This is a book about the modern medical version of acupuncture, often called Western medical acupuncture (WMA) which is widely practised by health professionals today. It is the second edition of the work (the first appeared in 2008) and is described as a companion to Medical Acupuncture: A Western Scientific Approach (Elsevier, Edinburgh, 2016), now also in its second edition. The authors are all among the foremost proponents of WMA in Britain and so are well placed to produce a book of this kind.
Its primary intended audience is health professionals who have recently completed a training programme in modern acupuncture and want to consolidate and extend their knowledge of the subject. But it will also interest more experienced practitioners, because it includes a large amount of up-to-date research evidence for acupuncture that is otherwise not easy to find gathered together in an accessible form.
The book has 19 chapters. Chapter 1 is an introduction and provides a description of WMA and how it differs from traditional Chinese medicine (TCM). The remaining chapters are divided into five sections: 1. Principles; 2. Effects Mechanisms Techniques; 3. The Evidence Base; 4. Practical Aspects; 5. Treatment Manual. There are also five detachable cards illustrating classical acupuncture points, myofascial trigger points, and pain referral zones. As this summary will indicate, there is a progressive shift in focus throughout the book, from evidence for acupuncture as a science-based treatment to the practical aspects, but this is not a rigid separation and even the more research-oriented sections bring out the practical implications of what they describe.
I shall now look at the individual sections in more detail.
Section 1 has three chapters (Chapters 2–4). The first is a preliminary overview of what WMA is and how it is thought to work. Acupuncture is mainly although not wholly a treatment for pain, and Chapter 3 looks at the modern understanding of pain mechanisms in the nervous system and how these relate to acupuncture. Chapter 4 describes some basic acupuncture techniques, to be elaborated later.
Acupuncture modernists always have to decide where they stand on the question of classical acupuncture points. Some, of whom I am one, prefer to avoid that terminology almost completely, but here the authors do use it, although with reservations. 'This book uses classical acupuncture point names as a convenient convention, though each point's effects are not as specific as traditionally believed, and nerves may be stimulated effectively almost anywhere in the body.'
What I found particularly welcome both in this section and throughout the book is the absence of dogmatism. The authors state their views but they recognise the existence of different approaches to treatment within the broad scope of modern medical acupuncture: 'nothing in acupuncture should be standardized—except safety.'
Section 2 is concerned with the mechanisms of acupuncture—how it works. A lot of new research on the question has become available since the first edition in 2008. The physiological mechanisms are discussed under a number of headings: local effects, segmental (spinal) effects, and general (central) effects. There is too much information here to summarise in a review, but this is an important section because it provides much of the support for the authors' treatment recommendation in later chapters.
This section includes a description of myofascial trigger points (MTrPs), which figure prominently in WMA. This is particularly useful for doctors, who are unlikely to have encountered the subject in their ordinary clinical training. It is treated here both theoretically and practically, including an account of how to diagnose and treat MTrPs.
The concluding chapter in this section is on traditional Chinese medicine (TCM). There is a succinct account of the ancient ideas and the authors consider how relevant, if at all, TCM concepts are to modern practice. 'A rational approach based on knowledge obtained scientifically can explain many of the concepts of TCM.'
The authors provide a fair summary of TCM but I question whether it is still necessary to include it in a book on WMA. I think we are rapidly approaching, or have already passed, the point where the subject can be regarded as of purely historical interest, in which case it could be omitted or at least relegated to an appendix.
Physiology is important in modern acupuncture but we also need clinical evidence of efficacy, and this is the subject of Section 3. Critics sometimes claim that acupuncture is 'just a placebo' because many trials find little or no difference between 'real' and 'sham' acupuncture. But this begs many questions, especially the problem of what constitutes a 'sham' acupuncture treatment. The authors show convincingly why it is so difficult to devise an adequate placebo treatment in acupuncture. Nor is this the only practical difficulty that attends clinical trials in this field. For example, 'blinding' of patients can be difficult (blinding of the practitioner is all but impossible). In spite of these difficulties there is good evidence of efficacy in at least some disorders.
Safety is a literally vital consideration in acupuncture and Section 3 concludes with a chapter reviewing the evidence on this question. The authors find that acupuncture is generally safe if done by adequately trained practitioners and is usually safer than most other treatments that are available. Aggravation of symptoms may occur but is seldom severe and is certainly not required for effective treatment, as is sometimes claimed, so the risk should be reduced as much as possible.
Questions of safety again figure prominently in Section 4. The first three chapters in this section (14, 15, 16) 'are essential reading for clinical practice'. They cover preparing for treatment, effective needling techniques, and safe needling. All the safety issues mentioned here are incontrovertible, but (as noted earlier) there is room for discussion about some of the techniques described.
For example, the authors advise the use of guide tubes for beginners because they make needle insertion easier. This is true, but many experienced acupuncturists dislike guide tubes and don't use them, and I'm not sure that it is necessary to impose them on beginners. I think that most newcomers to acupuncture quickly learn to insert the needles without them, at least the standard (30mm) needles; the longer (50mm) needles are probably best used with guide tubes, at any rate to start with.
On the question of how long the needles should be left in situ ('retention'), there is a widespread idea that this should be 20 minutes, and the authors think that this may be because it takes this length of time for beta-endorphin levels to reach a maximum in the central nervous system. However, they think that 10 minutes is often long enough for a clinical response. I should say that much briefer insertion is usually effective in most cases, and the authors do acknowledge the use of this technique by some practitioners. Needle retention is probably one of the most widely debated subjects in acupuncture.
The concluding chapter in Section 4 deals fairly briefly with other techniques often bracketed together with acupuncture, such as moxibustion, auricular acupuncture, and the use of lasers. The authors find little advantage in embarking on most of these.
Section 5 is a 'Treatment Manual' describing various possible approaches to try in different disorders. To avoid any misunderstanding, the authors emphasise that this section only makes sense if you have read everything that precedes it; they are not providing 'recipes' or rules to be followed without thought. 'You have discovered the principles of acupuncture in the previous chapters; here you find some guidelines to point you in the right direction.'
The book is very well produced, with abundant diagrams, and is written in an approachable style that makes it easy to read. Each chapter begins with headlines summarising its contents to indicate what the student should learn by reading it, and concludes with a useful review of its main message.
Some acupuncture enthusiasts want to emhasise what they perceive as its differences from mainstream medicine. The alternative view is that acupuncture should be reinterpreted in the light of modern knowledge and integrated with mainstream methods of treatment, and that is the present authors' opinion. 'It is time to reconsider acupuncture and its strange phenomena in ways that are credible to Western science.'