Acupuncture For Cynics

Acupuncture For Cynics

Have You Always Been Curious About Acupuncture, But Were Never Quite Sure Where To Stick The Needles? If you associate acupuncture with needles, pain and weird alternative medicine then you are horribly misinformed about the benefits of the world's oldest form of medicinal treatment.

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Acupuncture And Traditional Chinese Medicine

In our classification scheme, acupuncture is part of a world medicine system (traditional Chinese medicine) and is categorized as both a stimulation-based and an energy-based technique. Its origin dates to at least 600bc, preceding the availability of iron and steel for fashioning needles.26 Acupuncture theory postulates a system of channels or meridians on the body named after organs or Acupuncture Acupuncture Massage Aromatherapy Therapeutic touch Music bodily systems, and a vital energy called qi that flows through the channels. Acupuncture points lie along the channels. Good health and well-being occur when the flow of energy is balanced. Illness occurs when the energy flow is out of balance. It may be depleted from a channel or it may accumulate within a channel at a point of obstruction. By needling acupuncture points, the flow of qi can be restored to its proper balance. Acupuncture technique and theory are embedded in traditional Chinese medicine, which in turn springs from...

Brief history of acupuncture

During the fourth to the tenth centuries, acupuncture became ingrained in Chinese medicine and was officially recognized as an independent specialty of the Imperial Medical Academy of the Tang government in 618AD. During this same period, acupuncture, together with other branches of Chinese medicine, was introduced to other countries such as Japan.28 During the eleventh to the early twentieth century, volumes of written material came out on acupuncture prescriptions. Acupuncture training programs became established in China, which allowed the growth of clinical experience with acupuncture and refinement in techniques. Complications of acupuncture were documented, lists of dangerous points appeared, and indications for acupuncture were identified. As western medicine was introduced in China in the eighteenth century, acupuncture began to lose official favor. It was banned from the imperial court in 1822, but was still practiced widely and its use spread in Europe and other countries...

The Action of Acupuncture at the Peripheral Acupuncture Point

De Qi sensation has been described in the TCM as the therapeutic signal for acupuncture treatment. This De Qi sensation has been characterized by the patient as a sensation of heaviness, numbness, and soreness and aching (Wang et al. 1985). In the meantime, the acupuncturist experienced the sensation of needles being caught. It is now believed that De Qi sensation is caused by the activation of A and C fibers in the skeletal muscle (Wang et al. 1985, Pomeraez 1998), and recent studies have also demonstrated the insertion and rotation of acupuncture needles resulting in the reorganization of the local connective tissue fibers and illicit difference type of mechanical signals-post-stimulation being processed (Langevin et al. 2001a, Langevin et al. 2001b).

The Action of Acupuncture at the Central Nervous System

The central pathways of acupuncture were mapped by the use of functional magnetic resonance imaging (fMRI) techniques. Interestingly, scientists discovered that the areas of brain affected by acupuncture stimulations include the hypothalamus, nucleus accumbens, rostral part of the anterior cingulate cortex, the amygdale formation, and the hippocampal complex. Most of the activated areas are shared with areas activated in acute and chronic pain states (Besson 1999, Anderson et al. 1997, Casey et al. 1996, Parienet et al. 2005). This indicates that acupuncture could relieve pain by unbalancing the equilibrium of distributed pain-related central networks. At present, acupuncture stimulation may affect peripheral tissue organization and interfere with pain signal processing along the central nervous system, either through direct signal interference or by the release of chemical substrates.

Acupuncture in the Clinical Setting The United States Experience

In the early 1990s, by an act of congress, the NIH formed an Office of Alternative Medicine, which subsequently became the National Center for Complementary and Alternative Medicine (NCCAM). The main objective of the center was to fund basic and clinical research in various complementary alternative medicine (CAM) therapies with the ultimate goal of proving clinician's evidence-based approaches. With the support from NIH, the first consensus guidelines for clinicians summarized the evidence on the use and effectiveness of acupuncture in a variety of medical conditions. Although the consensus statement did not strongly recommend the use of acupuncture for all the pain syndromes, acupuncture has been accepted as a technique for peripheral sensory stimulation in the therapy of painful syndromes. Similar to other CAM researches, the validity of clinical acupuncture studies and their outcomes are significantly affected by the methodological approach employed. Important study variables...

History of Acupuncture

Nixon American President Acupunture

Acupuncture is one of many therapeutic interventions utilized in traditional Chinese medicine (TCM). The seminal TCM textbook, Huang Di Nei Jing (Inner Canon of the Yellow Emperor or The Inner Canon of Huangdi), was compiled around 305-204 BCE (Fig. 16.1). This textbook covered the theoretical foundation of Chinese medicine (Unschuld 1985). It is composed of two volumes Shu Wen and Ling Shu. Each volume has 81 chapters and is written in a question and answer format between the mythical Huangdi and his ministers. The first volume, Shu Wen, also known as Simple Questions basically covers the theoretical foundation of Chinese medicine and its association with diagnosis and treatment methods. The second volume, Ling Shu, also known as Spiritual Pivot mainly describes meridians, acupuncture points, and acupuncture techniques and has laid a solid foundation for clinical acupuncture theory. Due to the complexity and the depth of the original Ling Shu, there were great discrepancies among the...

Traditional Principle of Acupuncture

Traditionally acupuncture is embedded in a complex theoretical framework that provides conceptual and therapeutic directions. Acupuncture relies on ordinary human sensory awareness, and its fundamental assertion is similar to the kindred philosophical systems of Confucianism and Taoism (Hahn 1982). The contemplation and reflection on sensory perceptions and ordinary appearances are sufficient to understand the human condition, including both health and illness. The foreign-sounding key words of acupuncture language such as Yin, Yang, dampness, wind, fire, dryness, cold, and earth as well as strange concepts have acted as a formidable barrier for acceptance by many Westerners. In reality, these key words represent human meteorologic conditions, which are sometimes pathologic and disruptive, but sometimes necessary and healthy (Kaptchuk). The following examples are to illustrate the Chinese prospective of Yin-Yang and Qi and how acupuncture works (Liu and Akira 1994).

Acupuncture risks

Common side effects of acupuncture include syncope or near-syncope in approximately 1 percent of patients, bruising around the needle site in less than 1 percent of needle sticks, and persistent soreness from needling that outlasts the treatment by hours to days. Contact dermatitis has been reported and attributed to the nickel content in most stainless steel needles.35 Acupuncture should be avoided during pregnancy or used with caution due to the apparent effect of uterine muscle contraction and cervical dilation that has been produced by stimulating certain points.36'37 Other risks of acupuncture can be divided into organ or tissue damage and infections. The lung is the organ most likely to be injured during acupuncture. Several reports of unilateral and bilateral pneumothorax have emerged.35,38,39,40 Cases of spinal cord and peripheral nerve injuries have been associated with acupuncture due to migration of a broken needle fragment or a purposefully retained needle.41,42,43,44...

Acupuncture Therapy

Any imbalance in Yin-Yang and Qi has to be dynamically harmonized in order to restore the body back to a healthy condition. By applying acupuncture therapy onto specific points of the body, one can shift a person's illnesses into a healthy condition. It appears that acupuncture has the capacity to dry, cool, warm, augment, deplete, redirect, reorganize, unblock, restore, and stabilize based on the specific needs of a particular illness. Several interventional techniques are commonly described to perform traditional acupuncture (Fig. 16.6a-f Table 16.1). The most common technique is one that inserts hair-thin needles into specific acupuncture points on the body to correct disruptions in harmony. Heat stimulation is a technique also known as moxibustion, which burns the herb Artemisia vulgaris either onto acupuncture points through needles or indirectly near the acupuncture point. The whole purpose of applying moxibustion is to warm or move the Qi. Vacuum stimulation is also Figure 16.6...

Evolving Concepts of Pain

Among the earliest recorded systems of pain management, dating back over 4,000 years, is Chinese acupuncture. In this medical system, pain is felt to represent an imbalance between yin and yang, the two vital opposing attributes of life force, or qi. Later, the ancient Egyptians considered the experience of pain to be a god or disincarnate spirit afflicting the heart, which was conceptualized as the center of emotion. Aristotle and later Galen both described pain as an emotional experience or a passion of the soul (Birk 2006).

The Health of Our Nation

Dissatisfied with conventional health care and concerned about pharmaceutical side effects, increasing numbers of patients are being drawn to the use of CAM therapies. CAM therapies include health care practices and products that are not usually prescribed by conventional medical practitioners. They include acupuncture, Aruveyda, chiropractic and massage therapies, special diets, and vitamin mineral antioxidant and megavitamin therapies. In 1994, 40 percent of the general public reported CAM use and Americans spent between 36 billion to 47 billion on CAM therapies in 1997 mostly out-of-pocket.15 The majority of CAM users are educated, affluent, and were between the ages of 30 and 49. Their expressed dissatisfaction with conventional medicines' ability to treat chronic illness was cited as the main reason they turned to CAM therapies.16

The Medical Community and Supplements

Therapies, acupuncture, relaxation, and megavitamin treatments. They were least familiar with homeopathy and naturopathy treatments. While many felt CAM therapies can present a safety threat to the public, they also perceive that offering CAM therapies will attract patients to their practices and offer promising new forms of treatment. It is noted that by 1998, 64 percent of medical schools incorporated some form of CAM education into their curricula, indicating future physicians will be much better informed about CAM therapies and medicines.32

Types Of Cam Therapies

Chronic pain is one of the primary reasons that patients try CAM therapies. Patients look for ways to relieve not only the daily pain but the anxiety and uncertainty that the pain produces. Many of the techniques are minimally invasive, such as acupuncture, or noninvasive, such as the energy therapies of Reiki or therapeutic touch (TT). Because many patients are attracted to this type of therapy, incorporating it into the plan of care can help track outcomes and determine benefit. Because the use of these therapeutics is controversial and research is limited, it is helpful to monitor the benefit of these therapies when they are added to a plan of care. Body-based therapies, such as hot and cold therapy, massage, yoga, exercise, and acupuncture Acupuncture Acupuncture is one of the oldest CAM therapies. It originated in China where it balanced the yin and yang or energy of life forces (ASPMN, 2010). The Chinese believe that balancing the life energies creates a flow of energy called...

The Principle of Pain and Its Physiology

Chinese theory indicates that pain is frequently associated with stagnation or obstruction of Qi, and the application of acupuncture stimulation unblocks this obstruction and stagnation resulting in the resolution of this pain (Liu and Akira 1994). The Western physiology of pain perception and modulation describes a multilevel system that is activated once an injury occurs under normal circumstances. The peripheral activation leads to a series of events processing toward the central nervous system. This leads to a sequence ofevents including signal processing along neural pathways, immunologic, hormonal release, and psychobehavioral responses (Wang et al. 2008). Pain perception and inhibition accept a dynamic, malleable, and complex set of interacting neurons with gene regulation and expression producing a variety of neuropeptides and cytokines at both the peripheral and the central nervous systems (Besson 1999, Melzack and Wall 1965, Bolay and Moskowitz 2002). The recognition of the...

Acute Postoperative Pain

Since July 26, 1971, the landmark event documenting that Mr. James Reston received acupuncture for acute post appendectomy pain, the Western medical society has been fascinated by the acupuncture analgesia There are numerous acupuncture techniques that can be used for the management of acute postoperative pain. Kotani et al. (2001) conducted a RCT that applied intradermal needles to Back Shu acupoints in a group of patients who were scheduled to undergo major abdominal procedures. These acupuncture needles were inserted 2 h before induction of anesthesia and retained in place for 48 h postoperatively. The investigators found that patients in the acupuncture group reported a significant reduction in postoperative pain and analgesic requirements and postoperative nausea and vomiting when compared to the sham group. Usichenko et al. (2005) conducted a RCT to determine the analgesic effect of auricular acupuncture in a group of patients undergoing a total hip arthroplasty. Sixty-one...

Interventions refuted by evidence or insufficient evidence

Jedel & Carlsson's systematic review of seven controlled clinical trials to assess the efficacy of biofeedback, acupuncture and TENS in TMD once again showed poor methodology and no evidence for effectiveness of these therapies 41 . Another systematic review on acupuncture came to the same conclusions 42 .

Nonpharmacological Options

Non-pharmacologic options for trauma patients include transcutaneous electrical nerve stimulation (TENS), acupuncture, and relaxation techniques. In general, these therapies tend to be most useful as adjuncts to either nerve blocks or pharmacotherapy or in patients with mild pain. Relaxation techniques such as guided imagery, self-hypnosis, and biofeedback are most beneficial in patients with high anxiety levels, whereas the best candidates for eye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapies are cognitively intact patients willing to take an active role in treatment. The treatment of coexisting psychopathology is critical to optimizing pain treatment outcomes and should not be underestimated. In fact, long-standing anxiety from poorly managed pain has been associated with depression and posttraumatic stress disorder.

Pharmacologic management

Oxcarbazepine,80 carbamazepine combined with ami-triptyline,81 phenytoin,82,83 valproate,84 nortriptyline (although this study is listed as for central pain, most are from peripheral nerve generators),85 mexiletine,86 and acupuncture.87 A small open label trial of topiramate for various central pain states (n 7) showed no efficacy.88

Special Techniques in Pain Management

There are a number of therapeutic modalities and interventions available for management of acute and chronic pain (Loeser et al. 2001). The appropriateness of an intervention depends in part on the etiology and nature of the patient's pain, the potential risks of the procedure, and the likelihood of beneficial effects. Generally, conservative modalities are employed first. Certain procedures (e.g., acupuncture, physical therapy) carry relatively fewer risks than more aggressive interventions (e.g., neurosurgical interventions). However, if less invasive measures fail, one may advance in terms of the number of concurrent modalities applied and eventually perhaps to those interventions that carry more risk (see Table 7-1). nerve stimulation Acupuncture Transcranial magnetic stimulationa

Physical interventions

Therapies, such as biofeedback, relaxation exercises, lifestyle changes (e.g. diet, discontinuing bike riding, changing a workstation), acupuncture, massage therapy, chiropractic therapy and meditation have all been suggested to improve symptoms 19, 21 . Grade C recommendation (sbsence of directly applicable clinical studies of good quality) intra-vesical anesthetics, intravesical heparin, intravesical hyaluronic acid, bladder distension, nerve blocks epidural, diet, acupuncture.

Management And Prognosis

The first step in management of carefully diagnosed AFP is patient education. The patient may need help in order to accept the fact that there is no infection or bad tooth'' that can be easily treated or extracted. The next step is pharmacological treatment where the first choice is TCAs such as amitriptyline.60, 117 V Treatment with TCA must be continued for several months since the analgesic effect can take weeks to occur. When pain relief has been reached, TCA treatment can be phased out, but if the pain returns it may be necessary to continue TCA treatment.121 Anticonvulsants such as gabapentin may also have some effect.101,117 V Unfortunately, not many randomized controlled clinical trials have been performed. Surgery has been reported to cause pain aggravation and should only be performed after the confirmed presence of pathology, for example a periapical granuloma. Other types of treatments such as acupuncture, transcutaneous electric nerve stimulation (TENS), and biofeedback...

Box 154 Pain treatment options urolithiasis [4851

Doxazocine) (Level II) Nitroglycerine and other nitrates (Level IV) Lithotripsy (Level I) Analgesics, antispasmodics Opioids including tramadol (Level II or III) Antimuscurinics (Level III or IV) Phosphodiesterase IV inhibitors (Level II) Surgical procedures for stone removal (Level III) Acupuncture (Level III) TENS (Level II)

Box 156 Pain treatment options dysmenorrhea [6973

Acupuncture acupressure (Level III) Aromatherapy (Level III) Magnet therapy (Level III) dysmenorrhea. If no pelvic pathology is identified, then surgical neuroablative treatment may be considered. Other potential options with varying degrees of supportive evidence include long-acting hormonal therapies and nontraditional remedies such as vitamin E and B1 supplementation, magnesium supplementation, various other dietary and herbal remedies, acupuncture, and transcutaneous electrical nerve stimulation (TENS). A Cochrane review of high-frequency TENS for the treatment of dysmenorrhea found it to be more effective than placebo in relieving menstrual-related pain. However, the TENS group did experience a higher rate of muscle vibration, skin tightness, headache, and skin irritation 70-73 .

Multidisciplinary pain management

Evaluation of somatic and psychological components of chronic pelvic pain by different health care specialists. One program utilizing cognitive-behavioral therapy, acupuncture, and tricyclic antidepressants was successful in reducing pain by at least 50 percent in 85 percent of the subjects.180 Other studies have suggested that similar results maybe obtained with a multidisciplinary team.143, 158,182,183,184 In a prospective randomized, controlled study, the multidisciplinary approach combining the traditional gynecologic treatment with psychological, dietary, and physical therapy input was found to be more effective than traditional gynecologic (medical and surgical) management of cure.143 II

Nonpharmacologic treatments

Two studies appear to have been published on the use of neurostimulation in PHN. In 62 patients weekly acupuncture was compared to mock TENS over eight sessions 96 . No difference in pain relief was found between the two groups in both, approximately one-fifth reported improvement irrespective of the treatment. Genuine TENS was inferior to combined clomipramine and carbamazepine in a moderate-quality study involving 29 patients (odds ratio 0.15 95 CI 0.03-0.7) 97 . There is currently insufficient evidence to support the use of either acupuncture or TENS in PHN.

Nonpharmacologic therapies

Unencumbered by significant side effects and efficacious, nonpharmacologic therapies are highly recommended in the treatment of both acute and chronic pediatric headaches. Such modalities include biofeedback with relaxation and cognitive-behavioral therapies and may modify the multiple factors that trigger and or exacerbate the migraine headaches and disability cycle.113 I Less information is currently available for acupuncture and alternative medicine therapies.114 II , 115 III

Other treatment options

Several other treatment options are available for the child with FAP however, little is known about the efficacy of most. Acupuncture has been increasingly utilized however, the one controlled study assessing acupuncture in adults with irritable bowel syndrome155 II reported no significant differences between groups treated with true versus sham acupuncture. Reflexology massage, similarly investigated in adult IBS patients, has demonstrated no clear benefit.156 IV Mechanical treatment through the use of transcutaneous electrical nerve stimulation is also often clinically used,157 V but has not been researched in a controlled manner.

Consumers are Taking Control of Their Health

Consumer research shows that almost 50 of Australians have used (non-prescribed) alternative medicine at least once in the past year, while 18 have used it two or more times. Twenty per cent of people have visited at least one alternative practitioner in the past 12 months and 30 are likely to do so in the near future. The attitude held by 49 of respondents is that conventional and alternative medicines are complementary. There is a strong belief (65 ) in the validity of alternative medicine. Thirty-one per cent of people intend to visit a naturopath, 26 intend to use acupuncture and 19 intend to visit a homeopath for health care (L. Dangar, personal communication).

Case 2 Gareth Suneil Ramessur Mbbs Bsc Hons FRCA DipHEP

In whiplash injury, pain course can be difficult to predict. Pain can persist for many years. There could be periods of remission and exacerbation. Regular medications and interventions such as physiotherapy, trigger point injections, and acupuncture have all been tried with variable success. Another interesting aspect of pain in such situations is that the ongoing litigation can have a profound psychological effect and can affect patient's Gareth says he would like to try acupuncture as one of his friends has had some success with it. Pain experience is purely subjective. In situations like whiplash injury, there is no single measure that is 100 successful. In fact, a multimodal approach is often the favored path. You should always try to give a thoughtful consideration to the patient's beliefs and preferences. You agree that Gareth should try acupuncture, while continuing his medications, physiotherapy, and rehabilitation program.

A stepwise treatment approach to FMS

In cases of persisting symptoms after first-line treatment, the APS recommended tender point injections, local manual therapies and acupuncture for focal pain, tramadol, SNRI, anticonvulsants for generalized pain, and psychiatric treatment in cases of major mood disorder as second-line therapy. The German guideline recommended multicomponent therapy in cases of persisting restrictions of daily activities as second-line therapy.

Dysesthetic Vulvodynia

Generally considered a diagnosis of exclusion, it presents commonly in perimenopausal and postmenopausal women as nonspecific superficial vulvar burning or perineal discomfort with intermittent, deep, aching pain. Patients deny entry dyspareunia. Physical examination is normal, with no tenderness on palpation. Pudendal nerve tenderness, hyperesthesiae, or hypoesthesiae in a saddle distribution extending from the mons pubis to the upper inner thighs and posteriorly across ischial tuberosities may be noted on examination.187 The etiology may be secondary to an aberration in cutaneous nerve perception (pudendal nerve distribution S2-S4) at either the central or peripheral level. Tricyclic antidepressants starting at 10 mg q.d. to 40-60 mg q.d. may be of benefit in this condition.188 Topical 5 percent lidocaine may provide additional benefit. Other reported treatments, although of unproven effectiveness, include acupuncture, pelvic floor muscle, physical therapy, TENS, regional nerve...

Key Learning Points

Acupuncture has ancient roots, but remains one of the most well-researched of practices. Originating in the late eighteenth century as the brainchild of mainly one man, Samuel Hahnemann, homeopathy is based on unique concepts of the energetic properties of matter and the paradoxical idea that potency increases as dilution increases. It is widely practiced in Europe, India, and Asia.

Stimulation therapies

The value of percutaneous electrical nerve stimulation (PENS) in painful diabetic neuropathy was assessed in one short-term sham-controlled crossover study which randomized 50 patients to receive either active PENS or sham PENS (acupuncture only) 101 . Patients who received active therapy showed a significant reduction in pain scores. The effects of traditional acupuncture in CPDN were studied in one uncontrolled trial 102 . Forty-six patients (of whom more than half were on standard medical treatment for painful neuropathy) received up to six courses of classic acupuncture analgesia over 10 weeks over 75 noted an improvement in pain symptoms. The patients were followed up for a period that ranged from 18 to 52 weeks during which time only 8 34 needed further acupuncture.

The Treatment of Pain

The view of the body as a representation of changes in the natural world, with energetic disproportions envisioned as the etiology of pain, required the development of treatments that would address these imbalances. Examples include the 4,000-year-old practice of acupuncture, which involves the insertion of needles at particular points or along particular meridians, which are then manipulated to either drive energies into or out of the affected system, thereby providing a direct revision of the imbalanced qi. Additionally, the application of humoral opposites (see Table 1.2), cupping, blood letting, purging, the use of topical and oral herbal compounds, and distraction by creating a competing, more severe pain, were all employed as means to return balance and alleviate pain.

Treatment of pain in DSP and ATN

Two randomized, double-blind studies found no significant difference in efficacy between amitriptyline and placebo in HIV-related peripheral neuropathy.31,32 I Both studies were of sufficient quality to be included in a systematic review.28 Both studies involved comparisons between several different treatments. Kieburtz et al.31 compared amitriptyline, mexiletine, and placebo in 145 patients. Neither active treatment was superior to placebo in terms of efficacy. The authors comment that the study sample size was smaller than originally planned. Study enrolment was discontinued on the recommendation of the safety committee that suggested that even with full enrolment the trial would not be able to demonstrate a statistically significant benefit of either intervention. The study by Shlay et al.32 was an unusual design in that it compared acupuncture to amitriptyline or placebo, acupuncture versus sham acupuncture, or amitriptyline versus placebo. The study design was modified during...

Shu Ming Wang MSci MD Janet S Jedlicka PhD Otrl Anne M Haskins PhD OTRL and Jan E Stube PhD OTrl

Harris is a 45-year-old, otherwise healthy man suffering from lower back pain. He over exerted himself lifting a heavy box from the floor. He did not experience immediate pain until the following morning. He complained that his pain was very severe and had significantly affected his movement. He stated that he experienced sharp pain associated with every movement. The pain radiated downward over the buttocks and both legs. He had no other symptoms, and an MRI of his back was normal. The patient received several sessions of massage, but his symptoms and pain did not subside. As a result, he is here to receive acupuncture treatment. Manual acupuncture is administered include at the UB 63, and patient experiences instant relief of his low back pain. Other points considered include UB 57 and GB 34. UB 63 is an acupoint located on the lateral side of the foot, directly below the anterior border of the external malleolus, on the lower border of the cuboid bone. This particular point is...

Chronic Lower Back Pain

Table 16.2 Acupuncture points commonly used in clinical acupuncture studies. LR3 Taichong On the dorsum of the foot, in the fossa distal to the junction of the first and second metatarsal bones, 2 in. proximal to the margin of the web of the toe this acupuncture point has been used in migraine and adjunct for lithotripsy studies SP6 Sanyinjiao 3 in. directly above the tip of the medial malleolus, in the fossa posterior to the medial margin of the tibia this acupuncture point has been used in migraine headache, colonoscopy, and labor analgesia studies ST36 Zusanli In the fossa 1 fingerbreadth lateral to the anterior margin of the tibia and 3 in. inferior to the acupoint Dubi (ST 35), which is located at the lower border of the patella, in the depression lateral to the patellar ligament this acupuncture point has been used in osteoarthritis, migraine, colonoscopy, and postoperative pain studies LI4 Hegu On the dorsum of the hand, between the first and the second metacarpals, at the...

Nonpharmacologic Measures

Applications of cold (to reduce inflammation) or heat (to reduce spasms) to muscles or joints are commonly employed techniques but evidence for an analgesic benefit is mixed. Hypnosis has been shown to reduce pain associated with medical procedures however, it requires specific training and time to administer. Transcutaneous electrical nerve stimulation (TENS) has shown conflicting results in terms of an analgesic benefit in the acute setting, but it has been shown to reduce the need for pharmacologic analgesics. There is limited evidence of benefit in the acute setting from relaxation and guided imagery. Acupuncture and electro-acupuncture have been shown to be of benefit in the acute setting both to improve pain and to reduce common opioid side effects however, they require specific training and time to administer.

Sreekumar Kunnumpurath Mbbs Md Fcarcsi Frca Ffpmrca

Vincent is a 54-year-old artist who has made significant contributions to the world of art in the recent past. About 9 months ago, he was involved in a fight at a local bar and an assailant stabbed him in the left shoulder. Although the injury was deep, he underwent immediate surgery and his shoulder injury was repaired without much problem. He had an uneventful recovery. However, after discharge from the hospital, he continued to suffer from pain in the left shoulder, which slowly started to involve his left arm. He was under the care of his primary care physician who prescribed him various analgesics, physiotherapy, TENS, and even suggested acupuncture. Unfortunately, he failed to respond to all these therapeutic measures. He was then referred to the pain physician who found that Vincent's initial injury had healed well, and noted a few trigger points over his left shoulder which he treated with injections. He yet again failed to respond. He was then started on gabapentin without...

Options for Pain Management

The following discussion reviews options for labor analgesia, including nonmedicated and medicated pain relief methods. Nonpharmacologic analgesia techniques include prepared childbirth (LaMaze), aromatherapy, hypnotherapy, acupuncture, and transcutaneous electrical stimulation. Pharmacologic techniques include systemic analgesia, regional analgesia, and nerve blocks.

Advanced Interventional Techniques

Multiple intervention modalities can be used to control pain, when pharmacological pain control is suboptimal. Some of these include transcutaneous electrical nerve stimulation (TENS) unit patch, trigger point injections, epidural pumps, acupuncture, intrathecal pump placement for morphine, clonidine and other medications, intradiscal electrothermal therapy (IDET), nerve ablation therapy, facet joint injections, cryoablation, radiofrequency nerve ablation, peripheral nerve blocking catheters, fluoroscopic guided nerve blocks for cancer pain, and ganglion blocks for chronic regional pain syndrome (CRPS). Use of a particular technique in a patient, is guided by etiology of pain, concomitant co-morbidities, and the patient's current clinical status, than by age. Cancer is most prevalent in the elderly and is the third leading cause of death in the geriatric population. Celiac plexus block, hypo-gastric

Placebos and Procedures

On occasion, the placebo effect from an invasive procedure can be even more powerful than the placebo effect from medication. In 2006, Kaptchuk et al. examined the effects of sham acupuncture compared to a sham pill on patients with arm pain due to repetitive stress injury. They found that over the course of the trial, improvement in pain score and symptom severity scale increased in the group receiving sham acupuncture more than in the group receiving the sham pill (Kaptchuk et al. 2006).


Interdisciplinary management of chronic spinal pain17 or 15,000 for acupuncture for chronic neck pain18 (up to 100,000 per QALY is usually considered to be justified). These measures are useful in order to help refine pharmacoeconomic models of managing pain.19 Cost benefit - the ratio of healthcare expenditure to financial benefit (i.e. the sum of treatment cost savings, reduced disability benefits, and wages earned) considered in purely monetary terms.


Many commonly used first-line strategies such as analgesic, anti-inflammatory agents, tricyclic antide-pressants, reduction in the number of pillows, stress management, and postural advice have not been studied but remain mainstays of treatment. Other modalities such as acupuncture, traction, electrotherapy, and psychotherapy are of uncertain value and also need further study 2 .

Clinical Summary

The problems that arise in the relief of pain associated with chronic conditions are more complex. Repeated daily administration of opioid analgesics eventually will produce tolerance and some degree of physical dependence. The degree will depend on the particular drug, the frequency of administration, and the quantity administered. The decision to control any chronic symptom, especially pain, by the repeated administration of an opioid must be made carefully. When pain is due to chronic nonmalignant disease, measures other than opioid drugs should be employed if possible. Such measures include the use of NSAIDs, local nerve blocks, antidepressant drugs, electrical stimulation, acupuncture, hypnosis, or behavioral modification. However, highly selected subpopulations of chronic nonmalignant pain patients can be maintained adequately on opioids for extended periods of time.

Physician attitudes

And alternative therapies and less rigid about their lack of scientific foundation. In a meta-analysis of 12 surveys of physician perceptions regarding complementary medicine, Ernst and co-authors15 concluded that most of the surveys implied that physicians perceived complementary therapies as moderately useful and or effective. Manipulative therapies (osteopathy or chiropractic), acupuncture, and homeopathy were deemed most useful or effective in the majority of these surveys. All but one of the 12 surveys was of physicians in general practice in the UK, Europe, New Zealand, and Israel. Medical schools in the US and Europe are responding to the new awareness of CAM's pervasiveness. Forty percent of European medical schools offer some form of CAM training.18 A survey of family practice residency program directors and US medical school family medicine department chairs revealed that nearly 30 percent were currently teaching some form of complementary or alternative medicine.19 Another...


Even more problematic is the term natural as in natural healing, natural medicine, or naturopathy. The term generally implies techniques that rely only on botanicals and substances that are used in their natural form, i.e. are not modified by chemical or physical processes. The scope of what natural healing means has expanded to include techniques such as massage and acupuncture and other approaches that purport to promote the body's own power to heal itself by correcting mechanical or energy

Scientific basis

Acupuncture, more than any other CAM therapy, has been studied scientifically. The discovery of opioid receptors and endorphins has led to a large number of investigations into the role these receptors and ligands play in experimental acupuncture analgesia. Few of these studies contradict the involvement of the endorphin system, and several lines of evidence demonstrate that the endogenous opioid system is part of acupuncture analgesia. Acupuncture analgesia can be reversed with opioid antagonists such as naloxone.47,48,49,50 Increased endogenous opioid production has been measured directly after acupuncture.51,52 Antiserum to opioid receptors has been shown to block acupuncture analgesia. By 1982, biogenic amines had been implicated in acupuncture analgesia in numerous studies reviewed by Han and Terenius.53 Ablating the descending inhibitory pathway for pain at the dorsal and medial raphe nuclei blunted acupuncture analgesia. Blocking serotonin receptors in rabbits and rats also...

Scope of practice

Many chiropractors do not adhere to the vitalistic view of innate intelligence, preferring a more mechanical interpretation of what goes wrong in the spine to cause disease. All schools of chiropractic rely on a construct of the subluxation complex, which is the target of their treatment. Other differences that distinguish various practitioners lie in the scope of techniques used. Many chiropractors employ techniques of conventional physical therapy such as the application of heat, ice, ultrasound, or electrical stimulation to the soft tissues as supplementary treatment. Some chiropractors are also trained in and practice acupuncture and many provide counseling about nutrition, offering various nutriceuticals to augment their practice. Patients may seek out these eclectic practitioners as general CAM healthcare providers, but the central core of chiropractic treatment is still the therapeutic manual manipulation of the spine.


Her physician advises her to discontinue all of them if possible. What alternative therapies can be recommended This case highlights the importance of CAM in the everyday practice of medicine. Herbal or nutriceutical treatments will most likely be avoided because of the uncertainty of these agents in pregnancy. Acupuncture may also carry at least a theoretical risk of premature labor. Self-management techniques such as biofeedback, yoga, and hypnosis can all be recommended. Osteopathic and chiropractic treatment can be beneficial, particularly if musculoskeletal factors trigger or influence headache. The herbal agent feverfew, which is commonly used in migraine, should be avoided during pregnancy.

Qi and Meridians

Qi is considered as the essence of life (i.e., vital energy ) that cycles around the body and maintains all organs' functions (Fig. 16.4). Qi flows through a hypothetical network of channels called meridians that interconnect the various organs. Figures 16.5a and b are illustrations of Conception Vessel Meridian and Heart Meridians listed in the TCM textbook. Along the meridians, there are acupuncture points where Qi travels immediately below the skin surface. Qi appears to not only provide the linkage between internal organs but also carry vital information from internal organs to the skin surface. In the normal healthy condition, Qi flows in regular rhyme. However, any state of disharmony or any imbalance in Yin-Yang will also cause disturbances in Qi flow. The disturbances of Qi lead to manifestation of symptoms of illnesses.

Migraine Headache

Migraine is a very common disorder being characterized by enhanced sensitivity of the nervous system. The attack is associated with activation of the trigeminal vascular system. In 1989, a self-administered questionnaire was sent to a sample of 15,000 households (Srewart et al. 1992). A designated member of each household initially responded to the questionnaire. Each household member with severe headache was asked to respond to detailed questions about symptoms, frequency, and severity of headaches. After a single mailing, 20,468 subjects (63.4 response rate) between 12 and 80 years of age responded to the survey (Srewart et al. 1992). Migraine headache cases were identified on the basis of reported symptoms using established diagnostic criteria. An estimated 17.8 of women and 5.7 of men, i.e., about 8.7 million females and 2.6 million males, experiencing migraine found to have one or more migraine headaches per year in the United States (Srewart et al. 1992). Of these, 3.4 million...

Physical treatments

Included in this category are the range of hands-on techniques of physiotherapy, osteopathy, and chiropractic and the treatment modalities of transcutaneous electrical nerve stimulation (TENS) and acupuncture which are often offered by physiotherapists but which are also extensively practiced by other healthcare professionals. There is also some overlap with the treatment modalities espoused by alternative and complementary medicine. The problems of evaluating the use of TENS in chronic pain generally are discussed in a systematic review by McQuay and Moore,57 I who conclude that there is no good evidence in support of its use and that more studies are needed. Only one of the 38 randomized controlled trials included in this study looked specifically at a neurologic disorder (postherpetic neuralgia) and this compared TENS with acupuncture, as did many of the studies in this paper. The difficulty of blinding (especially the recipient) seems insuperable at present, but some problems with...


Exercises, biofeedback and EMG, hypnosis, relaxation, imagery, ultrasound, phonophoresis and iontophoresis, acupuncture and TENS. It is thought that provision of an ideal occlusion will reduce abnormal muscle activity and so reduce pain. A variety of so-called stabilization splints have been used which are worn at night when it is thought most likely that patients clench and grind their teeth (parafunctional habit). The oral appliances predominantly cover one or other arch either completely or partially. Some attempt to realign the maxillomandibular relationship whereas others do not seek to change the relationship. They can be made of soft plastic but many are rigid and attached to the teeth by clasps. Evidence for their efficacy has not been proven.

Treatment Strategy

Treatments with the lowest risk of adverse effects should be tried first. Evidence supporting conservative nonpharmacologic treatments (e.g., physiotherapy, exercise, transcutaneous electrical nerve stimulation, CBT, acupuncture) is limited however, given their presumed safety, nonpharmacologic treatments should be considered whenever appropriate. Simple analgesics (e.g., acetaminophen, NSAIDs) are usually ineffective in pure neuropathic pain but may help with a coexisting nociceptive condition (e.g., sciatica with musculoskeletal low back pain). Additionally, early referrals to a pain clinic for nerve blocks or other interventional therapy may be warranted in some cases to facilitate physiotherapy and pain rehabilitation.

Acute neck pain

For the treatment of acute neck pain, the Australian Acute Musculoskeletal Pain Guidelines Group found evidence that collars were ineffective, and found evidence to be lacking or insufficient on the effectiveness of acupuncture, analgesics, manipulation, passive mobilization, electrotherapy, gymnastics, multidisciplinary biopsychosocial rehabilitation, muscle relaxants, neck school, nonsteroidal anti-inflammatory drugs, patient education, spray and stretch, traction, or transcutaneous electrical nerve stimulation (TENS).100 I The literature pertaining to this evidence is reviewed in detail elsewhere.100,101

The Spine Care Team

Work or home ergonomic issues for CLBP patients as well. Complementary and alternative medicine practitioners, such as those who provide massage therapy, acupuncture, manipulation, or other manual medicine techniques, also have an increasingly large role in the care of patients with acute and chronic spine problems.

Massage therapy

Massage therapy can be thought of as soft tissue manipulation using the hands.115 II Various types exist, but most have evolved out of traditional Swedish school massage popularized decades ago. The goals of massage therapy include sedation, adhesion reduction, fluid mobilization, muscular relaxation, and vascular changes. For chronic LBP, there is only limited evidence that suggests massage is superior to sham treatment, exercise and postural training, relaxation exercise, acupuncture, or self-care education. Combining massage therapy with education and exercises may be better than using massage

Chronic Neck Pain

In chronic neck pain, there is no solid evidence that the use of the following is effective traction, use of cervical collar, TENS, acupuncture, botulinum toxin injections, conventional physical therapy, and manipulation therapy. Exercises appear to be as effective as manual therapy or physical therapy in reducing pain. There is evidence that percutaneous radiofre-quency neurotomy for cervical facet pain provides pain relief for chronic neck pain. Pain from the facet joints can be diagnosed by diagnostic blocks of the medial branches that innervate the joints.

Alternative medicine

Nontraditional approaches to CPP include chiropractic treatment, hypnosis, and acupuncture.18'180 A prospective study on chiropractic treatment in 18 CPP patients demonstrated significant improvement in pain and functioning over a six-week treatment period of flexion distraction and trigger point techniques.180 III A randomized controlled study found a 90 percent improvement in dysmenorrhea with acupuncture compared with only 36 percent in the placebo group.181 II A Cochrane review21 I of acupuncture for pain relief with dysme-norrhea concluded that there was insufficient evidence to determine the effectiveness of acupuncture in reducing dysmenorrhea.

Other Therapies

Acupuncture90, 91 have also been reported to have benefits for pain, tenderness, quality of life, and well-being for FMS patients. However, there have also been negative studies for acupuncture, but it may be of benefit to some patients. A number of miscellaneous treatments have also been used in FMS including therapy with lasers, magnets, ultrasound, and music vibration. Clearly, the paucity of evidence does not allow a firm conclusion and recommendations to be made regarding these therapies.


Physical therapy involving massage, manipulation and passive movements may prevent trophic changes and vascular congestion in the stump. Other treatments, such as transcutaneous electrical nerve stimulation, acupuncture, ultrasound and hypnosis, may in some cases have a beneficial effect on stump and phantom pain. At least three studies have examined the effect of transcutaneous electrical nerve stimulation on phantom pain, but the results are not consistent. One study showed an effect of a Farabloc, a metal-threaded sock to be worn over the stump 43 . It has been suggested that visual feedback with a mirror can eliminate painful phantom limb spasms. In a larger clinical trial of 80 amputees, however, Brodie et al. 44 failed to find any significant effect of mirror treatment on phantom limb pain, sensation, and movement. Flor et al. 4 demonstrated that sensory discrimination training obtained by applying stimuli at the stump reduced pain in five upper limb amputees. The...

Opioid Antagonists

Although high doses of antagonists might be expected to alter the actions of endogenous opioid peptides, the detectable effects usually are both subtle and limited. This most likely reflects the low levels of tonic activity of the opioid systems. In this regard, analgesic effects can be differentiated from endocrine effects, in which naloxone causes readily demonstrable changes in hormone levels (see below). Interestingly, naloxone appears to block the analgesic effects of placebo medications and acupuncture.


In the United States, the high rates of CAM use crosses socioeconomic, racial, and geographic boundaries but those who used CAM in 2002 were more likely to be white, female, college-educated, with age less than 65, living in the western US, with a higher annual household income.12 The types of therapies that patients use will depend on many factors besides patient preference, such as availability and cost. As reported in a 2002 survey by Tindle et al.,12 the most common therapies were herbal medicine (18.6 percent) and relaxation techniques (14.2 percent), chiropractic care (7.4 percent), and yoga (5 percent), while acupuncture was used by 1 percent of the population. The number of visits to a CAM practitioner varies depending on the nature of the therapy. Thus, chiropractic, acupuncture, and massage therapy will require more visits to a practitioner in a given time period than herbal medicine or homeopathy.


Dysmenorrhea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynecological complaint. Based on epidemiologic studies, at least 72.7 of female adolescents reported pain or discomfort during their period and almost 58.9 of them reported decreased activity and 45.6 reported school or work absenteeism (Taylor et al. 2002). A survey conducted on a group of female adolescents indicated that the majority of the respondents identified dysmenorrhea as one of the problems interfering with their academic performance and school absenteeism. Thus dysmenorrhea and premenstrual symptoms are common pediatric pain problems (Helms 1987). Common treatment for dysmenorrhea includes medical therapy such as NSAIDs or oral contraceptive pills (OCPs). Both modalities work by reducing myometrial activity (contractions of the uterus). The efficacy of conventional treatments such as NSAIDs is considerable. However, the failure rate can be as high as 20-25 . It is not...

Labor Analgesia

Acupuncture and related interventions have been considered as alternatives for pain relief for epidural labor analgesia. Acupuncture and related interventions were compared with meperidine consumption for labor analgesia. A randomized, non-blinded, controlled study found a decrease in the requirement for meperidine in the acupuncture group as compared to a control group with the same parity (Ramnero et al. 2002). Chung and colleagues applied acupressure as the analgesic for the first stage of labor (Chung et al. 2003). These investigators found that during the first stage of labor the patients who received acupressure reported significantly less labor pain compared to patients who received sham or no treatment. A recent study by Lee et al. (2004) performed a sham-controlled RCT to evaluate the analgesic effects of acupressure on the intensity of labor pain and duration of labor. These investigators reported that labor pain score during the first hour following the intervention was...

Surgical Analgesic

Anecdotal reports from China indicate that acupuncture can be used successfully as a sole analgesia method for a variety of surgical procedures such as open-heart surgery (Cheng 2000). However, there are limited data from the Western world to support the claim and experience demonstrated in the Chinese experience. The data available in the literature are inconsistent. In early 1970, Schaer (1979) conducted a study using EA as surgical analgesia in a group of women undergoing gynecological procedures. Based on the hemodynamic changes during the surgery, a small dose of fentanyl would be administered. The investigator found that EA was as effective as 0.27 xg kg of fentanyl given intravenously every 10 min. Grief and colleagues (Greif et al. 2002) performed electrical stimulation at the lateralization control point near the ear tragus and reported that this intervention significantly decreased the desflurane anesthetic requirements ( 25 ). Similarly, Taguchi and colleagues (2002) who...