中文

Theory of Acupuncture in Pain Management


    acupuncture for pain

     

    According to Chinese acupuncture theory, there are over 350 acupuncture points on the body that connect to 12 principal and 8 secondary pathways called meridians.(1) These pathways are thought to conduct Qi, ( translated as energy or life force) throughout the entire body. Health is maintained by the unobstructed flow of Qi that regulates the physical, mental and spiritual balance. In addition, the opposing forces of yin and yang regulate all organs. When the entire system is in balance, optimal health occurs. Disease occurs when there are obstructions to the flow of Qi, deficient or excessive Qi, or when there is an imbalance of yin and yang. By placing needles in strategic acupuncture points, acupuncture relieves obstructions to the flow of Qi, balances yin and yang and restores general balance. Acupuncture treatments are individualized, based on the individual’s unique characteristics. For example, patients with same low back pain complain might receive different treatments if their imbalance of yin and yang are different.

    In modern medical research, acupuncture has been shown to have measurable physiologic effects that may explain the mechanism of pain relief by acupuncture. When needles are inserted into acupuncture points, regional increases in blood flow occur (measured by skin temperature recordings) and laser Doppler flow values and electromagnetic impulses increase. (2) The nerve stimulation sends messages to the spinal cord, brain stem and hypothalamus. These stimulate the release of endogenous opioids such as beta- endorphins, met-enkepalins, and dynorphin.(3) In addition, acupuncture affects the release of neurotransmitters and neuropeptides such as serotonin and melatonin.(4) These may explain the relaxing effects seen after acupuncture. Enhanced immune function also occurs. For example, patients with asthma who receive acupuncture have increased CD3+ and CD4+ cells and decreased IL-6 and Il 10 and eosinophils after acupuncture treatment. (5) There also may be inhibition of the nociceptive pathways involved in pain processing.(6) Recent studies using functional MRI have demonstrated that acupuncture has quantifiable effects on the central nervous system. (7)

    Acupuncture has been used in virtually any medical condition, but most westerners go to acupuncturists for pain control. Typically, acupuncture is a series of biweekly or weekly treatments. A typical session involves 5-15 needles and a treatment lasts from 20-60 minutes. Usually there is a clinical response within 10 treatments. Maintenance treatments are usually necessary.

    Available Data

    Osteoarthritis

    A recent well designed study has been published that has shown the effectiveness of acupuncture. (8) Berman studied 570 patients with osteoarthritis of the knee in a randomized controlled trial. Patients were randomized to the true acupuncture group that received 23 acupuncture treatments over 26 weeks, the sham acupuncture group with the same number of treatments or to an education control group. The primary outcomes of pain and function were measured at 4, 8, 14, and 26 weeks by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Patients were allowed to continue all medications. Pain decreased and function increased to clinically significant degrees in the true acupuncture group only. Pain decreased in the true acupuncture group at all assessments, but did not reach statistical significance until week 14. The WOMAC pain score decreased 3.6 units (40% decline) in the true acupuncture group compared with 2.7 units in the sham acupuncture group. Statistical improvement in function occurred by the 8th week. Function improved more than 12 units, corresponding to a 40% improvement. Patient assessment of global function, the time to walk 6 minutes, quality of life measures and medication usage did not differ between the groups. Side effects were minor and not significant.

    Headache

    Although many new pharmaceutical agents have been developed to treat headaches, substantial numbers of patients continue to have pain, despite medications. This has led many to try non-drug approaches to headache, especially acupuncture.

    Vickers(9) randomized 401 patients with chronic headache (predominantly migraine) to acupuncture (12 treatments over 12 weeks) or to usual care. All patients continued their usual medications. There was a 34% reduction in headache scores in the acupuncture group compared with 16% reduction in the control (p=0.0002). Pain free headache days were reduced in the acupuncture group by 1.8 days/28 days. There was also improvement in 3/9 variables in quality of life as measured in the SF-36 including physical functioning, energy and health change. Visits to physicians, sick days and use of medications were reduced, but did not reach statistical significance.

    In conclusion, preliminary studies support the use of acupuncture in headaches, especially migraine headaches.

    Other Painful Conditions

    Many pain conditions have demonstrated improvement with acupuncture. A partial list includes: lateral epicondylitis(10), peripheral neuropathy (11), temporomandibular disorders(12), phantom limb pain (13), chronic pelvic pain (14), irritable bowel syndrome and other functional gastrointestinal disorders(15) and Crohn’s disease. (16) These studies have generally included small sample sizes.

    Adverse Effects

    The risk of serious events associated with acupuncture treatments is quite low and is estimated at 0.5 per 10,000 treatments. (17) Almost all practitioners use single use, disposable needles. The needles are thin (less than 30 gauge), flexible and solid. The most common side effects are minor ecchymoses and forgotten needles. Acupuncture can safely be performed on patients taking antiplatelet drugs. Infections are rare, but have been reported. Vasovagal reactions have also been reported.

    References

     

    1. Helms J. Acupuncture Energetics- A Clinical Approach for Physicians. Berkeley, CA: Medical Acupuncture Publishers;1995.
    2. Kuo TC, Lin CW, Ho FM. The soreness and numbness effect of acupuncture on skin blood flow. Am J Chin Med. 2004; 32:117-129.
    3. Cheng RS, Pomeranz BH. Electroacupuncture analgesia is mediated by stereospecific opiate receptors and is reversed by antagonists of type I receptors. Life Sci.1980;26:631-638.
    4. Spence DW, Kayumov L, Chen A, Low, A Jain,U, Katzman MAA. Acupuncture increased nocturnal melatonin secretion and reduced insomnia and anxiety: a preliminary report. J Neuropsychiatry Clin Neurosci. 2004;16 :19-28.
    5. Joos S, Schott C, Zou H, Daniel V, Martin E. Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complement Med. 2000;6:519-525.
    6. Cao X. Scientific bases of acupuncture analgesia. Acupunct Electrother Res. 2002;27:1-14.
    7. Yoo SS, The EK, Blinder RA, Jolesz FA. Modulation of cerebellar activities by acupuncture stimulation: evidence from fMRI study. Neuroimage. 2004;2:932-940.
    8. Berman BM, Lao L, Langenberg P, Lee WL, Gilpin A. Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee. Ann Intern Med.2004; 141:901-910.
    9. Vickers AJ, Rees RW, Zollerman CE, McCarney R, Smith C, Ellis, N et al. Acupuncture for chronic headache in primary care: large, pragmatic, randomized trial. BMJ.2004; 328(7442):744, Epub 2004 Mar 15.
    10. Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture of the alleviation of lateral epicondyle pain: a systematic review. Rheumatology.2004; 43:1085-1090.
    11. Phillips KD, Skelton WD, Hand GA. Effect of acupuncture administered in a group setting on pain and subjective peripheral neuropathy in persons with human immunodeficiency virus disease. J Altern Complement Med.2004;10:449-453.
    12. Wong YK, Cheng J. A case series of temporomandibular disorders treated with acupuncture, occlusive splint and point injection therapy. Acupuncture Med.2003; 4:138-149.
    13. Bradbrook D. Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupunct Med. 2004; 2:93-97.
    14. Chen R, Nickel JC. Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Urology. 2004; 61:1156-1159.
    15. Ouyang H, Chen JD. Review article: therapeutic roles of acupuncture in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2004; 20:831-841.
    16. Joos S, Brinkhaus b, Maluche C, Maupai N, Kohnen R, Kraehmenr N et al. Acupuncture and moxibustion in the treatment of active Crohn’s disease: a randomized controlled study. Digestion. 2004: 69:131-139.
    17. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 3:122-133.