Standard of Practice of Acupuncture as adopted by RIMAC, Malaysia Academy of Acupuncture - Under the President Acupuncture , Prof Dr Nik Omar

Also adopetd by:

The Aga Khan University Hospital
Department of Physiotherapy



Operation Guideline


For

Acupuncture by Physiotherapists
Jan, 2012


Forward

The content of this guideline was based on epidemiological and

other research evidence available in international literature and

guidelines, supplemented where necessary by the consensus

opinion of the Dean of Research Institute of Malaysian

Acupuncture , Prof. Dr. Nik Omer.



Approved by the;


Head of the Department of Physiotherapy.


Introduction

Acupuncture has been embraced as one of the treatment modalities within the scope of
Physiotherapy practice. In response to the increasing demand on acupuncture by
patients, acupuncture has been incorporated as one of the therapeutic interventions of physiotherapists. Thorough Physiotherapy Assessment, a procedure by which
collection of relevant information and quantified data is conducted prior to
treatment. Treatment modalities including acupuncture, and other physiotherapy
equipment resolving the clinical problems, are explained and implemented to
the patient. Parameters of acupuncture are selected based on assessment protocols
and knowledge of human anatomy, neuroanatomy, neurophysiology in pain and
motor control and related information on physiology and pathology of the conditions
treated.

All physiotherapists practicing acupuncture have to abide strictly the work instruction set by the department of Physiotherapy.

Standards of Practice of Acupuncture by
Physiotherapists



All Physiotherapists who practice acupuncture should:-


1. Have successfully completed a training program in acupuncture.


2. Apply acupuncture as one of the treatment modalities of the physiotherapy
profession.

3. Maintain a standard of documentation by using SOAP method.


4. Comply with standards of infection control procedures as recommended.



Formulation of Acupuncture Treatment Plan

A. Assessment
1. Subjective and objective information from patients.
2. Area and type of acupuncture intervention are identified and discussed with
patient/ family.


B. Intervention Plan
1. Goal for acupuncture intervention should be set.
2. Problems, goals and intervention program (including acupuncture and other
appropriate Physiotherapy modalities) should be discussed with patients.
3. Contra-indications and precautions for acupuncture and all intervention
should be discussed.
4. Verbal consent for acupuncture treatment must be obtained from patients.
5. Intervention plan and time frame of therapy are designed.

C. Implementation of Acupuncture Treatment
1. All safety precautions are taken and use only disposable needle.
2. Warning regarding inappropriate responses should be given to patients.
3. Hygiene and sterilization procedures for both patients and therapists are followed.
4. Standards of waste disposal and handling of blood and body fluid are followed.
5. On going reassessments are needed and appropriate changes will be made
if so required.
6. Records describing acupuncture points, penetration depth, angle of insertion,
and treatment dosage are documented.


Contra-indications and Precautions of Acupuncture

A good knowledge of anatomy is essential in order to avoid structural damages
such as nerves, organs or arteries.

A. Prohibited Areas for Needling


The following areas should be avoided at all times.
1. Scalp area of infants before the fontanelle has closed
2. Nipples and breast tissues
3. Umbilicus
4. External genitalia
5. Eye balls


B. General Precautions


1. Patients with uncontrolled movement are not suitable for acupuncture.
2. Patients allergic to metals may not be suitable for acupuncture without medical clearance.

C. Special Precautions


1. Dangerous or vulnerable points which may lead to damage - Certain useful points which are potentially dangerous and therefore require special attention in their use.

For example, these apply to:


a. Orbit of eye.

b. Certain neck points.


c. Points over lung tissues unprotected by bone or cartilage.

d. Points near arteries.


e. Point over gallbladder .

f. Liv 3 (Taichong ), hypertensive patients may suffer from a rapid drop of BP


g. Ah Shi points close to vulnerable structures


i. Avoid needling certain pathological sites e.g. varicose veins;
inflammatory areas; malignant tumours; areas of unhealthy skin


j. Avoid needling deep and perpendicularly on points of the chest, hypochondria and spine.


2. Pregnant patients-Avoid acupuncture in the first trimester of pregnancy as needling may cause a “miscarriage”, or in the last 3 months as it may cause premature labour. Also to avoid points that are considered especially likely to
disturb a pregnancy. e.g.

a. LI 4 (Hegu)
SP 6 (Sanyinjiao)
K 3 ( Taixi )
b. points over lower abdomen
c. ear points related to endocrine and genito-urinary system d. scalp points for genital and motor sensory areas
e. strong electro-stimulation to acupuncture points.


3. Diabetics patients- 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 level.


4. Frail Patients- Patients with a weak constitution after prolonged chronic illness may
tolerate acupuncture poorly. Strong manipulation is not recommended.


5. Active/Powered-Implant Patients- Patients with active/powered implants such as :
cardiac pacemakers and neurostimulators should not be given electro-acupuncture.


6. Confused Patients- Great care must be taken with patients who are unable to
understand the acupuncture procedure.


7. Children- Parental consent must be obtained for treatment of children.


8. Bleeding disorders:-
a. naturally occurring haemorrhagic diseases like haemophilia.
b. drug-induced bleeding, like warfarin
c. apply pressure on each point on removing needles


9. When Sensation of acupuncture cannot be obtained at a conservative needle depth,
let the needle rest and allow Sensation of acupuncture to come to the needle
over time.


10. Acupuncture should not be inserted in a limb with lymphoedematous swelling.
Broken skin is a source of potential infection and cellulitis, and the patient could
continue to ooze fluid from the sites of needle insertion.


Warnings Given to Patients Prior to Acupuncture
Treatment


1. In the process of acupuncture treatment, there may be a very mild pain/
discomfort during insertion of needles.
2. The normal sensation during the retention of needles is soreness, heaviness /

fullness, local/ radiating paraesthesia and/ or warmth.

3. Do not move or contract muscles over the treatment areas.

4. Do not fall asleep.


Acupuncture Infection Control Procedure


A. Practitioner Preparation


1. Practitioners should wash hands with liquid soap/ disinfected solution and
thoroughly pat dry hands before and after acupuncture application to patients.


2. Any cut/breaks in skin should be covered with water-proof dressing or sterile
disposable glove worn.


B. Patients’ skin preparation


For patients with normal immune system


1. The patient’s skin should be clean and free from cut, wound and infection.


2. The patients’ skin should be inspected for dirt and grease.


3. The needling site must be disinfected prior to acupuncture using disinfectant such
as 70-80% ethanol.


C. Needle Insertion


1. Sterile, single-use, disposable acupuncture needles with guide-tubes are recommended.


2. Ensure the portion of the needle to penetrate the skin does not come into contact with the bare fingers of the practitioner, or any non-sterile surface.


3. The number of needles inserted must be documented


D. Needle Manipulation


1. Manipulate needle using the handle of the needle. Avoid touching the shaft of the needle.


2. In the case of long needles, a sterile glove may be used to grasp the top of the needle shafts for insertion and/or manipulation.


E. Needle Removal


1. Withdraw needle by grasping needle handle, using a sterile, dry swab/cotton wool ball to apply pressure to the insertion point to prevent bleeding.


F. Handling of Blood and Body Fluid


1. Care must be taken to avoid contact with patients’ blood and body fluid.
Should bleeding occur, a dry cotton wool ball should be used to absorb it. The used cotton wool ball should be put into an appropriate bin.


Management of Possible Complications


Possible complications

Suggested Management
1. Pain caused by needle inserted deep into tissues and hitting pain receptor nerve fibers Adjust the depth and direction of needle insertion
2. Pain caused by needle with fibrous tissue during manipulation Gently rotate the needle back and forth until the fiber is released
3. Pain caused by unskilled manipulation or excessive stimulation Massage the affected area gently with clean gauze for a while after withdrawal of
needle
5. Mild Haematoma Haematoma may resolve by itself.
Reassure patient.


Patient Information for Acupuncture



1. Please inform your physiotherapist if you have any of the following conditions:

pregnancy

on Warfarin or other similar medications

haemophilia

diabetes mellitus

hypertension

epilepsy

pulmonary tuberculosis

hepatitis

infectious diseases

cardiac pacemaker

deep brain stimulator

other electronic implants

2. Please keep the body parts for treatment clean and free of any ointment before acupuncture.

3. Avoid being hungry, thirsty and unduly tired before acupuncture.

4. Avoid wearing tight outfits and metal accessories over the body parts for acupuncture.

5. During acupuncture, please relaxed and do not change position or move.

6. Please empty your bladder before acupuncture. This is especially important if acupuncture is applied to the lower abdominal region.

7. Do not touch the needles or other acupuncture equipment.

8. Do not fall asleep during acupuncture.

9. During acupuncture, you may have one or more of the following sensations: soreness, heaviness, fullness, local or radiating paraesthesia, and warmth. These sensations are normal. Such sensations may last for a period of time after treatment.

10. After acupuncture, there may be mild bruising over the treatment area, it will subside gradually.

11. If you have any discomfort during acupuncture, please inform your physiotherapist immediately by pressing the emergency bell given.

12. Please consult your physiotherapist for any queries.