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On-line version ISSN 1980-220X
Rev. esc. enferm. USP vol.43 no.4 São Paulo Dec. 2009
Nurses' perception about diseases that are treated by acupuncture*
Enfermedades tratadas y tratables por acupuntura, según la percepción de las enfermeras
Leonice Fumiko Sato KurebayashiI; Genival Fernandes de FreitasII; Taka OguissoIII
INurse, acupuncturist. M.Sc. in Nursing,
School of Nursing, University of São Paulo. São Paulo, SP,
IINurse. Ph.D. Professor at School of Nursing at University of São Paulo, São Paulo, SP, Brazil. firstname.lastname@example.org
IIINurse. Full Professor at School of Nursing at University of São Paulo, São Paulo, SP, Brazil. email@example.com
The objective of this study was to identify and analyze nurses' perceptions about diseases that are treated by acupuncture, taking into consideration: (1) the diseases of nurses who had received acupuncture treatment; (2) nurses' diseases which might be treated by acupuncture; (3) suggestions of diseases treatable by acupuncture. This exploratory study was performed with 33 nurses working at 11 health units in southeast São Paulo; places in which acupuncture treatment was available. Results showed that acupuncture was mostly used for stress (10.7%), anxiety, migraines, lumbar pain, myoma and obesity (7.1% each). Acupuncture was suggested as treatments mostly for musculoskeletal diseases (42%), and chronic-degenerative diseases (10%).
Key words: Acupuncture. Complementary therapies. Public health nursing.
Este trabajo objetivó identificar y analizar las percepciones de las enfermeras acerca de las enfermedades tratadas y tratables por la acupuntura. Fueron consideradas: (1) las enfermedades de las entrevistadas que ya se habían sometido al tratamiento con acupuntura; (2) las enfermedades que las enfermeras tienen que podrían ser tratables por la acupuntura; (3) las sugestiones de enfermedades tratables por la acupuntura para el paciente de Unidades de Salud. Investigación de naturaleza exploratoria fue realizada con 33 enfermeras, en 11 Unidades de Salud de la Región Sureste del Municipio de São Paulo, donde había la terapia de acupuntura. Los resultados demostraron que la acupuntura fue más utilizada para el tratamiento de estrés (3/21, equivalente a 10,7%) y para ansiedad, migraña, lumbalgia, mioma y obesidad (2/21, correspondiente a 7,1% cada una). Fue más sugerida para el tratamiento de enfermedades músculo-esqueléticas (34/82, equivalente a 41,5%), y enfermedades crónico degenerativas (8/82, equivalente a 10%).
Descriptores: Acupuntura. Terapias complementarias. Enfermería en salud pública.
This study originated from the need to learn about the opinion of nurses from Public Health Units about the use of acupuncture in the treatment of diseases, since it is currently the world's most accepted complementary medical practice. The use of acupuncture is accepted in the public health system of China, where the practice arose many millennia ago. A document released by the World Health Organization (WHO) in 1985, namely The Role of Traditional Medicine in Primary Health Care in China reports the use and importance of traditional Chinese therapies in the country's health care system(1).
Acupuncture is an ancient technique that aims to diagnose diseases and promote cure by stimulating the body's defensive strength. The process consists of realigning and redirecting energy by stimulating acupuncture points with fine metallic needles, laser, pressure or other approaches. Acupuncture is only one technique of traditional Chinese medicine. Chinese medicine includes herbs, diets, massage and exercises. All techniques are developed based on the idea of the inseparability of body and environment, and the intrinsic relationship between the microcosm and the universe, which are influenced by the same energy.
In the first years of the 20th century, China was an overpopulated country with a social, economic and political organization that did not provide the population with adequate standards of health, education, housing, sanitation, and so on. It was only in the mid-20th century with the establishment of the People's Republic of China under Mao Zedong and the rebirth of traditional Chinese medicine that acupuncture again became widespread in China. It was resumed along with other popular practices as an emergency solution for the health sector in order to save the population from chaos and abandonment. To the present day, in many poor countries, traditional medicine is still used to care for the needy population. Also, it is important to point out that acupuncture is considered a form of traditional medicine in countries where these traditional and popular practices are the primary basis for healthcare. Acupuncture is considered a form of Complementary and Alternative Medicine in countries where the main medical practice is allopathic medicine. The WHO published guidelines for 2002-2005 that aimed to integrate Traditional Medicine/Complementary and Alternative Medicine (TM/CAM) into national health systems by developing and implementing national programs and policies. This document encouraged the release of guidelines for regulating and controlling the provision of acupuncture and other traditional medical services. The document was intended, among other things, to enhance accessibility, availability and feasibility of acupuncture in other countries. The importance of making the technique accessible to poor populations was emphasized; also, its rational and therapeutic use by health providers and consumers was encouraged(2).
In 2003, in order to make acupuncture more visible as an efficient and safe therapy for many diseases, the WHO released a list of diseases that can be treated with acupuncture(3). A list of controlled clinical studies on acupuncture treatment for different diseases, which were collected prior to 2002 from many different countries, was reported. This list was also mentioned by the Federal District government in the Regulations and Procedures Manual for Therapeutic and Natural Medicine Center of Integration in 2005(4).
According to this document, there is a broad scope of therapeutic uses for acupuncture for acute and chronic diseases, for all ages, including in particular the elderly. It can be suggested for all care levels, presenting high rates of solvability and efficiency. Although acupuncture is accepted in the East as an effective method for pain relief, it can also be used for disorders of the respiratory, digestive, and nervous systems, in addition to psychological and emotional problems. The main focus of acupuncture treatment must be the person as a whole and not only symptomatic relief. Therefore, when performing a diagnosis and treatment through acupuncture, many symptoms can simultaneously achieve full or partial remission, because the treatment engages the energetic whole.
In Brazil, long before these initiatives, a nurse already reported in 1983 a growing interest in the Brazilian population in Complementary and Alternative Therapies (CAT) and noted the importance of making nurses aware of this movement. This interest, according to the author, was a result of the following factors: the elevated prices of private medical assistance, the high cost of medication, precarious public health service assistance, the efficacy of this therapy, and the absence of side effects(5).
More recently, in 2002, the Municipal Secretary of Health of São Paulo approved the use of integrating and complementary practices and released a Thematic Guidebook of Traditional Chinese Medicine. Acupuncture, however, has been performed only by medical professionals, although it has been acknowledged as a specialty for other professional health categories(6). In May of 2006, Regulation # 971(7) approved the National Policy of Integrating and Complementary Practices by the Department of Health, establishing guidelines for the use of these therapies in Public Health Units in the country. In this resolution, it is expected that acupuncture can be practiced by the whole health team, once it constitutes acupuncture as a multi-professional activity. These measures can enhance the volume of services provided to the population in health units. They are consistent with the principles and precepts previewed by the Single Health System. Therefore, it is important that nursing professionals have the necessary knowledge and are updated on the opportunities that are offered to them.
In view of these initial considerations, this research aims to discuss nurses' perceptions of the employment of acupuncture through other research, and mainly through the list of diseases that can be treated by acupuncture released by the WHO in 2003. The intention is to increase awareness about acupuncture in the public health network as a multi-professional practice.
This is an exploratory study carried out with 33 nurses from 11 Public Health Units in the Southeast Region of the City of São Paulo, using a semi-structured questionnaire. Data were collected after orientation, clarification and signing of a Free and Informed Consent Form. The data collection instrument comprised 3 questions: (1) Have you already received acupuncture? If yes, what was the purpose? (2) If not, for what purpose would you use it? (3) For what case would you suggest acupuncture? The interview was carried out during the nurses' working period, previously booked, in the period of June and July of 2007 in Basic Health Units and Expert Clinics. These units offered acupuncture treatment for the population, performed by doctors with acupuncture courses. The research was approved by Resolution #104/07 by the Ethics Committee of the Mayor's Office of São Paulo.
Results were recorded and transcribed. Statistical analysis was done from frequency results descriptions and proportions of answers found regarding the diseases treated and suggested for acupuncture.
Table 1 was built from nurses' answers about diseases they have treated with acupuncture when answering the following question: Have you already received acupuncture? If yes, what was the purpose?
Table 1 demonstrates the percentages found regarding the diseases. From the list of diseases treated among nurses, the highest percentages were found for stress (3/21 or 10.7%) and anxiety, migraine, low back pain, myoma, and obesity (2/12 or 7.1%). Other diseases had only one occurrence (1/21 or 3.6%).
The nurses who had never used acupuncture were asked if they would treat anything with it and for what purpose it would be. The results are presented in Table 2. Of those problems experienced by nurses that they would treat with acupuncture, but that they have not yet treated with acupuncture, the most common was back pain and back problems, with 3/15or 18.8% of the occurrences.
Finally, we presented the illnesses suggested by nurses to be treatable with acupuncture in Table 3, as an answer to the following question: For which case would you suggest acupuncture?
We found that acupuncture is often suggested for pain in general, back pain, joint pain, muscle pain, fibromyalgia, and tendinitis, corresponding to 31/82 or 41.5% of suggestions. Chronic diseases including diabetes, high blood pressure, and obesity were the second most common category of diseases treatable by acupuncture according to nurses' experience, with 10% of the suggestions (8/82).
The World Health Organization organized a review of the clinical studies of acupuncture carried out in the last two decades. Also, it performed a survey of acupuncture in different countries around the world. Results were published in Acupuncture: review and analysis of reports on controlled clinical trials. Forty-three diseases were listed as treated or treatable by the technique. However, the document pointed out that the studies did not consistently meet good scientific standards, making their results somewhat questionable. It noted the importance of sham or placebo acupuncture or of an experimental design that would answer questions on the effectiveness and reach of the technique(3).
Four main categories were created. Category one comprised diseases, symptoms or conditions for which acupuncture was demonstrated as an effective treatment. The following diseases were mentioned: rheumatoid arthritis, headache, sciatic nerve, major depressive disorder, cervical, knee, lower back and post-operative pain, chronic high blood pressure, labor induction, nausea and vomiting, radiotherapy and chemotherapy reactions, and many other conditions. Category two contained symptoms and conditions that demonstrated good therapeutic results with acupuncture. However, the effectiveness of acupuncture for gout, arthritis, asthma, colitis, substance abuse, type II diabetes, fibromyalgia, insomnia, obesity, and competition stress syndrome has not been sufficiently demonstrated. Two other categories that need further study were also created.
Stress was the first complaint mentioned by nurses as a disease treated, as indicated by Table 1. Although pain was the main symptom treated by acupuncture in the East, it seems that stress is the worst condition. There are many factors that lead to stress in the nursing area. The following were mentioned: working environment structure, nursing team, reduced number of workers, physical environment, insufficient time to perform nursing care, bureaucratic tasks, and administrative activities that are time-consuming and consequently place the nurse away from direct contact with the client and others(8).
In health units, nurses tend to experience everything as their own, with no specific delineation of their role, blinding the institution and the health team. Their experience is marked by a covering image, a compound of the work developed in the process of healthcare, filling 'empty spaces' left by the multi-professional team(9). In this context, lack of autonomy and support are causes of stress for nurses. Organizations can reduce stress by providing an organizational environment that respects nurses' opinions, actions, and positions in their work process, acknowledging their role in the institution and in the multi-professional team.
A study carried out in Austria with auricular acupuncture for anxiety treatment is also worth mentioning. The subjects were thirty-six patients with gastrointestinal problems who were being transported to the hospital by ambulance. Seventeen were chosen to receive an application in a relaxing location and 19 on an inactive or sham location in the auricular area. Auricular acupuncture was demonstrated to be an effective treatment for decreasing stress and anxiety; because patients in the relaxing group reported a significant decrease in anxiety compared to the sham group when they arrived at the hospital. Patients' pain perception during treatment and disease results were more positive in the relaxing group(10).
The complete list organized by WHO presents a multitude of diseases of the human body, from physical to mental and emotional disorders. However, painful diseases are the most mentioned, and the effects of acupuncture are compared to those of morphine. In fact, pain is possibly the most common cause that leads people to seek medical services. People in pain experience various degrees of anxiety and distress. The main effects of acupuncture are sedation, pain relief, and homeostatic, immune, psychological and motor recovery.
This same point of view was observed in Tables 2 and 3 that mentioned acupuncture as promising for pain treatments in general. In Table 2, the main indication for treatment of those who had never been treated with acupuncture, but would like to start, was back pain and back problems, with 3/15 or 18.8% of the total. Table 2 also includes other pain complaints: bursitis, kidney stones, migraines, general pain, and tendinitis with a percentage of 6.7% (1/15) for each of these diseases.
Acupuncture is an important complementary therapy not only for nurses to use, but also for treating the members of the professional nursing team, who often suffer from chronic back pain, especially low back pain due to work activities. Low back ailments affect more than 9 million people in the USA, causing 25% of incapacities due to work-related health problems. In the nursing field, the incidence of low back pain is over 80%, and the ailment causes more than 150 million dollars in lost working days per year. According to the authors, Eastern chronic pain treatments are controversial and commonly ineffective. Acupuncture has demonstrated to be beneficial when previous treatments with medication, rest, epidural injections, physiotherapy, osteopathy, chiropractics and surgery have failed(11).
In Table 3 we can see that acupuncture is often suggested for pain in general, back pain, joint pain, muscle pain, fibromyalgia, and tendinitis, which together account for 34/82 or 41.5% of suggestions. Chronic diseases such as diabetes, high blood pressure, and obesity came in second, with 10% of the suggestions. Also, migraine indications are significant (7.3% or six occurrences), as are respiratory problems such as asthma and bronchitis with 7.3% (6/82) and anxiety with 6.1% (5/82).
Acupuncture can be beneficial in the treatment of chronic diseases that are prevalent in the elderly in São Paulo. The Southeast Region of the city of São Paulo has the second lowest rate of population growth in the city, suggesting that the elderly population is larger than in other regions. Mortality rate data present the following three leading causes of death: ischemic heart disease, vascular brain diseases, and pneumonia(12).
Diseases that were treated, treatable and suggested to be treatable by nurses were also named by the World Health Organization. When studying the WHO survey of diseases treatable by acupuncture, we found important conditions selected in the first category as treatable: chronic hypertension and vascular brain disease. These conditions are common causes of death in the region where the research was carried out, especially among the elderly, justifying the importance placed on this practice in the public health network. In category two, "diseases, symptoms or conditions where acupuncture demonstrated therapeutic effects, but which require more proof", we found other diseases such as type II diabetes, obesity and bronchial asthma. These conditions were also named by nurses who suggested acupuncture for the treatment of diabetic, hypertensive and obese patients.
Some researchers mention that patients seek acupuncture in Eastern countries because it is a "more natural" choice, a safe complementary technique for treating chronic diseases(13). Although Western medicine has achieved great progress, chronic disease treatments have been its biggest challenge. A study published in 2000 in the Mexican journal Medicina Física y Rehabilitación on the use of complementary therapies for chronic diseases concluded that there seems to be a great incidence of the use of complementary therapies in chronic disease patients concurrently with conventional allopathic medicine. These chronic diseases include cancer, arthritis, major depressive disorder, AIDS, gastrointestinal diseases, chronic renal insufficiency, Alzheimer's disease, multiple sclerosis and even dermatologic diseases. However, it is important to state that many patients do not tell their doctors about a complementary treatment because they are afraid of receiving a negative reaction(14).
This information indicates that there is still a long way to come regarding the use of acupuncture by Western doctors. In the future, to unite allopathic and complementary medicine to promote the welfare of the elderly, pregnant women, and patients with high blood pressure, chronic renal diseases, and hepatic diseases is intended. Acupuncture can be applied to chronic and severe pain conditions and to neurologic, orthopedic, physical medicine, rheumatologic, and gynecological-obstetric conditions and in the general and surgery clinic areas(15).
Therefore, we understand that acupuncture can be applied to a broad scope of treatable diseases. Also, it is important to point out that its aim is to treat the energetic imbalance of meridian channels that leads to manifestations and the materialization of a disease. The Thematic Guidebook of Traditional Chinese Medicine of the Health Secretary of the City of São Paulo emphasizes these principles. Primary factors that cause energetic imbalance must be treated in addition to the suppression of symptoms. The disease classification used in traditional Chinese medicine is therefore addressed both in diagnostic and therapeutic terms to the ill subjects and their individual constitutions. This stands in contrast to Western medicine, which selects the disease and its identification, etiology and classification as the study object. Traditional Chinese medicine presents cosmologic elements in the diagnosis and the therapeutic model(6).
The increase in the use of acupuncture in public health services has been observed in many Western countries, including Brazil. Simultaneously, the population is becoming increasingly elderly. It is well known that above 60 years of age, the incidence of chronic diseases increases and brings the elderly difficulties in executing routine tasks, along with feelings of annulment and segregation, and limitations in politics and social acquaintanceship. The complexity of factors that are inherent to aging create a need for multi-disciplinary care delivery modalities like acupuncture(16).
From the opinions collected in the interviews and the studies reviewed, we conclude that acupuncture can be useful as a preventive, curative and rehabilitating technique for many acute and chronic diseases. It can play an important role in disease prevention, since its focus is the treatment of energetic disorders that are primary and previous to diseases. Results demonstrate that nurses' perceptions of acupuncture with regard to its therapeutic possibilities do not differ from those promoted by the World Health Organization. Acupuncture was used by nurses for the treatment of stress, anxiety, migraine, low back pain, myoma, obesity, and other conditions. It was also suggested for the treatment of musculoskeletal diseases such as back pain, spinal disc herniation, bursitis, migraines, and tendinitis, and for chronic degenerative diseases such as diabetes mellitus, high blood pressure and obesity. Although nurses demonstrate knowledge of acupuncture's many therapeutic actions, this knowledge originated from experience as patients and from listening to patients who had the service provided in the studied health units. We came to the conclusion that more studies must be performed in this area in order to promote the benefits of acupuncture for as many people as possible so that the practice can be extended to the whole professional team in the public health network.
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Received: 03/31/2008 *
Extracted from the thesis "Acupuntura na Saúde Pública: uma realidade
histórica e atual para enfermeiros", School of Nursing, University of
São Paulo, 2007.
* Extracted from the thesis "Acupuntura na Saúde Pública: uma realidade histórica e atual para enfermeiros", School of Nursing, University of São Paulo, 2007.