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Session 8

Neurological mechanisms 3. Acupuncture – no more than a ‘theatrical’ placebo?

Learning outcomes

By the end of the session you should be able to demonstrate

➢ an understanding of non-specific treatment effects

➢ an understanding of the challenges associated with testing the specific effects of acupuncture

➢an awareness of the debate which threatens to undermine acupuncture’s use in NHS clinical practice

DiscussionIf acupuncture is no more than a theatrical placebo, should we still offer it as a treatment?

BMJ http://www.bmj.com/content/339/7735/Editorials.full.pdf•Editorial •Christmas 2009:

Secret remedies: 100 years on Time to look again at the efficacy of remedies

Author David Colquhoun1.1Department of Pharmacology, University College London, London WC1E 6BT

“Acupuncture: a rather theatrical placebo, with no real therapeutic benefit in most, if not all, cases”

Response

Colquhoun imperils BMJ editorial policyAdrian R White, Clinical research fellow Peninsula Medical School

Colquhoun’s commentary exposes an important dilemma for science publishing: does healthcare benefit more from passionate polemic unrestrained by peer review, or from carefully constructed argument and balanced, well informed writing?

Science begins with definitions. Colquhoun defines acupuncture as: ‘A rather theatrical placebo, with no real therapeutic benefit in most, if not all, cases.’ This definition comprises vague, ambiguous terms and is internally inconsistent… It is not a serious contribution to a debate on health care.

…It reads quite plausibly until you check the references.’ So check the references, and Colquhoun cites – his own blog! That source of balanced debate well known to be based on reasoned argument and critical analysis. When I contributed some data to the blog, in the form of standardised mean difference and confidence intervals from a systematic review of acupuncture, it met the predictable two responses: Doh (as in ‘I haven’t actually read the studies or meta-analyses on acupuncture’) ; and, And Anyway (as in ‘And anyway, acupuncture can’t work because qi and meridians don’t exist’).

Be aware of the on going arguments amongst the scientific community which set out to dispute or

undermine the effectiveness of acupuncture.

One of the principal arguments is that genuine acupuncture is no more effective than placebo

Characteristic and incidental (placebo) effects in complex interventions such as acupuncture. Paterson C, Dieppe P.

BMJ. 2005 May 21;330(7501):1202-5. Review.

“The specific effects on non-pharmaceutical treatments are not always divisible from placebo effects and may be missed in

randomised trials”.

‘Incidental factors are generic and independent of treatment effect’

➢Talking

➢Listening

Focused attention and empathy

➢Acupuncture consultation style

All influence outcome

‘Characteristic and incidental effects are distinct and additive’

With acupuncture the characteristic factors of needling, aspects of the diagnostic process (TCM more so), aspects of talking and listening, constitute the acupuncture treatment – all these aspects are interwoven not additive

Paterson C, Dieppe P. BMJ. 2005 May 21;330(7501):1202-5. Review.

Implications for trials of acupuncture

➢“ A sham ‘placebo’ controlled acupuncture trial is based on the supposition that the needling alone is the characteristic treatment element”

➢Aim of these studies is to explore if needling has a specific therapeutic effect beyond that of placebo

➢If factors other than the needle are characteristic of acupuncture, the difference between the groups may greatly underestimate the total treatment effect of the intervention

➢In randomised controlled trials it is generally seen that both sham and genuine acupuncture have good treatment effects

Paterson C , Dieppe P BMJ 2005;330:1202-1205

©2005 by British Medical Journal Publishing Group

Application of randomised controlled design to trial of non-pharmaceutical intervention such as acupuncture.

How inactive is the ‘placebo’ control in acupuncture research

Placebo should be physiologically inert

Examples of ‘placebo’ controls

➢Needling non-acupuncture points➢Needling superficially➢Non-penetrating needles➢Blunt ‘toothpick’➢Inactive laser➢Inactive TENS

All involve touch –stimulating superficial C-fibres

Are minimal, superficial or sham acupuncture procedures acceptable as inert placebo controls?

Lund I, Lundeberg T. Acupunct Med. 2006 Mar;24(1):13-5.

A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Cherkin DC et al. Arch Intern Med. 2009 May 11;169(9):858-66.

Use of placebo or sham controlled trial designs for acupuncture may lead to false negative results

Paterson C , Dieppe P BMJ 2005;330:1202-1205

Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Hopton et al. Pain Pract. 2010 Mar-Apr;10(2):94-102. Epub 2010 Jan 8.

“The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions. If this conclusion is correct, then we ask the question: is it now time to shift research priorities away from asking placebo-related questions and shift toward asking more practical questions about whether the overall benefit is clinically meaningful and cost-effective?”

1. Expectation of acupuncture - suggestibility

Factors that may influence response to treatment

An fMRI study on the interaction and dissociation between expectation of pain relief and acupuncture treatment. Kong J, Kaptchuk TJ, Polich G, Kirsch I, Vangel M, Zyloney C, Rosen B, Gollub RL. Neuroimage. 2009 Sep;47(3):1066-76

Significantly greater fMRI signal decrease after genuine acupuncture with high expectancy (VH) compared with genuine acupuncture with low expectancy treatment (VL) on meridian side (VH > VL). L indicates left side of the brain, rACC: rostral anterior cingulate cortex; MPFC: medial prefrontal cortex; OPFC: orbital prefrontal cortex.

Results

Results

All participants who received genuine acupuncture (high and low expectancy) compared with those who received sham demonstrated f-MRI signal changes in areas of the brain associated with descending inhibition, e.g. PAG, thalamus, insula.

2 mechanisms involved

➢ ‘bottom-up’ peripheral - central modulation

➢ ‘top-down’ expectancy- emotional modulation

Conclusion. The analysis on two acupuncture groups with different expectancy levels indicates that expectancy can significantly

influence acupuncture analgesia for experimental pain

Yellow Emperor’s classic of internal medicine (Huang Di NeiJing) 1st Century BC

“ …if a patient does not consent to therapy with positive engagement, the physician should not proceed as the therapy will not succeed”

Neuro-realismOctober 30th, 2010 by Ben Goldacre in bad scienceBen Goldacre, The Guardian, Saturday 30 October 2010

“So an article in the Washington Post takes a view on pain, and whether the subjective experience of it is enough: “patients have long reported that acupuncture helps relieve their pain, but scientists don’t know why. Could it be an illusion?” They have an answer. “Now brain imaging technology has indicated that the perception of pain relief is accurate.”

“Another says that brain imaging “provides visual proof that acupuncture alleviates pain”. The reality, of course, is much simpler: for your own personal experience of pain, which is all that matters, if you say that your pain is relieved, then your pain is relieved (and I wish good luck to any doctor who tells his patient their pain has gone, when it hasn’t, just because some magical scan says it has)”.

fMRI has it’s place in understanding acupuncture but it needs to be put into context

Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, Kirsch I, Schyner RN, Nam BH, Nguyen LT, Park M, Rivers AL, McManus C, Kokkotou E, Drossman DA, Goldman P, Lembo AJ. BMJ. 2008 May 3;336(7651):999-1003.

2. Patient therapist interaction

How you interact with your patient significantly influences the effectiveness of your treatment.

Summary paper

Factors contributing to therapeutic effects evaluated in

acupuncture clinical trials. Shi GX, Yang XM, Liu CZ,

Wang LP. Trials. 2012 Apr 21;13:42

Placebo-induced improvements: how therapeutic rituals affect the patient's brain. Benedetti F. J Acupunct Meridian Stud. 2012 Jun;5(3):97-103. Epub 2012 Apr 10

“This recent research has revealed that …placebo-induced biochemical and cellular changes in a patient's brain are very similar to those induced by drugs. This new way of thinking may have profound implications in clinical trials and medical practice both for pharmacological interventions and for nonpharmacological treatments such as acupuncture”.

The role of qualitative research…

Understanding how and why acupuncture is effective in relieving pain in some cases but not others(explore non-specific treatment effects).

Same presentation, different response

Patients' experiences of Western-style acupuncture: the influence of acupuncture 'dose', self-care strategies and integration.Paterson CJ. Health Serv Res Policy. 2007 Apr;12 Suppl 1:S1-39-45

Abstract (edited)METHODS: 18 patients who were having Western-style acupuncture, for the first time, for a health problem of at least three months duration.RESULTS: The interviewees complained of chronic pain and moderate or severe disability which was resistant to conventional treatment. Their experience of acupuncture was diverse and varied according to the 'dosage' of acupuncture received, the inclusion of self-care strategies, and their relationship with the practitioner. The majority of patients benefited …However, some patients were disappointed by the treatment, distressed about 'wasting people's time', and about the lack of continuity of care. People who benefited most had good general health and a single problem.CONCLUSIONS: Patients showed discerning judgment regarding the 'dosage' of acupuncture they required, and combined acupuncture with exercises to good effect.

RESULTS: Patients perceived acupuncture as alleviating a number of RA symptoms including the relief of rheumatic pain and improvements in mobility. Acupuncture was additionally perceived as alleviating a number of consequential secondary symptoms of RA, such as fatigue, depression and sleeplessness. These effects allowed patients to feel normal again and regain their lives, and resulted in improvements in patients' lifestyle, emotional well-being and self-image. Acupuncturist affiliation impacts on both patient experience and perception of effects.

CONCLUSIONS: Acupuncture elicits a range of effects which contribute to improvements in RA patients' quality of life.

Thirteen patients with RA.

Are we measuring the right outcome - in clinical practice and in clinical trials?

"When I first started going I was going in on my knees, but I came out and I was skipping": exploring rheumatoid arthritis patients' perceptions of receiving treatment with acupuncture. Hughes JG. Complement Ther Med. 2009 Oct Dec;17(5-6):269-73.

Listen to Patients – interviews may reveal what constitutes optimal dose; and what influence response to treatment.

www.healthtalkonline.org

Patient 5 (hyperlink below) 42 year old male with Rheumatoid Arthritis. Diagnosed aged 17. ‘Acupuncture was very helpful’.

Acupuncture no more than a theatrical placebo Summary

• Ritual - Characteristic and incidental effects are distinct and additive

• Suggestibility• Enhanced patient therapist relationship• Placebo response produces biochemical changes in the brain• Measure the right outcome – well being, emotional strength,

coping, not simply just levels of pain

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Session 9

Myofascial Trigger Point Pain an Enigma -The Theory and Scientific Evidence

Learning outcomes

By the end of the session you should be able to demonstrate

➢an understanding of the construct of myofascial trigger point (MTrP) derived pain - from its conception to the present day

➢an awareness of alternative theories explaining MTrPs

➢a critical appraisal of the literature used to support the clinical construct of MTrP derived pain

1. Kellgren (1930’s)

Muscle and fascia produce pain in referral patterns typical to each muscle.

Muscles injected with hypertonic saline

Kellgren JH. (1938) Observations on referred pain arising from muscle. Clin.Sci. 3:175-190.

Referred Pains from Muscle. Kellgren JH. Br Med J. 1938 Feb 12;1(4023):325-7

Clinical construct development

Janet Travell (1940’s) began injecting muscle tender points with procaine

2.Travell & Simons (1940’s to 1980’s)

Travell & Simons mapped pain referral patterns – introduced term MTrP (1983;1999)

Mechanical headache. Travell J. Headache. 1967 Apr;7(1):23-9.

© Dr Mike Cummings BMAS

3. Correlation between MTrPs, acupuncture points and meridians

Trigger points and acupuncture points for pain: correlations and implications.Melzack R, Stillwell DM, Fox EJ. Pain. 1977 Feb;3(1):3-23.

Clinical features of Active MTrPs

➢Palpable hypersensitive spot (nodule) located in a taut band of skeletal muscle

➢Compression or stretch of spotreproduces the patients painproduces a referred pain pattern characteristic of that

muscle

➢Restricted stretch range of movement

➢Local twitch response (diagnostically unreliable)

New views of myofascial trigger points: etiology and diagnosis. Simons DG. Arch Phys Med Rehabil. 2008 Jan;89(1):157-9

Clinical features of Latent MTrPs

➢ Latent MTrPs are defined as points located in taut bands of skeletal muscle which are tender on palpation, but which are not associated with a clinical pain condition.

➢ Simons hypothesises that latent MTrPs convert into active MTrPs through overuse of the muscle (Simons et al 1999).

Q how might you test this hypothesis?

➢Sudden injury

➢Sustained postures

➢Repetitive activity

MTrPs are believed to develop in response to

Footnote for discussion: This theory is based on patient observation – little supporting empirical evidence, is that a problem?

Aetiology of MTrPs – the theorySimons’ integrated hypothesis

New views of myofascial trigger points: etiology and diagnosis.Simons DG. Arch Phys Med Rehabil. 2008 Jan;89(1):157-9

Scientific evidence supporting Simons’ hypothesis is limited

1. Contradictory evidence from needle EMG studies

2. No supporting evidence from BTX-A studies

Spontaneous Needle Electromyographic Activity in Myofascial Trigger Points in the InfraspinatusMuscle: A Blinded Assessment. Couppé et al Journal of Musculoskeletal Pain, 2001, Vol. 9, No. 3

:7-16 Endplate potentials are common to midfiber myofacial trigger points. Simons et al. Am J Phys

Med Rehabil. 2002 Mar;81(3):212-22

Botulinum toxin for myofascial pain syndromes in adults.

Soares et al.Cochrane Database Syst Rev. 2012 Apr 18;4:CD007533.

3. Microdialysis

Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascialtrigger points.Shah et al. Arch Phys Med Rehabil. 2008 Jan;89(1):16-23

Results

Similar substances detected in painful muscle at non-MTrPsites in upper trapezius whiplash injured patientsBiochemical alterations in the trapezius muscle of patients with chronic whiplash associated disorders (WAD)—a microdialysis study.Gerdle B et al. Eur J Pain. 2008 Jan;12(1):82-93.

An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Shah JP et al J Appl Physiol. 2005 Nov;99(5):1977-84.

4.Ultrasound

In 10 of the 11 subjects (90.9%) with clinically identified active MTrPs no abnormality was detected with the diagnostic ultrasound. In one out of the 11 (9.1%), an abnormal area corresponding to the region of the MTrP was reported (this diagram show exception).

Conclusion - diagnostic ultrasound was unable to significantly identify or observe any soft tissue changes in the region of clinically identified active MTrPs.

A blinded pilot study investigating the use of diagnostic ultrasound for detecting active myofascial trigger points.Lewis J, Tehan P. Pain. 1999 Jan;79(1):39-44

5. Magnetic Resonance Elastography

Identification and quantification of myofascial taut bands with magnetic resonance elastography. Chen et al. Arch Phys Med Rehabil. 2007 Dec;88(12):1658-61

6. Doppler ultrasoundObjective sonographic measures for characterizing myofascial trigger points associated with cervical pain.Ballyns et al. J Ultrasound Med. 2011 Oct;30(10):1331-40

Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Sikdar et al. Arch Phys Med Rehabil. 2009 Nov;90(11):1829-38

A & B ‘normal’ upper trapezius; C to F MTrP sites in upper trapezius

Cohen & Quintner (2008) suggest that ‘in the face of evidence of refutation’ we should ‘stop flogging a dead horse’ and reject the

concept of MTrP pain as a clinical entity.

The horse is dead: let myofascial pain syndrome rest in peace. Cohen M, QuintnerJ. Pain Med. 2008 May-Jun;9(4):464-5.

1. Peripheral Neuropathy

Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct. Quintner JL, Cohen ML. Clin J Pain. 1994 Sep;10(3):243-51

MTrPs – clinical feature of another underlying cause

2. Joint Pathology

The role of trigger point therapy in knee osteoarthritis Yentür et al Pain Clinic 15 (4)385-390

Injection in the cervical facet joint for shoulder pain with myofascial trigger points in the upper trapezius muscle. Tsai et al. Orthopedics. 2009 Aug;32(8)

➢MTrP pain is not as clear cut as it would first appear

➢No definitive diagnostic test

➢Could be a secondary feature of another condition

Nonetheless MTrP derived pain still forms the basis for research and is accepted in clinical practice

MTrP pain – an enigmaSummary

Discussion points

➢What are we doing when we ‘dry needle’ MTrPs?

i.e. What do you believe is the mechanism of effect?

➢Does it matter where in the muscle you needle?

➢Does it matter how you needle the point? (technique)

(discuss further in session10)

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Session 10

Acupuncture for Myofascial Trigger Point Pain - The Evidence

Learning outcomes

By the end of the session you should be able to demonstrate a critical understanding of

➢ the laboratory evidence and

➢ the clinical researchused to support the use of acupuncture for MTrP pain

DiscussWhether or not there is sufficient evidence to support acupunctures continued use for this condition

1. Simons’ hypothesis – needle causes mechanical disruption of contracted muscle fibres, resulting in increased blood flow, O2 and nutrients which resolves the ‘energy crisis’.

2. Segmental analgesia

Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. Srbely et al. J Rehabil Med. 2010 May; 42(5) :463-8

Why needle MTrPs ? Proposed mechanisms of effect

Clinical Research

The needle effect in the relief of myofascial pain.Lewit K. Pain. 1979 Feb;6(1):83-90

Observational study. 241 patients with chronic myofascial pain 87% showed an association between dry needling of MTrPs and immediate and lasting pain relief

Secondary Research

Needling therapies in the management of myofascial trigger point pain: a systematic review. Cummings TM, White AR. Arch Phys Med Rehabil. 2001 Jul;82(7):986-92. Review

Systematic review of 27 RCTs investigating needling therapies for MTrP pain.

➢ No evidence that injection of any substance produces a better response than inserting the needle alone

➢ Inconclusive whether or not needling had a specific effect above and beyond that of placebo

Secondary Research

Acupuncture and dry needling in the management of myofascialtrigger point pain: a systematic review and meta-analysis of randomised controlled trials.Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Eur J Pain. 2009 Jan;13(1):3-10.

➢ 1 study. Direct MTrP needling plus usual care v usual care alone (Di Lorenzo 2004) n=101. significant reduction in post stroke shoulder pain in MTrP needling group (p<0.001)

➢ 2 studies. Direct MTrP needling v local needling (Chu 1997; Itoh2004) no significant difference between interventions

➢ 4 studies. Direct MTrP needling v sham ‘placebo’ intervention

Results (n=7)

Weighted mean difference = 14.09 (95% CI -5.81 to 33.99)

Difference between acupuncture and sham is not statistically significant

ResultsMeta-analysis of direct MTrP needling v sham

Discussion

Lack of evidence is disappointing

Limitations identified by this systematic review

➢Small sample size – type II error

➢Sample population inappropriate

➢Considerable variation in treatment

Updated review

➢ 10 new RCTs. 3 met inclusion criteria.

➢ 1 concluded that needling was superior to usual care.

Comparison of miniscalpel-needle release, acupuncture needling, and stretching exercise to trigger point in myofascial pain syndrome. Ma et al. Clin J Pain. 2010 Mar-Apr;26(3):251-7

➢ 2 adopted a placebo control and were added into the original

meta-analysis

Effectiveness of acupuncture/dry needling for myofascialtrigger point pain Tough EA White, AR Physical Therapy Reviews Volume 16, Number 2, April 2011 , pp. 147-154(8)

Myofascial trigger point needling for whiplash associated pain--a feasibility study.Tough et al. Man Ther. 2010 Dec;15(6):529-35

Trigger point acupuncture for treatment of knee osteoarthritis--a preliminary RCT for a pragmatic trial. Itoh K et al. Acupunct Med. 2008 Mar;26(1):17-26

Review : Dry needling for MTrP

Comparison: 02 acupuncture

Outcome: 01 Dry needling vs sham

Study Treatment Control WMD (random) Weight WMD (random)

or sub-category N Mean (SD) N Mean (SD) 95% CI % 95% CI

Itoh 2008 8 39.00(9.50) 7 10.60(13.90) 17.63 28.40 [16.18, 40.62]

Tough 2010 17 32.00(24.00) 17 18.00(23.00) 16.05 14.00 [-1.80, 29.80]

Ilbuldu 20 36.15(30.71) 20 28.26(31.39) 14.50 7.89 [-11.36, 27.14]

Huguenin 29 18.00(22.50) 30 18.00(17.50) 18.40 0.00 [-10.31, 10.31]

Itoh 2006 10 37.70(13.10) 9 -0.60(12.50) 17.92 38.30 [26.78, 49.82]

Itoh 2007 8 18.60(13.20) 8 9.50(20.70) 15.51 9.10 [-7.91, 26.11]

Total (95% CI) 92 91 100.00 16.67 [3.23, 30.11]

Test for heterogeneity: Chi² = 28.74, df = 5 (P < 0.0001), I² = 82.6%

Test for overall effect: Z = 2.43 (P = 0.02)

-100 -50 0 50 100

Favours control Favours treatment

Acupuncture is statistically superior to sham

Results

DiscussionLack of a standardised approach to needling

➢ 9 studies used ‘indirect’ needling Classical acupuncture points (n=7); Superficially over the site of MTrP (n=1); Clinically identified MTrPs distal to area of pain (n=1)

➢ 4 studies combined classical acupuncture point needling with needling MTrPs

➢ 8 studies used deep direct needlingNeedles left in situ (n=4); MTrPs needled one by one – ‘sparrow pecking’ technique (n=4)

➢ Variation in duration of sessions and number of sessions

Does it matter where you needle?

Studies comparing indirect needling (i.e. needling acupuncture points not the MTrP directly) with an inactive control

➢ 4 reported results of acupuncture being superior to sham in reducing pain.

➢ 4 reported within group improvements but no between group difference in outcome

Acupuncture/dry needling for MTrP pain

Summary

➢ Direct acupuncture needling is likely to be the most effective approach?

➢When treating patients with regional MSK pain and clinically identified MTrPs, combining usual care (e.g. exercise) with needling appears more effective than usual care alone

➢Common schedule 1 Rx per week for 3 weeks

➢No reports of patients getting worse

➢No reports of adverse events

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Session 11

Electro-acupuncture - An Introduction

Learning outcomes

By the end of the session you should be able to demonstrate

➢ a basic knowledge of the origins of electro-acupuncture (EA)➢ an understanding of the neurophysiological concepts underpinning its use ➢ an understanding of when EA would be an appropriate alternative to manual acupuncture➢ a knowledge of the precautions and contraindication of EA➢ safe and appropriate clinical application of EA (including dose and condition)

EA was developed in China in 1950’s specifically for surgical analgesia (reduce the effort of continual manual stimulation)

“…works in too few patients to be of practical value”

Adopted by practitioners in the West and used primarily for chronic nociceptive pain conditions

Limited research on it’s use for➢acute pain➢as an adjunct to surgical analgesia

Assessment of acupuncture as a method of analgesia during operation.

Borzecki M, Kacki J. Anaesth Resusc Intensive Ther. 1976 Jan-Mar;4(1):53-60.

History of Electro-acupuncture

Human and rodent laboratory research

➢ Identified that different kinds of neuropeptides are released by EA with different frequencies. ➢ EA of 2 Hz accelerates the release of enkephalin, beta-endorphin and endomorphin➢100 Hz selectively increases the release of dynorphin. ➢ A combination of the two frequencies produces a simultaneous release of all four opioid peptides, resulting in a maximal therapeutic effect.

Frequency range

Clinical application. Set 3 second periods alternating between 2-4Hz and 80-100Hz

Acupuncture and endorphins. Han JS. Neurosci Lett. 2004 May 6;361(13):258-61.

Neuromodulators: opioid peptidesWhite et al 2008 An Introduction to Western Medical Acupuncture

Peptide Main site Receptor Blockage by naloxone

Relevant EA frequency (Hz)

β-endorphin Midbrain,PAG(pituitary)

μ & δ Low dose 2-4

Enkephalin Dorsal horn of spinal cord

μ & δ Low dose 2-4

Dynorphin Brainstem and spine

к High dose 50-100

Orphanin Widespread μ Unknown 2-4

Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee.Ahsin et al. Pain. 2009 Dec 15;147(1-3):60-6.

Clinical research investigating EA use for chronic pain

20 patients received EA at classical acupoints

20 received ‘sham’ EA (no stimulation) at non-acupoints

In EA group pain intensity levels (VAS & WOMAC) were sig. reduced. A rise in plasma β-endorphine and a fall in plasma cortisol were measured

immediately following EA but not following sham acupuncture

17 patients received EA

18 patients received sham EA (superficial needling of non-acupoints

with inactivated EA)

9 withdrew during Rx period and 3 during follow-up

Both groups showed a significant reduction in OLM consumption

EA 39% ; sham 25%

Reduction lasted for 8 weeks in EA group but for the whole 12 weeks in

sham group

Why might this be?

The effect of electroacupuncture on opioid-like medication consumption

by chronic pain patients: a pilot randomized controlled clinical trial.

Zheng et al. Eur J Pain. 2008 Jul;12(5):671-6.

Clinical research investigating EA use for

chronic pain

Acupuncture post op – hyperlink to video

Clinical research investigating EA use to reduce postoperative pain

Randomised, controlled study of preoperative electroacupuncture for postoperative pain control after cardiac surgery. Coura et al. Acupunct Med. 2011 Mar;29(1):16-20.

Electroacupuncture reduces the evoked responses of the spinal dorsal horn neurons in ankle-sprained rats. Kim et al. J Neurophysiol. 2011 May;105(5):2050-7.

Laboratory research investigating EA for local acute pain

Measured dorsal horn neuron activities and ability to weight bear

EA was applied to the SI-6 acupoint contra-lateral limb(10 Hz, 1 ms pulse width, 2 mA intensity) for 30 minutes

“The inhibitory effect of EA on hyperactivities of dorsal horn neurons of ankle sprained rats was blocked by the alpha adrenoceptor antagonist, phentolamine but not by the opioid receptor antagonist, naltrexone”

Proposed EA suppresses dorsal horn neuron activity via the alpha-adrenergic descending inhibitory systems at the spinal level

Long-term synaptic plasticity in the spinal dorsal horn and its modulation by electroacupuncture in rats with neuropathic pain.Xing et al. Exp Neurol. 2007 Dec;208(2):323-32.

Laboratory research investigating EA for neuropathic pain

“The different modulation on spinal LTD or LTP by low- or high-frequency EA may be a potential mechanism of different analgesic effects of EA on neuropathic pain. LTD of synaptic strength in the spinal dorsal horn in spinal nerve ligated rats may contribute to the long-lasting analgesic effects of EA at 2 Hz”

Safe practice

Do not needle➢ across the head and neck (clinical case of scalp EA causing angina. Cause

unknown)

➢ in areas of sensory denervation

➢ across the thorax – either the chest wall or arm to arm

➢ close to the carotid sinus or vagas nerve as may cause bradycardia

➢ near the recurrent laryngeal nerve as may cause laryngeal spasm

➢ in patients with electrical pacemakers although…

White et al 2008. An introduction to Western Medical Acupuncture. Chapter 12

Electroacupuncture on a patient with pacemaker: a case report.

Vasilakos DG, Fyntanidou BP. Acupunct Med. 2011 Jun;29(2):152-3

50-year-old female patient, with severe low back pain resistant to all treatment methods.

The only treatment that seemed to have some positive effect, but of extremely short duration, was acupuncture.

Her condition deteriorated considerably, and after due consideration she was treated with EA.

Even after the first EA treatment, the patient's condition improved.

Since then, she has received many EA courses during the past 2 years without any complications or side effects.

The results suggest that EA might be a safe alternative for patients with a pacemaker. Every patient should be considered with care, individually.

EA unit and its application

➢ Insert needles in usual way - in linked pairs (do not use plastic handled

needles)

➢ Units have 3 or 4 pairs of leads

➢ Ensure machine is switched off and turned down!

➢ Connect needles across the site of pain e.g. knee joint

➢ Turn up two parameters – frequency and intensity

➢ Frequency range from 2Hz to 100Hz

➢ 20 to 30 minutes treatment time

➢ 6 to 8 sessions

Summary & Practical application

Which clinical conditions would you treat with EA?

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Session 12

Current hot topics and latest research

Learning outcomes

By the end of the session you should be able to demonstrate:

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