Hi everyone, I'm so excited to welcome you to this presentation that we put together pre-recorded for you for AAPMNR. The title is To The Point, Evolution, Evidence, and Experience of Acupuncture. Myself and two of my co-members from the AAPMNR fit board are here with me today as session directors, Dr. Bonnie Wong and Dr. Charlene Su. And then we're really excited to be welcoming three faculty members from all over the country at the conclusion of the slides to do a panel discussion based on questions that have arisen from us, from other people we know interested in acupuncture, and we also opened it up to Twitter and Facebook before we recorded this. So I'm really excited, let's jump into this. So we had four goals and objectives for this talk today. The first was to just define acupuncture and list three of the basic principles, to describe at least two mechanisms of action in the way that acupuncture works, to list two evidence-based acupuncture indications in PMNR practice, and finally to list two different acupuncture training programs that are available to physiatrists. So I wanted to just talk about acupuncture a little bit more broadly in terms of just traditional Chinese medicine, which is a broad range of disciplines that includes acupuncture, but also different disciplines such as massage, Chinese herbal medicine, and different kinds of exercises. And I wanted to talk about this because all of these practices have shared common concepts. And the first is something called Yin-Yang theory, which is looking at the same thing but in two different aspects. Yin-Yang represents the duality of nature. Yang is active, bright, hot, and Yin is inactive, dark, and cold. And the traditional Chinese medicine theories say that when you have an imbalance of these two, that's what leads to illness. And a second shared concept, in addition to Yin-Yang theory, is something called the theory of five elements. So it states that there are five elements, which are wood, fire, earth, metal, and water, and these kind of represent five categories of things in the natural world. And there can be normal or abnormal interactions between them, and again, when you have these abnormal interactions, that's what leads to illness. So just generally, what is acupuncture? We have a picture of it here, and it's the practice of inserting fine needles through the skin at specific designated points for pain relief and or to treat disease. And so there's a few basic principles of acupuncture that we want to talk about. So first is something called the Zhang-Fu theory, which is the classification of internal organs. And you have a picture off to the right showing you the Zhang organs and the Fu organs. And so Zhang, the Zhang organs are ones that are Yin in nature, and the Fu refers to Yang kind of in nature. And the second principle is something called Qi, which is matter and energy that flows along channels or meridians. It's the most active of the body's substances. It's also kind of talked about with blood and different body fluids, but Qi is considered to be the most active one. And if you have, again, these imbalances of Qi, in theory those can be corrected with acupuncture. And the third basic principle, and this is sort of the most important I would argue, is knowing the meridians. And so these are meridians that are pathways that carry the Qi throughout the body. And so there's considered to be 12 regular and 8 extra. And they can become blocked during any sort of disease process. And so when you are inserting needles, what you're looking for is the patient to report something called Da Qi, which is the sensation along the channel. It can feel like a heaviness, like a tingling, an aching, a pressure, and it is thought to be due to the polarization and ionization of pathway tissues. And so there are different meridians that, between those and a few extra points, there's a total of 361 acupoints. And so here you can see the stomach meridian over to the right of the screen. And this is one of the longest meridians that tracks over the entire body. And then for comparison, we put here the lung meridian, which is actually pretty short, not that many points compared to the stomach meridian, and it just runs basically along the arm. And so in terms of just, you know, what is an acupuncture point, how do you know where to put the needles? Is there something about the acupuncture points that makes them different? And there is. In fact, it's been studied. There's actually a palpable surface depression. So when you're running your fingers and you're measuring where the points are, you can actually feel the skin depress a little bit. They've looked at kind of the surface conductance and they found that there's decreased electrical resistance and there's also increased conductance. These points are hypersensitive in a lot of people, which means they might have more pain just from pressing or palpating over these points, and they actually have a higher temperature. And a lot of the times they correspond to different nerve endings. And so we have it italicized at the bottom here, but in terms of when you're inserting the needle, we talked about that da qi. So you're you're putting it at a depth where you want to elicit that da qi, and it depends on which point, but usually it's a half a centimeter to 0.8 of a centimeter. And so how does acupuncture work? There are many theories that have evolved over time, and as the research has improved, the first slide we're going to talk about talks about some of the ones that have been described in the past and are sort of not falling out of favor, but are getting replaced by kind of the new or more exciting research that's been going on. So all of them are sort of based on the fact that when you stimulate an acupuncture point, this causes biochemical changes that affect the body's natural healing abilities. So the first one is the humoral theory. And so this is saying that basically when you do acupuncture, you're affecting the release of endorphins, norepinephrine, serotonin, ACTH, different endocannabinoids. There's also the gait control theory, which most of us in PMNR are familiar with. And so this is saying that acupuncture acts via synaptic inhibition at the spinal cord level. And then the third part is something called electroacupuncture, when you use a machine that is similar to a TENS machine and you connect it to the needles. And what they found is that lower frequencies with high intensities, it can actually affect the release of endorphins. And then at high frequencies but at a lower intensity, acupuncture can act via the gait control theory and release of serotonin and norepinephrine. So moving into some of the newer theories, these are newer because they're taking advantage of really exciting research techniques such as fMRI. So the first one is there's cortical effects that the fMRI studies have shown. You see changes in cerebral blood flow before and after acupuncture in the somatosensory regions, but also in the affective and cognitive processing regions. And you also see kind of scaling back and going to the local level, a release of adenosine and resulting activation of the A1 receptors. And this has been shown in both animal and human studies. And so, you know, a lot of people ask about the safety and adverse effects of acupuncture. And, you know, we're gonna hear from our panelists in a bit. This is one of the safest treatments that we can offer our patients. The FDA regulates the manufacturing use of needles and requires single-use needles to remain sterile. And in terms of the most common side effects, they're pretty mild. A little bit of fatigue, you might get local pain at the site of the acupuncture needle insertion, maybe headache or dizziness. And of course, you know, the technique is going to rule all here. If you have a practitioner who has poor technique, they may leave retained needles in, but as long as you're kind of counting the needles you're putting in and taking out, this should be very easily avoidable. And just, we wanted to finish up with some of the relative contraindications to acupuncture. And I put relative in brackets because there really are very few contraindications to acupuncture. So pregnancy is not a contraindication. It can be done. There are just certain points that you need to be aware of to avoid because they can actually induce labor. If a patient is on blood thinner, again, this isn't a contraindication per se, but it's just more of a to be aware of and it might just cause them to have maybe a larger hematoma at the site of acupuncture. Extreme debility is one that I would say is a stronger contraindication. You know, acupuncture is actually likened to like running three miles or going to the gym and working out. And so, you know, we tell our patients to sort of take it easy after they get a treatment that day. And patients who are really deconditioned or debilitated, they just might have a harder time tolerating the treatment. And then patients who have a pacemaker and or an IUD, depending on where you're doing the acupuncture, that might be a contraindication as well. And definitely for STEM. And so that's the end of my talk. I'm gonna pass it over to my colleague, Bonnie, and she's gonna take over here. Thank you. Thanks, Rosa. So now that we've heard about kind of the theories, the mechanism, the action of acupuncture, how can we, as physiatrists, utilize acupuncture in our clinical practice and what are some common indications? So acupuncture is most commonly used for pain, but there are a variety of other symptoms, conditions, diagnosis, diseases that acupuncture can also be used for. So according to the NIH consensus statement, they noted that there was clear evidence of the benefit of acupuncture for post-operative, as well as chemo-related nausea, vomiting, and post-operative dental pain. However, they also stated that acupuncture may be effective as a standalone or adjunctive therapy for a lot of the things that we see as physiatrists, such as stroke rehab, headache, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, and carpal tunnel syndrome. And as you can imagine, you know, researching acupuncture is extremely challenging for a variety of reasons, including just kind of the difficulty of understanding and applying this Eastern treatment, Eastern philosophy, traditional Chinese medicine, to our Western diagnoses. In addition, creating or designing a strong study design with an appropriate control group, you know, whether or not sham acupuncture is really an appropriate control group, as well as kind of the lack of standardized treatment interventions. You know, there's many different types of acupunctures. There's many different schools of thoughts, philosophies of acupuncture, and so when you look at studies of acupuncture, you know, there's different techniques, different types, even the frequency and duration of treatment is different. So it's really hard, and all of this makes it difficult to really study acupuncture. However, you know, especially in recent years, there has been more research done in acupuncture, and evidence is good for low back pain and knee osteoarthritis. They're two common conditions that we see often in clinic, and we'll kind of dive into the evidence behind both low back pain and knee osteoarthritis. So as we know, so for chronic low back pain, you know, it's a leading cause of disability. It has huge economic impact worldwide, and so I thought it was a really important step, and an exciting thing that some of you may know, but that CMS recently announced earlier this year, their decision to cover acupuncture for Medicare patients with chronic low back pain. So many patients who've had low back pain for 12 weeks or longer, and not due to any other kind of systemic cause. And so this decision was really based on kind of their own review of recent meta-analysis, systematic reviews, looking at consensus statements, guidelines, expert opinions, as well as, you know, a way that to combat the opioid crisis in the United States. So they felt that acupuncture was a relatively safe procedure, like what Rosa mentioned, and that there was sufficient evidence to support the use of acupuncture in patients with chronic low back pain. And so Medicare does allow up to 12 visits in 90 days, and then depending on if patients are benefiting from acupuncture, they can add, or we can add an additional 8 visits for a maximum of 20 treatments per year. So let's look at a little bit, some of the studies looking at chronic low back pain and acupuncture. So this is an article published in the New England Journal of Medicine in 2010, and this article basically summarized that from previous research, it seems like real acupuncture may have the same effects as sham acupuncture, but regardless, real or sham acupuncture seem to be better than no acupuncture or conventional treatment. There's many areas of uncertainty, including, you know, how much of this is just the placebo effect, what are the psychosocial factors that play a role into this, such as, you know, patients' beliefs and expectations that their pain will improve with acupuncture, or how much, you know, just having increased attention, increased time with a physician, a practitioner, you know, plays a role into this, the effect that acupuncture or sham acupuncture has, and then again, you know, the appropriateness of choosing a sham intervention or the appropriateness of sham intervention as a control group. And so talking a little bit more about sham acupuncture, placebo acupuncture, this was a systematic review and meta-analysis published recently in the Journal of Pain Research, and they're really looking to see if sham acupuncture or placebo acupuncture improve low back pain. And so there's many different ways that studies have described sham acupuncture, one of them being, you know, doing acupuncture, doing the procedure, the usual procedure at non-acupuncture point, so not in the meridian or not at the specific acupuncture point and just at a different location. There are also these needles that kind of have a blunt tip and it retracts, so you put it on the actual acupuncture point but it doesn't penetrate the skin. And so do these sham acupuncture procedures have any benefit in improving low back pain? So they looked at seven randomized control trials and they concluded that sham acupuncture was more efficacious for pain and relief post-intervention compared to routine care and compared to patients who are just on the waiting list. And so this really kind of questions the appropriateness of using sham acupuncture as the control intervention in this research. And moving on, this was a systematic review that was done by American College of Physicians, it was their clinical practice guidelines, and basically they reviewed all the current evidence of non-pharmacological therapies for low back pain, and this included acupuncture as well as stuff like yoga, tai chi, mindfulness-based stress reduction. But in particularly, you can see on this chart on the right-hand side of the screen, that for acupuncture, for the use of acupuncture in chronic low back pain, there was low quality of evidence, low quality evidence that acupuncture was associated with moderate improvement in pain, but no effect on function when compared to sham acupuncture. And when looking at the trials that they looked at looking at acupuncture compared to no acupuncture, there was moderate quality evidence that showed that acupuncture was associated with moderate improvement in pain and function compared to no acupuncture. And then in comparison to medication, so these were trials that looked at medications such as NSAIDs, muscle relaxants, other analgesics, and they found that there was, they would characterize it as low quality evidence that acupuncture was associated with a small improvement in pain and function compared to medication. So they concluded that there seemed to be low to moderate strength evidence that supports the effectiveness of acupuncture for chronic low back pain. And so based on this, they released, you know, their guidelines in 2017, American College of Physicians, and it included acupuncture, and the recommendation for patients with chronic low back pain, the American College of Physicians recommends that physicians and patients initially, so first-line treatment, select non-drug therapy, and this is including acupuncture. Another, you know, prominent medical organization, so North American Spine Society, they released guidelines this year that included acupuncture as well for treatment for chronic low back pain. So they stated that in patients with chronic low back pain, the addition of acupuncture to usual care is recommended for short-term improvement of pain and function compared to usual care alone. They also do mention, like we had mentioned, like one of the articles previously mentioned, is that there is still conflicting evidence that acupuncture provides improvement in pain and function when compared to sham acupuncture. But importantly, they mentioned the cost effectiveness of incorporating acupuncture therapy in the management of patients with low back pain in some of the studies that they reviewed. And so I hope that gives you guys some, you know, other, you know, articles that you can look at if you're more interested in why acupuncture can be used as a tool to treat patients with chronic low back pain. And now I'll pass it on to Charlene, who will talk about knee osteoarthritis. Thanks, Bonnie. My name is Charlene, and I'll be chatting about acupuncture for chronic knee pain. And here you'll find that the evidence base isn't as robust for acupuncture as it is for treating chronic low back pain. So first, I'd like to start with a randomized controlled trial that was published in JAMA in 2014 by Hinman et al. And here the authors randomized community volunteers with chronic knee pain to four groups, no acupuncture, needle acupuncture, laser acupuncture, and sham laser acupuncture. And they provided treatments once or twice weekly for 12 weeks with no needle or laser acupuncture compared to sham at 12 weeks. They noticed modest improvements in pain at 12 weeks with needle and laser acupuncture, but not at one year. So they concluded that neither laser nor needle acupuncture conferred a sustained benefit over sham for pain and function. Next up, I'd like to talk about another randomized controlled trial. And this was published in the Annals of Internal Medicine in 2004 by Berman et al. And here they randomized patients with knee osteoarthritis to 23 true acupuncture sessions over 26 weeks or 23 sham acupuncture sessions over two weeks. The results at 26 weeks showed that the true acupuncture group had significantly greater improvement than the sham group in WOMAC function score, pain score, and patient global assessment. Moving on to meta-analyses, here we have a meta-analysis published in the Journal of Bone and Joint Surgery in 2016 by Lin et al. And here the authors searched PubMed and based on the Cochrane Central Register of Controlled Trials for studies published through 2015 that compared sham acupuncture, usual care, or no intervention for patients with chronic knee pain and clinically diagnosed or radiographically confirmed knee osteoarthritis. They identified 10 randomized controlled trials for inclusion and found that the acupuncture group demonstrated short-lived superior pain and improvement in physical function at 13 weeks, but not at 26 weeks. And here's another meta-analysis, just a somatic review. This one was published in the Journal of Rheumatology by White et al. in 2007. And they searched databases and articles and identified 13 randomized controlled trials for inclusion and found that acupuncture was superior to sham for pain and WOMAC function in the short and long-term follow-up. Now, when we get to the various associations who are comprised of members who treat patients with chronic knee pain, we find that there isn't a strong recommendation for using acupuncture to treat chronic knee pain. The Osteoarthritis Research Society International in 2014 said that the recommendation was uncertain, that the randomized controlled trials did not reach the investigator's threshold for clinical significance. In 2019, the American College of Rheumatology said that they conditionally recommended acupuncture for patients with knee OA because while the true magnitude of the effect is difficult to discern, the risk of harm is minor. In 2013, the American Academy of Orthopedic Surgeons said that they cannot recommend acupuncture for treating chronic knee pain due to osteoarthritis and the strength of this recommendation was strong. So, here are my references in case you'd like to access them in the future. There's more research coming out. And now I'd like to continue on with our demonstration of common acupuncture points. Thank you. And I think I'll start at the L4-5 here, do that set of paraspinals, then go up and down from there and maybe a little bit out. Is this the regional? That is the regional. Approach. And that actually would be what we would do if we were doing pins, except here we're going to use moxide instead of electricity to stimulate the navels. You okay? Mm-hmm. You're still okay? Dr. Morales, could you talk us through which points you're picking for the low back and why? Right. So, all of these points are on the bladder meridian. All of them, because bladder meridian kind of covers most of the back. And I'm picking them based on where the pain is. So, it's sort of a regional treatment where we're trying to cover the big area where pain is. And this is another bladder line, the inner bladder line. So, strictly speaking, we could go even lower because she said her pain is in the butt, but in this position, kind of hard to get there. So, we'll do that. And this here, midline, is the governor vessel, or dew line. So, we'll do a point up here. More up here, which is sort of a traditional point for low back. So, we could have done more, and we could have done more of these inner points, or not. So, I'm going to light up. This is the dry herb called Artemisia vulgaris, or mugwort. So, I'm going to use my little torch and fire it up. And again, this is just another way to stimulate the needles. You can twirl them, you can electricize them, or you can use heat. And in general, this is the most pleasant way. How does it feel, Jen? It's very comfortable. Not too hot? No. I can control the degree of the intensity of the heat by either how close I get or how fast I move. So, if I slow down, it's going to get a little hotter. And you can see how there's nice redness around the needles, which is a young, healthy reaction to acupuncture needles. It tends to get less and less as people are older. I'm going to take these out. This treatment essentially surrounds the knee joint from the front, and it's a lovely treatment for any knee problem, but I use it a lot for osteoarthritis. Seven needles with electrical stimulation. This one here, Spleen 9, some people argue you need to go periosteal in order to get good effect for osteoarthritis, which I'm not going to do, but in general, you can go until you touch the bone on this one. These two are the eyes of the knee. You okay? And the last one is an extra point called Heading, which is midline going a little retro patellar. So, that's the needles. And in this case, instead of Moxa, we're going to use electrical stimulation. I'm taking gloves off because it's easier to manipulate the wires without, and the wires always tang. As you can see, I'm alternating the positive and negative electrodes, sort of in a daisy chain fashion, so that the current flows both up and down each side, and also across. And I'll do the stimulation at 4 Hertz. And generally, I'm not going to do it now, but I would increase the intensity until the patient just feels it, and then I would leave it at that level. That's the treatment. So, if you want to do a quick treatment for someone who is stressed out, there's a couple of points you can do. The first point is here. This is a point called Yin Tang, or Third Eye, right here. The other point is back here, which is a point called Governor Vessel 20. It's sort of on top of the head where posterior fontanelle used to be. Very relaxing point. And then there's a couple of ear points. There's one over here called Shen Men, and there's one over here called the Tranquilizer Point. And if you do them all together, the person will definitely, within a few minutes, relax. Today, we're joined by a great team of panelists, all with very interesting and unique backgrounds. We have Dr. Alex Moroz, Dr. Stacy Hall, and Dr. Chi-Hsieh Tang. If you guys wouldn't mind, would you mind introducing yourselves? We're going to start with Dr. Moroz. Of course. Thank you for inviting me. I practice in New York City. I practice musculoskeletal and sports medicine, and about 15 years ago, I added acupuncture to my practice, and now it's probably around 60% of my time. Great. Thank you. And next, we'll go with Dr. Stacy Hall. Hi. I do pediatric rehabilitation medicine at the University of Texas Health Science Center at Houston, and I practice at TRUT Physicians Children's Memorial Hermann and Shriners Children's Hospital. I actually took an acupuncture course when I was a fellow, and it was wonderful. I have been able to incorporate it into my pediatric practice, and I am generally using it on kids that have acute or chronic pain, and a number of my patients actually have arthrobaricosis. Great. Thank you. And lastly, we'll have Dr. Chi-Hsieh Tang. Yeah. My name is Chi-Hsieh Tang. I'm a physiatrist. I work at Washington University in St. Louis. I'm in the orthopedic surgery department, so I just do outpatient musculoskeletal medicine. I took the Helms Medical Institute acupuncture course back in 2000—well, actually, when I was a resident, so like in 2008. So I've been doing acupuncture for 10-plus years now, and I actually—I got some further learning about five years ago. I went to China, and I met a very famous acupuncturist who was kind of combining Western and Eastern medicine together. So after that, I've actually been doing more and more acupuncture. So I would say it's—I would—at this point, it's 50 to 60 percent of what I do. Great. Great. We're so fortunate to have all you guys joining us. Thank you so much for generously donating your time. I'll have a—I'll start off with the first question, and if each of you could answer this, that would be fantastic. The question is, what are the most common indications for which you use acupuncture in your practice? I can start. I use it primarily within my sub-specialty, which is musculoskeletal and sports. So I use it as one of many tools for that patient population. Occasionally, I will treat somebody with unusual indications for my practice, like problem sleeping or stress or digestive problems, but I would say 95 percent of the time, it's musculoskeletal joint muscle pain. Great. And Dr. Hall? Yeah. So I only see pediatric patients, and the primary indication that I'm using it for is acute or chronic pain. I would like to incorporate acupuncture versus spasticity in the future, but right now, I'm mainly just doing it for pain patients. Yeah. For me, it's—I think my indications are pretty similar to Dr. Moro's. Any sort of pain, really, any pain complaint, acupuncture works really well for. In particular, it can be kind of vague pain, or, you know, with a lot of the other interventions that we do, like injections, those are very targeted approaches, and obviously, a lot of times, patients don't fit into those nice new boxes. So with the acupuncture, it doesn't matter. Like we can have, you know, non-myotomal, non-dermatomal distribution pain. It can help with that. They can have some numbness or tingling with it. It can help with that. They can have some functional difficulties. It can help with that. So I think—and especially if their imaging is relatively normal, like there's not an obvious structural pathology, I think those are really good acupuncture candidates. So we're going to—I have another question for the panel, and we can start with Dr. Pascoli to answer it first, and then we'll go on to the faculty members. So the audience is interested in what program each of you guys got certified in and whether you guys learned a regular acupuncture. In terms of program certification, what is the time commitment and the cost of these programs? Yeah, thanks. So I think I bring a unique perspective here in that I'm the only house staff member actively doing the certification, which is really exciting. It was actually one of the reasons I chose NYU for residency because Dr. Moroz has actually built it into our residency as an option to choose into that track. So I'm doing the medical acupuncture course at that SUNY downstate, which is in Brooklyn, New York. So we have two parts. The first is a didactic portion, which we do 200 hours that's mostly consists of doing videos and then going on the weekend to get the actual coursework done. The cost for that was $4,000, and then we're really lucky in that we have built in the clinical portion to do back at NYU. So Dr. Moroz and then one of our other attendings, Dr. Charles Kim, serve as faculty for the resident-run acupuncture clinic. So most of us are going for the 100 clinical hours that New York State recommends or mandates to have. A couple other of us are going for the 150 hours that New Jersey requires for you to practice acupuncture. So everyone will complete between 100 and 150 hours of clinical time by the time they finish and then we graduate residency with an additional license to do acupuncture. Dr. Morales, can you tell us a little bit about the training that you did? Yeah, I did the Helms program as well. I did it from 2004 to 2005. At the time the commitment was 10 days on-site and then a lot of hours in distance learning. And in terms of cost, I think at the time for residents it was something around seven or eight thousand dollars. And if you did it as an attending, then it was closer to ten, plus the travel costs for the on-site piece. And I think Dr. Tang also took the Helms course and then Dr. Hall, I think. If you could just talk a little bit about the other course that you took. Yeah, so I did the Harvard course for physicians and it looks like that's actually no longer offered anymore and it's now called the acupuncture course. But I would really recommend it. It was a Japanese style acupuncture and it's palpation based, so I feel like it really complemented my DO training very well. It's a Kiko Matsumoto style that they do there and I would highly recommend it. And I think you were also asking me about auricular acupuncture briefly. We did learn about that in my course, but it's not something that I have personally incorporated into my practice. Great, thank you. We've mentioned a lot of different types of acupuncture already in this discussion. Japanese type, Eastern, Western, auricular. What are the different types of acupuncture and how can that training differ between practitioners? And I think we'll start off with Dr. Tang. You mentioned that you were trained in both Eastern and Western style. Yeah, so I think the most traditional or the oldest form of the acupuncture is the, you know, traditional Chinese medicine type acupuncture, TCM. That talks about, you know, like energy circulation, qi, different organ dysfunction. I think most licensed acupuncturists, that's kind of the style that they practice, although there's variation there as well. You know, within the Helms course, I think they do a pretty good job of teaching you different styles and they try to incorporate a more Western medicine bent to things. Like things they teach would be like percutaneous electrical nerve stimulation for like back pain. You kind of needle along the paraspinal muscles depending on, you know, your dermatome distribution of pain. There's like gun intramuscular stimulation where you're kind of, you're basically needling with the multifidus muscles, the paraspinal muscles, because they think that that can also cause central sensitization, you know, more peripherally. You have like the Japanese style which is more superficial. And I guess one thing that I didn't realize early on was just how varied, there are a lot of different styles and things, different kinds of acupuncture. When I, in 2015, I was able to go to China and learn sort of this different style which has actually really changed my practice. It's actually quite different than what I initially learned. And, you know, so one of the main differences actually with the needling, I expect people to get immediate pain relief. So usually for acupuncture, what we're taught is, you know, you kind of put the needles in, you come back next week, we reevaluate. But with the structure-based acupuncture that I'm doing now, you put a needle in and you expect them to feel better. And you kind of do a physical exam right afterwards. And that can kind of help guide your treatment and things like that. So anyways, in China there are a lot of different, a lot more variation than we may realize. In other parts of the world, I'm sure too. And if I could piggyback on that question, Dr. Tang, could you, would you mind explaining the difference between acupuncture and dry needling? Sure. So I think, I think that question sort of depends on who you ask. So, you know, some people think that there might be a big distinction. Other people would say that there maybe is not as much of a distinction. So one thing is that it depends on who's doing it. So if a physical therapist does it and they're training, it's usually going to be called dry needling. If a licensed acupuncturist does it, it's going to be called acupuncture. As like a medical doctor, you can kind of take your pick. You know, and it just depends on where you received your training. Because there are also a lot of dry needling courses available. Usually the training for that is less rigorous. There's less intense, less rigorous. You don't have to learn as much of the theory as you do with acupuncture. So I think, you know, medical doctors, I've seen people call it dry needling people or whatever, what they're doing or other people call it acupuncture based on your training. So, but one big distinction is kind of where it came from. So Chinese medicine is where acupuncture came from, whereas Western medicine in terms of Travelle, Janet Travelle was the first person that started doing kind of dry needling. Initially, dry needling was done with hypodermic needles. They would just kind of put the needle in the body and deactivate trigger points. You just wouldn't inject anything. But then it kind of evolved. And now when most people talk about dry needling, the physical therapists are using acupuncture needle. So like I said, you know, I think that there may not, the distinction is almost more of like, depending on the person that's doing it. I sort of look at acupuncture as a big umbrella, and then dry needling as a little bit of a subset of it. But, you know, I think that depends on different people's viewpoints. I don't know, Dr. Moroz or Dr. Hall, if you have any things you want to add to that question? I was going to say with the Japanese style acupuncture in general, we are not placing the needles in the painful area, where as opposed to a dry needling, you are directing it towards the painful area to help relieve that muscle tension. But that's just my experience. Yeah, I agree. I sort of gravitated away from putting needles in the trigger points, which is very effective, but kind of uncomfortable. And I tend to do other things. I treat a lot of trigger points, but similarly, I try not to go right in there. What other information about patients' symptoms or their pattern of symptoms do you use to decide which type of acupuncture to incorporate into your practice for that patient? I use my Western medical diagnosis to arrive at the diagnosis, and then I use acupuncture as one of many tools to apply towards this diagnosis. I do not use the traditional Chinese diagnosis that involves looking at the tongue, pulse, smell, sight, etc., etc. Yeah, I agree. I do a very similar thing. I do the Western medicine diagnosis, look at their imaging, do a physical exam, and that sort of guides me in terms of what areas to needle or what to do. In terms of the different styles, I also took the—I don't know if you guys are familiar with like Steko, fascial manipulation stuff. So I took some of his courses. So I think that, you know, whether you needle more deeply or more superficially, to me, maybe can also depend on if you think it's like a superficial fascial problem versus like a deeper, deep fascia, you know, myofascial problem. That also is a distinction. So yeah. So, you know, and then, you know, you can do different needle manipulations, too. You know, a lot of it—I also try to get—a lot of times we'll try to get a local twitch response, and that's key for me in terms of releasing different muscles. Yes, and I do the same where I use the Western diagnosis and then tailor my treatment plan to that. And my physical exam will help to determine whether or not I may or may not do dry needling. And what I normally do for kids, and this has worked really well, is that I actually do the acupuncture first, and then I do the dry needling, and they seem to tolerate it a lot better. In terms of those interested in incorporating acupuncture, how do you bill for acupuncture, and how many people do you need to see to break even? And Dr. Morales, we can start with you. Okay. Yeah, I think the acupuncture codes are pretty standard. They're 97810, 97811, 97813, 978—978—what is it? 97814. So those are the standard acupuncture codes, and they go for like 15 minutes, and first 15 minutes, then subsequent 15 minutes, either without electrical stimulation or with electrical stimulation. So most insurances don't cover acupuncture, although recently Medicare actually did start acupuncture for a chronic low back pain. But the problem with that is, so they're basically paying you—they're paying $65 for a 30-minute treatment, which for most physicians doesn't make it worth your time to do. So that's sort of the challenge with acupuncture, is like how do you get it paid for and make it worth your time to do in clinic? And I think the break-even point really depends on what sort of practice you're in, right? So if you're in a private practice setting, if you're a single provider, you can keep overhead costs lower, so your break-even point's going to be less. Versus if you're—I think if you're at an academic center like where I am, like there's certain expectations about how much you have to bring in. I'm supposed to—I could make more money doing other things, like I do—you know, I do lumbar injections, epidural injections as well. I could make much more money doing that, but it's—you know, it's not as effective, and I don't feel like it's the right thing for a lot of patients, whereas the acupuncture is the right thing, I think, for a lot of patients. So you have to—for me, it's about doing what you think is the best for patients. So it's just—for me, the acupuncture is about not losing money. It's about like kind of, like you said, breaking even. I charge $200 per session for treatment, which is like half an hour, but then I have a few breaks built in there. So that's kind of how I do it, but it would be different depending on your practice. Dr. Morales, would you be able to comment a little bit about your practice? Can you hear me? Yes. Okay. So gradual increase in how many insurance plans cover acupuncture, and we're at a point whereby commercial plans will cover, which is very different from where I started 15 years ago, where maybe 10% covered. But very, very roughly, if you work eight-hour days, and you work five days a week, and if you take four weeks vacation, then you will have about $300,000 before taxes just doing acupuncture, provided you have three rooms. So one way that you can make it worth your while is by having multiple rooms where you can treat people at the same time or stagger them a little bit. Well, thank you. Cut off in the beginning. Are you doing—you said you're billing through commercial insurances or maybe cash pay, or how is that working in your practice? About 80% is billed through insurance, and about 20% is billed out-of-pocket. And then, Dr. Hall, would you mind commenting on how you have navigated billing and incorporating acupuncture to your practice? Yes, of course. So in my prior practice, I actually did a flat fee. It was $125. In my current practice, a lot of the patients are through Schreiner, so it's basically charity. But if I'm seeing them at a different clinic or a different hospital, I do bill insurance if I'm able to. I would say mine, maybe—are you in New York? I guess, Dr. Moore, maybe there's more insurance companies that cover there, potentially. But I'm probably like 80% self-pay and then 20% insurance. Yeah, so in terms of building practice, I think in your situation, it would take more years to grow than in my current situation because there's a lot less patients who are willing to pay out-of-pocket. This is how it was when I started, and I'm sure when you started, it was even more so, where you had to develop reputation and sort of be in one place for a few years to build up volume. As long as we're on the topic of building acupuncture into our practice, we actually crowd-sourced a few questions online on Facebook, and our questions that we received for the panelists were along those lines, generally. So what supplies do you recommend to start incorporating acupuncture into your practice, and what patient populations do you generally try and start with? We can go with Dr. Hall first. Yeah, so if you're looking just to have the most basic supplies, I think, really, you just need needles and a nice massage-type table to start. You could also use an electro-acupuncture device if you're into that, but I think those are the most basic things that you really need. Yeah, I agree, and that's one of the beauties of acupuncture is that you don't need a bunch of supplies. I don't need a fancy fluoroscope machine. I don't need a fancy ultrasound machine. So you can, I have like a little toolbox that I carry around, and you basically, everything you need is in the toolbox. A massage table would be nice, yeah. Are there certain patient populations that you find it easier to start incorporating acupuncture into your practice with? I think all of us will agree that if you start with pain, you won't go wrong. Mm-hmm, yeah, agreed. I think that, I mean, you know, maybe you don't want to pick, like, the super chronic, chronic, although acupuncture actually does work well for those, a lot of those people, the really chronic pain patients that have seen five other providers and they're not getting better, and actually that usually, acupuncture is usually a good solution for them, but it, that might not be who you want to start with. I would say just more, you know, a few months of some sort of musculoskeletal pain, especially if you've done the workup, the imaging, there's nothing terribly wrong, like, but they have pain. Those are, those are good patients. Well, thank you guys so much for your time and really just answering some of the questions that, you know, a lot of us have about acupuncture and wanting to incorporate it into our practice. Are there any end remarks that you guys would like to make to kind of encourage or advice you can give to us, you know, early career physiatrists and training physiatrists, or even, you know, seasoned attendings who are interested in learning acupuncture and really using it as part of our toolbox in PM&R? Well, I think acupuncture is a really wonderful tool to have in your toolbox. It's very safe. It's very difficult to harm your patient, and most of the time it works really well. So if you're open to learning about it, I would definitely encourage it. Yeah, I agree. I think that one thing is to kind of keep an open mind, keep learning new techniques, new things, because I think the more you learn, the better you get. And I think as I've learned more things, I think you're able to predict the results better. One thing that was a little bit frustrating initially maybe with acupuncture was people come in and they've had pain and you don't know what else to offer them, and then that's why you offer them acupuncture. You're like, well, you've tried all these things, nothing helps. Okay, we can try it. Maybe there's a, you know, 50% chance you'll get somewhat better, right? But then if you can kind of increase your training, you can get like better results, more reliable results. You can get them, you can get a really good sense that this is going to help you or not going to help you. But I agree. I think that, you know, people are, more people than you think want, they don't want to take meds. You know, this is a very natural way. You're actually getting it a lot of times at the root cause of problems. Like a lot of myofascial dysfunctions, you're actually treating the problem, not just like having to take a medication. So I think it is a lot of people, it's palpable for a lot of people. I agree. Patient acceptance is very, very high. Even in pediatrics. Especially in pediatrics. Well, thank you all again so much. We'll provide, if it's okay with you guys, we'll provide your email addresses or ways to reach out to us as the session directors if anyone else has further questions. Thank you.

acupuncture

traditional Chinese medicine

Yin-Yang theory

theory of five elements

Zhang-Fu theory

Qi

meridians

biochemical changes

pain management