also include: acupressure, electro-acupuncture, laser acupuncture, moxibustion, cupping, scraping and magnetotherapy.

As with any subcutaneous or intramuscular injection, avoidance of infection in acupuncture requires:

· a clean working environment;

· clean hands of the practitioner;

· preparation of the needling sites;

· sterile needles and equipment, and their proper storage;

· aseptic technique; and careful management and disposal of used needles and swabs.

The treatment room should be free from dirt and dust, and should have a speciai worlking area, such as a table covered with a sterile towel, on which sterile equipment shouid be placed. mis equipment (including trays of needles, cotton wool balls and sticks, and 70% alcohol) shouid be covered with a sterile towel untii needed for use. Adequate light and ventilation should be provided throughout the treatment rooms.

Practitioners should always wash their hands before treating a patient. Washing the hands again immediately before the acupuncture procedure is particuiarly important in preventing infection, and shouid include thorough lathering with soap, scrubbing the hands and fingernails, rinsing under running water for 15 seconds, and carefui drying on a clean paper towel.

Many acupuncturists palpate the acupuncture point after the needling site has been prepared. In such cases, their fingertips shouid again be cleaned with an alcohol swab. The use of sterile surgicai gloves, or individuai finger stalls, is recommended for the protection of the patient and the practitioner, especially if the latter has cuts or abrasions. Those with infected lesions on the hands should not practise until they are healed.

1.3 Preparation of the needling sites

The needling sites should be clean, free from cuts, wounds or infections. The point to be needled shouid be swabbed with 70% ethyl or isopropyl alcohol, from the centre to the surrounding area using a rotary scrubbing motion, and the alcohol allowed to dry.

Sterilization is required for ali needles (filiform, plum-blossom, seven-star, subcutaneous, round-head subcutaneous), cups and other equipment used (storage trays, forceps, guide tubes for needles, cotton wool balls and sticks, etc.).

Disposable sterile acupuncture needles and guide tubes are strongly recommended in all instances. However, the use of disposable needles shouid not slacken the practitioner's vigilance in adopting aseptic techniques in other aspects of clinicai practice. All disposable needles should be discarded iuunediately after use and placed in a speciai container.

Each sterile filiform needle should be used for puncturing once, and once orily. Plum-blossom or seven-star needles may be used repeatedly on one and the same patient, but must be sterilized before being used for another paùent, or else disposable plum-biossom heads shouid be used.

Sterilization procedures shouid conform to those described in the Appendix. The ffierapist is responsible for ensuring that these standards are maintained.

lmmediately after use, reusable needles and other contaminated equipment shouid be immersed in an effecfive chemical disinfectant, then soaked in water, with or without detergent and, after carefui cleaning, thoroughly rinsed in water before being packaged for resterilization.

The sterilized package shouid be stored in a safe and clean area, well ventilated and free from excessive humidity, to preclude any possibility of condensafion and mouid growth. The maximum safe storage time varies with the type of packaging. Needies shouid be placed in a test tube which shouid then be plugged with cotton wool, and clearly labelled with an expiry date not more than seven days after the date of sterilization. Improper storage conditions may, however, cause equipment to lose steritity long before the expiry date. The integrity of the package shouid be inspected before use. Sterile needies stored in needle trays shouid be resterilized at the end of the day because the trays may become contaminated during use in treatment.

The needle shaft must be maintained in a sterile state prior to insertion. Needles shouid be manipuiated in such a way that the practitioner's fingers do not touch the shaft. If there is difficuity in inserting a long needle, such as that used in puncturing GB 30 huantiao or BL 54 zhibian by just grasping its handle, the shaft shouid be held in place with a sterile cotton wool ball or swab. The use of disposabie sterile surgicai gloves or finger stalls makes it easy to manipuiate needies without contamination.

On withdrawing a needie, a sterile cotton wool ball shouid be used to press the skin at the insertion site, thus protecting the patient's broken skin surface from contact with potential pathogens, and the practitioner from exposure to the used needle shaft and the patient's body fluid. All compresses or cotton wool balls contaminated by blood or body fluids must be discarded in a special container for infectious waste.

In view of the "reguiatory action" of acupuncture, it is difficuit to stipuiate absolute contraindications for this form of therapy. However, for reasons of safety, it shouid be avoided in the following conditions.

Acupuncture may induce labour and, therefore, shouid not be performed in pregnancy, unless needed for other therapeutic purposes and then only with great caution.

Just the act of neediing with a certain mode of manipuiation at certain acupuncture points may cause strong uterine contractions and induce abortion. However, this may have a use in pregnancy for the purpose of inducing labour or shortening its duration.

Traditionally, acupunture, and moxibustion are contraindicated for puncture points on the lower abdomen and lumbosacral region during the first trimester. After the third month, points on the upper abdomen and lumbosacral region, and points which cause strong sensations shouid be avoided, together with ear acupuncture points that may also induce labour.

Acupuncture is contraindicated in emergencies. In such cases, first aid shouid be applied and transport to a medical emergency centre arranged.

Acupuncture shouid not be used to replace a necessary surgical intervention.

Acupuncture shouid not be used for the treatment of malignant tumours. In particuiar, neediing at the tumour site shouid be prohibited. However, acupuncture may be used as a complementary measure, in combination with other treatments, for the relief of pain or other symptoms, to alleviate side-effects of chemotherapy and radiotherapy, and thus to improve the quality of life.

Needling shouid be avoided in patients with bleeding and clotting disorders, or who are on anticoaguiant therapy or taking drugs with an anticoaguiant effect.

Stainiess steel is the materiai of choice for acupuncture needles. Each shouid be carefully checked before use. If it is bent, the shaft eroded, or the tip hooked or blunt, the needie is defective and shouid be discarded.

It is recommended that the quality of manufacture of acupuncture needles be controlled by the nationai health authority.

3.2 Position of patient

The patient shouid assume a comfortable posture before neediing and be requested to remain stili and not to change position abruptly during treatment.

During acupuncture treatment, the patient may feel faint. The neediing procedure and the sensations it may cause shouid therefore be carefuily explained before starting. For those about to receive acupuncture for the first time, treatment in a lying position with gentle manipuiation is preferred. The complexion shouid be closely watched and the puise frequenfly checked to detect any untoward reactions as early as possible. Particuiar care shouid be taken when neediing points that may cause hypotension, e.g. LR 3 taichong.

Symptoms of impending faintness include feeling unwell, a sensation. of giddiness, movement or swaying of surrounding objects, and weakness. An oppressive feeling in the chest, palpitations, nausea and sometimes vomiting may ensue. The complexion usually turns pale and the puise is weak. In severe cases, there may be coldness of the extremities, cold sweats, a fall in blood pressure, and bss of consciousness. Such reactions are often due to nervousness, hunger, fatigue, extreme weakness of the patient, an unsuitable position, or too forcefui manipuiation.

If warning symptoms appear, remove the needles immediately and make the patient lie flat with the head down and the legs raised, as the symptoms are probably due to a transient, insufficient biood supply to the brain. Offer warm sweet drinks. The symptoms usually disappear after a short rest. In severe cases, first aid shouid be given and, when the patient is medically stable, the most appropriate of the following tre atments may be applied:

• press GV 26 shuigou with the fingernail or puncture GV 26 shuigou, PC 9 zhongchong, GV 25 suliao, PC 6 neiguan and ST 36 zusanli; or

• apply moxibustion to GV 20 baìhui, CV 6 qihai and CV 4 guanyuan.

The patient will usually respond rapidly to these measures, but il the symptoms persist, emergency medical assistance wìll be necessary.

All patients about to receive acupuncture shouid be asked if they have a history of convuisions. Patients who do have such a history shouid be carefully observed during treatment. If convuisions do occur, the practitioner shouid remove all needles and render first aid. lf the condition does not stabilize rapidly or if convuisions continue, the patient shouid be transferred to a medical emergency centre.

During needle insertion

Pain during insertion is usually due to clumsy technique, or to blunt, hooked or thick needles. It may also occur in highly sensitive patients. In most patients, skilfui and rapid penetration of the needle through the skin is painless. The correct teclmique and optimum degree of force to use must be learned through practice. A few devices may facilitate smooth and fast penetration, such as the use of needle guide tubes (which hold the needie steady over the point while it is tapped into place), and the "flicking-in" technique (a method of inserting the needle by flicking the upper end of its handie with the middie or index finger of one hand while the handle of the needle is loosely held by the index and middle fingers of the other hand, with the tip of the needle lightly touching the acupuncture point). The "acupuncture sensation" of soreness, tingling and heaviness indicating the arrivai of qi (deqi) at the point shouid be distinguished from painfui reactions.

After insertion

Pain occurring when the needle is inserted deep into the tissues may be due to hitting pain receptor nerve fibres, in which case, the needle shouid be lifted untii it is just beneath skin and carefuily inserted again in another direction.

Pain occurring when the needle is rotated with too wide an amplitude, or is lifted and thrust, is often due to it becoming entwined with fibrous tissue. To relieve the pain, gently rotate the needie back and forth until the fibre is released.

Pain occurring while the needie is in piace is usually caused by it curving when the patient moves, and is relieved by resuming the original position.

After withdrawal

This is usually due to unskilled manipuiation or excessive stimuiation. For mild cases, press the affected area; for severe cases, moxibustion may be applied in addition to pressure.

 

3.6 Stuck needle

After insertion, one may find it difficuit or impossibie to rotate, lift and thrust, or even to withdraw the needie. mis is due to muscle spasm, rotation of the needle with too wide an amplitude, rotation in only one direction causing muscle fibres to tangie around the shaft, or to movement by the patient.

The patient shouid be asked to relax. If the cause is excessive rotation in one direction, the condition will be relieved when the needle is rotated in the opposite direction. If the stuck needle is due to muscle spasm, it shouid be left in place for a while, then withdrawn by rotating, or massaging around the point, or another needie inserted nearby to divert the patient's attention. If the stuck needle is caused by the patient having changed position, the oùginal posture shouid be resumed and the needle withdrawn.

3.7 Broken needle

Breaks may arise from poor quality manufacture, erosion between the shaft and the handle, strong muscle spasm or sudden movement of the patient, incorrect withdrawal of a stuck or bent needle, or prolonged use of galvanic current.

If, during insertion, a needie becomes bent, it shouid be withdrawn and replaced by another. Too much force shouid not be used when manipuiating needles, particuiarly during lilting and thrusting. The junction between the handie and the shaft is the part that is apt ~o break. Therefore, in inserting the needie, onequarter to one-third of the shaft shouid always be kept above the skin.

If a needle breaks, the patient shouid be told to keep calm and not to move, so as to prevent the broken part of the needle from going deeper into the tissues. If a part of the broken needle is stili above the sidrì, remove it with forceps. If it is at the same level as the skin, press around the site gently until the broken end is exposed, and then remove it with forceps. If it is completely under the skin, ask the patient to resume his/her previous position and the end of the needie shaft will often be exposed. If this is unsuccessfui, surgical intervention will be needed.

 

 

Negligence in using strict aseptic techniques may cause local infection, especially in ear acupuncture therapy. When such infection is found, appropriate measures must be taken immediately, or the patient referred for medical treatment.

Needling shouid be avoided in treating areas of lymphoedema.

Burning of the skin shouid be prevented in indirect moxibustion. Although scarring moxibustion is performed by means of burning the skin so as to resuit in non-bacterial suppuration, this technique shouid only be used with the fuli knowledge and prior consent of the patient. It is a special therapeutic technique only performed at speclfic points

Direct moxibustion shouid not be applied to points on the face, or at sites where tendons or large blood vessels are located. Moxibustion with non-bacterial suppuration near a joint is also inappropriate because the joint movement may make healing difficuit. Special care shouid be taken in patients with reduced levels of consciousness, sensory disturbance, psychotic disorders, puruient dermatitis, or in areas of impaired circuiation.

Electricai stimuiation is potentially harmfui. It is contraindicated: in pregnancy; if the patient has a pace-maker; if there is lack of skin sensation; and in cases of impaired circuiation, severe arterial disease, undiagnosed fever or severe skin lesions.

Carefui monitoring of the electrical stimuiation is recommended to prevent neural injury. Galvanic current shouid be used for oniy a very short period of time.

Low energy laser therapy may harm the eyes and both patient and operator shouid wear protective glasses.

If administered correctly, acupuncture shouid not injure any organ. However, if injury does occur, it may be serious.

There are a great many acupuncture points, some which carry little or no risk and others where the potentiai of serious injury always exists, particuiarly in unskilled or inexperienced hands.

As training programmes in acupuncture are intended for different levels of personnel, it follows that they shouid be adapted to the knowledge, abilities and experience of those concerned. At elementary levels, the selection of acupuncture points shouid be limited. At professionai levels, the range can be expanded but, even so, the use of certain points and manipuiations shouid stili be restricted to those with great experience.

The following passages present examples of points which carry particuiar potential risk. As in all forms of treatment, it is important to measure risk against expected benefit.

Certain areas shouid not be punctured, for example: the fontanelle in babies, the external genitalia, nipples, the umbilicus and the eyeball.

Special care shouid be taken in neediing points in proximity to vital organs or sensitive areas. Because of the characteristics of the needles used, the particuiar sites for neediing, the depth of needle insertion, the manipuiafion techuiques used, and the stimuiation given, accidents may occur during treatrnent. In most instances they can be avoided if adequate precautions are taken. li they do occur, the acupuncturist shouid know how to manage them effectively and avoid any additional harm. Accidentai injury to an important organ requires urgent medical or surgica' help.

Chest, back and abdomen

Points on the chest, back and abdomen shouid be needled cautiously, preferably obliquely or horizontally, so as to avoid injury to vital organs Attention shouid be paid to the direction and depth of insertion of needies.

Lung and pleura

Injury to the lung and pleura caused by too deep insertion of a needie into points on the chest, back or supraclavicuiar fossa may cause traumatic pneumothorax. Cough, chest pain and dyspnoea are the usual symptoms and occur abruptly during the manipuiation, especially if there is severe laceration of the lung by the needle. Altematively, symptoms may develop gradually over several hours after the acupuncture treatment.

Liver, spleen and kidney

Puncture of the liver or spleen may cause a tear with bleeding, locai pain and tenderness, and rigidity of the abdominal muscles Puncturing the kidney may cause pain in the lumbar region and haematuria. If the damage is minor the bleeding will stop spontaneously but, if the bleeding is serious, shock may follow with a drop of biood pressure.

Central nervous system

Inappropriate manipuiation at points between or beside the upper cervical vertebrae, such as GV 15 yamen and GV 16 fengfu may puncture the medulla oblongata, causing headache, nausea, vomiting, sudden slowing of respiration and disorientation, followed by convuisions, paralysis or coma. Between other vertebrae above the first lumbar, too deep needling may puncture the spinal cord, causing lightning pain felt in the extremities or on the trunk below the level of puncture.

Other points

Other points which are potentially dangerous and which therefore require special sIdii and experience in their use include:

• BL 1 jingming and ST 1 chengqi, located close to the eyeball;

• CV 22 tiantu, in front of the trachea;

• ST 9 renying, near the carotid artery;

• SP 11 jimen and: SP 12 chongmen, near the femoral arterv; and
• LU 9 taiyuan on the radial artery

Care shouid be taken in neediing areas of poor circuiation (e.g. varicose veins) where there is a risk of in£ection, and to avoid accidental puncture of arteries (sometimes aberrant) which may cause bleeding, haematoma, arterial spasm or more serious complications when pathological change is present (e.g aneurysm, atherosderosis). Generally, bleeding due to puncture of a superficial blood vessel may be stopped by direct pressure.

Patient records shouid contain fuli details of the medical history, clinical findings, diagnostic data, treatment plan and the response to treatment. They shouid be regarded as confidential.

Sterilizafion is defined as the destruction of all microbes, including bacteriai spores (Bacillus subtilis, Clostridium tetani, etc.). High-level disinfection is defined as the destruction of all microbes, but spores may survive if initially present in large numbers.

Steam sterilization is the most widely used method for acupuncture needles and other instruments made of metal. It is nontoxic, inexpensive, sporicidal and rapid if used in accordance with the manufacturer's instructions (e.g. time, temperature, pressure, wraps, load size and load placement). Steam sterilization is only fuily effective when free from air, ideally at 100% saturated steam. Pressure itself has no influence on sterilization, but serves as a means of obtaining the high temperatures required.

Dry heat can also be used for sterilìzing needles and parficularly for sterllizing materials that might be damaged by moist heat, but it may cause the needle to become brittle. It requires higher temperatures and longer sterilizafion times.

Recommended sterilizing temperatures and times for steam under pressure, and for dry heat, are shown in the table below.

Instruments made of rubber or plastic which are unable to stand the high temperature of an autoclave can be sterilized chemically, at appropriate concentrations and ensuring adequate immersion times (e.g. 6% stabilized hydrogen peroxide for six hours).

For cupping, it is recommended that glass rather than rubber or plasfic cups should be used since glass can withstand the bigher temperatures required for sterilization.

It shouid be noted that bolling needies in water is not sufficient for sterilization, nor is soaking in alcohol, since these methods do not destroy resistant bacterial spores or certain viruses.

A high level of disinfection is achieved when instruments are boiled for 20 minutes. mis is the simplest and most reliable method of inacfivating most pathogenic microbes, including HìV, when sterilization equipment is not available. Bolling shouid be used only when sterilization by steam of dry heat is not available. Hepatitis B virus is inactivated by boiling for several minutes; HIV, which is very sensitive to heat, is also inacfivated by boiling for several minutes. However, in order to be sure, boliing should be continued for 20 minutes.

Chemicai disinfection is used for heat-sensifive equipment that may be damaged by high temperatures. Most disinfectants are effective against a limited range of microorganisms oniy and vary in the rate at which they destroy microorganisms. Items must be dismantled and fully immersed in the disinfectant. Care must be taken to rinse disinfected iterns with clean water so that they do not become recontaminated. Chemical disinfectants are unstable and chemicai breakdown can occur. They may also be corrosive and irritating to sItin. Protective clothing may be required. Chemical disinfection is not as reliable as boiling or sterilizafion. The agents include:

• Chlorin-based agents, e.g., bleach
• aqueous solution of 2% glutaraldehyde
• 70% ethyl or isopropyl alcohol.

(Source: WHO - GPA/TCO/HSC/95/16 p.16 and WHO AIDS Series 2, 2nd edition, p.3, 1989.)

All sterilizers shouid be checked periodìcally. The sterilizer should be loaded in accordance with the manufacturer's instructions, with enough air space between packages to permit the proper circuiation and penetration of steam or hot air. The effectiveness of sterilization shouid be reguiarly checked with biologicai indicators, autoclave control indicators or such other tests as may be devised to ensure that the contents of the load have been subjected to sterilizafion conditions.

Use of a new pattern of sterilizing box to contain needles is recommended. The box is made of a speciai kind of metai sensitive to heat, with air holes that open automatically under high temperature, and dose when the temperature falls below 75⁰C.

Dr Steven K.H. Aung, President, World Natural Medicine Foundation, "Natural, Integrated and Compassionate Medicine for All", 9904-106 Street, Edinonton, AB TSK 1C4, Canada.

Dr Jean Bossy, Professeur des Universités, Service d'Explorations Fonctionnelles du Système Nerveux et Acupuncture, Centre Hospitalier Universitaire, G. Doumergue, Boite Postale 26, 5 rue Hoche, 30029 Nimes, France.

Dr Joseph M. Helms, Founding President, American Academy of Medical

Acupuncture, 2520 Milvia Street, Berkeley, California 94704, United States of America.

Dr Sung-Keel Kang, Chairman, Department of Acupuncture & Moxibustion, College of Oriental Medicine, Kyung Hee University, No. 1 Hocki-dong Tongdaemun-ku, Seoul 130-702, Republic of Korea.

Professor Kenji Kawakita, Department of Physiology, Meiji College of Orientai Medicine, Hiyoshi, Funai, Kyoto 629-03, Japan.

Dr Petrus Gito Mario, Chief of Traditional Health Manpower Section, Ministry of Health, J'. H.R. Rasuna Said Kav. X.5 No.: 04 s/d 09, Jakarta 12950, Indonesia.

Dr Emilio Minelli, President, Italian Society of Acupuncture, Via Schiaparelli 17, 20125 Milan, Italy.

Professor Carole Rogers, Head, University of Technology, UTS College of Acupuncture, Department of Health Sciences, Facuity of Science. P.O. Box 123, Broadway, NSW 2007, Australia.

Professor Umberto Solimene, Università Degli Studi di Milano, Istituto di Anatomia Umana Normale, Catedra di Idrologia e Climatologia Medica I, Centro di Ricerche in Bioclimatologia Medicina, Via Cicognara, 7, 20133 Milan, Italy.

Dr zhu-Fan Xie, Former Director of Institute of Integrated Medicine, First Hospital, Beijing Medical University, 1, Xi An Men Street, Beijing 100034, People's Republic of China.

Dr Li Yutang, Director, Acupuncture Institute, Nanjing University of Traditional Chinese Medicine, 282 Hanzhong Rd, Nanjing 210029, People's Republic of

China.

 

Secretariat

Dr Xiaorui zhang, Medicai Officer, Traditionai Medicine, Action Programme on Essentiai Drugs, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland.

Mme Maryse Cestre, Secretary, Traditionai Medicine, Action Programme on Essentiai Drugs, World Health Organization, Avenue Appia, 1211 Geneva 27, Switzerland.