Guide Line Akupunture Dis 09 BC -...

TRADITIONAL ANDCOMPLEMENTARYMEDICINEPRACTICEGUIDELINES ONACUPUNCTURE

Second Edition, November 2009

First Edition, October 2007Second Edition, November 2009

All rights reserved. No part of this book may be reproduced,stored, or transmitted in any form or by any means, electronic orotherwise, including photocopying, recording, internet or anystorage and retrieval system without prior written permission fromthe publisher.

Published by:Traditional and Complementary Medicine Division

Ministry of Health Malaysia

ISBN 978 -983-44754-5-1

Cover design by :Mohd Affendy Baharudin

Traditional and Complementary Medicine Division

ACKNOWLEDGEMENTS

1. INTRODUCTIONS

2. OBJECTIVES

3. ACUPUNCTURE3.1 Concept3.2 Treatment

4. PROCEDURES AND TECHNIQUES

5. CONDITIONS BENEFITS FROM ACUPUNCTURE

6. CONTRAINDICATIONS

7. SAFETY AND ADVERSE EFFECTS7.1 Precautious and Treatment

8. STANDARD OF PRACTICE FOR ACUPUNCTURE8.1 Prevention of Infection8.2 Technique / Mode of Delivery8.3 Maintenance of Skill

9. APPENDICESAppendix 1 : Acupuncture Clerking FormAppendix 2 : Screening FormAppendix 3 : Acupuncture Consent formAppendix 4: Guide in Treatment Plan of Acupuncture for Chronic

Pain and Post Stroke ManagementAppendix 5 : Hand Washing TechniquesAppendix 6 : SterilizationTable 1 : World Health Organisation indications for AcupunctureTable 2 : National Institutes of Health Consensus Panel on

AcupunctureTable 3 : Conditions for which acupuncture may be indicated

(American Academy of Medical Acupuncture)

10. REFERENCES

11. COMMITTEE MEMBERS

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ACKNOWLEDGEMENTS

Special thanks to every individual andorganizations that have in one way or anothercontributed comments and advices during thepreparation of the Traditional andComplementary Medicine Practice Guidelines onAcupuncture.

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TRADITIONAL AND COMPLEMENTARY MEDICINE PRACTICE GUIDELINES ON ACUPUNCTURE

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1. INTRODUCTIONS

Traditional medicine is the knowledge, skills and practice of holistic health care, recognized andaccepted for its role in the maintenance of health and the treatment of diseases. It is based onindigenous theories, beliefs and experiences that are handed down from generation to generation1.Although modern medicine is widely spread, traditional medicine still exists and widely used inmany countries. Interest in traditional medicine has increased over the last decade. People are nowmore prepared to look for alternative approaches to maintain their health.

WHO’s traditional medicine programme was developed in conjunction with the adoption of thehealth for all strategy and the primary health care approach. The Regional Strategy for TraditionalMedicine in Western Pacific Region was prepared to help guide national governments, WHO andother partners in the efforts to ensure the proper use of traditional medicine and its contribution formaintaining health and fighting diseases in the Region. One of the strategies indicates the need topromote public awareness and access to traditional medicine. It recommends that government andnon government organization should motivate healers to cooperate and voluntarily share theirhealing knowledge and practices. Access to traditional medicine through informed choice shouldbe facilitated and mutual understanding between practitioners of traditional and modern medicineshould be promoted.

In January 2006 ,the Malaysian Cabinet had approved the establishment of Traditional andComplementary Medicine ( T&CM) unit in three hospitals, Hospital Kepala Batas in Penang, HospitalPutrajaya in Federal Territory of Putrajaya and Hospital Sultan Ismail in Johore. The implementationof the pioneer project is towards integrating traditional and complementary medicine into the existingpublic healthcare delivery system.

To implement the services, the unit is provided with T&CM practice guidelines on the three modalitiesof treatment.


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2. OBJECTIVES

The objectives are to promote the highest standards in the practice of the acupuncture modalitiesof treatment and to ensure public safety.

3. ACUPUNCTURE

Acupuncture is a branch of traditional Chinese medicine which mainly involves the theory ofmeridians, location, usage, indications and combinations of acupoints, needling manipulations2.

3.1 ConceptAcupuncture is among the best known of traditional and complementary therapies.Acupuncture is a treatment method that originated more than 3,000 years ago in China andis practiced in most of the world3. Acupuncture is a traditional Chinese medical techniquefor unblocking chi (ch’i or qi) by inserting needles at particular points on the body to balancethe opposing forces of yin and yang. When yin and yang are in harmony, chi flows freelywithin the body. Key principles in traditional Chinese medicine are that both wellness andillness result from an imbalance of yin and yang. Yin refers to feminine aspect of life:nourishing, lower, cool, deficient, inside receptive, protective, soft , yielding while Yang ismale counterpoint: hard, dominant, energetic, upper, hot , excessive, outside, creative. Themovement between these opposite forces, name Qi, (chi) channels of energy that runs inregular patterns through the body and over its surface. These energy channels, calledmeridians, are like rivers flowing through the body to irrigate and nourish the organs andtissues. An obstruction in the movement of these energy rivers is like a dam that backs up theflow in one part of the body and restricts it in others.

The meridians can be influenced by needling the acupuncture points; the acupuncture needlesunblock the obstructions at the dams, and re-establish the regular flow through the meridians.Acupuncture treatments can therefore help the body’s internal organs to correct imbalancesin their digestion, absorption, and energy production activities, and in the circulation oftheir energy through the meridians.

The modern scientific explanation is that needling the acupuncture points stimulates thenervous system to release chemicals in the muscles, spinal cord, and brain. These chemicalswill either change the experience of pain4 (e.g endogenous opioid neuropeptides) or they


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will trigger the release of other chemicals and hormones which influence the body’s owninternal regulating system.

The improved energy and biochemical balance produced by acupuncture results in stimulatingthe body’s natural healing abilities, and in promoting physical and emotional well-being.

3.2 TreatmentNeedle acupuncture treatment is effective for postoperative and chemotherapy nausea andvomiting, nausea of pregnancy, and postoperative dental pain. It is also effective as an adjuncttherapy in stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia(general muscle pain), low back pain, carpal tunnel syndrome, and asthma5,6,7,. Acupunctureis particularly useful in resolving physical problems related to tension and stress and emotionalconditions.

Acupuncture treatments can be given at the same time with other techniques are being used,such as conventional Western medicine. The number of treatments needed differs from personto person.

4. PROCEDURES AND TECHNIQUES

Treatment starts with a case history, assessment on the client’s condition and the indications foracupuncture. During clerking for the case history and doing the assessment for suitability foracupuncture, the practitioner are required to document all findings in the clerking form. (Appendix1 : Acupuncture Clerking Form ). Additional information can be obtain in the screening form if sorequired (Appendix 2 : Screening Form). During the assessment, if the client is not suitable for thetreatment, advice to seek appropriate medical treatment should be given. (please refer Section 6 :Contraindications)

Before starting any procedures or treatment, practitioner are required to explain the procedures tothe patient prior signing the consent form (Appendix 3 : Consent Form For Acupuncture). Allprocedures are also required to be documented in patient’s record. The number and frequency offollow up visit for Acupuncture treatment are catered according to individual bases (Appendix 4:Guide in Treatment Plan of Acupuncture for Chronic Pain and Post Stroke Management). However,any adverse reaction or side effect that occurs must be reported and documented in appropriateform for further action.


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The patients’ records must contain full details of the medical history, clinical findings, diagnosticdata, treatment plan, prescribed points and the response to treatment. They should be regarded asconfidential and kept properly.

5. CONDITIONS BENEFITS FROM ACUPUNCTURE

The World Health Organization has identified more than 40 medical conditions effectively treatedwith acupuncture (see table 1). NIH Consensus Panel has also identified conditions that benefitwith acupuncture (see table 2). The American Academy of Medical Acupuncture has suggested alisting for use by hospital credentialing committees in which the matter of medical acupunctureprivileges are considered ( see table3 ).

6. CONTRAINDICATIONS9

6.1 PregnancyAcupuncture may induce labour and, therefore, should not be performed in second andthird trimester. However, should there is a strong indication for acupuncture to be carriedout, acupuncture can still be carried out for pregnant women at all gestational age providedstrict precaution are taken into account to avoid certain acupuncture points that may inducecontraction of the uterus including acupuncture points at lower back and lower abdomen.

6.2 Medical Emergencies and Surgical ConditionsAcupuncture is contraindicated in emergencies. In such cases, first aid should be appliedand transport to a medical emergency centre arranged.

Acupuncture should not be used to replace a necessary surgical intervention.

6.3 Malignant TumoursAcupuncture should not be used for the treatment of malignant tumours. In particular, needlingat the tumour site should be prohibited. However, acupuncture may be used as acomplementary measure, in combination with other treatment, for the relief of pain or othersymptoms, to alleviate side-effects of chemotherapy and radiotherapy, and thus to improvethe quality of life.


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6.4 Bleeding DisorderNeedling should be avoided in patients with bleeding and clotting disorders, or who are onanticoagulant therapy or taking drugs with an anticoagulant effect.

6.5 Accident and Untoward Reaction• Fainting• Burning during moxibustion• Local infection• Stuck / broken needle• Pain during and after needle insertion as well as after withdrawal• Injury to important organs• Convulsion

7. SAFETY AND ADVERSE EFFECTS

Side effects of acupuncture are extremely low and often lower than conventional treatments. However,recommended by the NIH that patients need to be fully informed of their treatment options, expectedprognosis, relative risk and safety practices to minimise the risks prior to undergoing acupuncturetreatment.

As an invasive technique, acupuncture has some risks, which include organ puncture, for example,pneumothorax, cardiac tamponade, damage to neural and vascular structures, infection, metalallergy, local pain, bruising, bleeding, or hematoma formation. Serious injury is extremely rare,given the millions of acupuncture needles placed annually worldwide8.

7.1 Precautious and Treatment9

7.1.1 MealsBefore acupuncture procedure: every patient is advised to have light meals / breakfast as afasting patient may be at risk of fainting episodes or hypoglycaemia. Too heavy a meal mayalso lead to ineffective acupuncture.

7.1.2 FaintingDuring acupuncture treatment, the patient may feel faint. The needling procedure and thesensations it may cause should therefore be carefully explained before starting. For thoseabout to receive acupuncture for the first time, treatment in a lying position with gentlemanipulation is preferred.


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If warning symptoms (feeling unwell, a sensation of giddiness, movement or swaying ofsurrounding objects, and weakness) appear, remove the needles immediately and make thepatient lie flat with the head down and the legs raised, as the symptoms are probably due toa transient, insufficient blood supply to the brain. The symptoms usually disappear after ashort rest. If the symptoms persist, emergency medical assistance will be necessary.

7.1.3 Burning During MoxibustionBurning of the skin should be prevented in indirect moxibustion. It is a special therapeutictechnique only performed at specific points by trained acupuncture practitioners oracupuncturists.

Direct moxibustion should not be applied to points on the face, or at sites where tendons orlarge blood vessels are located. Special care should be taken in patients with reduced levelsof consciousness, sensory disturbance, psychotic disorders, purulent dermatitis, or in areasof impaired circulation.

7.1.4 Local InfectionNegligence in using strict aseptic techniques may cause local infection, especially in earacupuncture. When such infection is found, appropriate measures must be taken immediately,or the patient referred for medical treatment.

7.1.5 Stuck NeedleAfter insertion, one may find it difficult or impossible to rotate, lift and thrust, or even towithdraw the needle.

The patient should be asked to relax. If the cause is excessive rotation in one direction, thecondition will be relieved when the needle is rotated in the opposite direction. If the stuckneedle is due to muscle spasm, it should be left in place for a while, then withdrawn byrotating, or massaging around the point, or another needle inserted nearby to divert thepatient’s attention. If the stuck needle is caused by the patient having changed position, theoriginal posture should be resumed and the needle withdrawn.

7.1.6 PainDuring Needle InsertionPain during insertion is usually due to clumsy technique, or to blunt, hooked or thick needles.It may also occur in highly sensitive patients. In most patients, skilful and rapid penetrationof the needle through the skin is painless. Therefore, the correct technique and optimumdegree of force to use could minimised pain during needle insertion.


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After InsertionPain occurring when the needle is inserted deep into the tissues may be due to hitting painreceptor nerve fibres, in which case, the needle should be lifted until it is just beneath skinand carefully inserted again in another direction.

Pain occurring when the needle is rotated with too wide an amplitude, or is lifted and thrust,is often due to it becoming entwined with fibrous tissue. To relieve the pain, gently rotate theneedle back and forth until the fibre is released.

Pain occurring while the needle is in place is usually caused by it curving when the patientmoves, and is relieved by resuming the original position.

After WithdrawalThis is usually due to unskilled manipulation or excessive stimulation. For mild cases, pressthe affected area; for severe cases, moxibustion may be applied in addition to pressure.

7.1.7 Injury to Important organsIncorrect insertion of the needle may cause injure to important organ. Therefore, specialcare should be taken in needling points in proximity to vital organs or sensitive areas. Inmost instances they can be avoided if adequate precautions are taken. Accidental injury toan important organ requires urgent medical or surgical help.

7.1.8 ConvulsionAll patients about to receive acupuncture should be asked if they have a history of convulsions.Patients who do have such a history should be carefully observed during treatment. Ifconvulsions do occur, the practitioner should remove all needles and render first aid. If thecondition does not stabilize rapidly or if convulsion continue, the patient should be transferredto emergency centre at hospital.

8. Standard of Practice for Acupuncture

In competent hands, acupuncture is generally a safe procedure with few contraindications orcomplications. Nevertheless, there is always a potential risk, however slight, of transmitting infectionfrom one patient to another (e.g. HIV or Hepatitis) or of introducing pathogenic organisms. Safety inacupuncture therefore requires constant vigilance in maintaining high standards of cleanliness,sterilization and aseptic technique. This standard is based on the Guidelines on Basic Training andSafety in Acupuncture (WHO) and Standard Precautions by Ministry of Health.


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8.1 Prevention of Infection

8.1.1 Clean Working EnvironmentThe treatment room should be free from dirt and dust, and should have a special workingarea, such as a table covered with a sterile towel, on which sterile equipment should beplaced. This equipment (including trays of needles, cotton wool balls and sticks, and 70%alcohol) should be covered with a sterile towel until needed for use. Adequate light andventilation should be provided throughout the treatment rooms.

8.1.2 Hand WashingHand washing is a process of removing of transient, potentially pathogenic micro-organismsfrom the hands. Practitioners should always wash their hands before and after treating apatient. Washing the hands again immediately before the acupuncture procedure isparticularly important in preventing infection. Hands should be properly washed followingthe effective hand-washing technique as shown in Appendix 5.

Many acupuncturists palpate the acupuncture point after the needling site has been prepared.In such cases, their fingertips should again be cleaned with an alcohol swab.

8.1.3 Appropriate use of Personal Protective EquipmentThe use of sterile surgical gloves, or individual finger stalls, is recommended for the protectionof the patient and the practitioner, especially if the latter has cuts or abrasions. Those withinfected lesions on the hands should not practise until they are healed. It is recommendedthat:• Sterile surgical gloves should be worn prior on removing of the Acupuncture needles.• Gloves should be promptly removed after touching these materials.• Change gloves in between procedures and between patient contact.• Gloves should be discarded after a procedure.• Hands should be washed immediately after removing gloves.

Note: Under certain circumstances, wearing surgical gloves may affect the accuracy of theacupuncture points and the method of application like obtaining and to sense the “qi”.

You may use a forcep to hold sterile cotton wool balls to replace glove if needed or wearsurgical glove while removing needle.

8.1.4 NeedlesDisposable needles should be used for all acupuncture procedures.


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8.1.5 Preparation of the Needling SitesThe needling sites should be clean, free from cuts, wounds or infections. The point to beneedled should be swabbed with 70-75% ethyl or isopropyl alcohol, from the centre to thesurrounding area using a rotary scrubbing motion, and the alcohol allowed to dry.

8.1.6 Disinfection and Sterilisation of patient-care equipmentSterilisation is required for cups and other equipment used (storage trays, forceps, guidetubes for needles, cotton wool balls and sticks, etc.)• Disposable, single-use instruments and items should be used whenever possible, for

example disposable sterile acupuncture needles and guide tubes are stronglyrecommended in all instances.

• When reusable items are used, they must be thoroughly cleaned, disinfected and sterilisedafter each use. Immediately after use, reusable needles and other contaminated equipmentshould be immersed in an effective chemical disinfectant, then soaked in water, with orwithout detergent and, after careful cleaning, thoroughly rinsed in water before beingpackaged for sterilisation. However, no special procedures are required in the existingdisinfection and sterilisation procedures to deal with the HIV virus (Disinfection andSterilisation Policy, KKM 1998). Sterilisation procedures should conform to those describein the Appendix 6.

• Safety precautions should be practised in handling sharp instruments at all times.• HIV is readily destroyed by heat at 70-80 degree Celsius. If autoclaves are not available,

reusable items may be disinfected by boiling for 10-30 minutes.

8.1.7 Storage of Needles and EquipmentThe sterilised package should be stored in a safe and clean area, well ventilated and freefrom excessive humidity, to preclude any possibility of condensation and mould growth.The maximum safe storage time varies with the type of packaging. Needles should be placedin a test tube which should then be plugged with cotton wool, and clearly labelled with anexpiry date not more than seven days after the date of sterilisation. Improper storage conditionsmay, however, cause equipment to lose sterility long before the expiry date. The integrity ofthe package should be inspected before use. Sterile needles stored in needle trays should beresterilised at the end of the day because the trays may become contaminated during use intreatment.

8.1.8 Disposal of Acupuncture Needles• Must use approval sharp container• Sharps containers must be placed at the work sites.• Sharps containers should not be more than two-thirds full before disposal.

TRADITIONAL AND COMPLEMENTARY MEDICINE PRACTICE GUIDELINE ON ACUPUNCTURE

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8.1.9 Management of Soiled/Contaminated Linen• Staff handling soiled linen should wear disposable latex/rubber gloves at all times.

Handling should be done only when necessary and no sorting is allowed.• Used linen should be placed into laundry bags at site.• Soiled linen soaked with blood or body fluid should be placed into appropriate laundry

bags with biohazard label.

8.1.10 Aseptic Needle TechniqueThe needle shaft must be maintained in a sterile state prior to insertion. Needles should bemanipulated in such a way that the practitioner’s fingers do not touch the shaft. If there isdifficulty in inserting a long needle, such as that used in puncturing GB 30 huantiao or BL 54zhibian by just grasping its handle, the shaft should be held in place with a sterile cottonwool ball or swab.

On withdrawing a needle, a sterile cotton wool ball should be used to press the skin at theinsertion site, thus protecting the patient’s broken skin surface from contact with potentialpathogens, and the practitioner from exposure to the used needle shaft and the patient’sbody fluid. All compresses or cotton wool balls contaminated by blood or body fluids mustbe discarded in a special container for infectious waste.

8.2 Technique / Mode of Delivery

8.2.1 There are many different types of Acupuncture method. Among all of those methods, majorityof Traditional Chinese Practitioners or Acupuncturists use Electro Acupuncture, Chinese HerbalMoxa, Electrical Stimulation, Laser Therapy and Magneto-Therapy.

In future, any introduction of a new technique, it needs to be justified and endorsed by theT&CM Council.

8.2.2 Under normal circumstance, several treatments are required to produce an effectivestimulation in acupuncture session. However, it depends on the types of sickness andprescribed medicine.

8.3 Maintenance of Skill

Each of the practitioners should have treated and punctured minimum hundred patientsannually at least two patients in a day in order to maintain their skill. However, the bestpractice is believed to be ensured and maintained with 15 patients in a day.

APPENDICES


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APPENDIX 1 : ACUPUNTURE CLERKING FORM11, 12


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APPENDIX 2 : SCREENING FORM


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SAMPLE

1. Rawatan Urutan Melayu Ya Tidak

• Penyakit darah beku di anggota kaki Deep venous thrombosis• Kepatahan Tulang• Luka yang berdarah• Luka yang baru• Kecederaan akibat kebakaran• Demam yang tinggi• Mengandung• Masaalah kulit• Penyakit Osteoporosis

2. Rawatan Akupuntur

• Menggunakan perentak jantung (pacemaker) atausebarang implan elektrikal

• Mengalami masalah pendarahan• Mengambil ubat pencairan darah "anti-coagulants' atau

sebarang ubat-ubatan• Telah mengalami kerosakan injapjantung atau sebarang

risiko-risiko khusus terjadinya jangkitan

3. Rawatan Penjagaan Ibu selepas bersalin

• Pendarahan selepas bersalin• Kesakitan dibahagian peranakan• Demam• Kemurungan

Kesesuaian untuk Rawatan

Ya

Tidak Rujukan dari / kepada

Nama Pegawai : Tandatangan :

Tarikh:

TANDA VITALPemeriksaan fizikalTekanan Darah mmHg : ____________ Dextrostix (utk kes DM shj) : ____________ mmolKadar denyutan nadi : ____________Suhu badan : ____________

Kontraindikasi untuk Perubatan Tradisional dan Komplementari


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APPENDIX 3 : ACUPUNTURE CONSENT FORM


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APPENDIX 4 : GUIDE IN TREATMENT PLAN OF ACUPUNCTUREFOR CHRONIC PAIN AND POST STROKE MANAGEMENT 11, 12

CHRONIC PAIN

Number ofsession

Breakdown ofsessions

Assessmentfor effectiveness

Maximum sessiongiven in the

unit for cases

20 session

Treatment given every dayor alternate day within

treatment period.

First 10 sessions :assess the effectivenesof acupuncture points

Second 10 session:assess the effectiveness

of treatment

30 sessions

POST STROKE

5 sessions

Treatment given every dayor alternate day within

a weeks period.

Done on the fifth session

10 sessions


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Rotational rubbing, with clasped fingers of righthand in left palm and vice

APPENDIX 5 : HAND WASHING TECHNIQUES

HAND WASHING TECHNIQUES

Palm to palm versa Right palm over left hand and vise

Palm to palm fingers interlaced fingers Back of finger to opposing palms with interlocked

Rotational rubbing of right thumb clasped in leftpalm and vice versa.

1 2

3 4

5 6


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1. Sterilization of acupuncture needles and equipment

Sterilization is defined as the destruction of all microbes, including bacterial spores (Bacillus subtilis,Clostridium tetani, etc.). High-level disinfection is defined as the destruction of all microbes, butspores may survive if initially present in large numbers.

2. Methods of sterilization

Steam sterilization is the most widely used method for acupuncture apparatus and other instrumentsmade of metal. It is nontoxic, inexpensive, sporicidal and rapid if used in accordance with themanufacturer’s instructions (e.g. time, temperature, pressure, wraps, load size and load placement).Steam sterilization is only fully effective when free from air, ideally at 100% saturated steam. Pressureitself has no influence on sterilization, but serves as a means of obtaining the high temperaturesrequired.

Recommended sterilizing temperatures and times for steam under pressure, and for dry heat, areshown in the table below.

Recommended methods of sterilization

* Steam under pressure (e.g. autoclave, pressure cooker)

Required pressure: => 15 pounds per square inch (101 kilopascals)

* Dry heat (e.g. electric oven)

Temperature Time

160°C 120 minutes

170°C 60 minutes

180°C 30 minutes

(Source: WHO - GPA/TCO/HCS/95/16 p.15.)

APPENDIX 6 : STERILIZATION

Temperature Time

115°C 30 minutes

121°C 15 minutes

126°C 10 minutes

134°C 3 minutes


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Instruments made of rubber or plastic which are unable to stand the high temperature of an autoclavecan be sterilized chemically, at appropriate concentrations and ensuring adequate immersion times(e.g. 6% stabilized hydrogen peroxide for six hours).

It should be noted that boiling needles in water is not sufficient for sterilization, nor is soaking inalcohol, since these methods do not destroy resistant bacterial spores or certain viruses.

3. Disinfection

A high level of disinfection is achieved when instruments are boiled for 20 minutes. This is thesimplest and most reliable method of inactivating most pathogenic microbes, including HIV, whensterilization equipment is not available. Boiling should be used only when sterilization by steam ofdry heat is not available. Hepatitis B virus is inactivated by boiling for several minutes; HIV, whichis very sensitive to heat, is also inactivated by boiling for several minutes. However, in order to besure, boiling should be continued for 20 minutes.

Chemical disinfection is used for heat-sensitive equipment that may be damaged by high temperatures.Most disinfectants are effective against a limited range of microorganisms only and vary in the rateat which they destroy microorganisms. Items must be dismantled and fully immersed in thedisinfectant. Care must be taken to rinse disinfected items with clean water so that they do notbecome recontaminated. Chemical disinfectants are unstable and chemical breakdown can occur.They may also be corrosive and irritating to skin. Protective clothing may be required. Chemicaldisinfection is not as reliable as boiling or sterilization. The agents include:

• chlorine-based agents, e.g., bleach• aqueous solution of 2% glutaraldehyde• 70% ethyl or isopropyl alcohol.

(Source: WHO - GPA/TCO/HSC/95/16 p.16 and WHO AIDS Series 2, 2nd edition, p.3, 1989.)

4. Maintenance

All sterilizers should be checked periodically. The sterilizer should be loaded in accordance withthe manufacturer’s instructions, with enough air space between packages to permit the propercirculation and penetration of steam or hot air. The effectiveness of sterilization should be regularlychecked with biological indicators, autoclave control indicators or such other tests as may be devisedto ensure that the contents of the load have been subjected to sterilization conditions.


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Table 1 : World Health Organisation indications for Acupuncture

Table 1 . World Health Organisation indications for Acupuncture

Musculoskeletal disorder

• Cervicobrachial syndrome• Frozen shoulder• Tennis elbow• Sciatica• Low back pain• Osteoarthritis

Disorder of the mouth

• Toothache• Post extraction pain• Gingivitis• Acute and chronic pharyngitis

Gastrointestinal disorders

• Spasm of the esophagus andcardia

• Hiccup• Gastroptosis• Acute and chronic gastritis &

colitis• Gastric hyperacidity• Chronic duodenal ulcer (pain

relief)• Acute bacillary dysentery• Constipation• Diarrhea• Paralytic ileus

Bronchopulmonary disorder

• Acute bronchitis• Bronchial Asthma*

• Respiratory tract• Acute sinusitis, rhinitis• Acute tonsillitis• Common cold

Well – Demonstrated evidencesof effectiveness

Chemotherapy- induced nauseaDental painNausea of pregnancyPostoperative nausea

* most effective in children and in patients without complicating disease.Ref : World Health organization list of common conditions treatable by Chinese medicine :http://tcm.healthinfo.org/who-treatment-list.htm. Accessed 30/4/2007

Table 2 : National Institutes of Health Consensus Panel on Acupuncture

*NIH Consensus Statement : Acupuncture. 1997;15:1-34( available at http://consensus.nih.gov/cons/107/107_intro.htm. Accessed 30/4/2007

Table 2 . National Institutes of Health Consensus Panel on Acupuncture

Potentially useful

AddictionAsthmaCarpal tunnel syndromeEpicondylitisFibromyalgiaHeadacheLow back painMenstrual crampsStroke rehabilition.

Neurologic disorder

• Headache and migraine• Trigeminal neuralgia and

intercostal neuralgia• Facial palsy (early stage ie

within 3-6 months)• Paresis after stroke• Peripheral neuropathies• Sequelae of poliomyelitis( early

stage, within 6 mo)• Meniere disease• Neurogenic bladder dysfunction• Nocturnal enuresis• Disorder of the eye

Acute conjunctivitis

• Central retinitis• Myopia ( in children)• Cataract ( without

complications)


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• Acute and chronic pain control

• Posttraumatic and post operative ileus• Muscle spasm, tremors, tics, contractures• Paresthesias• Anxiety ,fright ,panic• Drug detoxification• Neuralgias (trigeminal, herpes zoster, post

herpetic, other)• Seventh nerve palsy sequelae of cardiovascular

accident (aphasia , hemiplegia)• Certain functional gastrointestinal disorder (

nausea and vomiting, esophageal spasm,hyperacidity, irritable bowel disease, constipa-tion, diarrhea,etc)

• Headache, vertigo ( Meniere), tinnitus• Phantom pain• Frozen shoulder

• Cervical and lumbar spine syndromes• Plantar fasciitis• Arthritis / arthrosis• Bursitis , tendonitis,carpal tunnel syndrome• Sprain and contusions

Table 3: Conditions for which acupuncture may be indicated ( American Academy ofMedical Acupuncture)

Table 3: Conditions for which acupuncture may be indicated(American Academy of Medical Acupuncture)

• In fractures, assisting in pain control, edema andenchancing healing process

• Temporomandibular joint derangement , bruxism

• Dysmenorrhea, pelvic pain• Insomnia• Anorexia

• Atypical chest pain ( negative workup)• Idiopathic palpitations, sinus tachychardia

• Allergic sinusitis

• Persistent hiccups• Selected dermatomes

(urticaria,pruritus,eczema,psoriasis)

• Urinary incontinence,retention (neurogenic,spastic,adverse drug effect)

• Abdominal distension /flatulence• Severe hyperthermia• Cough with contraindications for narcotics• Acupuncture anaesthesia for high –risk patients

American Academy of Medical Acupuncture.Available at: http://www.medicalacupuncture.org Accessed October 11, 2006


26

10. REFERENCES

1. The Regional Strategy for Traditional Medicine in Western Pacific Region, Western PacificRegion (WPRO), Manila 2002.

2. WHO International Standard Terminologies on Traditional medicine in the Western PacificRegion. WHO Regional office for the Western Pacific.2007. http://www.wpro.who.int/publications/PUB_9789290612487.htm

3. A. White and E. Ernst, A brief history of acupuncture, Rheumatology 2004;43:662–663.

4. I. L. Bonta, Acupuncture beyond the endorphin concept? Medical Hypotheses (2002)58(3), 221- 224.

5. National Institutes Of Health Panel Issues Consensus Statement On Acupuncture , Nov1997.

6. Jonathan Roberts, David Moore, Mapping the evidence base and use of acupuncturewithin the NHS, West Midlands Health Technology Assessment collaboration report(2006). http://www.rep.bham.ac.uk/2006/Mapping_Acupunture.pdf

7. World Health Organization, Acupuncture : Review and Analysis of Reports on ControlledClinical Trials ,2002

8. Victor S. Sierpina, MD; Moshe A. Frenkel, MD , Acupuncture: A Clinical Review SouthMed J. 2005; 98 (3): 330-337

9. World Health Organization, Guidelines on Basic Training and Safety in Acupuncture.Geneva, 1996 (WHO Consultation on Acupuncture from 28th October to 1st November1996 at Cervia, Italy).

10. Executive Summary: The Statutory Regulation of the Acupuncture Profession – The Reportof the Acupuncture Regulatory Working Group. The Prince of Wale’s Foundation forIntegrated Health (on behalf of The Acupuncture Regulatory Working Group), 2003.

11. Traditional and Complementary Medicine Division, Ministry of Health Malaysia,Consensus Meeting on Improvement Strategy in Traditional and Complementary Medicine(T&CM) Services in Integrated Hospital with T&CM Practitioners, March 2009.

12. Traditional and Complementary Medicine Division, Ministry of Health Malaysia,Workshop on Patient Record Documentation for Traditional and ComplementaryMedicine Practitioner, October 2009.


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11. COMMITTEE MEMBERS

Review and Improvement Strategies of Traditional and Complementary MedicinePractice Guideline Workshop For Acupuncture , 2008.(Working group)

Dr Hj Mohd Suhaimi Abd. MajidTraditional and Complementary Medicine Division


Ms Wong Wei ChyiTraditional and Complementary Medicine Division


Ms Yeu Su FenPhysiotherapy DepartmentPenang General Hospital

Ms Hasnah JohariQualified Nurse

Traditional and Complementary Medicine UnitSultan Ismail Hospital

Ms Haironi IsmailPhysiotherapy Department

Putrajaya Hospital

Ms Norsuzaida AbdullahTraditional and Complementary Medicine Unit

Putrajaya Hospital

Mr Wan Hasif Azim Nik MansorTrained Medical Assistant

Traditional and Complementary Medicine UnitPutrajaya Hospital

Mr Chin See HooiChinese Traditional Medicine ( Acupuncture) Practitioner

Traditional and Complementary Medicine UnitPutrajaya Hospital

Mr Liu Sheau FeiChinese Traditional Medicine ( Acupuncture) Practitioner

Traditional and Complementary Medicine UnitKepala Batas Hospital

Mr Liow Tuck SoonChinese Traditional Medicine Practitioner

TRADITIONAL AND COMPLEMENTARY MEDICINE PRACTICE GUIDELINE ON ACUPUNCTURE

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Editorial MembersFor Traditional and Complementary Medicine Practice Guideline.

Dr Ramli Abd GhaniDirector

Traditional and Complementary Medicine DivisionMinistry of Health Malaysia

Jaafar LassaSenior Principal Assistant Director


Dr Shamsaini ShamsuddinSenior Principal Assistant Director


Dr Fariza Dato’ FadzilPrincipal Assistant Director


Dr Zalilah AbdullahPrincipal Assistant Director


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