L. KOCH 
 

1 - Introduction

Acupuncture has been known and used in China for at least 2500 years. This therapy, formerly little used in the United States, has developed there since President Nixon's visit to China in 1972. Since then millions of patients have been treated by it at thousands of practitioners'.
To take stock of the issue, the National Institutes of Health (NIH) organised from. 3 to 5 November 1997 a conférence on acupuncture chaired by a group of twelve specialists representing a variety of fields (acupuncture, pain, psychology, psychiatry, rehabilitation, drug abuse, family practice, internal medicine, health policy, epidemiology, statistics, physiology, biophysics, patients).
Twenty-five papers were presented during these three days; approximately 1200 people attended.

2 - Consensual protocol*

After a day and a half of presentations and discussions the twelve specialists tried to answer in a consensual protocol the five following questions:
How effective is acupuncture compared with the use of placebos or sharn acupuncture?
Compared or combined with other therapies (including the absence of other therapies), what place does acupuncture occupy in treatinent?
What do we know about the biological effects of acupuncture which could help in understanding the way it works?
What results must be obtained for acupuncture to be incorporated in the present healthcare system?
What are the directions for future research?

3 - How effective is acupuncture compared with the use of placebos or sham acupuncture?

There are few studies or high quality research that respect the currently applied rules. Most papers are confined to reporting on cases or series of cases that do not really demonstrate efficacy.
The greatest majority of studies deal only with needle acupuncture (manual or electric) on adults and do not address the long tenn.
Most hurnans and animals have a beneficial response to acupuncture although some studies appear to contradict this observation.
It is proven that needle acupuncture is effective in treating nauseas after operations, chernotherapy (adults) and probably those experienced by pregnant women.
As regards pain treatinent, acupuncture is effective against post-operative toothache. Some studies demonstrate a decrease in other pains, whereas others do not find any efficacy in treating pain.
It is proven that acupuncture is not effective in stopping smoking
The use of sham acupuncture in a control group is very tricky. It appears to have an intermediary result between real acupuncture and a placebo.

4 - Compared or combined with other therapies (including the absence of other therapies), what place does acupuncture occupy in treatment?

When several therapies exist, the choice often depends on several factors, particularly the patienfs prefèrence. Contrary to generally accepted ideas, the results of studies and research are far from. always being in favour of conventional. Medicine.
One of the advantages of acupuncture is that the secondary effects are considerably lower than with many drugs or other treatrnents which could be used (for instance anti-inflammatory drugs).
Many clinical experiments and a few research results appear to demonstrate that acupuncture could be indicated in many cases.

5 - What do we know about the biological effects of acupuncture which could help in understanding the way it works?

Many studies both on animals and on men have shown that acupuncture can have multiple biological effects, either locally or at a distance. It appears well established that opiate peptides are released during acupuncture. Other biological effects have been evidenced without their clinical actions being clear.
The definition and characterisation of acupoints remains controversial. This is even more the case regarding certain concepts of oriental medicine such the circulation of Qi, which is nevertheless the basis of acupuncture treatment.
Some of the biological effects observed also appear with sham acupuncture or other stimuli (big pains, violent exercises, relaxation).
In any therapy, including acupuncture, there is a non-specific effect which may be powerful (relation with the patient, degree of confidence, patient's expectations).
Although there are still many unknown factors in the mechanisms leading to the therapeutic effect, a considerable number of biological changes resulting from. acupuncture have been observed. Research should continue.

6 - What results must be obtained for acupuncture to be incorporated in the present healthcare system?

The incorporation of acupuncture in the present system. will be facilitated by a better understanding between oriental medicmie (global approach) and western medicine (treatment of the disease). A major step has also been taken in this direction by acupuncturists being better trained and accredited by official. bodies.
Although the secondary, hannful effects, of acupuncture are extremely rare (cases of pneumothorax are mentioned), saféguards should be introduced, such as information for patients and throwaway sterile needles.
More than a million Americans each year adopt acupuncture in addition to conventional. medicine. GPs and acupuncturists should communicate more. So that all can have access to acupuncture, the reimbursement of such medical procedures should be encouraged and facilitated.

7 - What are the directions for future research?

A certain number of questions are still unanswered. The answer to these questions should help to complete the assessment of acupuncture.
Who adopts acupuncture and for what conditions ?
Epidemiologic studies should help address this question.
Can the efficacy of acupuncture in the cases where it appears promising be demonstrated ?
Relatively few high-quality, randomised and controlled trials have been published.
Such studies should be strictly devised to assess the efficacy of acupuncture.
Other studies like those carried out in clinical epidemiology can also provide useful information.
Do the various theoretical bases of acupuncture lead to différent treatinents ?
Research projects should study the various theoretic orientations (China, Japan, France) and their influences on the locating of acupoints.
Apart from. fixed acupuncture points, all of the oriental medical systera should be studied.
What fields of public research are likely to facilitate the introduction of acupuncture into the present healthcare system ?
Can new aspects be discovered regarding the biological bases of acupuncture ?
Mechanisms leading to a western scientific explanation are beginning to appear. That is encouraging and can shed new light on other physiological processes.
Does the human body have an energy system with clinical applications ?
This theory, which is behind acupuncture, is worth being studied.
How do these approaches and the answers to these questions differ between peoples with an age-old tradition of acupuncture and those who have only recently discovered this therapy ?

8 - Conclusions

The studies have given mixed results for a certain number of reasons, particularly because of the difficulties related to placebos and sham acupuncture. Encouraging results have been reached: efficacy has been proven in some cases. Future studies will probably find other indications
Fundamental research has begun to elucidate the mechanisms involved in acupuncture, but much remains to be done.
The use of acupuncture as a therapy is at its beginnings; many practical problems still remain to be solved. There is a reasonable hope that acupuncture will find its place alongside conventional. medicine.

* This is the summary of the consensual protocol of the conférence. This protocol, the list of participants and a bibliography can be consulted on Intemet at the following address:

 http://odp.od.nih.gov/consensus/cons/107/107_intro.htm

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