Contents

Introduction 2

Register of physiotherapists 2

Standards of practice 3

Safety and Hygiene 3

Professional points 4

Recommended sterilisation procedures 5

AIDS and Hepatitis 5

Problems, precautions and contra-indications 6

Useful References 9

Guidelines for Musculo-skeletal Pain 10

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Introduction.

This document is produced by the Acupuncture Association of Chartered

Physiotherapists and provides a Code of good conduct for those
physiotherapists who use acupuncture as part of their physiotherapy treatment
programmes. The Code should be read and understood by all such
physiotherapists who will then be expected to abide by it. All training courses
recognised by the AACP, whether short or long will be expected to teach to
this minimum standard. It is acknowledged that there are different levels of
practice and philosophical views currently existing among physiotherapists but
it is hoped that eventually a consistently high overall standard of excellence
will be achieved.

It is recommended that the practice of acupuncture by physiotherapists

should be governed by Rule 1 of Professional Conduct of the CSP :-
"Chartered Physiotherapists shall only practice to the extent that they
have established and maintained their ability to work safely and competently
and shall ensure that they have appropriate professional liability cover for that
practice."

Acupuncture Education Register

A register is held by the AACP of all members with the details of their
acupuncture training and additional qualifications where appropriate. In future,
only those physiotherapists undertaking training courses recognised by the
Education Committee of the AACP will be admitted to full membership of the
AACP and have further training recorded in this Register.
It is now mandatory to provide an individual Register Number when
dealing with outside bodies such as the Blood Transfusion Board.

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Standards of Practice
After assessment of the patient, if the physiotherapist
considers acupuncture to be an appropriate treatment the
following steps should be taken.

1. Clear explanation
The patient should be told of the proposed treatment and what is entailed.
This explanation should include;
The procedure of needle insertion into the skin.
The possible use of additional stimulation to the needle, manual, electrical or
heat.
The possibility of transient symptoms during and after treatment, fatigue,
faintness or temporary aggravation of the symptoms being treated.

2. Consent
After the treatment has been explained the patient's consent to treatment must
be unequivocally obtained (from the parent in the case of a minor) and must
be recorded in the case notes, this informed consent being the same as that
obtained for other physiotherapy modalities.

3. Safety and Hygiene

The treatment area should be clean and private with washing facilities near
at hand. Wet surfaces must be disinfected regularly. It is recommended that a
fresh cover to the plinth or treatment table should be used for each patient.

The physiotherapist should ensure that hands and nails are clean when
giving treatment and these must be washed before and after every treatment.
Any cuts or breaks in the skin should be covered with a waterproof dressing.

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The underlying principle of most Health Authority policies for AIDS and
Hepatitis B is that the patient should be assumed to be infected and
acupuncture treatment should always be carried out with all necessary care.

The needling sites should be clean, free from cuts, wounds or infection. The
point to be needled should be swabbed with 70% ethyl or isopropyl alcohol,
from the centre to the surrounding area using a rotary motion, and the alcohol
be allowed to dry. (WHO recommendation 1999)

It is recommended that disposable pre-sterilised needles are used.

All discarded needles must be disposed of in a SHARPS box, clearly

marked DANGER- CONTAMINATED NEEDLES. These should either be
incinerated or disposed of according to the advice of the local
Environmental Health Officer.

Care must be taken to avoid contact with the patient's blood, should
bleeding occur, an injection swab or sterile, dry, cotton wool should be
used to absorb it and disposed of carefully according to local hospital
practice. In private practice these soiled swabs should be sealed in
plastic bags and disposed of according to the advice of the local
Environmental Health Officer.

Professional Points
Evaluation of the effect of each treatment is important to both the patient and
the physiotherapist. It is vital that careful, accurate records be kept in order
that all treatments can be monitored. To this end it is recommended that the
names of all patients receiving acupuncture be listed along with the conditions
under treatment in order to facilitate future audit. This will also make it possible
to trace the spread of any infection. Physiotherapists in the UK have been
fortunate to have had the backing of the CSP and the DSS and have been
able to use acupuncture as freely as any other modality as long as their
training has been adequate. This has, in part, been due to good
communication with other members of the patient's medical team and this must
be maintained.

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Recommended Sterilisation procedures

The AACP only recommends the use of pre-sterilised disposable needles.

There are many varieties available, it is wise to check just how the
manufacturers claim the sterilisation occurs and what documentation is
available to support the claim.

Use of disinfecting chemicals is no longer recommended.

Further information may be obtained from AIDS and Skin Piercing, Booklet 5, DHS Crown Copyright.
November 1987

AIDS AND HEPATITIS

AIDS, or Acquired Immune Deficiency Syndrome, is an infection transmitted by
a virus, the Human Immunodeficiency Virus (HIV). Although this organism has
been isolated from blood, semen and saliva of AIDS sufferers, only the first is
a likely source of infection in skin piercing techniques. To all intents and
purposes , from the point of view of skin piercing AIDS is transmitted in the
same way as Hepatitis B and the measures used to prevent Hepatitis B will be
adequate to prevent AIDS transmission also. In the event of an accident the
practitioner might be at risk of contracting AIDS from a patient but this
possibility is remote and also exists with Hepatitis B. There is evidence that
the AIDS virus is the least infectious of the two; there is also evidence that HIV
is more sensitive, this means that it may be inactivated after a short time in the
environment. Nevertheless it is imperative that high standards of hygiene and
care are maintained at all times.

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HEPATITIS A
This is known as infectious Hepatitis and is transmitted via the faecal/oral
route with an incubation period of about four weeks. It is associated with
conditions of poor sanitation.
HEPATITIS B
Serum Hepatitis, transmitted essentially through the blood system with an
incubation period of from 6 weeks to 6 months. It is spread either by
penetration of the skin with infected needles or contact with broken skin from
contaminated apparatus or surfaces. It is of risk both to patient and therapist.
It should be remembered that a therapist may contract the infection from an
apparently healthy person who is incubating the disease but who is not yet ill.
HEPATITIS C
This is a relatively newly described virus which, like Hepatitis B causes acute
Hepatitis and may lead to chronic liver disease and death.
It is transmitted by blood also and can be avoided by using the same
precautions as those used for AIDS and Hepatitis B.

PROBLEMS, PRECAUTIONS AND

CONTRA-INDICATIONS

PAINFUL TREATMENT
The needle may be painful on insertion but the pain should not persist after
the initial stimulation is achieved. If pain persists the needle should be
removed.

AREAS NOT TO BE PUNCTURED

Certain areas should not be punctured, for example: the fontanelle in
babies, the external genitalia, nipples, the umbilicus and the eyeball.

BROKEN NEEDLE
If the needle breaks in situ, the point of entry should be marked and
immediate medical help sought. Using a needle of the correct length at
each point will minimise this risk.
Patients with uncontrolled movements who are unable to remain still for any
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length of time are not suitable for treatment.

DROWSINESS
Some patients may feel very relaxed and even sleepy after treatment. They
should be advised not to drive until they have fully recovered.

INFECTION
The skin should always be carefully examined for infection prior to
treatment, if there is any indication of possible infection medical advice
should be sought. Very thin and fragile skin should not be needled. Extra
care should be taken with auriculo-acupuncture as the ear tissue is prone
to infection. Surface wax should always be removed with an alcohol swab.

NEEDLE STICK INJURY

Those physiotherapists working in the NHS should follow their Health
Authority Needle Stick policy. Those in private practice should consult their
own doctor or seek advice from the nearest casualty department.

ALLERGY
Some patients are allergic to specific metals and any known allergy of this
nature should be ascertained prior to treatment with needles.

FAINTING
During acupuncture treatment, the patient may feel faint. The needling
procedure and the sensations it may cause should therefore be carefully
explained before starting. A first treatment should always be given with the
patient comfortably supported in a lying position. Particular care should be
taken when needles points which may cause hypo-tension eg. Liver 3,
Large Intestine 4.

Symptoms of impending faintness include feeling unwell, a sensation of

giddiness, the room moving, or a feeling of weakness. There may be a
restricted feeling in the chest accompanied by palpitations, nausea or
vomiting. The complexion turns pale or greenish and the pulse is weak.

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Such reactions are said to be due to nervousness, hunger, fatigue an

unsuitable treatment position or strong manipulation of the needles.

If warning symptoms appear, remove the needles immediately and lay the
patient flat with legs raised as the symptoms are probably due to transient
insufficient blood supply to the brain. The symptoms usually disappear after
a short rest. Offer a warm sweet drink.
Where there is loss of consciousness, strong pressure on Ren 26
Renzhong can bring a rapid response.
If symptoms persist medical assistance will be necessary.

Please note this kind of reaction is very rare.

Special care should be taken when needling the following;

PREGNANT PATIENTS
There is a danger of miscarriage when treating patients in the first trimester
of pregnancy if the wrong points are used. It is essential that practitioners
are aware of these. Extra care must be taken with the selection of points at
all times during a pregnancy.

EPILEPTICS
Care should be taken when needling patients with a known history of
epilepsy.

DIABETICS
Care should be taken when needling diabetic patients because of the
danger of poor peripheral circulation and the effect of some points on blood
sugar levels.

CIRCULATORY SYSTEM
Care should be taken in needling areas of poor circulation, where ther is a
risk of infection, and to avoid accidental puncturing of arteries,(sometimes
aberrant) which may cause bleeding, haematoma, arterial spasm or more
serious complications when pathological change is present. Generally,
bleeding due to puncture of a superficial blood vessel may be stopped by

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direct pressure.

FRAIL PATIENTS
Patients with a weak constitution after prolonged chronic illness will tolerate
acupuncture poorly. Minimal treatment must be given. Extra care should be
taken with those with known low blood pressure.

PACEMAKERS
Patients with pacemakers should not be given electro-acupuncture.

CONFUSED PATIENTS
Great care must be taken with patients unable to understand the procedure.
Those unable to co-operate must not be treated.

PATIENTS RECEIVING DRUGS

The therapist must check on the nature of the drugs prescribed and take
appropriate precautions; ie extra care to prevent bleeding with patients on
anti-coagulant medication, explaining these to the patient.

POTENTIALLY HAZARDOUS ACUPOINTS

Special care should be taken in needling points in proximity to vital organs

or sensitive areas. Accidental injury to an important organ requires
urgent medical or surgical help

Chest, back and abdomen

Points on the chest, back and abdomen should be needled cautiously,
preferably obliquely or horizontally, so as to avoid injury to vital organs.
Attention should be paid to the direction and depth of insertion of the
needles.

Lungs and Pleura

Injury to the lung and pleura caused by a needle inserted too deep may
cause traumatic pneumothorax. Cough, chest pain and dyspnoea are the

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usual symptoms and can occur abruptly during the manipulation, especially
if there is severe laceration of the lung by the needle. Alternatively,
symptoms may develop gradually over several hours after the acupuncture
treatment.

Liver, spleen and Kidney

Puncture of the liver or spleen may cause a tear with bleeding, local pain
and tenderness and rigidity of the abdominal muscles. Puncturing the
kidney may cause pain in the lumbar region and haematuria. If the damage
is minor the bleeding will stop spontaneously, but if the bleeding is serious,
shock may follow with a drop in blood pressure.

Central Nervous system

Inappropriate manipulation at points between or beside the upper cervical
vertebrae, such as Du 15, Yamen or Du16, Fengfu, may puncture the
medulla oblongata, causing headache, nausea, vomiting, sudden slowing of
respiration or disorientation, followed by convulsions paralysis or coma.
Needling too deep between the thoracic vertebrae may cause lightning pain
below the needling level or in the extremities.

NB
It is wise to stick to points that have been taught and to use new points with
extreme caution if they are located in the hazardous areas listed above.

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Useful references

1. CSP Rules of Professional Conduct.

2. Health and Safety at Work Act 1974.

3. Local Authority Byelaws on:-

Disposal of contaminated waste.

Fire Regulations.

Use of premises for treatment of patients by Acupuncture.

(Local Government; Miscellaneous Provision Act 1982)

4. Infections Control Policy of Local Health Authority.

5. Hygienic Skin Piercing, an Update . (1994)

Professor N.D. Noah.

6. AIDS and Skin Piercing, Booklet 5, (1987)

DHS Crown Copyright.

7. The Hepatitis C Handbook. Matthew Dolan (1998)

Catalyst Press

8. Guidelines on basic training and safety in acupuncture

(1999) World Health Organisation

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Supplement;

AACP Acupuncture Treatment Guideline for

Musculo-skeletal pain

Objectives of the Guideline:

1 To provide a framework, complying with minimum safety standards, for physiotherapists

introducing acupuncture into the treatment process for musculo-skeletal pain.
2 To provide objective end points for practitioners to evaluate the effectiveness of their
treatments.
3 To involve patients both in the treatment process and the collection of evidence in order to
further improve practice.

Definitions

Musculo-skeletal pain - uncomplicated pain resulting from either trauma

or disease recognised as arising from the
musculo-skeletal system.

Acupuncture - the insertion of a needle, or needles, into the

body at specific points.(Acupoints can also be
treated by non-invasive associated techniques)

Rationale

The recommendations in this document are based upon published clinical trials of
acupuncture, a questionnaire survey of current clinical practice by AACP members and further
consultation with focus groups.

It is accepted that many different approaches may be taken in assessment and diagnostic
techniques, and the guideline aims only to provide a systematic framework within which decisions
can be made with regard to precise treatments.

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The Treatment Process

Assessment of the patient

It is vital that careful, accurate records be kept in order that all treatments can be monitored.
(1)

Subjective assessment Objective assessment

Full demographic details Relevant physical examination

Reason for referral Functional scale *

Medical and Social history MYMOP evaluation (2) *

Lifestyle Pain assessment, pain scale *

Subjective history Body chart *

Full description of pain Medication consumption *

( * Possible audit points)

Suitability for Acupuncture

Any patient is suitable for acupuncture if the following precautions and contra-indications are considered;

Contra-indications
Metal allergy
Needle phobia
Infection at needle site
Haemophilia

Precautions- (dependent on level of training)

Oedema at needle site
Pregnancy
Diabetes
Epilepsy
Cognitive difficulties
Immunodeficiency
Anti-coagulants
Pacemaker (electro-acupuncture)

(If unsuitable for acupuncture with needles, explain to patient and discuss alternatives, eg Laser, TENS,
US, IF or Acupressure.)

SAFETY

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It should be stressed that the process of treatment should be performed in strict adherence to the AACP
Safety Guidelines.
Treatment plan
1. Prepare patient.
Explanation, techniques, possible adverse reactions.
Obtain verbal consent from patient or parent/ advocate.
Record consent.

2. Agree estimate of the number of treatments with the patient together with expected
outcome.
This will depend on the type/nature and duration of the pain.

Treatment

1. Select type of acupuncture and/or related technique (s).

Include all other treatments as needed.
eg, posture correction, lifestyle advice, manual therapy, exercise etc.

2. Length of treatment is dependant on the type and duration of the pain. It would be
expected that a chronic painful condition of more than 6 weeks may need a minimum
of 6-8 treatments before any improvement is observed.
More acute pain of a shorter duration (less than 4 weeks) may be successfully
addressed in fewer treatment sessions. (3,4)

Reassessment

1. At each attendance.
Monitor progress and be prepared to change or modify treatment.

2. When the agreed number of treatments are completed:

Assess and decide with the patient the likely benefit of further treatment.

Discharge

1. Inform the referring agency as appropriate.

2. Record outcome by repeating the objective measures.

3. Define reason for discharge.

4. Enter patient details in the therapists' acupuncture register.

Audit/ Evaluation

The objective measures should be undertaken with a view to measuring

the progress of treatment and the effectiveness of the modalities used.

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Flowchart

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It is recognised that the actual practice of acupuncture depends on the

training and philosophy of the practitioner.

Key points of the treatment process

Ø Assessment to include objective measures

Ø The criteria for suitability for acupuncture treatment will be recorded

Ø Treatment process will be discussed with patient prior to commencement of an

episode of care

Ø Treatment progress will be assessed at each session

Ø Objective measures to be reassessed on discharge and outcome noted

References
1. AACP Guidelines for Safe Practice (2000 revision)

2. MYMOP: Measure Myself Outcome Profile.

Patterson C, Measuring Outcomes in Primary Care: A patient generated measure, MYMOP
compared with SF36 (1996) BMJ312 20 April 1016-20

3. Richardson PH, Vincent CA, (1986) Acupuncture for the relief of pain: A review of evaluative
research. Pain 24 ,15-40.

4. AACP Questionnaire 1996. (Pub. AACP 1998)

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