Acupuncture for pain
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Acupuncture can treat physical and mental discomforts of chronic pain

Acupuncture can treat physical and mental discomforts of chronic pain | Acupuncture for pain | Scoop.it
Acupuncture can treat physical and mental discomforts of chronic pain

DR. DWIGHT CHAPIN

Special to The Globe and Mail

Published Tuesday, Feb. 03 2015, 3:07 PM EST

Last updated Tuesday, Feb. 03 2015, 3:19 PM EST

22 comments54531421714AA

“Aging is not for the faint of heart. Moving from my bed to the toilet to pee in the middle of the night for the fourth time can feel like an Olympic endurance event. As I made my way to the bathroom last night, I think the snapping and popping of my achy joints actually woke up my wife. I am always tired and just can’t move like I used to. It hurts too much when I try.”

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– Stephen, 61

Stephen is a new patient at my clinic. Suffering from chronic low-back pain and osteoarthritic knees, he was interested in trying acupuncture to help alleviate his pain.

Anyone living with chronic pain knows that it amounts to much more than physical discomfort. Anxiety and depression, fatigue, sleeplessness, lack of drive, a weakened immune system and disability often accompany long-term pain, suggesting that the condition is more of a whole-brain disorder than simply erratic pain signalling.

Moving through life in a body that reminds you of its significant limitations with every movement can have a devastating impact on your mental health and quality of life. Like it is for many Canadians, this is Stephen’s reality.

It is estimated that one in five Canadians suffer from chronic pain. With an aging population this number is likely to climb. Statistics Canada reported that roughly 27 per cent of seniors living at home and 38 per cent of those living in health-care institutions suffer from chronic pain – and 60 per cent report that it interferes with most daily activities.

By definition, chronic pain is any pain lasting more than 12 weeks. It is different from acute pain, a normal sensation that acts like a warning of possible injury. Chronic pain, which can persist for months or more, may begin after an initial trauma or injury, such as a back sprain, as it did many years ago for Stephen. There may also be an unresolved cause, such as illness. In some cases, however, the cause remains unknown.

Pain itself often modifies the way the central nervous system functions. A patient can actually become more sensitive and experience greater pain with less provocation. This is called “central sensitization.” Patients are not only more sensitive to things that should hurt, but ordinary touch and pressure can also become painful. Their pain can have an “echo,” which fades more slowly than in other people.

The physical toll of chronic pain is obvious. The emotional toll is not, but can be equally devastating. The emotional stress of chronic pain can amplify the experience, creating a vicious cycle. Anxiety, depression, hopelessness, anger and fatigue interact in complex ways with chronic pain and may decrease the body’s production of natural painkillers. Even the body’s most basic defences may be compromised. There is considerable evidence that long-term, unrelenting pain can suppress the immune system.

Treating patients with chronic pain presents many challenges. There are no standards, and traditional medical approaches commonly tend to look at chronic pain as a secondary problem. This opinion, however, is changing. Clinicians who specialize in treating chronic pain now recognize that it is not merely a sensation, like touch or smell, but rather is significantly influenced by how the brain processes pain signals. More and more experts and institutions are beginning to define chronic pain as a disease.

This shift is leading many clinicians to recommend acupuncture – often thought of as a last resort – as a therapy of choice. Acupuncture is increasingly being recognized by Western medicine as an effective alternative or adjunct to conventional treatments for a long list of conditions, including headache, menstrual cramps, joint pain, low-back pain and asthma, as well as for the side effects of chemotherapy and nausea related to pregnancy.

Although acupuncture has long been used to treat chronic pain, its effectiveness has been a controversial topic among physicians and scientists. This is largely because no biological mechanism has been identified to explain how the insertion and stimulation of specialized needles at specific points on the body generates lasting effects.

In an extensive analysis, published in 2012 in JAMA Internal Medicine, data from nearly 18,000 individuals involved in 29 high-quality clinical trials demonstrated that acupuncture is an effective treatment for chronic back and neck pain, osteoarthritis, shoulder pain and headaches. Acupuncture has been shown to be more than just a placebo.

I commonly use acupuncture in my practice as a pain management tool for patients suffering from chronic pain. After more than 15 years of experience, nearly every day I witness a patient’s positive response to acupuncture that cannot be explained using Western medicine. It is understood that acupuncture triggers the release of endorphins, the body’s natural painkilling chemicals, and affects the part of the brain that governs serotonin, a brain transmitter involved with mood, resulting in pain relief. But there is more to it than that. Acupuncture triggers a healing response that is still not clearly understood.

Stephen is not looking for a miracle or the ability to wind back time. A pain-free walk to the toilet in the middle of the night, however, would make him a happy man. With an open mind and a good sense of humour, this is where his journey will start.

Health Advisor contributors share their knowledge in fields ranging from fitness to psychology, pediatrics to aging.

Dr. Dwight Chapin, B.Sc(H)., D.C., is the clinic director of High Point Wellness Centre in Mississauga (highpointclinic.com), team chiropractor for the CFL’s Toronto Argonauts and on-site clinician for employees of The Globe and Mail. Follow him on Twitter @HighPtWellness.

Bedford Acupuncture's insight:
"In an extensive analysis, published in 2012 in JAMA Internal Medicine, data from nearly 18,000 individuals involved in 29 high-quality #clinical #trials demonstrated that #acupuncture is an effective treatment for #chronic #back and #neck #pain, #osteoarthritis, #shoulder #pain and #headaches. Acupuncture has been shown to be more than just a placebo."
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I have been informed of sports acupuncture whereby acupuncture is used to stimulate body healing | Ask an expert | Health onformation | AXA PPP healthcare

I have been informed of sports acupuncture whereby acupuncture is used to stimulate body healing | Ask an expert | Health onformation | AXA PPP healthcare | Acupuncture for pain | Scoop.it
The Answer

It is unclear exactly how acupuncture needling works but there is evidence that in many cases it can be an effective addition in the treatment of sports injuries. Acupuncture has historically been used for the treatment of pain which is often a hindrance to functional recovery and confidence following a sports injury.  The techniques used in sports acupuncture are similar to those of recognised Western and Chinese acupuncture disciplines. The difference is that the treatments are administered by practitioners with an interest in sports injuries and with a focus specifically on rehabilitation of injuries usually occurring within the sport setting. Other standard therapies such as physiotherapy, osteopathy and chiropractic treatments can be used in conjunction with acupuncture to ensure maximal beneficial effect.

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Managing chronic pain in the non-specialist setting: a new SIGN guideline - including acupuncture

Managing chronic pain in the non-specialist setting: a new SIGN guideline - including acupuncture | Acupuncture for pain | Scoop.it
CHRONIC PAIN AND THE NEED FOR A GUIDELINE

Chronic pain, defined as pain lasting beyond normal tissue healing time (taken to be 3 months),1 is a syndrome that affects a large proportion of the primary care population. It is ‘significant’ in around 14% of UK adults, imposing a heavy burden on the physical and psychosocial health of sufferers, their families and society, at high cost to the healthcare services.2 It was estimated in 2002 that people with chronic pain account for 4.6 million GP appointments in the UK, at an annual cost to the NHS of £69 million, equivalent to the employment of 793 GPs.3 Although many clinical conditions can lead to chronic pain, there are common underlying neurobiological and psychosocial mechanisms, and the impact is generally independent of the clinical aetiology. Effective assessment and treatment of chronic pain therefore means that GPs should have:

adequate education and knowledge;

access to evidence-based effective management strategies; and

agreed criteria for referral to specialist clinics.

Unfortunately, none of these requirements is generally in place.

Undergraduate training in management of pain is demonstrably minimal, accounting for <1% of programme hours,4 despite its high prevalence and impact. Much of the available evidence for potential interventions is derived from specialist settings or in specific clinical conditions, making it difficult to apply to a general primary care population. Even standard treatments, such as drugs, often lack evidence for effectiveness …

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Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study -- Norrbrink and Lundeberg 29 (2): 108 -- Acupuncture in Medicine

Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study -- Norrbrink and Lundeberg 29 (2): 108 -- Acupuncture in Medicine | Acupuncture for pain | Scoop.it

Home > Volume 29, Issue 2 > ArticleAcupunct Med 2011;29:108-115 doi:10.1136/aim.2010.003269Original papersAcupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory studyCecilia Norrbrink1,2, Thomas Lundeberg3

+Author Affiliations

1Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden2Neuro-Spinal Division, Department of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden3Foundation for Acupuncture and Alternative Biological Treatment Methods, Sabbatsbergs Hospital, Stockholm, SwedenCorrespondence toCecilia Norrbrink, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm 18288, Sweden; cecilia.norrbrink@ki.seAccepted 11 February 2011Published Online First 6 April 2011Abstract

Objective The study sought to explore the possibility of using acupuncture and massage therapy for relieving neuropathic pain following spinal cord injury (SCI).

Design 30 individuals with SCI and neuropathic pain were assigned to treatment of either massage or acupuncture, with 15 individuals in each group. Both groups received treatment twice weekly for 6 weeks. Treatments were evaluated at the end of treatment and 2 months later (follow-up).

Results Data were analysed on an intention-to-treat basis. Within the groups, ratings of present pain, general pain, pain unpleasantness and coping improved significantly at the end of treatment after acupuncture compared to baseline values, and following massage therapy ratings of pain interference on the Multidimensional Pain Inventory improved. At follow-up no significant improvements were seen.

Between-group differences were seen regarding ratings of worst pain intensity at the end of treatment, and regarding pain unpleasantness and coping with pain at follow-up, both in favour of acupuncture.

At the end of treatment, eight of the 15 individuals receiving acupuncture and nine receiving massage reported an improvement on the Patient Global Impression of Change Scale, and at follow-up six patients in the acupuncture group and one patient in the massage group still reported a favourable effect from the treatment.

Few side effects were reported and neither dropout from the study did this due to adverse events.

Conclusion Neuropathic pain following SCI is often only partially responsive to most interventions. Results from this study indicate, however, that both acupuncture and massage therapy may relieve SCI neuropathic pain. For this reason, larger randomised controlled trials are warranted for assessing the long-term effects of these treatments.

Introduction

We lack knowledge of how to treat neuropathic pain due to spinal cord injury (SCI) satisfactorily. Treatment is therefore a great challenge for care givers.1 Current treatment recommendations are based on the few studies of this patient group and on algorithms for treating peripheral neuropathic pain. With these tools we can sometimes relieve such pain following SCI to some extent, but rarely enough for the individuals to be satisfied. The lack of satisfaction can also be related to the fact that many of the drugs used have severe unwanted side effects.

Regarding other treatments, sensory stimulation with transcutaneous electrical nerve stimulation has been studied mainly in peripheral neuropathic pain conditions and is considered to be an effective complement.2 In some individuals with central neuropathic pain, transcutaneous electrical nerve stimulation may induce pain alleviation3 but often less than in peripheral neuropathies.

In rodent studies, acupuncture has been studied after peripheral nerve injury and is effective for hyperalgesia4 and allodynia,5 6 signs considered as consequences of nerve damage and associated with neuropathic pain.

Treatment with acupuncture has, however, not been extensively studied in peripheral or central neuropathic pain conditions in humans. Only two randomised controlled studies have been carried out7 8 and both report no or very little difference between acupuncture and the control treatment. However, in one of these studies verum acupuncture was compared to sham acupuncture, defined as needle insertions in deep muscles but not in acupuncture points followed by needling stimulation. This type of control is controversial since it is most likely not an inert treatment.9 Two uncontrolled studies showed positive effects compared to baseline values when treating diabetic neuropathy10 and HIV-related neuropathic pain.11

In SCI, a within-subject-design study using acupuncture showed promising results for treating overall pain but less good for the cohort with central neuropathic pain.12 Still, in 42% of those individuals, pain intensities were alleviated by at least two units on a 0–10 numerical rating scale (NRS)—which is not a negligible effect in this patient group.

Massage therapy has not been studied for treating neuropathic pain following SCI but it decreased anxiety13 in individuals with SCI.

In a previous survey14 individuals with SCI reported massage to be one of the most effective non-pharmacological treatments for SCI chronic pain but spoke less of acupuncture. Similar results have been reported in other studies.15 16

Based on these results an exploratory study was designed to assess the possibility of using medical acupuncture and massage therapy for relieving neuropathic pain due to SCI. Both treatment modalities activate endogenous pain inhibitory systems, however they are believed to act through different mechanisms.17 18

Methods and individualsIndividuals

Individuals with SCI and pain were recruited from a spinal unit in Stockholm, Sweden through advertisements and through mailed enquiries. Inclusion criteria were an SCI more than 2 years previously and pain diagnosed as neuropathic at or below level19 due to the SCI of more than 6 months duration. All individuals were asked not to change current pain medication or any other treatments during the treatment period but were allowed to stay on concurrent medication.

Study design

The study was carried out using a sequential controlled design. The first 15 individuals giving informed consent for the study and fulfilling the inclusion criteria were assigned to western medical acupuncture and the following 15 to massage. The assignation procedure was unknown to the individuals who were all willing to receive both acupuncture and massage. The treatment period consisted of 6 weeks with treatment twice weekly. The treatments were evaluated at the end of treatment and at follow-up 2 months later using a mailed questionnaire.

Acupuncture

Acupuncture points were chosen individually and needles were inserted in areas with preserved sensation. Points were chosen from a western medical perspective, that is, placed in areas with pain and in strong general acupuncture points. In addition, earpoint Shenmen and GV20 were selected as possible complements. Needle insertion was carried out using the recommended depth allowing for muscle stimulation.20 Stimulation was initially manual and from the third or fourth session four points were stimulated with high frequency (80 Hz) electroacupuncture (CEFAR Acus 4; Cefar AB, Lund, Sweden). Points stimulated in the upper extremity were either LI11–LI4, LI15–LI11 or LI15–LI4, and in the lower extremity ST32–GB34, ST32–ST36 or BL54–BL54. In total 13–15 points were used in each session. The intensity was high, giving non-painful paresthesia. During manual acupuncture de qi was elicited three times at each session of 30 min.

The acupuncture procedure is described according to the Standards for Reporting Interventions in Clinical Trials of Acupuncture.21

Massage

Classical massage therapy was carried out in areas with pain and preserved sensation with individuals lying on a massage table. The massage consisted of non-painful light pressure effleurage and petrissage. It was important that the massage did not cause discomfort for the individuals and therefore stimulation in areas with allodynia or unpleasant feelings from touch were avoided.

Outcome measuresPrimary outcome measures

The individuals rated their general and their worst pain intensities, and pain unpleasantness, during the last week using a visual analogue scale (VAS). They also rated present pain intensity at baseline, at the end of treatment (6 weeks) and at follow-up (2 months). In addition they rated the global pain-relieving effect on the Patient Global Impression of Change Scale (PGIC)22 at both end of treatment and follow-up.

A decrease of two units or more in pain intensity ratings on a 0–10 NRS23 has been considered clinically significant, and 1.8 units or more in individuals with SCI (defined as ‘my pain decreased to a meaningful extent’).24 Translated to a VAS with a range of 0–100, a decrease of 18 units or more was considered to identify a responder.

Secondary outcome measure

As secondary outcome measures the Hospital Anxiety and Depression Scale was used to rate anxiety and depression,25 the Multidimensional Pain Inventory—Swedish language version (MPI-S)26 part I, to assess the psychosocial consequences of pain, and a sleep questionnaire27 to assess quality of sleep. Further, Fugl-Meyer's Life Satisfaction instrument (LiSat – 9)28 29 was used. In the analysis only the global rating of life satisfaction was considered. In addition, individuals rated how well they were able to cope with their pain on an 11-point NRS anchored ‘not at all’ (0) and ‘very good’ (10).

Spasticity was assessed using the modified Penn Spasm Frequency Scale,30 for frequency and severity. Spasm frequency is reported from 0=no spasms to 4=spontaneous spasms occurring >10/h, and severity of spasms from 1=mild to 3=severe.

The study was approved by the Regional Ethics Approval Board in Stockholm, Sweden.

Statistics

Data were analysed on an intention-to-treat basis with missing data in dropouts replaced using the last-observation–carried-forward method.

Patient and treatment characteristics are presented using descriptive statistics: number of observations, mean and SD. Outcome variables are further presented by group using median and IQR before and after treatment.

Determination of the between-treatment difference measured with the PGIC was tested with the Mann–Whitney U test and the difference in number of respondents using the two-tailed Fisher exact test.

Svensson's rank-invariant method31 was used to estimate systematic changes in outcome variables (pain intensity, pain unpleasantness, coping, sleep quality, mood, life satisfaction, psychosocial consequences and spasticity) directly after treatment compared to baseline, and also 2 months after treatment compared to baseline.

Systematic group changes are explained by relative change in position (RP), that is, the proportion of individuals with a higher level minus the proportion of those with a lower level in the outcome variable. RP values range from −1 (all individuals decreased) to +1 (all individuals increased). Values close to 0 indicate a negligible systematic group change in the outcome measure. When RP≠0, the values after treatment are systematically higher (+) or lower (−) for the group than the initial values. RP was estimated together with the corresponding 95% CI. SE was calculated using the jack knife method. Differences between acupuncture and massage was estimated as the difference between RPstogether with the corresponding 95% CI. Negative differences between interventions (acupuncture vs massage) indicate that a larger proportion of individuals in the massage group decreased (or increased less) from baseline to the end of treatment, compared to those in the acupuncture group in the outcome variable.

All the tests were two-sided, and a significance level of 0.05 was chosen. All descriptive statistics were produced in STATISTICA V.7.0 (StatSoft, Tulsa, Oklahoma, USA) and RP values were calculated in SYSRAN V.1.0 (JK Biostatistics, Stockholm, Sweden) for Matlab V.6.0 (The MathWorks, Natick, Massachusetts, USA).

Results

Altogether 30 individuals were included in the study; 15 received acupuncture and 15 massage. The acupuncture group consisted of 12 males and 3 females with a mean age of 47.1 years (SD 11.1) and the massage group of 13 males and 3 females, mean age 49.8 (SD 9.2). Mean time since injury was 11.9 years (SD 12.3) in the acupuncture group and 12.9 years (SD 9.0) in the massage group. In the acupuncture group, 11 had a traumatic injury compared to 10 in the massage group.

Five of those receiving acupuncture and six of those receiving massage had tetraplegia. Ten of those in the acupuncture group and eight of those in the massage group were on concomitant pain medication including adjuvant analgesics.

Treatment

The acupuncture group received a mean of 10.5 treatments (SD 2.9) and the massage group 11.1 treatments (SD 2.1). One acupuncture patient's treatment was concluded after only eight sessions due to complete pain relief. Lacking compliance, one individual received only three sessions of electroacupuncture and thereafter manual stimulation.

Two individuals dropped out of the study, one in each treatment group, for reasons not related to the treatment itself. The acupuncture-group member moved abroad after one treatment and the massage-group member was hospitalised for pneumonia after eight treatments. One massage-group member did not return the follow-up questionnaire.

Adverse events

Compliance was high for both types of treatment. Almost half of those in the acupuncture group (n=7) reported being tired after the treatment initially and one reported a pain increase lasting 4–5 h after the treatment. Of those receiving massage, two reported soreness, one increased pain and one feeling extremely cold 4–5 h after the treatment resulting in poor sleep the first night after treatment.

Positive events

The acupuncture group reported the following positive side effects at the end of the treatment period: improved sleep (n=2), improved bladder (n=1) and bowel (n=1) function, decreased spasticity, less allodynia, more energy, less pain medication, feeling calm and relaxed (n=1 each). The massage group reported: improved function/less stiffness (n=6), improved sleep (n=5), improved relaxation (n=2), less spasticity (n=3), improved circulation (warm legs; n=2), less allodynia (n=2), fewer painful attacks (n=2), less medication (n=1).

At the follow-up individuals could report late-onset improvements. One patient reported improved sleep after acupuncture. In the massage group one reported using less muscle relaxants, and another increased wellbeing and mobility.

Primary outcome measures—pain and PGICBetween-group differences

At the end of treatment (6 weeks), there was a significant difference between the two groups in ratings of worst pain intensity (figure 1). There was also a significant change at follow-up (2 months) regarding ratings of pain unpleasantness; both in favour of acupuncture. No other differences between the two groups were detected.

View larger version: In a new window Download as PowerPoint SlideFigure 1

Between group differences at the end of treatment and at 2 months follow-up.

 

At the end of treatment, 8/15 individuals on acupuncture and 9/15 on massage reported an improvement on the PGIC (minimally improved–very much improved, figure 2). At follow-up 6/15 on acupuncture and 1/15 on massage still reported a positive outcome. The difference between the two groups was not statistically significant.

View larger version: In a new window Download as PowerPoint SlideFigure 2

Ratings of global pain relieving effect on the Patient Global Impression of change Scale.

 

Numbers of responders calculated as all those reporting a decrease in pain ratings of ≥18 mm measured with VAS are shown in figure 3. The differences seen were not statistically significant.

View larger version: In a new window Download as PowerPoint SlideFigure 3

Number of patients reporting a decrease of 18 units or more on a visual analogue scale at the end of treatment and at the 2 months follow-up. There were no statistically significant changes between those treated with massage and those treated with acupuncture calculated with Fisher's exact two-tailed test.

 

Ratings of general pain intensity and pain unpleasantness at end of treatment and follow-up are shown in figure 4 plotted against the baseline values.

View larger version: In a new window Download as PowerPoint SlideFigure 4

Ratings of pain intensity and pain unpleasantness plotted at end of treatment and follow-up

 Within-group differences

Ratings of general and present pain, and of pain unpleasantness, all decreased significantly at end of treatment with acupuncture but not after massage. In terms of median decrease in pain intensity ratings measured with VAS, this was similar in the two groups (table 1).

View this table: In this window In a new windowTable 1

Median values presented with IQR for primary and secondary outcome measures at baseline, end of treatment and follow-up

 

At follow-up no within-group differences were seen between pain variables.

Secondary outcome measures

At the end of treatment there were no between-group differences regarding the secondary outcome measures for pain or spasticity; but at follow-up, ratings of coping with pain as shown with a 0–10 NRS were in favour of acupuncture (figure 1). Within the groups, individuals on acupuncture reported improvement in coping with pain, and those on massage reported less pain interference. At follow-up no improvements were seen, but massage-group members reported worsened coping.

To see whether any of the assessed variables were important for ratings of coping with pain, a Spearman regression analysis was carried out. Pain intensity (r=−0.57), pain unpleasantness (r=−0.61), mood (r=−0.58), sleep (r=−0.55), MPI-pain severity (r=−0.67), MPI-pain interference (r=−0.59), MPI-perceived life control, (r=0.61) and MPI-affective distress (r=−0.65) all correlated moderately (r=0.50 to 0.69)32 with ratings of coping. Ratings of global life satisfaction had low (r=0.26–0.49) correlation with coping (r=0.46), and MPI- social support little if any (r<0.25; r=−0.06).

Discussion

In this exploratory study the average pain alleviation following a treatment course of acupuncture or massage was small but significant. It was larger for the affective component of pain than for the sensory component (intensity). At follow-up no significant effects on pain intensity or unpleasantness were maintained, but six of 15 acupuncture-group members versus one of 15 on massage still reported an improvement on the PGIC. Between-group differences, in favour of acupuncture, were seen only regarding ratings of worst pain intensity. Both methods presented few unwanted side effects and compliance was high. None dropped out due to adverse events.

The most pronounced effects were those of acupuncture on ratings of pain unpleasantness where a median decrease of 23/100 VAS units was seen immediately after the course. Acupuncture treatment reportedly modulates activity in limbic structures,33 which could partly explain these findings.

Effects of treatment on pain unpleasantness are not always assessed in clinical trials but they are recommended as an outcome measure.22

Ratings of pain intensity also decreased significantly after treatment with acupuncture. The median decrease in ratings of present pain intensity was 19/100 VAS units following acupuncture (general pain—15 units) and eight units following massage (general pain—14 units). In a large study of SCI neuropathic pain concluding that pregabalin has a positive effect on this type of pain,34 the mean reduction in pain scores on a 0–10 NRS was 1.92 before controlling for placebo. In a comparative study on gabapentin and amitryptiline35 in SCI and neuropathic pain, a mean decrease of VAS 2.14 was seen after treatment with amitryptiline and of VAS 0.75 after gabapentin.

Hanley et al24 reported that in SCI a reduction of 1.8 units or more on a 0–10 NRS was a clinically significant alleviation of pain, which we translated to 18 units on a 0–100 point VAS, and those reporting these values are defined here as responders. Even though no significant differences were seen between the two groups, immediately after the treatment course more individuals on acupuncture reported this amount of pain alleviation. Forty per cent (six of 15) versus 13% (two of 15) were responders regarding ratings of present and general pain intensity, figures similar to those found by Nayak et al12 in SCI and central neuropathic pain. Those authors found that 42% (five of 12 individuals) reported a decrease of at least two units on an NRS following 15 treatment sessions with acupuncture. Even though both studies used very small samples, these results are considered promising.

None of the present respondents reported worsening of pain using the PGIC, but one patient on acupuncture reported being minimally worse at the 2-month follow-up. Whether this was associated with the treatment course is not clear. In the study by Nayak and colleagues,12four of the total sample of 22 individuals reported an increase in pain intensity at end of treatment and that this persisted at follow-up. The reported average increase was 1.08 on a 0–10 NRS.

Nowadays it is recommended22 36 that the PGIC be added when evaluating the results of a clinical trial, since this instrument covers more aspects than only pain reduction. Our evaluation showed that the effects of both treatments rated on the PGIC were similar, with nine of 15 individuals (60%) on massage and eight of 15 (53%) on acupuncture reporting a favorable effect. At follow-up, six of 15 (40%) on acupuncture still reported an improvement but only one of 15 (7%) on massage. In a study on pregabalin for SCI neuropathic pain,3457% of those on active drug reported an improvement, using the PGIC immediately after the treatment period. This result is similar to those of both acupuncture and massage seen in the present study.

Both methods of sensory stimulation assessed in this study seemed to be able to decrease pain short-term in individuals with SCI and neuropathic pain. However, a difference between the two stimulation methods was seen: many individuals reported a small reduction following massage, but few reported a major alleviation following acupuncture. Three on acupuncture experienced a dramatic effect and long-term improvement. These long-term pain-alleviating effects have been attributed to activation of pain-inhibiting systems in cortical and subcortical pathways. While individuals with SCI and neuropathic pain may have symptoms in common, the origins and the mechanisms of their pain may vary. Different mechanisms can lead to different responses to therapy, and for this reason larger studies are warranted where possible effects can be studied in subgroups.

Both treatment modalities were safe and compliance was high. No individuals dropped out due to adverse events and no severe adverse events were reported. This is rare in pharmacological trials in the same patient group where the dropout rates are reportedly high with commonly used drugs: 16% on gabapentin, 18% on amitryptiline,35 30% on pregabalin,34 48% on tramadol37 and 50% on gabapentin.38

The treatments assessed had effects mainly on the primary outcome variable—pain. However, individuals also reported that their coping ability had improved after treatment with acupuncture. This might be associated with the decrease seen in pain ratings. Ratings of pain interference also decreased after massage. No other effects on mood, sleep quality, life satisfaction or spasticity were seen after either treatment modality.

This explorative study investigated few enrolled individuals, and with no placebo control. In addition the individuals were not randomised to the interventions. The results are therefore difficult to generalise.

However, within-group effects were significant following acupuncture treatment, and while few individuals responded very well, the effects seen in these individuals were long lasting, highlighting the need for larger randomised controlled studies. Also, the fact that both treatments were safe and had high compliance is important when considering their use in pain alleviation. Note, though, that knowledge about type and intensity stimulation, stimulation sites and number of treatments for optimal effect is lacking, so there might be more effective ways of treating neuropathic pain following SCI with acupuncture. The severity of the pain condition in this patient group indicates that the acupuncture course should maybe be longer than 12 sessions, with additional follow-up treatments.

Conclusion

Neuropathic pain following SCI is a condition unresponsive to many interventions. Results from this study indicate that both acupuncture and massage therapy may relieve SCI neuropathic pain and for this reason larger randomised controlled trials are warranted for assessing the long-term effects of these treatments.

Acknowledgments

This study was made possible by grants from The Swedish Association of Persons with Neurological Disabilities. Excellent support from Jan Kowalski, statistician, is gratefully acknowledged.

Footnotes

Competing interests None declared.

Ethics approval This study was conducted with the approval of the Regional Ethics Approval Board in Stockholm, Sweden.

Provenance and peer review Not commissioned; externally peer reviewed.

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Acupuncture may ease severe nerve pain associated with cancer treatment

Acupuncture may ease severe nerve pain associated with cancer treatment | Acupuncture for pain | Scoop.it
Acupuncture may help ease the severe nerve pain associated with certain cancer drugs, suggests a small preliminary study published in Acupuncture in Medicine.

 

Acupuncture may help ease the severe nerve pain associated with certain cancer drugs, suggests a small preliminary study published in Acupuncture in Medicine.

Cancer patients treated with taxanes, vinca alkaloids, or platinum compounds can develop a condition known as chemotherapy inducedperipheral neuropathy, or CIPN for short, as a by-product of their treatment. These powerful drugs can damage peripheral nerves, particularly in the calves and feet, which can result in severe nerve pain and/or difficulty walking. As yet, there is no effective antidote.

Out of a total of 192 patients with peripheral neuropathy eligible for inclusion in the study, 11 had developed their symptoms during a course of chemotherapy for various types of cancer. Six of these patients agreed to undergo acupuncture; the other five served as a comparison group.

Twenty needles were inserted at prescribed points and depths and left in place for 20 minutes during each of the 10 sessions. These were delivered over a period of three months by a senior doctor, who had been fully trained in acupuncture and had used the technique for 20 years.

Nerve conduction studies, to assess the signalling speed and intensity of two nerves in the same calf were carried out before acupuncture and again six months after chemotherapy in the six volunteers. The same studies on patients in the comparison group were carried out after they had completed their chemotherapy and then again six months later.

At the second neurological assessment, patients in both groups were asked to state whether they thought their condition had changed or stayed the same.

Clinical examination showed that all the patients had a mixture of numbness on touch and nerve pain, while nerve conduction studies showed evidence of damage to the sural nerve.

In those given acupuncture, both the speed and the intensity of the nerve signalling improved in five out of the six patients. And these same patients said their condition had improved. Among those in the comparison group, speed remained the same in three, fell in one, and improved in one. Intensity remained the same in one, improved in two, and decreased in two.

The authors point to previous research, which suggests that acupuncture may boost blood flow in the legs, which may in turn aid the repair of nerve damage.

"The data suggest that acupuncture has a positive effect on CIPN, as measured by objective parameters [nerve conduction studies]," write the authors, adding that their results are similar to those found in patients with nerve damage caused by diabetes and those with peripheral neuropathy of unknown cause.

They conclude that the results of this pilot study are "encouraging," and merit further investigation in a larger trial.

Provided by British Medical Journal 

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#Acupuncture for pain and inflammation:... - Shaftesbury Clinic | Facebook

#Acupuncture for pain and inflammation: now you can see the improvement as well as feel it.

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TCVM helps dog with painful back | Home & Garden | The Sun Herald

TCVM helps dog with painful back | Home & Garden | The Sun Herald | Acupuncture for pain | Scoop.it

14 August 2014 -

 

Chyna is an 11-year-old Rottweiler that was referred for arthritis in the spine and hip dysplasia. Chyna would have very painful episodes where she would drag her rear end. The radiographs showed a joint problem in the left shoulder and severe arthritic changes in both hips.

On Traditional Chinese Veterinary Medicine evaluation, Chyna had rear-end weakness and a sore on her left front leg. Her tongue was red, purple and dry. The pulses were fast, weak and deep on both sides and weaker on the left. The tongue and pulses indicated Yin deficiency. The weakness in the rear end indicated Kidney Qi deficiency. The purple in the tongue indicated pain and Qi stagnation. The muscle spasm indicated Qi stagnation.

The diagnosis was Bony Bi Syndrome with Kidney Yin/ Qi deficiency with Qi stagnation in the back, hips and left shoulder. The TCVM treatment principle was to clear stagnation and tonify Kidney Qi and Yin. Her constitution was an Earth.

Chyna was treated once a week for five treatments, then every two to four weeks for maintenance. The treatments consisted of dry needle acupuncture, electroacupunture, laser and aqua acupuncture.

Chyna was also prescribed some Chinese herbal formulas for pain and rear end weakness. On cold days, she is treated with moxibustion by the owner.

On her last visit, seven months after starting, Chyna looked great. She was moving very well and did not exhibit any muscle spasms or rear end weakness. She was full of energy and ran into the office.

Bi Syndrome is caused by invasion of pathogenic Wind, Cold and Damp, which block the flow of Qi and Blood, causing stagnation. The Qi/Blood stagnation lead to pain and decreased mobility. Chronic Bi syndrome leads to damage of Kidney Yang, and bone degeneration occurs, since bone is controlled by Kidney.

Bi syndrome can be categorized into wandering, painful, fixed, febrile and bony Bi.

If cold exacerbates the pain, then it would be called Painful Bi and the treatment would be to warm the Channels. If Dampness exacerbates the problem, then it is called Damp Bi or Fixed Bi.

Bony Bi consists of Yang and Yin deficiency with Qi Deficiency.

All these are chronic problems, and the treatment is different.

Therapy includes acupuncture, food therapy, Chinese herbs, exercise and Tui-Na.

In conventional terms, this would be arthritis, degenerative joint disease and intervertebral disc disease.

Chyna has responded well to the TCVM treatment, and her quality of life has improved. Since Bony Bi is chronic, a cure is not expected, but through TCVM, the pain can be minimized.

Research has shown TCVM can result in fewer medications with adverse side effects, fewer invasive neurosurgical procedures, faster recovery and an increased quality of life.

Dr. Connie Clemons-Chevis, has received certification in acupuncture, Tui-na and Chinese herbology through Chi Institute in Reddick, Fla., and China National Society of TCVM. Alternative Medicine for Pets offers TCVM services in Gulfport and Bay St. Louis.


Read more here: http://www.sunherald.com/2014/08/14/5746092/tcvm-helps-dog-with-painful-back.html#storylink=cpy

 


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Acupuncture Provides True Pain Relief in Study

Acupuncture Provides True Pain Relief in Study | Acupuncture for pain | Scoop.it
Acupuncture outperformed sham treatments and standard care when used by people suffering from osteoarthritis, migraines and chronic back, neck and shoulder pain.
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Fibromyalgia Treatment - Acupuncture as Fibromyalgia Treatment - Acupuncture as Chronic Fatigue Syndrome Treatment

Fibromyalgia Treatment - Acupuncture as Fibromyalgia Treatment - Acupuncture as Chronic Fatigue Syndrome Treatment | Acupuncture for pain | Scoop.it
Learn about acupuncture treatments for fibromyalgia and chronic fatigue syndrome, how Chinese acupuncture works, how to find a qualified acupuncturist in your area, and what to expect during acupuncture treatments for fibromyalgia.

 

"

According to experts, both Eastern and Western, the potential benefits of acupuncture include:

Less painBetter sleepRelaxationPossible immune system boostBetter overall health

Research released in 2008 showed that after 20 acupuncture treatments, people with FMS had significant improvements in pain and quality of life that lasted for 3 months after treatment was stopped, with a gradual decline in those areas until all benefit was gone after 2 years.

Acupuncture can be much safer than other therapies, especially if you're combining several different treatments. Benefits as a complementary therapy include:

No negative interactions with other treatments, including drugsExtremely mild side effectsLow risk"

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Review suggests acupuncture an effective complementary treatment for gout | Arthritis Research UK

Review suggests acupuncture an effective complementary treatment for gout | Arthritis Research UK | Acupuncture for pain | Scoop.it
Review suggests acupuncture an effective complementary treatment for gout Published on 26 February 2013

Research published in the journal Rheumatology suggests that acupuncture is an effective complementary treatment for patients suffering from gout.

The painful condition is characterised by a build-up of uric acid crystals in the joints and tissues that can lead to inflammation, intense pain and flaky skin over affected areas. Often, it affects the joint of the big toe.

Colleagues at Kyung Hee University in South Korean capital of Seoul analysed the results of ten different randomised controlled trials involving 852 gout patients to come to the conclusion.

In total, records from five different electronic databases were searched including lists of English and Chinese trials. All those involving acupuncture in combination with conventional gout therapy were included in the systematic review.

The team found that six studies containing 512 patients made a strong argument for reduction in uric acid levels in gout patients who had received complementary acupuncture treatment as compared to the control group. A further two studies containing 120 patient records indicated no significant difference.

Four studies comprising 380 patients also suggested a significant decline in the visual signs of the painful arthritic condition among members of the treatment group.

Overall, the team – led by Won Bok Lee of the university's Department of East-West Medicine, concluded that acupuncture is effective when combined with traditional gout treatments.

"The results of the studies included here suggest that acupuncture is efficacious as complementary therapy for gouty arthritis patients," they wrote.

"More research and well-designed, rigorous and large clinical trials are necessary to address these issues."

Arthritis Research UK's new complementary therapies report showed that acupuncture is effective in relieving the pain of low back pain, osteoarthritis andfibromyalgia. The charity is currently running a trial to examine the effectiveness of a nurse-led package of care for gout patients in a general practice setting.

 

- See more at: http://www.arthritisresearchuk.org/news/general-news/2013/february/review-suggests-acupuncture-an-effective-complementary-treatment-for-gout.aspx#sthash.hfc012uD.dpuf

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Possible Role of Acupuncture in the Treatment of Post-Zoster Limb Pain and Paresis, Journal of Neuropathic Pain & Symptom Palliation, Informa Healthcare

Possible Role of Acupuncture in the Treatment of Post-Zoster Limb Pain and Paresis, Journal of Neuropathic Pain & Symptom Palliation, Informa Healthcare | Acupuncture for pain | Scoop.it

Journal of Neuropathic Pain & Symptom Palliation 

Original Article

Possible Role of Acupuncture in the Treatment of Post-Zoster Limb Pain and Paresis
Case Report and Literature Review

 

2005, Vol. 1, No. 3 , Pages 45-49 (doi:10.3109/J426v01n03_05)

David Dongjie LiuMedical Director†, Gwen V. ChildsProfessor and Chair† andMukaila A. RajiAssistant Professor and Director†Division of Geriatrics and Memory Center, St. Vincent Infirmary Medical Center, One St. Vincent Circle, Suite 210, Little Rock, AR, 72205, USADepartment of Neurobiology and Developmental Sciences, College of Medicine, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR, 72205, USAMemory Loss Clinics, Sealy Center on Aging, Department of Internal Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0460, USA†Correspondence: David Dongjie Liu, Division of Geriatrics and Memory Center, St. Vincent Infirmary Medical Center, One St. Vincent Circle, Suite 210, Little Rock, AR, 72205, USAdliu@stvincenthealth.com†Correspondence: Gwen V. Childs, childsgwenv@uams.edu†Correspondence: Mukaila A. Raji, muraji@utmb.edu

 


Abstract

Background: Associations of inflammation with occurrence of pain and paralysis in shingles have been well documented. Thus, the anti-inflammatory effect of acupuncture might improve or hasten pain relief and motor recovery in patients with shingles-associated pain and paralysis.

Objective: To describe the possible role of acupuncture in motor deficit recovery and pain relief in a male patient with post-zoster neuralgia and limb paralysis.

Case Summary: The patient developed burning pain over his right shoulder followed by red painful vesicles over the right arm and right shoulder weakness. Despite hydrocodone, rofecoxib and gabapentin, these symptoms persisted. His physical examination and laboratory tests were normal except for the deltoid muscle strength of 1/5, and the C4 dermatome rashes. He received a 10-day course of intravenous acyclovir and prednisone, massage therapy, physical and occupational therapy. The rashes resolved. The pain-10/10 in severity-and paralysis persisted, even one month post-hospital discharge. In line with the Traditional Chinese Medicine method, 3–4acupuncture treatments per week were administered to the patient for 3 months. By the end of the 1st month of treatment, the patient muscle strength was 4/5 and his pain was 3/10. By the 3rd month, his muscle strength was 5/5 and his pain was down to 1/10. At the 18-month follow-up, he had normal muscle strength and was off all analgesic drugs.

Conclusion: The usefulness of acupuncture in the treatment of shingle-related neuropathic pain and motor paralysis merits further study in a large, controlled clinical trial.

KeywordsAcupuncture, shingles, post-zoster paresis, neuropathic pain, and post herpetic neuralgia


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Just What Is Acupuncture All About? What Should I Expect?

Just What Is Acupuncture All About? What Should I Expect? | Acupuncture for pain | Scoop.it

You may be depressed if you are not enjoying optimum health. How can you able to get help when your family doctor isn’t able to help? What can you do if the solutions presented are worse than the condition with which you present?

Do not expect results from acupuncture. Some see drastic changes after a single appointment, while others require multiple treatments to experience relief. Don’t worry if after that first appointment doesn’t result in much of anything. Exercise patience and let things take effect.

You don’t need to fear acupuncture because the needles used are not painful. This means that pain worry for you.

Make a list of prescription medications with you when you go for an acupuncture treatment. This will allow them a better idea of how to personalize your treatment.

Have the patience and try to stick with your acupuncture plan. Your loved ones may try to convince you from the possible benefits. The popularity of pharmaceuticals downplays ancient techniques valid. Stay with it to remain brave and committed to your body’s healing powers.

Never give up on your acupuncture treatment in the middle of a program. Just as with prescription drugs, you can’t stop half-way. You might not see the expected results at the end, even if you’re feeling pretty good before it’s over.

Acupuncture is different for everyone, but you aren’t going to know that until you have some done.Everyone differs in their approach and opinion, so don’t think that what worked for someone else will work for you. Talk with your acupuncturist if you’re in more pain than you feel there’s more pain than there should be.

Take time out of your busy schedule to rest and relax before and after each session. Try sleeping 8 hours of sleep the night after your session.

If your health insurance plan doesn’t cover acupuncture, start a bit of lobbying. If some of your coworkers are also interested in acupuncture, have them write the HR department of your company. It may be that the company will prompt them to add coverage.

Ask about the likely duration of your first visit before scheduling the appointment. You need to remain relaxed following your appointment. See how long it’ll take so you can schedule accordingly.

Give seasonal treatments of acupuncture treatment a try. For example, fall is usually cold, a treatment focusing on the lungs and respiratory wellness is in order. Fall treatment would focus on the lungs. Ask what your acupuncturist can recommend anything or add such treatments to your session.

If you have trouble moving around, you should ask the acupuncturist of your choice to do a house call. A lot of acupuncturists will travel to a client’s home for clients with mobility concerns. You may get charged extra since they have to drive there, but it might be worth it to you.

Make sure to eat healthy meals after your treatment session. Acupuncture brings out toxins from your body and a healthy diet will aid with that. If you indulge in unhealthy foods following your visit, you have accomplished nothing.

Speak to others who have visited an acupuncturist. Find out about their experiences and what they were feeling afterwards. Ask them about how it has affected their well-being. Keep your mind open and ask all the questions you may have.

By using natural remedies for treating pain, we need not worry about harmful side effects. By combining acupuncture with physical exercise and a healthy diet, you can renew your body and spirit. Use the information from this article to help you get the most out of your acupuncture sessions.

 
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Electroacupuncture at Acupoints Reverses Plasma Glutamate, Lipid, and LDL/VLDL in an Acute Migraine Rat Model: A (1) H NMR-Based Metabolomic Study. [Evid Based Complement Alternat Med. 2014] - PubM...

Electroacupuncture at Acupoints Reverses Plasma Glutamate, Lipid, and LDL/VLDL in an Acute Migraine Rat Model: A (1) H NMR-Based Metabolomic Study. [Evid Based Complement Alternat Med. 2014] - PubM... | Acupuncture for pain | Scoop.it

Evid Based Complement Alternat Med. 2014;2014:659268. doi: 10.1155/2014/659268. Epub 2014 Jan 28.

 

Electroacupuncture at Acupoints Reverses Plasma Glutamate, Lipid, and LDL/VLDL in an Acute Migraine Rat Model: A (1) H NMR-Based Metabolomic Study.

 

Gao Z1, Liu X2, Yu S2, Zhang Q3, Chen Q4, Wu Q2, Liu J3, Sun B3, Fang L4, Lin J5, Zhu BM6, Yan X3, Liang F2.Author information 

 

Abstract

 

 

Background. The objective of this study was to identify potential biomarkers of electroacupuncture (EA) on relieving acute migraine through metabolomic study. Methods. EA treatments were performed on both acupoints and nonacupoints on the nitroglycerin (NTG)-induced migraine rat model. NMR experiments and multivariate analysis were used for metabolomic analysis. Results. The number of head-scratching, the main ethology index of migraine rat model, was significantly increased (P < 0.01) after NTG injection.

 

The plasma metabolic profile of model group was distinct from that of the control group. Glutamate was significantly increased (P < 0.01), whereas lipids were significantly decreased (P < 0.01) in model rats. After EA at acupoints, the metabolic profile of model rats was normalized, with decreased glutamate (P < 0.05) and increased lipids (P < 0.01). In contrast, EA at nonacupoints did not restore the metabolic profile, but with six metabolites significantly different from acupoints group. Interestingly, the number of head-scratching and glutamate level were significantly decreased (P < 0.05) after receiving EA at both acupoints and nonacupoints.

 

Conclusions. EA at acupoints may relieve acute migraine by restoring the plasma metabolic profile and plasma glutamate, while EA at nonacupoints may modestly relieve acute migraine by decreasing plasma glutamate.

 

PMID: 24592282 [PubMed] Free full text

 

PubMed comprises more than 23 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher web sites.


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Chinese Medicine Offers Relief For The “Pain In Your Neck”

Chinese Medicine Offers Relief For The “Pain In Your Neck” | Acupuncture for pain | Scoop.it
#Acupuncture can be very beneficial for neck pain
Bedford Acupuncture's insight:
"At the best of times, #necks are particularly vulnerable to injury and, to make things worse, many people sit at computers all day, have bad posture, or regularly place their bodies in awkward positions, such as leaning over a laptop or hauling heavy bags.  #Acupuncture is a great way to relieve #neck #pain quickly."
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Effects of Wonli Acupuncture Procedure in Patients with LSS: A Clinical, Retrospective Study

Effects of Wonli Acupuncture Procedure in Patients with LSS: A Clinical, Retrospective Study | Acupuncture for pain | Scoop.it
Evidence-Based Complementary and Alternative Medicine (eCAM) is an international, peer-reviewed journal that seeks to understand the sources and to encourage rigorous research in this new, yet ancient world of complementary and alternative medicine.

 

Abstract

Background. Lumbar spinal stenosis (LSS) is a disease with increasing prevalence due to prolongation of average life span. Despite various treatment methods, many limitations remain unsolved. Objective. We are reporting cases of patients who have been treated with Wonli Acupuncture, a method of treating LSS by directly approaching the intervertebral foramen and interlaminar space with acupuncture needles different from those used in original acupuncture. Methods. A total of 82 patients with LSS were treated with Wonli Acupuncture, and out of those, 47 patients without exclusion criteria were selected for the following research. We compared the pretreatment VAS and ODI scores based on 1-year follow-up measurements. Results. The ODI value dropped by  on average (from  at the baseline to  at the reading)  and the average VAS also dropped by  (from  at baseline to  at the reading) .Conclusions. Wonli Acupuncture was found to have clinical efficacy for lumbar spinal stenosis.

1. Introduction

Spinal stenosis is defined as the narrowing of spinal canal due to the surrounding bone and soft tissues which results in physical pressure on the nerve root [1]. This is a disease common for the aged, generating lumbago and peripheral neuralgia as well as dysbasia and severe disability [2, 3]. As a result, the lumbar spinal stenosis is the main reason for spine surgery for people older than 65 [4–6]. However, the effect of surgical therapy is limited only to spine decompression, nerve root decompression, and lumbar body fusion of regressive lumbar spondylosis [7]. In addition, the nonoperative therapies such as pharmacological therapy, physical therapy, and manipulation have also little therapeutic effect and have weak clinical basis of use [8].

The lumbar epidural steroid injection is frequently used for patients with lumbar spinal stenosis [9–11]. But this therapy often fails to improve melosalgia and claudication [12, 13]. This is because spinal stenosis is generated by the complicated pathological process of fibrosis around the space-occupying lesions or nerves, causing interference of blood flow, ischemia, venostasis, venal fibrosis, and, in turn, nutrition deficiency [14–17].

To address these limitations, without using existing therapeutic modalities, a method of using physical tools was developed to remove attached tissues, to reduce pressure on the nerve, and to improve surrounding blood circulation. This is acupotomy. Developed by Zhou Han Zhang of China, acupotomy is advantageous for incision and sublation of attached tissues with its thick needle body and its end resembling a sharp knife [18]. Acupotomy has been used for spinal stenosis therapy and clinical studies have been published [19, 20].

 

 

 

However, acupotomy can damage tissues in the spinal canal such as nerve and blood vessels due to its sharp end. Therefore, we used a rounded tip with more curvature than original tools of acupotomy. We named this Wonli Acupuncture from one of the nine ancient classical needles. To date, there have been no studies revealing the therapeutic effect of Wonli Acupuncture needle on spinal stenosis. Accordingly, this case study research was designed to reveal the effect of the Wonli Acupuncture procedure on direct exfoliation of synechia around nerves.

2. Methods and Material
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Acupuncture may ease pain by triggering release of natural painkiller

Acupuncture may ease pain by triggering release of natural painkiller | Acupuncture for pain | Scoop.it
Study in mice suggests acupuncture stimulates cells to release one of the body's own painkillers

 

Sunday 30 May 2010 18.00 BSTAcupuncture could be damping down pain through a natural painkiller called adenosine. Photograph: Jon Feingersh/Getty Images

Scientists have performed acupuncture on mice with sore paws to pinpoint how the ancient Chinese medical practice might alleviate pain in humans.

After a half-hour session, the mice felt less discomfort in their paws because the needles triggered the release of a natural painkiller, say the researchers. The needles stimulated cells to produce adenosine, an anti-inflammatory and painkilling chemical, that was effective for up to an hour after the therapy was over.

The discovery challenges a widely held view among scientists that any benefit patients feel after having acupuncture is purely due to theplacebo effect.

"The view that acupuncture does not have much benefit beyond the placebo effect has really hampered research into the technique," saidMaiken Nedergaard, a neuroscientist at the University of Rochester Medical Centre in New York, who led the study.

"Some people think any work in this area is junk research, but I think that's wrong. I was really surprised at the arrogance of some of my colleagues. We can benefit from what has been learned over many thousands of years," Nedergaard told the Guardian.

Acupuncture was developed in China around 4,000 years ago. The procedure involves inserting fine needles at specific points around the body and then heating, twisting or even electrifying them.

Traditional practitioners claim acupuncture works by improving the flow of "qi energy" along "meridians", but the latest research, published in Nature Neuroscience, points to a less mystical explanation.

"I believe we've found the main mechanism by which acupuncture relieves pain. Adenosine is a very potent anti-inflammatory compound and most chronic pain is caused by inflammation," Nedergaard said.

The scientists gave each mouse a sore paw by injecting it with an inflammatory chemical. Half of the mice lacked a gene that is needed to make adenosine receptors, which are dotted along major nerves.

The therapy session involved inserting a fine needle into an acupuncture point in the knee above the sore foot. In keeping with traditional practice, the needles were rotated periodically throughout the half-hour session.

To measure how effective the acupuncture was, the researchers recorded how quickly each mouse pulled its sore paw away from a small bristly brush. The more pain the mice were in, the faster they pulled away.

Writing in the journal, Nedergaard's team describe how acupuncture reduced pain by two thirds in normal mice, but had no effect on the discomfort of mice that lacked the adenosine receptor gene. Without adenosine receptors, the chemical will have no effect on the mice when it is released in their bodies.

The acupunture had no effect at all in either group if the needles were not rotated.

Nedergaard said that twisting the needles seems to cause enough damage to make cells release adenosine. The chemical is then picked up by adenosine receptors on nearby nerves, which react by damping down pain. Further tests on the mice revealed that levels of adenosine surged 24-fold in the tissues around the acupuncture needles during and immediately after each session.

One of the long-standing mysteries surrounding acupuncture is why the technique only seems to alleviate pain if needles are inserted at specific points. Nedergaard believes that most of these points are along major nerve tracks, and as such are parts of the body that have plenty of adenosine receptors.

In a final experiment, Nedergaard's team injected mice with a cancer drug that made it harder to remove adenosine from their tissues. The drug, called deoxycoformycin, boosted the effects of acupuncture dramatically, more than tripling how long the pain relief lasted.

"There is an attitude among some researchers that studying alternative medicine is unfashionable," said Nedergaard. "Because it has not been understood completely, many people have remained sceptical."

Although the study explains how acupuncture can alleviate pain, it sheds no light on any of the other health benefits that some practitioners believe it can achieve.

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Acupuncture Biochemical Discovery For Low Back Pain & Discs

Acupuncture Biochemical Discovery For Low Back Pain & Discs | Acupuncture for pain | Scoop.it
Biochemical discoveries show that acupuncture stops lower back pain and benefits the spinal discs.

 

on 08 August 2014.

 

 

Acupuncture reduces lower back pain and disc degeneration. A new study demonstrates that electroacupuncture applied to specific acupuncture points on the back stimulates beneficial biochemical bodily responses that benefit the spine. Researchers successfully measured scientifically repeatable chemical responses to acupuncture that suppress intervertebral disc degeneration. 

The controlled acupuncture continuing education study compared true acupuncture with sham acupuncture to ensure that placebo responses to treatment were eliminated as variables. The laboratory experiment examined the effects of electroacupuncture at Jiaji (EX-B 2) points on the axially compressed lumbar discs of L4 and L5. Acupuncture was applied for a total of 20 minutes, once per day, for a total of 28 days. Electroacupuncture was administered at 2 - 15 Hz at 1 -2 mA bilaterally.

Compression of the lumbar discs induces pain, inflammation and disc degeneration. Two important chemical processes are involved in the body’s response to compression. Pain and degeneration of the spine are created, in part, by an inflammatory cascade of two proteins in the lumbar discs: increased matrix metalloproteinase-13 (MMP-13), decreased tissue inhibitor of metalloproteinase-1 (TIMP-1) proteins. The sham acupuncture group did not influence protein expression. However, the true Jiaji (Huatoujiaji) acupuncture group successfully reduced MMP-13 and upregulated TIMP-1 levels. The changes were clinically significant and the researchers note that increases in TIMP-1 are “remarkably higher” when electroacupuncture is applied. 

Biochemicals
MMP-13 is involved in healthy embryonic development but is also involved in human carcinoma, rheumatoid arthritis and osteoarthritis development. Acupuncture successfully downregulated abnormally high levels of MMP-13 caused by disc compression. TIMP-1 is a natural inhibitor of MMPs including MMP-13. TIMP-1 also promotes cellular proliferation and has anti-apoptotic functions. Acupuncture successfully upregulated TIMP-1 that had been suppressed by disc compression.

Acupuncture
Jiaji acupuncture points are located approximately 0.5 - 1.0 cun lateral to the depressions below the spinous processes of the vertebrae. They run along either side of the spine. According to Traditional Chinese Medicine (TCM) theory, Jiaji points regulate internal organs and benefit the spine. Master Hua Tou

Jiaji points have been used by acupuncturists for the treatment of pain and stiffness of the back for over 1,000 years. The discovery of the Jiaji points are attributed to the Han Dynasty physician Hua Tou (c. 140 - 208). As a result, the points are often called Huatoujiaji acupuncture points. Hua Tou is also credited with developing anesthesia for surgical procedures, advancing herbal medicine, developing TCM theory and for monumental advances in acupuncture and moxibustion. Now, modern research confirms a relationship between positive patient outcomes and biochemical responses induced by acupuncture needling of Jiaji points. Hua Tou is back in the news and his contributions continue to impact modern medicine.

Agreement
In related research, acupuncture is found highly effective for the treatment of chronic low back pain. Researchers at Dongzhimen Hospital conclude that acupuncture effectively decreases patient pain levels and reduces days missed from work due to low back pain in a randomized, controlled investigation. In yet another study of 236 patients that was published in the Journal of Musculoskeletal Pain, researchers conclude that acupuncture is effective for the treatment of low back pain. A total of fourteen acupuncture treatments were administered over four weeks in this randomized, controlled investigation. The researchers note that acupuncture has “beneficial and persistent effectiveness against CLBP (chronic lower back pain).”

The Jiaji study investigates local acupuncture. By contrast, many studies have also measured the effects of distal acupuncture on lower back pain. A single acupuncture point, LI4 (Hegu), was chosen as the focus of a distal acupuncture investigation. A group of 187 patients with chronic lower back pain received eighteen treatments at LI4 over seven weeks in this controlled clinical investigation. The participants had clinically significant reductions in lower back pain.

This article is a short list of acupuncture continuing education investigations demonstrating that acupuncture reduces lower back pain. In many ways, pain reduction put acupuncture on the medical map in the USA. Subjective reports of acupuncture’s ability to reduce pain have contributed to its popularity. Full time acupuncturists are found on the staff of professional baseball, basketball and football teams to assist in pain reduction and to enhance sports performance. Now, modern research supports the subjective reports of pain reduction with objective findings demonstrating acupuncture’s ability to stimulate healing within the body.


References:
Zou, J., G. F. Huang, Q. Zhang, Y. Gao, and B. Y. Wang. "[Effects of electroacupuncture stimulation of" Jiaji"(EX-B 2) on expression of matrix metalloproteinase-13 and tissue inhibitor of metalloproteinase-1 in intervertebral disc tissue in rabbits with lumbar intervertebral disc degeneration]." Zhen ci yan jiu= Acupuncture research/[Zhongguo yi xue ke xue yuan Yi xue qing bao yan jiu suo bian ji] 39, no. 3 (2014): 192-197.

Bahrami-Taghanaki, H., Y. Liu, H. Azizi, A. Khorsand, H. Esmaily, A. Bahrami, and Zhao B. Xiao. "A randomized, controlled trial of acupuncture for chronic low-back pain." Alternative therapies in health and medicine 20, no. 3 (2014): 13.

Mingdong, Yun. Na, Xiong. Mingyang, Guo. Jun, Zhang. Defang, Liu. Yong, Luo. Lingling, Guo. Jiao, Yan. Acupuncture at the Back-Pain-Acupoints for Chronic Low Back Pain of Peacekeepers in Lebanon: A Randomized Controlled Trial. Journal of Musculoskeletal Pain. P 107-115, V 20.

Hegu Acupuncture for Chronic Low-Back Pain: A Randomized Controlled Trial. Mingdong Yun, Yongcong Shao, Yan Zhang, Sheng He, Na Xiong, Jun Zhang, Mingyang Guo, Defang Liu, Yong Luo, Lingling Guo, and Jiao Yan. The Journal of Alternative and Complementary Medicine. February 2012, 18(2): 130-136. doi:10.1089/acm.2010.0779.

- See more at: http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1351-acupuncture-biochemical-discovery-for-low-back-pain-discs#sthash.MajRy2Jm.dpuf

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Namibia: Acupuncture Therapy Becomes Popular

Namibia: Acupuncture Therapy Becomes Popular | Acupuncture for pain | Scoop.it
Between 500 and 600 Namibians a month flock to the acupuncture unit manned by a team of Chinese doctors at the Katutura State Hospital in Windhoek.

 

Between 500 and 600 Namibians a month flock to the acupuncture unit manned by a team of Chinese doctors at the Katutura State Hospital in Windhoek.

  

Acupuncture is a component of the health care system of China that can be traced back to at least 2 500 years.

  

The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body that are essential for health.

  

Disruptions of this flow are believed to be responsible for disease. Acupuncture may, it has been theorized, correct imbalances of flow at identifiable points close to the skin.

  

The Chinese and the Namibian governments have an agreement through the Ministry of Health and Social Services whereby an acupuncture department was opened in 1996 at the Katutura State Hospital sponsored by the People's Republic of China.

  

Namibian patients can be treated free of charge for ailments such as back pains, other chronic pain, stroke, body injuries, gastro diseases, depression, insomnia and high blood pressure, amongst others.

  

The Chinese government funds the unit and it pays for the acupuncture machines and acupuncture medicine.

  

Speaking to New Era on Friday, Dr Jiwei Yu who is the head of Chinese doctors designated to the acupuncture department of the Katutura hospital said the Chinese technique of acupuncture is currently recognised and comparable to Western medicine.

  

He explained that they treat on average between 30 to 40 patients per day and on a monthly basis up to 600.

  

"Our patients vary from children to the youth and the elderly. We use different acupoints to treat different ailments. Acupuncture and massage is an old ancient treatment dating back some 2 000 years. To this day we use it all over China and it has now spread to other parts of the world including Namibia," Dr Yu noted.

  

Further, he said the technique is simple, convenient, effective and not expensive compared to modern medicine.

  

He also revealed acupuncture does not have side-effects like Western medicine.

  

"The patients get well when they come here because modern medicine normally does not help them much. We are very happy with the reception we get from our patients. Local people are friendly towards us," he said.

  

They are however faced with the language barrier because not all patients speak English. But he said the hospital has given them a nurse who sits at the department to assist with interpreting.

  

He called on more people to visit the acupuncture department for treatment.

  

Acupuncture is a family of procedures involving stimulation of anatomical locations on or in the skin by a variety of techniques.

  

The most thoroughly studied mechanism of stimulation of acupuncture points employs penetration of the skin by thin, solid, metallic needles, which are manipulated manually or by electrical stimulation.


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Acupuncture sensation during ultrasound guided acupuncture needling -- Park et al. 29 (4): 257 -- Acupuncture in Medicine

Acupuncture sensation during ultrasound guided acupuncture needling -- Park et al. 29 (4): 257 -- Acupuncture in Medicine | Acupuncture for pain | Scoop.it

Acupunct Med 2011;29:257-265 doi:10.1136/aim.2010.003616

Original papersAcupuncture sensation during ultrasound guided acupuncture needlingJongbae J. Park1, Margeaux Akazawa1, Jaeki Ahn1,2, Selena Beckman-Harned1,Feng-Chang Lin3, Kwangjae Lee1, Jason Fine3, Robert T Davis4, Helene Langevin5

+Author Affiliations

1Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA2Department of Physical Medicine & Rehabilitation, Inje University Sanggye-Paik Hospital, Seoul, Korea3Department of Biostatistics, Gillings School of Global Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA4Stromatec, Burlington, Vermont, USA5Department of Neurology, University of Vermont, Burlington, Vermont, USACorrespondence toDr Jongbae J. Park, Director, Assistant Professor, Asian Medicine and Acupuncture Research, Department of Physical Medicine and Rehabilitation, UNC-Chapel Hill, School of Medicine, 1st Floor, North Wing, UNC Hospitals, Campus Box #7200, Chapel Hill, NC 27599, USA; jongbae_park@med.unc.eduAccepted 13 April 2011Published Online First 4 June 2011Abstract

Background Although acupuncture sensation (also known as de qi) is a cornerstone of traditional acupuncture therapy, most research has accepted the traditional method of defining acupuncture sensation only through subjective patient reports rather than on any quantifiable physiological basis.

Purpose To preliminarily investigate the frequency of key sensations experienced while needling to specific, quantifiable tissue levels (TLs) guided by ultrasound (US) imaging.

Methods Five participants received needling at two acupuncture points and two control points at four TLs. US scans were used to determine when each TL was reached. Each volunteer completed 32 sets of modified Southampton Needle Sensation Questionnaires. Part one of the study tested sensations experienced at each TL and part two compared the effect of oscillation alone versus oscillation + rotation.

Results In all volunteers, the frequency of pricking, sharp sensations was significantly greater in shallower TLs than deeper (p=0.007); the frequency of sensations described as deep, dull and heavy, as spreading, and as electric shocks was significantly greater in deeper TLs than shallower (p=0.002). Sensations experienced did not significantly differ between real and control points within each of three TLs (p>0.05) except TL 4 (p=0.006). The introduction of needle rotation significantly increased deep, dull, heavy sensations, but not pricking and sharp sensations; within each level, the spectrum of sensation experienced during both oscillation + rotation and oscillation alone did not significantly differ between acupuncture and control points.

Conclusion The preliminary study indicates a strong connection between acupuncture sensation and both tissue depth and needle rotation. Furthermore, the new methodology has been proven feasible. A further study with an objective measurement is warranted.

Introduction

When determining how to define acupuncture and quantify the dose of acupuncture needling, acupuncturists focus on acupuncture sensation (often referred to as de qi; we choose to use the term ‘acupuncture sensation’ to avoid any potential misinterpretation). Acupuncture sensation, a core concept in traditional acupuncture theory, is traditionally believed to be the action of gaining control of the flow of vitality in the body (qi) using acupuncture needles. Early classic Chinese medical texts state that an acupuncturist will know when the correct sensation has been reached when he/she feels the needle grasp; thus, the early definition focused on the acupuncturist's perception.1 2 Yet, the term has, over time, come to connote the patient's perspective as reported by several texts in the early 20th century,3 4where patients report sensations of numbness, heaviness and deep soreness following acupuncture needling.5

Despite this, acupuncture sensation has been inadequately investigated by the scientific community. While a limited body of research and conflicting results are certainly factors, a more significant barrier to progress in this field is the continued dependency on the classical notion of acupuncture sensation without adequate critical evaluation of the term's validity or applicability. Since the seminal study by Vincent et al.,6 much of the current research has stagnated on the single research focus of subjective needling sensations; most literature on the subject involves creating subjective sensation scales.6,–,10 This focus limits scientific investigation of the physiological basis for acupuncture sensation and results in a disregard for anatomical structure. There is a pressing need for a scientifically based re-evaluation of acupuncture sensation, a rigorous investigation into its anatomical basis, and the quantification of needling techniques to improve acupuncture research and standardise acupuncture clinical practice.

A few studies have attempted to illuminate a potential physiological basis for needling sensations. A 1985 study found that certain relevant sensations corresponded with the activation of Aδ fibres,11 while more recent studies used fMRI to study the attenuation of signal intensity displayed at multiple levels of the cerebro-cerebellar and limbic systems during acupuncture sensation but not during acute pain,12 the role of individual differences in studying reactions to acupuncture using fMRI,13 and the different patterns of activation and deactivation in the brain elicited during acupuncture sensation and acute pain.14Nevertheless, the body of research on an anatomical basis remains insufficient.

Concerning needling techniques, several recent studies have concluded that deep needling is crucial for acupuncture sensation15 and is a more effective analgesic than superficial needling.16,–,18 On the other hand, Japanese acupuncture, which inserts needles superficially to depths just below the skin, also is said to elicit acupuncture sensation (hibiki).19 Other studies have found no difference in neural responses or therapeutic effect between shallow versus deep needling.20,–,22

While this confusion certainly warrants further investigation, this review also highlights the lack of investigation into needle manipulation. Only a few studies have measured the mechanical parameters of needling techniques. Langevin et al.23 first established that the biomechanical phenomenon of needle grasp in acupuncture is measurable. Follow-up studies found that needle rotation increases pullout force through connective tissue winding, which modifies the biomechanical behaviour of soft tissue.24 25

The lack of an established definition for needling has made it difficult to design a proper control. Although several control methods have been developed for acupuncture,16 26,–,28debate continues since the definition of acupuncture needling and the level of acceptable inertness of control methods have not been unequivocally resolved. Thus, a rigorous investigation into the physiological basis for acupuncture needling sensations will help illuminate the mechanisms of acupuncture needling and lead to the creation of better controls. Our study pairs a sensation questionnaire with ultrasound (US)-guided needling to specific, quantifiable tissue levels (TLs). This article reports the findings of a preliminary study.

Methods

Five healthy volunteers (three men and two women, aged between 28 and 36 years) were recruited in Chapel Hill. Inclusion criteria were being aged between 18 and 55, and having an education level of high school graduation or higher. Exclusion criteria included: a history of diabetes, neuromuscular disease, bleeding disorder or collagen vascular disease; acute or chronic corticosteroid therapy; and extensive scarring or dermatological abnormalities within 5 inches of the areas tested. Volunteers were excluded if they were pregnant, suspected or known; would be taking medications such as narcotics or psychiatric medicines during the study; or had an insurmountable fear of acupuncture. Volunteers taking anti-inflammatory or antihistamine medications were asked to discontinue use 3 days before testing. Testing was not scheduled during menstruation to avoid possible discomfort due to the cessation of anti-inflammatory medication. The Institutional Review Board at the University of North Carolina at Chapel Hill approved this study.

This preliminary study consisted of two steps. Step 1: characterise the spectrum of sensation experienced during US-guided needling of four anatomical TLs (epidermis, dermis, fascia, intramuscular) at acupuncture and non-acupuncture points (figure 1). Step 2: compare the effect of oscillation technique (vertical movement of needle 2.5 mm either side of the point depth, with a total incursion of approximately 5 mm at the frequency of 1 Hz) alone versus oscillation + rotation (approximately 360°) technique (corkscrew-like movement of needle approximately 5 mm deep at the frequency of 1 Hz) at skin penetration (TL 2) and perimuscular fascia penetration (TL 3) (figure 2). Although practitioners also use rotation alone, for this study we selected the two most frequently used simple stimulations. Seefigure 3 for a schematic of the study flow. The study team comprised an US specialist, a study acupuncturist and a study director. Each enrolled volunteer participated in one testing session, including both steps, lasting in total 1–2 h, during which time a total of four points (LI13 and LU4, on the lateral side of the upper arm (figure 4) and their corresponding non-points, 3 cm away from the classical meridians) on the body received acupuncture needling. There were four TLs tested in this study (figure 5): TL 1, needle pressed but not inserted into the skin surface; TL 2, needle inserted to the lower border of dermis; TL 3, needle inserted around 2 mm beyond the first perimuscular fascia; and TL 4, needle inserted around 15 mm beyond the first perimuscular fascia (figure 6).

View larger version: In a new window Download as PowerPoint SlideFigure 1

Study diagram: spectrum of sensation during needling to different tissue levels at acupoints and non-acupoints using randomised sequence and sides.

 View larger version: In a new window Download as PowerPoint SlideFigure 2

Study diagram: comparison of the effect of oscillation alone versus oscillation + rotation at tissue levels 2 and 3 using randomised sides and needling techniques.

 View larger version: In a new window Download as PowerPoint SlideFigure 3

Study flow for Step 1 and 2.

 View larger version: In a new window Download as PowerPoint SlideFigure 4

Location of acupoints for study.

 View larger version: In a new window Download as PowerPoint SlideFigure 5

Ultrasound image of L1-13, displaying anatomy and tissue levels of the study.

 View larger version: In a new window Download as PowerPoint SlideFigure 6

Ultrasound images displaying (A) anatomical tissue layers; (B) needle insertion through subcutaneous tissue; (C) needle insertion to first fascia; (D) needle insertion to intramuscular tissue.

 

Upon consent, we randomised subjects with a coin flip to see which side of the body would be needled first at which order of depth, either from level 1 to 4, or level 4 to 1. For the second experiment (LU4 and corresponding non-point), the randomisation determined which side would be needled first and the depth of TL (TL 2 or TL 3). This randomisation also served to eliminate the possible effect of a building-up of sensation. The order of needle technique was fixed, always oscillation first followed by oscillation + rotation.

Then, the acupoints were identified and marked by the study acupuncturist (JP) based on traditional methods.29 The approximate position was determined in relation to anatomic landmarks (eg, bones, tendons) and proportional measurements (eg, fraction of the distance between wrist and elbow creases). Within the area delineated by these landmarks, the precise position of each acupuncture point was determined by palpation, feeling for a slight depression or yielding of tissues. For each location, the right and left sides of the body were then randomly selected for acupuncture point and control point. On the side selected for the control point, a disk-shaped template 3 cm in radius was centred on the points to be acupunctured. The control point was marked on the perimeter of the disk at a 45° angle from the acupuncture point's meridian and as far as possible from the nearest bone and joint. Each acupuncture point was therefore paired with a corresponding control point on the opposite side of the body. The term ‘acupuncture/control location’ is hereafter used to refer to a corresponding pair of acupuncture and control points. Throughout testing, subjects were neither told nor were able to see or hear any indication of which side was used for each point (acupuncture point and control point) nor which sequential order (TL 1 to TL 4, or the reverse) and which needle manipulation type (oscillation or oscillation + rotation) was performed.

For each new insertion at each point, a new sterile, disposable needle (Seirin, Shimizu, Shizuoka, Japan) 40 mm in length and 0.25 mm in diameter was used.

Ultrasound imaging procedure

A live US image guided the investigator to locate the correct needling depth. For each acupuncture/control location, target needle insertion depth relevant for the target level was determined based on US measurement of the lower border of the dermis and perimuscular fascia. With US imaging, the dermis is a visible gray area underneath the thin, white epidermis layer, and the perimuscular fascia is distinguishable as an echogenic line separating two tissues of different echogenicity and compressibility (subcutaneous tissue vs muscle) (figure 5). US imaging was performed with an LOGIQ e US machine (GE Health Care, Wauwatosa, Wisconsin, USA) equipped with a 6–12 MHz linear array transducer. The transducer was always held perpendicular to the skin. In order to disinfect the needled area during the US, we used Surgilube sterile surgical ointment (Fougera, Melville, NY, USA) while using Aquasonic US transmission gel (Parker Laboratories, Fairfield, NJ, USA) for the initial US scanning. Between test points for each subject, the transducer was disinfected by submerging in isopropyl alcohol for 30 s. Between subjects, all parts of the instrument that came in contact with the subject's skin were disinfected.

The Southampton Needle Sensation Questionnaire

The Southampton Needle Sensation Questionnaire (SNSQ) consists of 17 sensation adjectives organised into two factors: aching sensations and tingling sensations. Patients were asked to record which of the sensations were experienced and the intensity on a scale of 0–3 (0=none; 1=slight; 2=moderate; 3=intense). The questionnaire can be completed in minutes, is user-friendly and has been shown in testing to be capable of measuring acupuncture sensations.30 For our preliminary study, we modified the SNSQ to better suit the American volunteer population of the study. Four sensations, ‘twinge’, ‘uncomfortable’, ‘bruised’ and ‘fading’, were removed from the questionnaire for a remaining total of 13 descriptors on the ground that these terms were confusing for the subjects, based on the recommendation of a college-educated native American English speaker (online appendix 1and figure 3).

Sensation descriptors

The primary study outcome was the four-response (0–3) scale of the 13 descriptors of sensation comprising the majority of items redefined in the SNSQ: pricking, sharp, stinging, throbbing, electric shock, warm, spreading, dull ache, heavy, numb, tingling, deep ache and pressure. In order to simplify the principal analysis, we dichotomised the sensation points of 13 indicators as our primary outcomes, that is, recording all 1, 2 and 3 responses as a ‘yes’ response. We conducted exploratory correlation analyses with the scale values. The spectrum of sensation in each depth/anatomical TL at either an acupuncture or non-acupuncture point was then defined by a sequence of 13 proportions of sensations that were expressed by subjects during the needling procedures. However, extending upon previous work,7 we assumed that each of four different stimulations by epth/anatomical TLs would elicit a constellation of three to four sensation descriptors. We therefore used only those ‘indicating’ sensations for hypothesis testing purposes to avoid a large number of simultaneous tests. More precisely, we used the descriptors ‘pricking’ and ‘sharp’ as the indicating sensations for TLs 1 and 2, and ‘dull’, ‘deep ache’ and ‘heavy’ as sensations for TLs 3 and 4.

Independent factors

There are two sets of independent factors. The first set of factors includes the anatomical layer factor (four levels: epidermis, dermis, perimuscular fascia and intramuscular tissue), and the acupuncture point factor (real and control, locations (arm LI13), sides of body (left and right) and insertion sequence). The second set of factors includes techniques (oscillation alone or with rotation).

Data analysis

Our general strategy of quantifying the association between the independent factors (eg, anatomical TLs, acupuncture points and needling techniques) and research outcomes (eg, intensity of sensation and needling force) includes initial exploratory analyses followed by McNemar's tests for paired outcomes or Fisher's exact tests for independent outcomes to test the hypotheses. Due to the limitation of our sample size, we assume outcomes from different arms or acupuncture points are independent. Outcomes from different TLs in the same acupuncture point were otherwise considered dependent. To simplify the analysis, we aggregated outcomes from TLs 1 and 2 to an indicator for a certain constellation of sensations; likewise for TLs 3 and 4. Since these two outcomes occurred in the same acupuncture point, they were considered as paired data in our analysis. Test results with p values smaller than 0.05 were considered statistically significant. All analyses were conducted using SAS V.9.2.

Results

All five healthy volunteers completed 32 sets of modified SNSQs. In all five healthy volunteers, the frequency of pricking, sharp sensations was significantly greater in TLs 1 and 2 than TLs 3 and 4 (p=0.007) (table 1 and figure 7); the frequency of sensations described as deep, dull and heavy, as spreading, and as electric shocks, was significantly greater in TLs 3 and 4 than TLs 1 and 2 (p=0.002) (table 1 and figure 7). The spectrum of sensation experienced during US-guided needling at acupoint (LI13) and that experienced at its corresponding non-acupuncture point did not significantly differ within each of three TLs (p>0.05) except TL 4 (p=0.006) (table 1 and figure 7 and summarised in table 2 and figure 8).

View larger version: In a new window Download as PowerPoint SlideFigure 7

At acupoint (LI13) and non-acupuncture points, the spectrum of sensation experienced during ultrasound-guided needling of four anatomical tissue levels (TLs) (five subjects × 16 administrations of modified Southampton Needle Sensation Questionnaire). Frequency of pricking, sharp sensations in TLs 1 and 2 > TLs 3 and 4 (p=0.007); the spectrum of sensation at acupoint (LI13) ≈ that at its corresponding non-acupuncture point within TLs 1, 2 and 3 (p>0.05) except TL 4 (p=0.006); the spectrum of sensation experienced during ultrasound-guided needling at acupoint (LI13) and that experienced at its corresponding non-acupuncture point did not significantly differ within each of three TLs (p>0.05) except TL 4 (p=0.006).

 View larger version: In a new window Download as PowerPoint SlideFigure 8

At acupoint (LI13) and non-acupoint combined, the spectrum of sensation experienced during ultrasound guided needling of four anatomical tissue levels (TLs) of five participants. OS, oscillation; OR, oscillation + rotation; p>0.05 when comparing acupuncture point and non-acupuncture point in each combination of TL and needle technique. The introduction of needle rotation significantly increased deep, dull, heavy sensations at TL 3 (p=0.021), but not pricking and sharp sensations (p=1.00); this increase occurred at TL 3 but not at TL 2 (p=1.00 for both indicating sensations).

 View this table: In this window In a new windowTable 1

At acupoint (LI13) and non-acupuncture points, the spectrum of sensation experienced during ultrasound-guided needling of four anatomical tissue levels (TLs) (five subjects × 16 administrations of modified Southampton Needle Sensation Questionnaire)

 View this table: In this window In a new windowTable 2

At acupoint (LI13) and non-acupuncture points (combined), the spectrum of sensation experienced during ultrasound-guided needling of four anatomical tissue levels (TLs) of five participants (five subjects × 16 administration of modified Southampton Needle Sensation Questionnaire)

 

The introduction of needle rotation significantly increased deep, dull, heavy sensations at TL 3 (p=0.021), but not pricking and sharp sensations (p=1.00); this increase occurred at TL 3 but not at TL 2 (p=1.00 for both indicating sensations) (table 3 and figure 9); and within each level, the spectrum of sensation experienced during both oscillation + rotation and oscillation alone did not significantly differ between acupoints and non-acupoints (table 3 and figure 9and summarised in table 4 and figure 10).

View larger version: In a new window Download as PowerPoint SlideFigure 9

At acupoint (LU4) and non-acupuncture point, the spectrum of sensation experienced during ultrasound-guided needling of four anatomical tissue levels (TLs). OS, oscillation; OR, oscillation + rotation; *p>0.05 when comparing acupuncture point and non-acupuncture point in each combination of TL and needle technique. The introduction of needle rotation significantly increased deep, dull, heavy sensations at TL 3 (p=0.021), but not pricking and sharp sensations (p=1.00); this increase occurred at TL 3 but not at TL 2 (p=1.00 for both indicating sensations).

 View larger version: In a new window Download as PowerPoint SlideFigure 10

At acupoint (LU4) and non-acupuncture points (combined), the spectrum of sensation experienced during ultrasound guided needling of four anatomical tissue levels of five participants. Within each level, the spectrum of sensation experienced during both oscillation + rotation and oscillation alone did not significantly differ between acupoints and non-acupoints.

 View this table: In this window In a new windowTable 3

At acupoint (LU4) and non-acupuncture points, of five participants, the spectrum of sensation experienced during ultrasound guided needling of four anatomical tissue levels (TLs) (five subjects × 16 administration of modified Southampton Needle Sensation Questionnaire)

 View this table: In this window In a new windowTable 4

At acupoint (LU4) and non-acupuncture points (combined), the spectrum of sensation experienced during ultrasound guided needling of four anatomical tissue levels (TLs) of five participants (five subjects × 16 administration of modified Southampton Needle Sensation Questionnaire)

 Discussion

The key findings of this preliminary study are as follows: (1) it is feasible to evaluate the sensations experienced by individuals following US-guided acupuncture needling at different TLs; (2) pricking, sharp sensations are more frequently sensed by needling at TLs 1 and 2 than at TLs 3 and 4, while sensations described as deep, dull and heavy, as spreading, and as electric shocks are sensed in reverse frequencies; (3) the spectrum of sensations by different TLs or different stimulations is not different between acupoint LI13 and its corresponding non-point at the same TLs; and (4) needle rotation increases deep, dull, heavy sensations, but not pricking and sharp sensations; and this occurs at TL 3 but not at TL 2.

US guidance, in our opinion, is the only non-invasive technique to offer real-time images of the tissue being stimulated by an acupuncture needle. This study reports that acupuncture guided by US is feasible and that it can establish at least the depth and anatomical TLs of needling.

The different frequencies of instances of experiencing a constellation of sensations caused by needling at TLs 1 and 2, and TLs 3 and 4 can lend support to the ideas that: (1) various subjective sensations involve different and relevant sensory receptors and needling at different TLs stimulates distinctive sensory nerves; and (2) pricking and sharp sensations are dominant in TLs 1 and 2, while those for deep, dull, heavy, spreading and electric shocks are prevalent at TLs 3 and 4. At this time, we must state that the sensations from TLs 3 and 4 overlap somewhat with those from TLs 1 and 2. From this observation, it is plausible that the traditional notion of acupuncture sensations refers to sensations stimulating or at least involving TLs 3 and 4.

Recently, the existence of distinctive acupoints has been challenged; some reported that needling itself is effective regardless of stimulating traditionally known acupoints or non-points.22 31 32 This leads to a further difficulty in using point aspect as a control method of acupuncture. Since the area that one acupuncture needle can stimulate is somewhat limited no matter the diameter of the needle and whether the stimulation takes place on acupoints or non-points, further clarification of where to needle as an experimental point or control point is urgently needed. In this respect, this study indicates that, at least from the viewpoint of the frequency of sensations, using a point 3 cm away from the LI meridian did not produce different sensations from those of LI13. With this notion, the authors emphasise we have not yet studied the difference between the clinical effects of stimulating these two points.

Langevin et al.23,–,25 reported that acupuncture with needle rotation can cause more tissue wrapping than insertion alone. However, questions such as whether or not this affects all TLs and if the TL in which the acupuncture occurs makes any difference have been waiting for answers. This study hints that tissue wrapping and the sensations it induces may be more prevalent in TL 3, which includes the perimuscular fascia.

Based on this study's promising results, we envision that further research through a larger-scale study will rigorously challenge the historical role of acupuncture sensation in acupuncture theory and practice. We seek to shift current research towards creating quantitative measures to gauge successful acupuncture treatments that are grounded not in the traditional definitions of Chinese medicine but in scientific understanding. Such a shift will improve acupuncture clinical practice by providing quantifiable standards by which to judge the success of acupuncture techniques and, in turn, will improve treatment quality. This research will also contribute greatly to a definition of acupuncture treatment for use in clinical trials in terms of criteria for adequate stimulation, for the first time based on scientific validation rather than clinical judgement. A larger-scale replication of this preliminary study will meet these goals by employing an innovative approach as well as improved methods and novel instrumentation measuring motion force and torque.

This study is innovative in its approach to needling depth. As noted above, there is much debate surrounding the relationship between acupuncture sensations and depth of needle penetration. However, previous research has examined needling at only two arbitrarily defined levels: ‘superficial’ and ‘deep’. The definition of these two terms varies among studies, but the majority describe ‘superficial’ as a set depth of 1–2 mm, the depth of insertion commonly used in Japanese traditional practice, and ‘deep’ to be 8–12 mm, the depth commonly used in Chinese traditional practice.14 18 21 By setting depth at predetermined measurements, these studies do not account or adjust for anatomical variation among study participants. To improve upon these methods, we are using a novel approach: Needling sensations are mapped at depths defined by tissue layers, beginning with pressing against the skin (non-penetrating), then penetrating to the lower border of the dermis, the perimuscular fascia and intramuscular tissue. This approach accounts for variability among participants and positions the findings in anatomy.

This study is also the first to use US to guide needling of different tissue layers in combination with the acupuncture sensation scale. This tight connection between anatomy and sensation has not previously been attempted in acupuncture research. Results can be applied to future research on acupuncture sensation and acupuncture needling.

To question and challenge the traditionally defined acupuncture sensation, we studied via US, using the previously validated SNSQ, the needling sensations experienced when different anatomical structures were stimulated. We are confident that this application will move acupuncture research toward creating measures to gauge successful acupuncture treatments that are grounded in a solid scientific understanding of the clinical practice of acupuncture. Such a shift will improve acupuncture's clinical practice by potentially providing more quantifiable standards by which to judge the adequacy of acupuncture applications.

Regrettably, this study only measured the subjective sensations of needling, not any objective data such as force or torque of needling. It would be desirable to measure force and torque of needling at different TLs and with different manipulation skills in future studies.

Conclusion

The preliminary study indicates a strong connection between acupuncture sensation and both tissue depth and needle rotation. Furthermore, the new methodology has been proven feasible. A further study with an objective measurement is warranted.

Summary points

▶ Needle sensation is important but little studied

▶ In this preliminary study, we investigated the sensations induced by needling volunteers

▶ The sensation varied according to tissue level and stimulation, but not location

Acknowledgments

JP was partially supported by the Jaseng Medical Foundation, Korea, and RTD was partially supported by NIH NCCAM grant (# R44AT002021).

AppendixView this table: In this window In a new windowAppendix 1

Modified Southampton Needling Sensation Questionnaire Sheet

 Footnotes

Competing interests None.

Patient consent Obtained.

Ethics approval This study was conducted with the approval of the UNC-Chapel Hill IRB.

Provenance and peer review Not commissioned; externally peer reviewed.


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5 Reasons You Should Try Acupuncture

5 Reasons You Should Try Acupuncture | Acupuncture for pain | Scoop.it

Years ago I watched Kiiko Matsumoto treat a hemiplegic patient who two years prior was knocked on her head by an ocean wave and lost sensation in the left side of her body. As Kiiko buzzed around the patient placing needles and pressing points, the patient reported, teary-eyed, that she could feel both her arms and hands. From that day on, I’ve been a firm believer in acupuncture’s healing potential. Most patients try acupuncture as a last resort when their doctors have declared their discomfort unfixable or psychosomatic, or prescription drugs have caused collateral damage. Some give it a try when their insurance plans cover a certain number of visits. Others have found community acupuncture offers a way to make regular treatments affordable. If you still haven’t tried acupuncture and are curious whether it’s worth your time and money, here are five encouraging reasons to give it a chance: 1. It's personalized healthcare. No two acupuncture patients receive the same treatment for the same disease or discomfort. Acupuncturists treat patients, not diseases. They are trained to take in every detail of you, from the sound of your voice to the quality of your skin to the sparkle in your eyes. They care about your whole story, past and present. They see your body as a network of interdependent parts: muscle, bone, fascia, organs, blood and body fluids, as well as more subtle layers like meridians and qi. They see what is deficient and what is stuck, mentally as well as physically, and make adjustments like a traffic cop, facilitating the body’s own healing ability.  2. It’s nothing to be afraid of. Sure, you may feel the needles and their immediate effects, but you needn’t be anxious. If you're suffering aches and pains on a daily basis, that chronic pain far outweighs any momentary mini pinch of a hair-thin sterile acupuncture needle.  3. It has lovely side effects.
You may go to acupuncture to cure your neck and shoulder pain, and find that the pain diminishes. Meanwhile, yourstress level, sleep quality, digestion, and overall mood improve too. 4. It gets to the root.
Acupuncture treatments are deeply healing because they focus not only on the patient’s current condition, but investigate why their symptoms are manifesting and aim to treat the underlying root cause.  5. It works. Acupuncture has been around since before recorded history. The earliest written record comes from a few hundred years before the common era. If it didn’t work, it certainly wouldn’t have lasted thousands of years and spread through hundreds of Asian medical lineages.   Scientists try to understand how acupuncture works from a biomedical perspective. Some refer to its effects on fascia, the connective tissue that surrounds all our muscles and organs. Some point to acupuncture’s ability to stimulate the limbic system and autonomic nervous system.  Some scientists claim in their studies that acupuncture is sometimes as effective as “sham acupuncture.” While they attempt to fit a versatile and non-linear medicine into a formulaic model with double-blind studies, the clinical experience of everyday practitioners and patients agrees with thousands of years of history — acupuncture works! For an official list by the World Health Organization on what acupuncture treats, click here.


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Acupuncture | Arthritis Research UK

Acupuncture | Arthritis Research UK | Acupuncture for pain | Scoop.it

Acupuncture

What is it?

Acupuncture involves inserting fine needles at particular points in your skin. The therapist may stimulate the needles manually, by heat (with a dried herb called moxa) or by a small electrical current (electro-acupuncture).



The needles are very fine, so having them inserted is rarely painful. Sometimes you may have a sensation of heaviness or tingling at the insertion site, and this is considered a good sign. 

Acupuncture seems to relieve pain by diverting or changing the painful sensations that are sent to your brain from damaged tissues and by stimulating your body’s own pain-relieving hormones (endorphins and encephalins). This pain relief may only last a short time at the beginning, but repeated treatment (usually weekly for six or eight sessions) can bring long-term benefit, often for several months. If the pain returns, then more acupuncture may help for another few months. 

As with all treatments to relieve pain (including physiotherapy, hand therapy and painkilling drugs), breaking the ‘pain cycle’ sometimes gives permanent relief. This depends on the stage of your arthritis, although acupuncture can help at almost any stage of your condition. As with many conventional treatments, it can’t cure or reverse the process of arthritis. 

Read more about pain and arthritis.

If you can’t tolerate conventional drugs then acupuncture may help you get through a painful episode. There’s now clear scientific evidence that it can be beneficial if you have osteoarthritis in your knees and low back pain. For this reason acupuncture treatment is increasingly available on the NHS in physiotherapy departments or through your GP.

Is it safe?

Acupuncture generally has a very good safety record, but there are certain risks. It can transmit diseases if the therapist doesn’t use single-use needles every time, but disposable needles are now standard practice, and there are strict guidelines regarding their disposal. 

Feeling dizzy or faint after a session of acupuncture is common, and it can occasionally cause bleeding and bruising.

- See more at: http://www.arthritisresearchuk.org/arthritis-information/complementary-and-alternative-medicines/complementary-therapies/acupuncture.aspx#sthash.dkGuHq7R.dpuf

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Acupuncture Weekly - headlines on acupuncture and pain

Acupuncture Weekly - headlines on acupuncture and pain | Acupuncture for pain | Scoop.it

Acupuncture Weekly, by Shaftesbury Clinic: Your weekly digest of acupuncture news and views. From Shaftesbury Clinic, Bedford. www.shaftesburyclinic.com

 

Headlines and links on acupuncture and ankylosing spondylitis, rheumatoid arthritis, dental pain, lower back pain and more.

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Acupuncture treatment of chronic low back pain reverses an abnormal brain default mode network in correlation with clinical pain relief -- Li et al. 32 (2): 102 -- Acupuncture in Medicine

Acupuncture treatment of chronic low back pain reverses an abnormal brain default mode network in correlation with clinical pain relief -- Li et al. 32 (2): 102 -- Acupuncture in Medicine | Acupuncture for pain | Scoop.it

Acupunct Med 2014;32:102-108 doi:10.1136/acupmed-2013-010423

Original paperAcupuncture treatment of chronic low back pain reverses an abnormal brain default mode network in correlation with clinical pain reliefJi Li1, Jun-Hai Zhang2, Tao Yi1, Wei-Jun Tang2, Song-Wei Wang3, Jing-Cheng Dong1

+Author Affiliations

1Department of Integrated Traditional and Western Medicine, Huashan Hospital Fudan University, Shanghai, China2Department of Radiology, Huashan Hospital Fudan University, Shanghai, China3Department of Rehabilitation, Huashan Hospital Fudan University, Shanghai, ChinaCorrespondence toDr Wei-Jun Tang, Department of Radiology, Huashan Hospital Fudan University, No 12 Wulumuqi Road Middle, Shanghai 200040, China; tangwj83@gmail.comReceived 11 July 2013Accepted 8 November 2013Published Online First 26 November 2013Abstract

Background Acupuncture is gaining in popularity as a treatment for chronic low back pain (cLBP); however, its therapeutic mechanisms remain controversial, partly because of the absence of an objective way of measuring subjective pain. Resting-state functional MRI (rsfMRI) has demonstrated aberrant default mode network (DMN) connectivity in patients with chronic pain, and also shown that acupuncture increases DMN connectivity in pain-modulator and affective-emotional brain regions of healthy subjects.

Objective This study sought to explore how cLBP influences the DMN and whether, and how, the altered DMN connectivity is reversed after acupuncture for clinical pain.

Methods RsfMRI data from 20 patients with cLBP, before and after 4 weeks of treatment, and 10 age- and gender-matched healthy controls (without treatment) were analysed using independent components analyses to determine connectivity within the DMN, and combined with correlation analyses to compute covariance between changes in DMN connectivity and changes in clinical pain. Visual analogue scale data were assessed to rate clinical pain levels.

Results Less connectivity within the DMN was found in patients with cLBP than in healthy controls, mainly in the dorsolateral prefrontal cortex, medial prefrontal cortex, anterior cingulate gyrus and precuneus. After acupuncture, patients’ connectivities were restored almost to the levels seen in healthy controls. Furthermore, reductions in clinical pain were correlated with increases in DMN connectivity.

Conclusions This result suggests that modulation of the DMN by acupuncture is related to its therapeutic effects on cLBP. Imaging of the DMN provides an objective method for assessment of the effects of acupuncture-induced analgesia.

Introduction

Chronic pain disorders involve pain that persists beyond the healing phase after an injury.1Chronic low back pain (cLBP) is a common chronic pain disorder and defined as pain in the lumbosacral area of the spine. In over 85% cases of cLBP, the cause is ‘non-specific’, and in many cases is associated with other chronic symptoms.2 Only 10–15% of cases are caused by structural spine disorders.3

Acupuncture has become a popular treatment for patients with cLBP because it has been shown to relieve pain effectively.4 ,5 In most studies in this field, the efficacy of acupuncture treatment for cLBP is measured by the patient's self-reported pain. Since chronic pain is a subjective sensation, objective observation of chronic pain is particularly difficult. Elucidation of the mechanism of acupuncture treatment is imperative to establish its theoretical basis.

Recent research using brain-imaging studies of pain has focused on alterations in brain activation, rather than the peripheral dysfunctions, associated with cLBP,1 ,6 and indicated that effective treatment should reverse abnormal brain activity.7

Most previous functional MRI studies of the brain-based mechanisms of chronic pain or acupuncture analgesia have concentrated on changes evoked by stimuli, such as the decreased deactivation that occurs during the execution of a task and the increased connectivity during pain stimuli.8 ,9 These studies have not been performed during the resting state, but during needle stimulation with an acupuncture needle, often in healthy people.10 ,11 Few have focused on post-therapeutic effects on chronic pain.12 Indeed, assessments of changes elicited by external stimuli (pain or acupuncture) do not equate to assessments of chronic pain or post-treatment relief of chronic pain because chronic pain is characterised by ongoing, spontaneous and intrinsic pain and is thus difficult to reliably elicit. The effects of acupuncture stimuli may not be separating the concurrent brain activity related to the sensory stimulation (ie, the needling of acupuncture points) from the brain activity associated with the therapeutic effects that result from the same stimulation.

Imaging studies of resting-state brain regions in healthy people have shown correlated activity that is known as the intrinsic ‘functional connectivity’ network.13 One important network related to pain and cognition is the ‘default mode network’ (DMN), which is more active during rest than during exposure to external stimuli.14 The connectivity maintains functional coupling of brain regions within the DMN, which is measured by the spatial correlation in activity between anatomically disparate brain regions (eg, the medial frontal gyri, posterior cingulate cortex and precuneus, inferior parietal lobule and lateral temporal cortex, etc) at rest.14 The time scales for intrinsic connectivities in the low-frequency range are of the same order as the connectivities seen during spontaneous pain fluctuations,15which provides additional support for the possibility of a connection between DMN connectivity and chronic pain or its modulation. More recent resting-state functional MRI (rsfMRI) data have also shown that the connectivity within the DMN is altered in some forms of chronic pain, including fibromyalgia,16 migraine,17 ,18 diabetic neuropathic pain19 and chronic back pain.20 Therefore, we propose that altered connectivity within the DMN is also associated with spontaneous chronic pain experienced by patients with cLBP. Furthermore, we propose that these alternations should be reversed by acupuncture treatment for cLBP that is associated with clinical pain relief.

RsfMRI is a relatively recently developed method that can be used to visualise the correlation between chronic pain and intrinsic connectivity of the DMN and how this connectivity is related to the ongoing pain that occurs in the resting basal state and the relief of that pain after intervention. Therefore, this method can be adopted to investigate how DMN connectivity correlates with the sustained effect of acupuncture beyond the time at which needles are taken out—that is, it can be used specifically to investigate the therapeutic effects of acupuncture.

This study focused on the spatial properties of resting-state functional connectivity in the DMN as reflected by DMN spatial component maps. First, we examined whether there were differences in DMN connectivity between healthy individuals and patients with cLBP. Second, we explored how DMN responses during rest were altered by long-term acupuncture treatment and whether the potential changes in DMN were correlated with changes in pain intensity in patients with cLBP.

Materials and methodsRecruitment

Ten healthy individuals (five female and five male, aged 37.7±5.1 years (mean±SD)) and 20 patients (10 female and 10 male, aged 38.1±6.4 years) with lower back pain recruited via invitation letters and telephone calls were enrolled in this study (table 1). All participants were staff of the traditional Chinese medicine (TCM) department and rehabilitation division of Huashan Hospital of Fudan University. Each participant provided written informed consent, and the ethics review board of Huashan Hospital of Fudan University approved all study protocols (ethical review No 2009-180).

View this table: In this window In a new windowTable 1

Summary of cases in control and patient groups

 Inclusion criteria

All participants were right-handed, with no history of significant medical or psychiatric disorders, and provided written informed consent. Patients had to have had continuous lower back pain and/or pain in a lower extremity for at least 3 months21 and to rate the intensity of their pain as ≥5 on a 0–10 VAS.

Exclusion criteria

Exclusion criteria were (1) previous acupuncture treatment for any condition, (2) previous serious spinal disorders such as tumours, infections, fractures or spinal stenosis, (3) complicated low back problem such as sciatica or prior back surgery, (4) administration of sedative or analgesic drugs within 24 h before the fMRI scan or the use of any additional pain treatments during the entire study period, including histories of taking opioid analgesics or narcotics, (5) conditions that made treatment difficult such as paralysis or seizure disorders, (6) conditions that might confound treatment effects or the interpretation of results, including severe fibromyalgia, rheumatoid arthritis and (7) contraindications for acupuncture or MRI, including clotting and bleeding disorders, or severe psychiatric conditions and claustrophobia.

Withdrawal criteria

Subjects were allowed to leave the study unconditionally without reason and instructed to withdraw if they met any of the exclusion criteria at any point during the study.

Study design

We used a standardised acupuncture prescription that is considered to be effective by experts in cLBP.22 Eight acupuncture points in the lumbar region and lower leg were chosen: BL23 (bilateral), lower back ah shi point, GV3, BL40 (bilateral) and KI3 (bilateral). Patients received 30 min acupuncture treatments three times a week for 4 weeks (12 treatments in total).

Subjects were asked to lie in the MRI scanner, to keep their minds blank and eyes closed and to avoid falling asleep.14 The patients with cLBP were scanned twice to acquire 6.87 min of rsfMRI data for each scan, before and after the 12 acupuncture treatment treatments. The healthy group was also scanned twice, with the same interval between scans as for the cLBP group, but no acupuncture treatment was performed on this group.

InterventionPractitioner backgrounds

Acupuncture treatment was administered by a clinical acupuncturist who has been in the TCM department of Huashan Hospital for 18 years. Assessment of pain was conducted by a doctor with 10 years of experience in the department of rehabilitation.

The needles

Sterile, disposable, 0.25 × 40 mm or 0.35 × 50 mm (diameter × length) stainless steel needles (Suzhou Medical Appliance Factory, Suzhou, People's Republic of China) were used once. Needles were generally inserted to a depth of 5–30 mm depending on the acupuncture point, and insertion was followed by manual stimulation to elicit the de qi sensation; this stimulation consisted of twirling the needle every 15 min and just before removal of the needle at the end of the 30 min acupuncture treatment.

Clinical pain assessment

Before each scan, patients recorded pain intensity on a VAS.

fMRI

MRI data were acquired using a 3 T GE Signa VH/i MRI scanner equipped with an eight-channel head coil. T1-weighted anatomical imaging was performed using a fast spoil gradient recall sequence (TR/TE=9.27/3.78 ms, flip angle=20°, FOV=240 × 240 mm; slice thickness=1.5 mm). Blood oxygenation level-dependent functional imaging was performed using a gradient echo T2*-weighted pulse sequence (TR/TE=2000/30 ms, flip angle=90°, FOV=240 × 240 mm, 26 axial slices, slice thickness=5.0 mm with no interslice gap, matrix=64 × 64, 200 time points for a total of 6.87 min). Digital Imaging and Communications in Medicine (DICOM) image data were collected after scanning.

Image preprocessing

Data preprocession was performed using SPM8 (statistical parametric mapping,http://www.fil.ion.ucl.ac.uk/spm/). Functional data were corrected for motion to compensate for any head movements using a linear (affine) transformation procedure (SPM-realign). Structural data were coregistered with the mean functional data (SPM-coregister) and normalised to the Montreal Neurological Institute (MNI) space using a standard MNI template (SPM-normalise). Functional data were also normalised and smoothed using a Gaussian kernel of 6 mm full width at half maximum (FWHM; SPM-smooth).

Imaging postprocessing

Independent component analysis (ICA), which can isolate the connectivities within the DMN properties from the rsfMRI data on the time-series scan, was performed on all preprocessed resting fMRI data using GIFT (Group ICA Toolbox, http://mialab.mrn.org/software/gift/) software. Independent component (IC) maps in the form of a z statistic were created, and the temporal coherence of activated/deactivated areas was examined with these maps. For each participant, an IC map of the DMN was extracted from the fMRI using the spatial correlation between the DMN template made by our group and the IC map.

Statistical analysis

One-sample t tests were performed to derive group maps of DMN connectivity, paired-sample t tests were performed to compare the changes in DMN connectivity before and after acupuncture in the patients with cLBP, and independent-sample t tests were performed to compare changes in DMN connectivity in the patients with cLBP before acupuncture with those of the normal controls. A cluster-corrected p<0.05 level was used as the threshold for statistical significance. Spearman rank order correlations between the clinical pain intensities (as measured on the VAS) of the patients with cLBP and the voxel numbers of the DMN property IC maps were obtained from the rsfMRI data (both before and after acupuncture) to investigate the relationship between changes in pain intensity and changes in DMN connectivity.

Results

The data from two sessions of rsfMRI were collected from all 10 healthy controls and 18 patients who completed 12 acupuncture treatment sessions; two patients withdrew because they had taken analgesic medication. The acquired data met the requirements for data processing, and the relevant DMN images were generated.

The main cLBP pain ratings were 5.95 (median 6; range 4–8) before treatment and 1.20 (median 1; range 0–2) after treatment, a significant difference (T=610, p<0.001, rank sum test, figure 1).

View larger version: In a new window Download as PowerPoint SlideFigure 1

VAS scores before and after treatment for the patient group. The box represents the 25–75% range.

 

The best-fitting IC maps for the healthy controls exhibited the expected anatomical scopes of the DMN connectivity at rest within the inferior parietal lobule, posterior cingulate cortex and medial areas of the inferior, middle and superior frontal gyri and the precuneus (figure 2A).

View larger version: In a new window Download as PowerPoint SlideFigure 2

(A) The default mode networks (DMNs) of the healthy volunteers during rest comprised the inferior parietal lobule, posterior cingulate cortex and medial areas of the inferior, middle and superior frontal gyri, and the precuneus. (B) The DMN connectivities in patients with chronic low back pain (cLBP) before treatment were reduced in the dorsolateral prefrontal cortex, medial prefrontal cortex, anterior cingulate gyrus, and precuneus compared with the control group. (C) After treatment the DMNs of the patients with cLBP were almost identical to those of the control group.

 

DMN connectivities in the patients with cLBP versus the healthy groups showed reductions of this network in the dorsolateral prefrontal cortex (DLPFC), medial prefrontal cortex (MPFC), anterior cingulate gyrus (ACC) and precuneus before treatment (figure 2B). After acupuncture treatment, the DMN connectivities in the patient group were almost identical to those of the control group. (figure 2C)

Specifically, the connectivities of the DLPFC, MPFC, ACC and precuneus were increased in the post-acupuncture scan relative to the pre-acupuncture scan in the cLBP group.

The mean number of voxels with DMN properties in the control group was 2047 and in the cLBP group was 1739 and 1998 before and after treatment, respectively; this difference was significant (p<0.01, figure 3).

View larger version: In a new window Download as PowerPoint SlideFigure 3

The mean number of voxels with default mode network (DMN) properties in the patient group before treatment (1739) and after treatment (1998) and in the control group (2047).

 

The correlation between the pre- and post-treatment differences in the mean numbers of voxels with DMN properties and the pre- and post-treatment differences in the spontaneous pain ratings of the patients with cLBP was statistically significant (r=−0.805, p<0.01, figure 4).

View larger version: In a new window Download as PowerPoint SlideFigure 4

Scatter plot showing the relationship between the numbers of voxels with default mode network properties and VAS scores of patients. Spearman correlation=−0.805, p<0.01.

 Discussion

Our main findings showed that patients with cLBP exhibited abnormalities in DMN connectivities during rest in comparison with the healthy controls; these abnormalities encompassed the DLPFC, MPFC, ACC and precuneus and were restored to normal after acupuncture treatment. Furthermore, reductions in clinical pain were positively correlated with increase in DMN connectivity.

Connectivity within the DMN is influenced and disrupted during rest in patients with frequent ongoing pain attacks.17 ,23 The ICA method we used extracted DMN properties (mean voxel numbers) from fMRI data that reflected connectivity within the DMN during rest, and this method showed that disruption of the connectivities of the DMN within the DLPFC, MPFC, ACC and precuneus can result from constant pain. This latter finding contradicts recent findings in patients with diabetic neuropathic pain or fibromyalgia, where the functional connectivities were increased across of variety of networks, including, for instance, the insula.16 ,19 Other studies, like ours, have shown that the ACC and insula are not functionally connected in chronic pain.23

Possibly, the insula was not seen in our study as it is not involved in DMN connectivity, although the insular cortex is commonly activated in brain-imaging studies of acute experimental pain.24 One study of chronic pain showed greater connectivity that extended outside of the classic boundaries of the DMN to the insula, and another study showed that the connectivity between insula and the ACC (which is a component of the DMN) was restricted in patients relative to healthy subjects.16 ,23 One hypothesis to explain these results is that, as the activities of the participating areas of the brain network component decreased, the shifts in the DMN extended out of the DMN to the insula and distorted the properties of the DMN. Additionally, the methods and parameters were different between these two analyses (ie, seed-based connectivity analysis was used in one of the studies), and the analgesic drugs might have influenced the results. Nevertheless, all these results indicate the value of using neuroimaging markers in the DMN to study the effects of acupuncture analgesia on chronic pain.

Studies from the same research team have shown that immediately after one acupuncture stimulation (ie, a few minutes to 30 min), connectivity in the DMN increases in pain-modulating, affective and memory-related regions such as the ACC, periaqueductal grey matter and amygdala in healthy people,10 while after long-term acupuncture plus drug treatment, connectivity between the DMN and insula is reduced in female patients with fibromyalgia.25 It is not known whether the long-term sustained changes found after multiple treatments in these studies are related to the immediate stimulus-related changes we have seen. To clarify this issue, 30 min acupuncture stimuli in every treatment session (in accordance with conventional acupuncture clinical practice) should be used over several weeks, and the DMN should be visualised with rsfMRI imaging technology and ICA method to examine the analgesic effects after acupuncture treatment for cLBP.

Our results show that the sustained effects of multiple treatments increased the resting DMN connectivity in patients with cLBP to levels similar to those elicited (transient sustained effects) by one stimulation in healthy controls. Interestingly, chronic pain involves the memory of pain, which can persist long after the initial pain source has been removed, and the inability to extinguish the memory of the original pain evoked can lead to centrally driven pain.26 We speculate that acupuncture for chronic pain that involves the transient sustained connectivity of every stimulation will transfer the pain from the DMN to affective and memory-related regions over multiple treatment sessions, which may help to erode centrally driven chronic pain memories. Therefore, we are planning to perform a study involving a long-term (4 weeks) course of acupuncture treatment and examine its therapeutic effects in rsfMRI conducted the day after the last acupuncture treatment. The study design, supported by clinical acupuncture practice, typically demands 12 sessions, regularly spaced three times a week.

In our patients with cLBP, the DMN maintained its spatial properties in the connectivity pattern of functional architecture, but was disrupted during ongoing pain attacks that affected various brain regions (the DLPFC, MPFC, ACC and precuneus) putatively involved in pain-modulatory and affective-emotional processing. It seems that chronic pain is associated with impaired cognitive abilities. We speculate that abnormal connectivity in the DMN, which is linked to self-referential cognition, is involved in processing of ongoing pain and also in modulating affective-emotional aspect of pain.27

The patients with cLBP in our study had secondary symptoms of panic and anxiety, as emotional reactions. Neuroimaging has shown the influence of emotional state on pain processing, particularly in the MPFC and ACC.28 The ACC belongs to the affective pain matrix, and its activity is also increased during placebo analgesia.29 This finding suggests that the emotional effects on pain processing during treatment also contribute to analgesia. In our study, the disrupted connectivity within the DMN was involved in pain-affective processing and was reversed after acupuncture treatment.

Our results correlating decreased self-reported pain relief scores with enhanced DMN connectivity provide a neuroimaging pain-network study of the effects of acupuncture on cLBP. Thus, the clinical efficacy of acupuncture was seen and evaluated through DMN connectivity. To determine whether the observed changes in the DMN are a common signature of acupuncture treatment for chronic pain, we will study other forms of chronic pain in the future.

This study raises several points for discussion. Our results showed reduced connectivity within the DMNs of patients with cLBP and might not be generalisable to other chronic pain conditions, such as fibromyalgia and migraine. However, qualitatively similar findings have been reported.23 Although a VAS is a simpler method of testing for clinical pain, especially low back pain, the effects of spontaneous pain on the accuracy of VAS measures during the same time of the scan are unknown.

Conclusion

Connectivity within the DMN was used as an objective neuroimaging marker that allowed us to track pain and its relief due to the therapeutic effects of acupuncture for cLBP. This advanced approach is an example of how an understanding of the mechanisms of cLBP can be facilitated by understanding the brain correlates of the therapeutic effects of acupuncture for chronic pain.

Summary points

Chronic pain is associated with an altered default mode network (DMN) connectivity.

DMN connectivity was measured in patients with chronic back pain before and after a course of acupuncture.

DMN was restored towards normal, in correlation with the degree of pain relief.

Footnotes

Correction notice This article has been corrected since it was published Online First. The order of the author list has been amended.

Contributors W-JT and JL were responsible for the study concept, design, statistical analysis and data interpretation, and wrote the draft of the manuscript. J-HZ and TY contributed to the data collection. S-WW contributed to the evaluation of patients’ pain level. J-CD supervised the study. All authors assisted in revision of the paper.

Funding This project was sponsored by the Foundation of Shanghai Municipal Health Bureau, China, No 2009013.

Competing interests None.

Patient consent Obtained.

Ethics approval The ethics review board of Huashan Hospital of Fudan University.

Provenance and peer review Not commissioned; externally peer reviewed.

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The National Institutes of Health (NIH) Consensus Development Program: Acupuncture and neuro-endocrine function research

The National Institutes of Health (NIH) Consensus Development Program: Acupuncture and neuro-endocrine function research | Acupuncture for pain | Scoop.it

Conclusions

 

Acupuncture as a therapeutic intervention is widely practiced in the United States. There have been many studies of its potential usefulness. However, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebo and sham acupuncture groups.

 

However, promising results have emerged, for example, efficacy of acupuncture in adult post-operative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma for which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program.

 

Further research is likely to uncover additional areas where acupuncture interventions will be useful.

 

Findings from basic research have begun to elucidate the mechanisms of action of acupuncture, including the release of opioids and other peptides in the central nervous system and the periphery and changes in neuroendocrine function. Although much needs to be accomplished, the emergence of plausible mechanisms for the therapeutic effects of acupuncture is encouraging.

 

The introduction of acupuncture into the choice of treatment modalities readily available to the public is in its early stages. Issues of training, licensure, and reimbursement remain to be clarified. There is sufficient evidence, however, of its potential value to conventional medicine to encourage further studies.

 

There is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.


Via Shaftesbury Clinic Bedford, Shaftesbury Clinic
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