Did you know that some massage therapists use acupuncture?
Registered Massage Therapists in Ontario are in a unique position, because of our high education standards we are afforded the opportunity to perform the modility of acupuncture for soft tissue injuries. In Ontario massage therapist take a accredited 2200 hour massage therapy program then they register with the College of Massage Therapists of Ontario (CMTO). After that, if a massage therapists chooses they can take a professional certification in acupuncture from any program recognized by the CMTO, for those who would like to learn more about the details of certification, I have provided links and excerpts from our regulatory body at the bottom of the post.
My experience with acupuncture started in 2010 after taking the 300 hundred hour Contemporary Medical Acupuncture for health professionals at McMaster University. This continuing education programs is an opportunity for massage therapists to study alongside physicians, chiropractors, physiotherapists and osteopaths. The course covers safe needling techniques, advanced assessment and treatment techniques, cadaver workshops, and provides an in depth examination of the biopsychosocial experience of pain.
Does Acupuncture Work?
Acupuncture faces a lot of skepticism, as it should, acupuncture has a long history that is not void of conceptualization error. Scientific knowledge has advanced our understanding of the human form and function, this has lead to a therapists and schools that have provided us with a reconceptualization of acupuncture, one of these being contemporary medical acupuncture. Building off some of these new models of acupuncture there is now literature that suggests that acupuncture works for some injuries including: low back pain, tension type headaches, neck pain and migraines.
Why Does Acupuncture Work?
If you use Occam's razor, acupuncture is a form of novel stimuli sending anti-nociceptive input to the central nervous system. This contributes to a number of neurophysiological changes across different areas of the peripheral and central nervous systems, including peripheral receptors, dorsal horn of the spinal cord, brainstem, sensorimotor cortical areas, and the mesolimbic and prefrontal areas.
Is Acupuncture a Placebo?
The existence of placebo-induced effects don't negate treatment-induced results, the meaning response, therapeutic alliance, ritual and context all play into the effects, the magnitude of a response may be influenced by mood, expectation, and conditioning. The placebo response is real and it is effective, which is why some may overlook other subtle physiological response such as sensory gating.
In my humble opinion acupuncture is more than a placebo, a 2012 Meta-analysis published in The Archives of Internal Medicine examined the role of acupuncture for patients with chronic pain. In this paper researchers looked at all accumulated randomized controlled trials, examining how acupuncture fared in treating people with chronic pain, what it found was acupuncture often worked better than no acupuncture control groups. The meta-analysis also concluded that there were significant differences between acupuncture and sham acupuncture. This to me would suggest that not all benefits are placebo, and that patients likely have a complex physiological response to acupuncture that INCLUDES but is not LIMITED to placebo.
In part two I will delve deeper into the physiology behind acupuncture, my hopes is that we can work together to clear up misconceptions about the modality of acupuncture.
Links for the curious
By choice, this is not a skeptical series on acupuncture, this post is deigned to bring some balance to the conversation and fill in some gaps. There are already a number of skeptical articles about acupuncture, so if you would like to read them please follow these links below.
• Acupuncture Doesn’t Work
• Does Acupuncture Work for Pain?
Joint Fact Sheet from the RMTAO and the CMTO:
Acupuncture Treatment Provided by Registered Massage Therapists
Is Acupuncture within the Scope of Practice for a Registered Massage Therapist in Ontario?
"Yes, an RMT may use acupuncture as part of their massage therapy treatment. Massage Therapy is the assessment of the soft tissue and joints of the body, the treatment and prevention of physical dysfunction and pain of the soft tissues and joints by manipulation to develop, maintain, rehabilitate or augment physical function, or relieve pain. An RMT must first conduct an assessment and determine if acupuncture is an appropriate treatment for the client’s condition. If so, the RMT will incorporate acupuncture into the treatment plan and it becomes a modality or tool used in treatment. The treatment provided is deemed Massage Therapy and is not considered stand-alone acupuncture.”
What is meant by a “modality”?
“A modality is a type of treatment or a tool used to treat a condition. There are a number of modalities that can be integrated into a Massage Therapy treatment plan that are taught outside of the entry to practice competencies. These include, but are not limited to: acupuncture, manual lymph drainage, ART, Aquatic Massage Therapy, and other similar forms of manual therapy.”
Screening for risk factors and other underlying conditions and asking for feedback from the patient during treatment are very important to ensure a safe and positive outcome for the patient. Any clinician who inserts needles in the chest wall must be educated in the risk, needle techniques, and deep anatomy. There are inherent risks with acupuncture, this includes the risk of infection and risk of pneumothorax but with appropriate training and caution this risk is very minimal. Treatments involve informed consent and the disclosure of literature, is both the patient and therapist are educated on the risks and benefits then the intervention may be an appropriate choice.
The Physiology of Acupuncture
Kagitani, F., Uchida, S., & Hotta, H. (2010). Afferent nerve fibers and acupuncture. Autonomic Neuroscience, 157(1-2), 2-8.
* This article reviews the experimental evidence showing that the effects of acupuncture are mediated by the activation of afferent nerve fibers innervating the skin and muscles.
Lund, I., & Lundeberg, T. (2015). Effects triggered in the periphery by acupuncture. Acupuncture and Related Therapies, 3(2-3), 24-34.
Min, S., Lee, H., Kim, S., Park, J., Chae, Y., Lee, H., & Park, H. (2015). Local Changes in Microcirculation and the Analgesic Effects of Acupuncture: A Laser Doppler Perfusion Imaging Study. The Journal of Alternative and Complementary Medicine, 21(1), 46-52.
Moerman, D. E. (2002). Deconstructing the Placebo Effect and Finding the Meaning Response. Annals of Internal Medicine Ann Intern Med, 136(6), 471.
Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders. Physical Therapy, 95(11), 1582-1591.
Zhang, R., Lao, L., Ren, K., & Berman, B. M. (2014). Mechanisms of Acupuncture–Electroacupuncture on Persistent Pain. Anesthesiology, 120(2), 482-503.
* This article is very detailed and shows the effects that acupuncture and electroacupuncture have on peripheral, spinal, supraspinal, and central structures and their relations with bioactive chemicals involved in attenuation or control of pain, such as opioids, serotonin, norepinephrine, amino acids, cytokines among others.
The Efficacy of Acupuncture
Berkman, R. (1999). Percutaneous Electrical Nerve Stimulation for Treatment of Low Back Pain. JAMA: The Journal of the American Medical Association, 282(10), 941-942.
Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., Macpherson, H., Foster, N. E., . . . Collaboration, F. T. (2012). Acupuncture for Chronic Pain. Arch Intern Med Archives of Internal Medicine, 172(19), 1444.
* This article examines the role of acupuncture for patients with chronic pain. In this paper researchers looked at all accumulated randomized controlled trials in examining how acupuncture fared in treating people with chronic pain, it concludes that “Not only did acupuncture work better than no acupuncture control groups, there were significant differences between acupuncture and sham acupuncture.” (This would suggest that not all benefits are placebo)
Vickers, A. J., & Linde, K. (2014). Acupuncture for Chronic Pain. JAMA, 311(9), 955.
Wu, M., Chen, K., Chen, I., Huang, S. K., Tzeng, P., Yeh, M., . . . Chen, C. (2016). The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLOS ONE, 11(3).
Yang, Y., Que, Q., Ye, X., & Zheng, G. H. (2015). Verum versus sham manual acupuncture for migraine: A systematic review of randomised controlled trials.Acupunct Med Acupuncture in Medicine.
Furlan, A. D., Tulder, M. W., Cherkin, D., Tsukayama, H., Lao, L., Koes, B. W., & Berman, B. M. (2005). Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews Reviews.
Linde, K., Allais, G., Brinkhaus, B., Manheimer, E., Vickers, A., & White, A. R. (2009). Acupuncture for tension-type headache. Protocols Cochrane Database of Systematic Reviews.
Trinh, K., Graham, N., Gross, A., Goldsmith, C. H., Wang, E., Cameron, I. D., & Kay, T. M. (2006). Acupuncture for neck disorders. Cochrane Database of Systematic Reviews Reviews.
Linde, K., Allais, G., Brinkhaus, B., Manheimer, E., Vickers, A., & White, A. R. (2009). Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews Reviews.