Getting stuck with needles sounds more like torture than a medical treatment. But there's evidence that acupuncture, a standard health practice in Asia, helps relieve pain. Should you try it for arthritis?

The Chinese therapy of acupuncture has been used for millennia to treat a range of ailments. Now it looks like Western medicine is getting the point.

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Acupuncture has become one of the most popular and accepted unconventional therapies within the United States. An estimated 15 million Americans have tried this needle therapy. It's offered in many chronic pain clinics, and is covered by some insurers and managed heath organizations. The World Health Organization recommends it for more than 40 conditions as diverse as asthma and chronic pain. The Food and Drug Administration regulates acupuncture needles as medical devices, the same as it does surgical tools. And in 1997, a National Institutes of Health panel found acupuncture to be an acceptable treatment for many pain conditions, including fibromyalgia and general musculoskeletal pain. And, no, it usually doesn't hurt after an initial "pinch" or sting. So it's no surprise that some rheumatologists are suggesting acupuncture, along with more conventional treatments, to their arthritis patients and a few even give acupuncture treatments themselves.

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"It's really almost mainstream now," says Stuart S. Kassan, MD, a rheumatologist in private practice in Denver who became an acupuncturist in 1996. "It's safe when done properly, and can be very helpful for pain."

However, Dr. Kassan says, many doctors do remain skeptical. "Some roll their eyes and say they can't believe I'm doing acupuncture," he says. "But rheumatologists see a lot of patients with problems we can't do anything about, especially chronic pain. We all become very frustrated. And this is where acupuncture makes its greatest impact: with patients who have failed conventional treatment."

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Don L. Goldenberg, MD, chief of rheumatology at Newton-Wellesley Hospital and professor of medicine at Tufts University School of Medicine in Boston, agrees. fibromyalgia specialist, he often works in conjunction with a medical doctor trained in acupuncture, which he finds often gives good results when used in addition to more conventional treatments. "Acupuncture clearly can help lots of chronic pain issues, including fibromyalgia," he says.

But it doesn't work for everyone. "Some people respond spectacularly, but not all," says Wendell Hatfield, MD, a Denver rheumatologist who is also a trained acupuncturist. "And as with all treatments for chronic conditions, it's not a cure. It helps control the symptoms."

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WHAT IS ACUPUNCTURE?

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Acupuncture is the use of fine needles inserted into the skin at precise points. It originated in China thousands of years ago, and is based on the theory that an essential life energy called qi (pronounced chee) flows through the body along invisible channels, called meridians. When the flow of qi is blocked or out of balance, illness or pain results. Stimulation of specific points along the meridians can correct the flow of qi to restore or optimize health, or to block pain, according to Chinese theory.

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The "acupoints" can also be stimulated with heated herbs (called moxibustion), magnets, mild electrical current (electroacupuncture), manual pressure (acupressure), low-frequency lasers, or even bee stings. A traditional Chinese medicine practitioner may also offer herbs along with lifestyle advice. (See "What Happens in an Acupuncture Treatment" below).

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Western scientists don't know exactly how acupuncture works. However, some acupoints correspond to areas, called trigger points, that are known to be rich in nerve endings, and studies show stimulating acupoints causes multiple biologic responses. Such stimulation can prompt a cascade of chemicals in the muscles, spinal cord and brain that releases the body's natural pain-killing endorphins, and can also affect circulation and other bodily systems.

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WHAT THE RESEARCH SHOWS

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Acupuncture has been described in thousands of writings throughout the centuries. Among the many recent studies are several that show it relieves osteoarthritis symptoms so well in one Scandinavian study that 25 percent of patients previously scheduled for knee surgery canceled their plans. That same study showed booster treatments once a month sustained the pain relief.

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Other studies have shown that acupuncture helps relieve pain from fibromyalgia and osteoarthritis; can decrease the number and severity of Raynaud's phenomenon attacks; helps ease conditions that can accompany arthritis such as depression and irritable bowel syndrome; and enhance conventional treatments for gout, when used in a combined therapy.

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However, a 1997 meta-analysis of 17 studies that looked at acupuncture in inflammatory diseases such as rheumatoid arthritis, spondylarthropathy, lupus and local and progressive systemic scleroderma found the studies failed to show the effectiveness of acupuncture for these conditions.

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Furthermore, many studies are not published in English and few acupuncture studies meet rigorous scientific standards. A 1999 analysis of studies that looked at acupuncture for fibromyalgia, for example, found seven that suggested it relieves pain, reduces morning stiffness and may improve sleep, but only one of those studies was considered to meet high scientific standards, says Brian Berman, MD, director of the Complementary Medicine Program (CMP) at the University of Maryland in Baltimore.

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Dr. Berman, who also practices acupuncture, says more and better studies are needed to measure the effects of acupuncture. The CMP has three NIH-funded studies underway looking at acupuncture and both osteoarthritis and post-operative pain.

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WHAT THE EXPERTS SAY

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There's enough research to suggest acupuncture relieves pain for some, and that it is safe when performed by a trained professional using sterile or disposable needles.

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Acupuncture appears to work best on fibromyalgia and soft-tissue pain, and to be least effective for rheumatoid arthritis or other systemic inflammatory conditions, doctors say. Relief is often temporary, and treatments can be time-consuming and expensive.

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"If asked, I encourage patients to try it and make up their own minds as to its usefulness," says Robert Bennett, MD, professor of medicine and chairman of the division of arthritis and rheumatic diseases at Oregon Health Sciences Center in Portland. "

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Acupuncture may not be covered by your insurance, even if given by a medical doctor. Costs vary across the country, but generally a first visit runs $75 to $150, with follow-up visits between $35 and $75. In the beginning, acupuncture's pain-relieving effects may last a week or less, Dr. Kassan admits. "But after four or five weekly treatments, many patients find they can progressively decrease the frequency and end up with monthly treatments. It may also decrease the need for pain medications."

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Other advocates believe acupuncture's effects may go beyond temporary pain relief. "Acupuncture is a stimulus that can help re-pattern the body and help break the chronic pain syndrome," says Ka-Kit Hui, MD, an internist and clinical pharmacologist who is director of the integrated Center for East-West Medicine at the University of California, Los Angeles. It can also stimulate circulation and people can be taught acupressure massage to help themselves, he says.

One thing experts concur on is that acupuncture won't cure arthritis. "Acupuncture doesn't replace conventional medicine," says Dr. Hatfield. "But it adds another dimension beyond what we have now."

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GOOD ADVICE

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Acupuncture is generally safe, but as with any therapy, conventional or alternative, you should observe some precautions.

Choose a therapist who is licensed and/or a graduate of a respected school of acupuncture, and who is willing to work with your doctor. Some 10,000 acupuncturists currently practice in the United States and most are regulated by the state in which they reside. About 4,000 doctors have completed a recognized acupuncture-training program.

Get a diagnosis from a medical doctor before undergoing acupuncture, to make sure you don't have a condition requiring prompt medical attention.
Don't stop your medications without consulting your doctor. Acupuncture works with, not instead of, conventional medicine.

Tell the acupuncturist about all health conditions, including pregnancy; and list all medications (including herbs and non-steroidal anti-inflammatory drugs that could cause you to bleed, for example).
Be sure the acupuncturist uses sterilized or disposable needles.

Don't take muscle relaxants, tranquilizers or painkillers right before acupuncture, as acupuncture may intensify the effects of these drugs.
Keep notes about your response to the treatment, and tell your doctor and acupuncturist about any changes.

Track your progress. If you have no response at all after four to six sessions, this therapy may not work for you. Or you may want to try another therapist, because, as in any therapy, skill levels vary.