AAcp guidelines for safe practice
Acupuncture Association of Chartered PhysiotherapistsV2 2012
produced by:The Acupuncture Association of chartered physiotherapists (AAcp)Southgate House, Southgate ParkBakewell Road, Orton SouthgatePeterborough, PE2 6YS
Tel: 01733 390012Fax: 01733 390057Email: [email protected]: www.aacp.org.uk
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Background These guidelines provide a code of best practice for Physiotherapists using acupuncture in clinical practice. All AACP recognised courses, both Training and CPD will teach to this minimum standard.
This issue (2.0 2012) has been updated from the previous version (Issue 1.11 2007).
It is acknowledged that there are different levels of acupuncture practice and varying philosophical views existing among Physiotherapists, but it is mandatory that a consistently high overall standard of clinical excellence is achieved and maintained. It is also acknowledged that clinical surroundings outside of the NHS are usually directly under the discretion of private practitioners. physiotherapists engaged within the NHS may have little control over practice surroundings, thus all suggestions made within this guideline are not mandatory, but in the form of a strong recommendation for best practice, no matter what the clinical environment. This also pertains to domiciliary treatments, sports clubs and other such areas of clinical work.
The AACP have updated previously developed rigorous guidelines (AACP Guidelines for Safe Practice, 2007) and adapted them to meet the current needs of the membership. The AACP are also grateful for contributions from previous sources including the British Acupuncture Council (BAcC) and the British Medical Acupuncture Society (BMAS).
The document itself is arranged into 6 sections: - Section 1 Introduction. The provision of acupuncture within the context of physiotherapy Section 2 Needling skills Section 3 Adverse eventsSection 4 Associated acupuncture techniquesSection 5 Personal health and hygieneSection 6 Workplace considerationsAppendices 1- 4
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Contents pageWorking as a Physiotherapist in the UK 04
Needling skills & consent 05
Blood donation & treatment records 06
Safe needling 07
Precautions 08 - 10
Adverse events - needle shock 11
Needle stick injuries 13
Risk of Blood Borne Viruses 13-14
Associated acupuncture techniques 15
Self needling/semi permanent needles 15
Seeds, auricular balls, moxa 15 - 16
Cupping 17
Auricular acupuncture 17
Electroacupuncture 17
Personal health and hygiene 18
Work place considerations 19
Domiciliary visits 19
Licensing of premises 20
Treatment room requirements & facilities 20 - 21
Disposal of needles & equipment 22
Appendix 1 Further resources 23
Appendix 2 Specimen consent form 24
Appendix 3 Specimen consent to moxa 25
Appendix 4 Disinfectants & cleaning solutions 26
References 27 - 29
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Working as a Physiotherapist in the UKThe practice of Acupuncture by Chartered Physiotherapists should be governed by The Code of Professional Values and Behaviour (1).
1 cSp members take responsibility for their actionsMembers• Demonstrateappropriateprofessionalautonomyandaccountability• Actwithintheirindividualscopeofpractice• Makeinformeddecisions.
2 cSp members behave ethicallyMembers• Adheretolegal,regulatoryandethicalrequirements• Actwithintegrity,honestyandopenness• Engagewithrelevantprofessionalandsocialcontexts.
3 cSp members deliver an effective serviceMembers• Puttheneedsofserviceusersatthecentreoftheirdecision-making• Respectandsupportindividuals’autonomy• Communicateeffectively• Workeffectivelywithothers.
4 cSp members strive to achieve excellenceMembers• Seektocontinuouslyimprove• Demonstrateinnovationandleadership• Supportothers’learninganddevelopment• Supportthedevelopmentofphysiotherapy.
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Needling skillsInforming your patientThe decision that acupuncture may be a useful modality within a treatment plan must be based on sound clinical reasoning following careful assessment of your patient. Having explained your proposed treatment plan to the patient you must then gain their informed consent to have acupuncture.
consentConsent is essential for any intervention that involves touching the patient, asking them to remove items of clothing, or using any instrument or modality that involves breaking the skin (2). Members should be aware that consent laws vary within each country and should ensure that they are familiar with the law in the country in which they work (2).
The patient must be told the nature and purpose of giving acupuncture treatment and the risks inherent with acupuncture explained. It is also expected that you outline the possible alternative treatment options that may be available. This may be done verbally or the patient may be given anexplanatoryleaflettoread.Thepatientshouldalwaysbegiventheopportunity to address concerns and queries regarding the treatment plan.Storeallconsentformswiththepatient’sclinicalrecords.
In line with the CSP, AACP strongly recommend that you obtain written informed consent from your patient prior to giving acupuncture (2). Most NHS Trusts insist on completion of in-house consent forms and written consent forms. Private practice should apply the same principles and mirror those forms in content.
There is a template consent form attached to the end of this document (Appendix 2).
(TheAACPhasasupplyofinformationleafletsforpatientsthatare
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availabletopurchasefromtheAACPofficeortheAACPwebsitewww.aacp.org.uk.)
consent for children and adolescentsYoung persons of 16 and 17 years old are permitted by law to give their own consent for physiotherapy. It is good practice to involve the parents in treatment decisions wherever possible providing the young person is willing (2).
Children under 16 years may consent to their medical treatment providing that the child:- a) is capable of understanding what is involved in their treatment b) can retain the information they have been given about their treatment c) is able to make a decision about their treatment based on this
information. This is known as Gillick Competent (2).
Acupuncture & blood donationThe NHS Blood and Transplant Service (NHSBT) no longer require their donorstosupplyBloodDonorCertificateswhendonatingblood.Theywill accept blood from donors who have had acupuncture as long as the acupuncture was provided by an HPC registered health professional. Members should still enquire if their patients are regular blood donors as the NHSBT will need to know the name of the physiotherapist who has administered acupuncture in order to check their HPC registration (3).
Treatment records Physiotherapists are required, wherever possible to use evidence based interventions to support treatment rationale and map the intervention with outcome measurements. These must be recorded clearly and concisely to demonstrate to a third party what they did, why they did it and when they did it (4)
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Record keeping is a professional requirement of all physiotherapy practiceandrequiresspecificskills.Failuretomaintainaphysiotherapyrecordwouldcauseconsiderabledifficultiesinrespectofanylegalproceedings (5).
What to record:• Aninformed,signedconsentformshouldbeincludedinpatientnotes• TheaccuratedocumentingofneedleplacementcitingtheWHO
recognised nomenclature, the depth of needling, uni or bilateral, the duration of the acupuncture treatment and any response to treatment
• Alladversereactionstoacupuncture,nomatterhowsmall,shouldberecorded in the notes
• Triggerpointsshouldbedescribedwithdepthofneedlingandmusclesnamed.Adiagramofneedleapplicationwithdifficultpointsmay be suggested e.g. Serratus Anterior
Example of treatment record sheet:
Date Points used
De Qi attained?
Twitch response?
Outcome Adverse effect
Safe needling technique Guidelines • Alwayswashyourhandsbeforecommencingacupuncture
treatment. • Coveranyexistingwounds,skinlesionsandallbreaksin
exposed skin with waterproof dressings or use gloves if your hands are extensively affected.
• Ensurethattheskinandneedlesiteareclean.Visiblysoiledor
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dirty skin should be cleaned with soap and water (7) Alcohol swabs using 70% isopropanol or 0.5% chlorhexidine may be used, but such use is not mandatory (6) (See P 17 for auricular acupuncture).
• Ifswabsareused,anewswabperacupuncturepointisrequired. Ensure the swabbed site is dry before commencing acupuncture. This may take up to 2 minutes
• Anewpre-packed,sterile,single-useneedleshouldbeusedforevery acupuncture point.
• Avoidtouchingtheshaftoftheneedletoensurethattheshaftofthe needle remains sterile at all times
• Whenusingalongneedleusesterilecottonwool,alcoholswabor a shorter sterile guide tube to support the shaft of the needle.
• NeedlesusedshouldallcarrytheC/Emarkandshouldbewithinthe‘useby’date.Discardanyneedlesyouthinkmayhave been contaminated or that have package seals that are damaged or open.
• Neverre-sheathaneedle.• Ifhandsbecomecontaminatedduringtreatmentensuretheyare
washed and rinsed with alcohol gel.
(For hand washing technique see http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947384669 )
Removal of Needles• Ensurehandsarewashedoralcoholgelhasbeenused.• Ensurethatthecottonwoolballisinsituastheneedleis
removed.• Placetheneedleimmediatelyintothesharpscontainerwhichis
close at hand.• Ifbloodispresent,ensurecottonwoolpressureremainsuntil
bleeding has stopped.• Disposeofcottonwoolintoclinicalwastebag.• Avoidre-palpationofaneedlepointunlesshandsareclean.
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Precautionspotentially Hazardous points This section is intended to draw your attention to the safety aspects when inserting needles into anatomical areas where PRECAUTION should be exercised. It is not meant to deter you from using some of the named points as long as you are consciously aware of the underlying anatomical structures in situ. However, if you are in any doubt it will be wise to consult a more experienced practitioner or an AACP mentor for further guidance. Be aware of the anatomical structure(s) underlying your needle at all times but especially those points that lie in close proximity to vital organs and sensitive structures. Depth of needle insertion should always be based on clinical examination of the area to be treated taking into account the patient’smorphologyandlocalanatomy.(8)
List of Acupuncture points that are potentially Hazardous
Location Points PrecautionHEADVertex of skull GV 20 (Baihui)
ShishencongNeedle subcutaneously beware of fontanelle
Occipital area GV 15, (Yamen)GV 16, (Fengfu)
Points lie over the foramen magnum. Use short needle (13mm) following the contour of the occiput and needle penetration of no more than ½ its length
Frontal and temporal area
Yintang, GB 14 (Yangbai)
Short needle inserted at an angle of no more than 30° to the horizontal
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THORAXIntercostal spaces
KI 22 (Bulang), KI 23 (Shenfeng), KI 24 (Linxu), KI 25 (Shencang), KI 26 (Yuzhong)
Angle the needle obliquely and needle no deeper than 6mm
Suprasternal area
CV 17 (Dangzong) Possibility of presence of a foramen in the sternum so needle obliquely either in a cephalad or caudad directionA sternal foramina under CV 17, is reported to occur in 9% of men and 4% of women (9)
VERTEBRAL cOLUMNCervical, thoracic and lumbar spine
Bladder and Huatojiaji points
Assessyourpatient’smusculature and needle obliquely or perpendicularly
SAcRUMSacral foramina
Bl 31 (Shangliao)Bl 32 (Ciliao)Bl 33 (Zhongliao)Bl 34 (Xiliao)
Aim to direct needle over the site of the foramen needle obliquely either cephalad or caudad
Eyes of the shoulder
Eyes of the knee
LI 15 (Jianyu) TH 14 (Jianliao)
ST 35 (Dubi) and Xiyan
Use a guide tube to ensure non-touch technique to the shaft of the needle.
Depth of needle penetration assessedbytheindividual’ssoft tissue presence
Avoid these points on patients on long term anti coagulant medication or haemophiliacs
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pOINTS TO AVOIDOver the umbilicus
Cv 8 (Shenque)
Over the nipple
St17 (Ruzhong)
Axilla Ht 1 (Jiquan)
Contraindicated points Pleasenotethatthesuggested‘Contraindicated’pointsaremainlybased on anecdotal evidence and knowledge of basic physiology.
Acupuncture during pregnancyAs in all your clinical practice you should only use acupuncture within the limits of your professional competence. You should ensure that you have been adequately trained to use acupuncture on a pregnant patient.
In pregnancy – Avoid LI 4; SP 6; UB 60, 67; SACRAL FORAMINAL POINTS B 31, 32, 33, 34
Thereisno‘scientific’evidencetosupporttheavoidanceofneedling LI 4 & SP 6 during pregnancy as these points have been included for the treatment of pelvic girdle pain with no adverse reaction (10). However, it must be stressed that caution must be exercised. Take extra care with selection of points at all times during pregnancy; minimise intensity of stimulation i.e. DeQi sensation and avoid the above points when patients have history of miscarriage or appear to have a weak constitution during the pregnancy.
Acute strokes The Royal College of Physicians Stroke Guidelines state that acupuncture should only be used for acute stroke within the context
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of a research project as acupuncture has been shown to increase circulation in brain tissue. If deemed appropriate patients should have hadaCATscantoconfirmthatanybleedinghasstopped(11),(12).
cancer patients Cancer patients undergoing active treatment may have low platelet andwhitecellcounts.Practitionersshouldbesatisfiedthatcurrentplatelet and white cell counts are within a normal range.
Particular care must be taken with patients who have had any surgical procedure involving removal of lymph nodes as this may precipitate lymphoedema. It is advisable not to needle an oedematous limb or a limb that is at risk of lymphoedema (13).
Do not give acupuncture in areas of spinal instability as the resultant relaxation of the surrounding muscles can potentially give rise to spinal cord compression (13).
poor skin condition Do not needle into areas of poor circulation, thin damaged skin, open wounds, areas of eczema, moles, tumours, warts and spots of any kind. Find an alternative suitable acupuncture point.If you suffer from a chronic skin disease such as eczema on your hands, you should avoid giving acupuncture when your skin lesions are active, or if there are extensive breaks in the skin surface (14).
DiabetesAcupuncture may precipitate a reduction in blood sugar levels therefore take care when treating diabetic patients and ensure that they have eaten before having treatment.
EpilepsyEstablishwhetherthepatient’sepilepsyisstable.Donottreatifthepatient has had a recent seizure. You are strongly advised to stay with your patient while the needles are in situ.
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Haemophilia and other clotting disordersThere are many conditions for which a patient may be prescribed anti-coagulant medication. The dose of anticoagulants will depend on the patients underlying condition. The INR (international normalised ratio) is the measure of desired amount of anti-coagulation medication. Commonly the ideal INR lies between 2.0-3.0 though this may vary according to the underlying condition. Bleeding is the major adverse effect of oral anticoagulants and any activities or procedures that may cause bleeding must be carefully considered in patients taking anti-coagulant medication. Although there have been no reported cases of bleeding-related complications from acupuncture being performed on anticoagulated patients, practitioners should be aware of possible bleeding complications in this sub-group of patients (15).
Care should be taken when treating haemophiliac patients with acupuncture.FactorVIIIlevelsshouldbeabove15%usefineneedles and use a guide tube when needling points close to joints (16). Do not needle into joint spaces.
The use of cupping or guasha on patients who are on anti-coagulants is not advised as these techniques could cause severe and prolonged bruising.
In the event of a patient having an unusual clotting disorder it is prudent to discuss your intentions to offer acupuncture with the relevant haematologist where possible.
Unsuitable patients Patients with uncontrolled movements, the confused and the very young are not suitable for acupuncture treatment.
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Adverse eventsFainting / needle shockMinor adverse events such as drowsiness, nausea, sweating or fainting associated with acupuncture treatment occur on average at a rate of 1.3% per thousand treatments (17). Although fainting is not a common adverse effect if it does occur it is most likely to dosoduringthefirsttreatment(17).Theneedlingprocedureandthe sensations it may cause should therefore be carefully explained before starting. All treatment should always be given with the patient comfortably supported on a couch in a safe position.
Symptoms of impending faintness include feeling unwell, a sensation of giddiness, the room moving, or a feeling of weakness, restricted feeling in the chest accompanied by palpitations, nausea or vomiting. The complexion turns pale and the pulse is weak. If warning symptoms appear, (pallor, nausea sweating) remove all the needles immediately.Wherepossible,laythepatientflatandraisethelegsslightly. Ensure the airways are clear. The symptoms usually disappear after a short rest. Ensure the patient is safe to leave the premises.
If the patient faints strong pressure on GV 26 (renzhong) can bring a rapid response. Acupressure could also be applied to PC6, ST36 and LI4.
Needle Shock wherein the patient describes symptoms such as light-headedness, general malaise, cold perspiration, nausea, chest tightness and, in extreme situations may proceed to lose consciousness is thought to be a vaso-vagal response. If any of these symptoms appear remove the needles and stay with your patient until they have recovered. An incident form must be completed and the event recorded as an adverse event in the patient notes, signed and dated. If symptoms persist, medical assistance will be necessary, though it should be noted that this kind of reaction is very rare.
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Needle shock may be avoided by: • Treatingpatientsinthelyingposition.• Needlinggentlyasatestdose.• Reassuringnervouspatients.• Ensuringthepatientisnotovertiredorhungry.• Avoidneedlingthethoracicareaoverthesympatheticchain
especially if the patient is anxious or fearful.
The commonest cause of fainting other than needle shock and anxiety is lack of food prior to treatment. Reassure anxious patients and ensure that the patient has not fasted before treatment.
Allfirstaidtrainingshouldbeappliedtoalleviatesymptoms.
(Physiotherapistsarerequiredtomaintainfirstaidtraining,accordingto their local policy)
Bleeding Stop any bleeding by applying cotton wool pressure and dispose of this immediately in a clinical waste bag.
Ensurethatanybloodorbodyfluidspillsarecleanedupwithdisinfectant solution.
Drowsy patients Some patients may feel very relaxed and even sleepy after acupuncture treatment. They should be advised not to drive until they have fully recovered.
Broken needle The incidence of broken needles is rare. However a tip may break off and remain in the patient. If this occurs:• Reassurethepatient,• Tryandremovetheneedletipwithforceps.
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If you are unable to do this:• Markthearea.• Writeupdetailednotes.• RefertothelocalA&Edepartment.• Bestpracticewouldbetoaccompanythepatient.• ContactAACPforsupportifyouareconcerned.(01733390012).
Stuck needle In the case of a needle that is resistant to removal: • Reassurethepatientandencouragerelaxation.• Takeoutalltheotherneedlesbeforetryingagain.• Massageorapplypressureneartheneedleusingacottonwool
ball.• Ifthisfails,insertasecondneedlenexttoit,orinanadjacent
acupuncture point.
Needle stick injuryThis is sometimes called a percutaneous injury. If the sharp is contaminatedwithbloodorotherbodyfluid,thereisapotentialfor transmission of infection. Although rare, injuries from sharps contaminatedwithaninfectedpatient’sbloodcantransmitanyof more than 20 diseases, including Hepatitis B, C and human immunodeficiencyvirus(HIV).
Immediate action:• Encouragethewoundtogentlybleed,ideallyholdingitunder
running water.• Washthewoundusingrunningwaterandplentyofsoap.• Don’tscrubthewoundwhilstyouarewashingit.• Don’tsuckthewound.• Drythewoundandcoveritwithawaterproofplasterordressing.• Discardtheneedle.• Recordtheinjuryinthepatientnotesanddocumenttheincident
and its circumstances in your accident book. Report the injury to your Manager.
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• Seekurgentmedicaladvice(forexamplefromyourOccupationalHealth Service, your GP, your local A&E or NHS Direct 0845 4647), where you will be given advice regarding Post-Exposure Prophylaxis.
Although the use of gloves have been shown to reduce the risk of transmission of infection using gloves does reduce manual dexterity and are not mandatory except if treating a patient known to be carrying a blood borne infection.
Acupuncture - risk of transmission of a Blood Borne Virus (BBV) as a result of a percutaneous injury.
Percutaneous injuries carry the greatest risk of exposure to and transmission of Blood Borne Viruses ( BBV) in the healthcare setting. The highest risks of injuries are in hospital wards, operating theatres and A&E units (18). The risk of infection of a BBV following a percutaneous injury within the health care setting has been estimated as 1 in 3 for HBV, 1 in 30 for HCV and 1 in 300 for HIV (18). This risk is greatest from deep penetrating injuries involving a hollow bore needle or a device visibly contaminated with blood.Although there are many devices that can cause percutaneous injuries such as scalpels, probes and hollow bore needles, 19% of reported injuries have been attributed to solid needles (18).
Within the healthcare setting reported exposure injuries in professions allied to medicine and in ancillary staff (e.g. porters, security and housekeeping staff) were much lower than nurses, doctors and dentists, (9%).The majority of these exposures were from inappropriately discarded needles, highlighting the consequences of non-compliance with universal precautions and safe disposal of clinical waste (18).
• Neverassumethatthereisnoriskofapercutaneousexposureto a BBV.
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• Neverre-sheathaneedle.• Disposeofeachneedleimmediatelyandcarefullyafteruseina
sharps bin and do not pass to another person.• Coveranycutsorgrazeswithawaterproofdressing.
Immunisation against HBV The risk of infection of Hepatitis B is 100 times greater than HIV. Members are strongly advised to consider the value and potential benefitofgainingimmunisationfromHepatitisB.
IN ALL cases of a percutaneous injury (needlestick or exposure via a wound) it is very important to assess the likelihood of transmission of a BBV. Members should seek advice from an Infection Control specialist via their GP, their Primary Care Trust or their local A&E.
Further information on the risk of transmission of BBV in the work place can be obtained from:
Eye of the Needle ReportHepBHepCHIVUnitedKingdomSurveillanceofSignificantOccupational Exposures to Bloodborne Viruses in Healthcare WorkersNovember 2008 www.hpa.org.uk
HSE guidance on BBV in the workplace: http://www.hse.gov.uk/pubns/indg342.pdf
Safety should be a priority. Ensure that you regularly update your education and training about safe working practices and that you are familiar with local policies and procedures.
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Associated acupuncture techniquesSelf needlingThe AACP does not support self-needling as it sees it as unnecessarily risky. (19)
Indwelling/semi- permanent needlesThe use of semi-permanent needles carries greater risk than conventional acupuncture techniques and AACP does not recommend their use. (20)
Acupressure balls/seedsThe use of auricular acupressure balls or seeds in the ear is a technique that carries less risk than semi-permanent needles. However, you are advised not to use them until you have been specificallytrainedintheiruse.
MoxaTo ensure safe and effective use of moxa practitioners must • Beadequatelytrained.• Ensuretheapplicationissafe.• EnsurethePhysiotherapydepartmentorprivatepracticehas
adequate damping facilities to prevent smoke detectors from being activated.
• Ensurethereisadequateventilationinthetreatmentroomto prevent patient/practitioner from developing respiratory problems.
• Theskinisswabbedfollowingmoxatoremoveanyashresidue.
precautions1. If moxa is burnt on the needle, ensure the skin beneath is
adequately shielded from burning moxa ash.2. Moxa is NEVER used on broken, fragile skin, on the face or sensitive,difficultareas.
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3. The patient is NEVER left unattended at any stage during the treatment.
4. If moxa is prescribed as a self-home treatment, the procedure is clearly explained, demonstrated and supervised before home treatment is allowed. Should any injury incur as the result of home moxa treatment, the sole responsibility lies with the practitioner in a court of law.
Ensure the patient is fully instructed and understands the implications of home moxa application before taking any moxa home. Patients should complete a consent form (see Appendix 3), accepting instruction and personal liability for the application of moxa at home. Both patient and practitioner should retain a copy of the signed agreement.
possible adverse effectsA) Minor burns • Holdaffectedareaundercoldrunningwaterfor10minutesor
until pain subsides.• Covertheburnwithcleannon-adhesivedressings.• DONOTuselotions,ointmentorcreams,adhesivedressingsor
break blisters. B) Serious burns • Startcoolingwithcoldrunningwater.• Seekprofessionalassistance.• Makethecasualtysafeandcomfortable.• Covertheburnwithsterile,nonadhesivedressing.• Treatforshock.• Transferformedicalattention.• DONOTuselotions,ointmentorcreams,adhesivedressingsor
break blisters.
cuppingTo ensure safe and effective use of cupping practitioners must be adequately trained.
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Useofcupsrequiringaflametoproducethevacuumisnotrecommended on NHS premises. Plastic vacuum cups with a suction pump or glass or rubber cups using a squeeze bulb are preferable.Ifyoudouseflameinprivatepremises,ensurethatyoucomplywithlegalrequirementstohaveafireextinguisher,andafireblanket on the premises.
Do not treat: • Onthelowerbackorabdomenduringpregnancy.• Directlyoveratraumatisedarea.• Overbrokenorulceratedskin.• Overoedematousarea.• Overareasofsunburn.• Overenlargedbloodvessels,varicoseveins,thromboses,
aneurism or advanced arteriosclerosis.• Overthethroat.
Do not use cupping on: • Patientswithorganiccardiacproblems.• Patientswhohavesufferedinflamedorganswherebleedingmay
be present.• Patientswithsevereanaemia.• Veryweakpatients.• Patientswithbleedingdisorders.• Thin,fragileskin.• Patientswithhypertension.• Children–undertheageof3.
Cleaning cups• Washallcupsindishwasherathightemperature,• Wiperimofcupwith70%isopropanol.
Auricular acupunctureTo ensure safe and effective auricular acupuncture practitioners must be adequately trained.
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Extra care should be taken with auricular acupuncture, as the ear tissue is prone to infection.
Before treatment surface wax should always be removed with a 70% isopropyl alcohol swab.
Always ensue that the ear is dry before commencing treatment.
Indwelling needles under a small piece of plaster should not be used as these may lead to a local infection of the cartilage of the ear known as perichondritis. This can result in deformity and may lead to the surgical excision of the damaged portion (6).
If the stimulus is required for a longer time than the treatment session, tiny metal balls or vaccaria seeds are recommended. Advise the patient to sleep with cotton wool in their ear to prevent any risk of the seed/metal ball falling into the ear canal.
Care must be taken to remove and dispose of all needles/seeds in a suitable and timely fashion. Take care as tiny needles can become lost in the clothing.
ElectroacupunctureTo ensure safe and effective use of electro-acupuncture practitioners must be adequately trained.
It should be standard practice to ask patients if they have a pacemaker before electro acupuncture is given.
Where a patient has an implanted cardiac pacemaker in situ, elecroacupuncture should not be used where the current is likely to traverse the heart, for example when needles are placed in opposite arms and linked by a current (21).
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All portable electrical appliances that are used in conjunction with acupuncture treatment on your premises must be maintained and serviced annually according to the Electricity at Work Regulations (1989) (22).
Personal Health and HygieneClean hands protect against transmission of infection (http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947384669).• Alwayswashhandsthoroughlywithsoapandwaterbetween
each patient. • Coverallcutsoropenwoundswithaprotectivewaterproof
dressing.• Ensureyourpatient’sskinisvisiblyclean.Needleinsertion
should only be performed through visibly clean skin. There is no evidence to support the disinfection of skin prior to acupuncture although it is advised when needling the head, face and ear (23).
• Followyourlocalinfectioncontrolguidelineswhereappropriate.• Useof70%isopropanolbasedhandgelisrecommended.
GlovesGloves are not required for acupuncture intervention in most circumstances. Gloves reduce dexterity, but their use is subject to discretion and may be chosen by the practitioner when the patient is known to carry a blood borne infection, if the patient has open woundsorifbodilyfluids(blood,vomit,urineetc)arepresentnearthe acupuncture site. They should also be worn if you have a skin condition or you have cuts that cannot be adequately covered with waterproof dressings.
The application of cotton wool on removal of the needle will prevent contactwithbodyfluidsifusedcorrectly.
Swabbing – see Page 7
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ANTT ( Aseptic No Touch Technique)There is no documented evidence to support the use of ANTT when giving acupuncture. Acupuncture treatments when practised by competent health professionals who strive to maintain high professional standards and who place a high emphasis on patient safety is a relatively safe treatment which carries a negligible risk of infection, documented at less than 1 per 66,000 (23).
Workplace considerationsAcupuncture may be practiced in NHS premises, in the community, in licensed private clinics or in sports clubs. In all situations practitioners must comply with all local regulations.
When practising acupuncture in the, community; licensed private clinics;sportsclubs,practitionersmusthaveadefinedbaseofatleastoneroomorofficewhichconformstotheHealthandSafetyExecutive Guidance on workplace requirements. (details are available at http://www.hse.gov.uk/pubns/indg244.pdf).
This room should comply with the Local Authority bylaws and should have adequate facilities for the storage of clean equipment, the temporary storage of soiled equipment, clinical waste and sharps containers and if necessary, the disinfection of equipment.
Transporting equipment In transporting equipment from the base premises to the treatment site practitioners must ensure that containers used for this purpose are lockable and tightly sealed when shut.
Ensure that sterile and soiled equipment are stored separately.
Domicillary visitsPractitioners must ensure that:
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• Everyattemptismadetoensurethattreatmentiscarriedoutin well lit, clean environment with easy access to hand washing facilities.
• Thebediscleanandcoveredwithdisposablecover.• Needlesaredisposedofinasharpsbinwhichislockablefor
transportation.• Enoughtimehasbeensetasidetomonitoranyadverse
reactions before departure.
After treatment practitioners should ensure that:• Soiledclinicalwasteisdisposedofinclinicalwastebags.• Paperproductsaredisposedofindomesticwaste.
Asinallacupuncturetreatmentensurethatthepatient’sskinisclean, free from cuts, wounds or infections. The routine use of swabs is not normally necessary depending on the local trust policy. Points may be swabbed with 70% isopropanol swabs but then must be left to dry before proceeding to needle.
Licensing of acupunctureIn accordance with the Local Government Miscellaneous Provision Act 1982, State Registered Physiotherapists are required to licence their premises for the provision of acupuncture in England and Wales.
The cost and terms of licensing varies from authority to authority and members should contact their local Authority to ascertain their local requirements.
In some areas AACP members are exempt from the need to license their premises; in these cases the practitioner must obtain an exemption statement from their local licensing authority as they will still need to keep a record that acupuncture is being given within the designated premises.
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In Northern Ireland, State Registered Physiotherapists are exempt from the need to licence their clinics (The Local Government (Miscellaneous Provisions) ( Northern Ireland) Order 1985 (http://www.legislation.gov.uk/nisi/1985/1208).
In Scotland HPC Registered Physiotherapists do not need a licence when practising acupuncture in a hospital or independent clinic (Civic Government (Scotland) Act 1982 (Licensing of Skin Piercing and Tattooing) Amendment Order 2006 (2006/604)) (http://www.legislation.gov.uk/ssi/).
Within London the London Local Authorities Acts 1991/2000. (LLA Acts 1991 / 2000) allows local authorities to exempt AACP members from the need to pay a licensing fee for their private clinics for the provision of acupuncture as part of their physiotherapy practice. Some individual Boroughs may choose not to adhere to the recommendation within this Act and may still require members to pay and license their premises. All premises must still be registered with the Local Authority.
Treatment room requirementsHand washing facilities with hot and cold running water and connected to the mains drainage system. Best Practice suggests that this should be located in the treatment room, but this is not mandatory.
• Soapshouldbeinliquidformanddispensedfromadispenser.• Handsshouldbedriedusingdisposablepapertowels.
Waste Disposal Bins:• Adisposablepolythenelinerfordrypaperwasteshouldbeused.• Afootoperatedpedalbinshouldbelocatedwithineasyreachof
the treatment couch.
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Treatment room facilitiesThe treatment room must provide: • Sufficientspaceformovement,safehandlingofequipmentand
performance of treatment.• Sufficientworksurfacestoestablishacleanfieldfortreatment.• Safestorageofallequipmentrelatedtoacupunctureand
physiotherapy especially in relation to the risk of contamination and to avoid risk to children and vulnerable adults.
• Cleancouches,couchcoversandcouchpapercovers.• Pillowsandcouchesshouldberegularlycleanedwith
appropriate cleaner (according to local protocol) at the end of the workingdayorintheeventofbloodandbodyfluidspillage.
Equipment for safe and hygienic practice • AllequipmentmustbeCE-markedandconformtocurrent
Medical Devices Agency legislation (24).• Allelectro-acupunctureequipmentmustbecheckedregularlybyaregisteredelectricalsupplierandacertificateofsafetyretainedon the premises.
• Single–use,pre-steriliseddisposableneedlesonlymaybeused.• Alldisposableequipmentmustberemovedbythe“use-by”date.• Glasscupsandotherre-usableequipmentmustbewashedinsufficientlyhotwater,preferablyinthedishwasherandstoredinaclean, dry place.
• Cottonwoolballsmustremainclean,butsterilecottonwoolisnot mandatory.
• SharpsboxesmustconformtoBS7320:1990andclearlymarked“Danger–ContaminatedNeedles-ToBeIncinerated.”They should be kept at a safe height, in a stable place and adjacent to the treatment couch.
• Itisarequirementtodisposeofallclinicalwastethroughanauthorised collection agency. AACP recommend that a licensed clinical waste contractor is used. All contracts, receipts for clinical waste collection are retained for inspection purposes.
• ThetreatmentareashouldhaveaFirstAidkitcomplyingwiththe
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HealthandSafety(FirstAid)Regulationscontainingasufficientsupply of equipment, which is checked monthly to ensure that contents remain in date.
Disposal of needles & equipmentEnsure that: • Allneedles,areimmediatelyplacedafteruseintheappropriate
sharps container. • Needlesmustnotbebentorreinsertedintotheplasticsheath
before discarding.• Alwaysdisposeofneedlescarefullyinasharpsbinatthepointof
removal.• Donotpasssharpstoanotherpersonfordisposal.• AllsharpscontainersconformtoBS7320:1990andareclearlymarked“DangerContaminatedNeedles-TobeIncinerated”.
• Allsharpscontainers,whennomorethanthreequartersfull,are disposed of in accordance with Local Authority Health Department Guidelines.
• TheSharpscontainershouldonlycontainsharps.Cottonwoolorother swabs must not be placed in the sharps box.
• Allclinicalwaste,paperwaste,swabs,cottonwooletcwhichhasbeencontaminatedwithpatientbodyfluidsSHOULDBEDISPOSED OF IN YELLOW CLINICAL WASTE SACKS and collected by a licensed agent.
• Clinicalwastemustbecollectedbyaregisteredwastecarrierand disposed of in an appropriate licensed manner according to the Controlled Waste regulations (1992) up-graded in 2011. All contracts, receipts for clinical waste collection are retained for one year for inspection purposes. (http://www.environment-agency.gov.uk/netregs/legislation/future/97620.aspx).
• Allotherwasteincludingpapertowels,swabsandcottonwoolwhichhasnotcomeintocontactwithbodyfluidsorspillagesas well as needle wrappings and guide tubes is disposed of in domestic waste.
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Appendix 1The Health and Safety at Work etc Act 1974 This Act sets out the general duties which employers have towards employees and members of the public, and which employees have to themselves and to each other and this forms the basis for British Health and Safety Law. http://www.healthandsafety.co.uk/haswa.htm.
The Management of Health and Safety at Work Regulations 1999 (the Management Regulations)Further, what employers are required to do to manage health and safety under the Health and Safety at Work Act are detailed in The Management of Health and Safety at Work Regulations 1999 (the Management Regulations). http://www.hse.gov.uk/pubns/hsc13.pdf.
This covers issues such as ensuring that equipment is: • Suitableforitsintendeduse.• Safeforuse.• Maintainedandservicedbyalicensedapprovedcontractoreachyear.• Usedbyadequatelyinstructedprofessionals.• Accompaniedbysafetyinstructionsandmethodsofwork.• Allpoweredequipmentmusthave“CEmarkings”conformingto
European Safety Standards (ESS).
The Practice Principal/ Practice Manager shall carry out a workplace risk assessment of the Practice. The outcome must be used as a strategic plan to implement safe working practice.
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995While contracting a blood borne virus such as hepatitis C from a needle stick injury is very rare, should this occur there is a duty to report this to RIDDOR. http://www.hse.gov.uk/riddor/ or your local HSEoffice.(http://www.hse.gov.uk/).
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Disability Discrimination Act (2004) / Equality Act (2010)According to the Disability Discrimination Act (2004)/Equality Act (2010) arrangements should be made for the reception and treatment of disabled persons. (www.drc-gb.org).
Appendix 2 consent to acupunctureAcupunctureisaformoftherapyinwhichfineneedlesareinsertedintospecificpartsofthebody.
Acupuncture is generally very safe. Serious side effects are very rare-less than 1 per 10,000.
You need to be aware that: • Drowsinessoccursaftertreatmentinasmallnumberofpatients
and if affected, you are advised not to drive. • MinorbleedingorbruisingoccursafterAcupunctureinabout3%
of treatments. • Painduringtreatmentoccursinabout1%oftreatments.• Existingsymptomscangetworseaftertreatment(lessthan3%
of patients). You should tell your physiotherapist about this, but it is usually a good sign.
• Faintingcanoccasionallyoccurincertainpatients,particularlyatthefirsttreatment.
• Single-use,disposableneedlesarealwaysusedinthisclinic.
In addition, if there are particular risks that apply in your case, your practitioner will discuss them with you.
Apart from the usual medical details, it is important that you must answer these questions.
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yes no
Are you a diabetic?
Haveyoueverexperiencedafit,faintorfunnyturn?
Haveyoubeenfittedwithapacemakeroranyotherelectrical implants?
Do you have a bleeding disorder ?
Are you taking anticoagulants or any other medication?
Do you have damaged heart valves or have any other particular risk of infection ?
Are you pregnant or actively trying for a pregnancy?
Do you suffer from metal allergies?
Do you know of any reason why you should not have Acupuncture?
Statement of consent Thepurpose,benefitsandpotentialrisksofacupuncturetreatmenthave been explained to me.
IconfirmthatIhavereadandunderstoodtheaboveinformationandI consent to having acupuncture treatment. I understand that I can refuse treatment at any time.
Patient / Legal Representative signature ...........................................
(Status if applicable)...........................................................................
Print Name.......................................................Dated........................
Physiotherapist................................................Dated........................
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Appendix 3consent form for MoxaPATIENT INFORMATION AND CONSENT FORM - MOXABUSTION
Please read this information carefully, and ask your practitioner if there is anything that you do not understand.
Iconfirmthatmytreatmentinvolveshomemoxatreatmenttaughtby my Physiotherapist for use only on my person, within my own home.
IconfirmthatIhavebeeninstructedintheuseofmoxaat:
• Points………………………………………………......
• Timeofapplication…………………………………….• Howtolightandextinguishmoxa.• Howtodisposeofmoxasticks.• Whattodointhecaseofminorandseriousburns.
Iconfirmthatmypractitionerhasdemonstratedtheuseofmoxaand that I have demonstrated my competence in applying moxa to my person, with supervision from the practitioner.
Statement of consent IconfirmthatIhavereadandunderstoodtheaboveinformationandI consent to the self-application of moxa at home. I understand that I can refuse treatment at any time.
Patient signature ..............................................................................
Print Name.......................................................Dated........................
Physiotherapist................................................Dated........................
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Appendix 4 Disinfectants and cleaning agents / hand and skin disinfection • Handsshouldbewashedinliquidsoapandwarmwater.• Alcoholbasedgel(70%isopropanolbased),isopropanolswabs,
or products containing 0.5% chlorhexidine may be used after washing.
• Isopropanol70%(gelandswabs)iscommonlyusedintheNHS.
Surface disinfection / equipment disinfection You must be aware of local policy regarding surface and equipment cleaning• Washsurfaceswithwaterandmilddetergentbeforeusingany
disinfectant. • HypochloritebleachsolutionisrecommendedbytheNHSfor
surface cleaning. • Practitionersmustensurethattheypreparethesolutionin
accordance with the manufacturers instructions. • Practitionersshouldbeawarethatbleachiscorrosiveandtoxic.• Proprietarybathroom&kitchencleaningagentsareeffective
and may be more convenient to use than hypochlorite bleach solution.
Equipment disinfection For disinfecting moxa dishes, glass cups, trays etc., practitioners should use one of the following prepared exactly according to manufacturers’instructions:• Hypochloritebleachsolution-seenotesabove.• Miltonsolution.
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References:1. CSPcodeofmembers’professionalvaluesandbehaviour
ISBN: 978 1 904400 31 8 www.csp.org.uk/code
2. Chartered Society of Physiotherapy Information paper: Consent and Physiotherapy Practice – PD078- Sept 2011 www.csp.org.uk
3. http://www.blood.co.uk/can-i-give-blood/who-cant-give-blood/
4. CSP core standards of Physiotherapy practice(2005). Standard no.14 www.csp.org.uk
5. General Principles of Record Keeping and Access to Health Records(PA47)October2000http://www.csp.org.uk/sites/files/csp/secure/csp_physioprac_pa47.pdf
6. BMAS Policy statements in some controversial areas of practice. Cummings M, Reid F. Acupuncture in medicine 2004; 22(3): 134-136
7. Skin Disinfection and acupuncture. Hoffman P. Acupuncture in Medicine 2001; Dec 19(2): 112-116
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11. Qi L, Zhang Z, Ye C, Li J, Hu J. Observation on acupuncture treatment of 322 cases of cerebral infarction and changes in serum HDL-C Fibrinogen, FDP, Hemorrheological indices etc during treatment. International Journal of Clinical Acupuncture 1990; 1(1):39-46
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13. Filshie J, Hester J. Guidelines for providing acupuncture treatment for cancer patients--a peer-reviewed sample policy document. Acupuncture in Medicine 2006 Dec;24(4):172-82
14. DoH General principles of bloodborne virus infection control and exposure prone procedures 2007 Gateway ref: 4557 http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4118230
15. Acupuncture In Patients Anticoagulated With Warfarin Joseph Sciammarella, MD Medical Acupuncture- A Journal For Physicians By Physicians, Volume 13 / Number 2 www.medicalacupuncture.com/aama_marf/journal/vol13_2/case4.html)
16. Acupuncture used in the Management of Pain due to Arthropathy in a Patient with Haemophilia Palle Rosted, Viggo Jørgensen Acupuncture in Medicine 2002;20(4):193-195
17. A Prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. MacPherson H, Thomas K, Walters S, Fitter M. Acupuncture in Medicine 2001;19(2): 93-102
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18. Eye of the Needle Report 2008 www.hpa/org/uk
19. Hopwood V and Campbell A Debate – Patients should be encouraged to treat themselves. J. of AACP Autumn 2007 P 57-61
20. Ernst E ,White A. Indwelling needles carry greater risks than acupuncture techniques British Medical Journal.1999 February 20; 318(7182): 536
21. John W Thompson, Mike Cummings Investigating the safety of electroacupuncture with a picoscope (tm) Acupuncture In Medicine 2008;26(3): 133-139
22. The electricity at Work Regulations http://www.hse.gov.uk/lau/lacs/19-3.htm
23. White A., 2006. The safety of acupuncture - evidence from the UK. Acupuncture in Medicine, 24 (Suppl),S53-57
24. Medical Devices Directive 93/42/EEC Details can be seen at: http://www.mhra.gov.uk/Howweregulate/Devices/MedicalDevicesDirective/index.htm
