TheClinical Use of Acupuncture in Oncology: Symptom Control This paper waspresentcd at thc ICMART Syn,pasiurn held at Bathin May 1993 Key wotds /\aupoints, CaDCcr, CaDcer Summary Medical acupunctLlrc is exlr-.ntell, useiul itj conttalling thc pain experietl.-.dbv ntaDy canter patients- lt is a camplei)entaty and aonsetvative therapJ, that traditionally helps to balant:ethe lktw of vital encrty, which in tunt lr-.lps tu relieve tutal pain. Tatal oncological pain includes disease and therapy rclatcd p.1in, rcla!-.d disaomforL anxtety and dcprcssion, and lack of eneryy.A number of acupaints are functionally -.ile.tive in relieving tl1csc syn)ploms, prttiaularlv when stinulated by w,ty ol lhe reiDft)ra-.ntent breathing and nccdling; Tllere are irlso hundreds oi Ql Gort rclaxaLion, breathing, posiure, cofccntraLion and mediLation exercises, some of rvhrch have been appliecl Lo cancer f6l. Perhaps thc bcst krown sel ol afli- cancer Q/ Cong cxcrciscs, known as lhe "Nevl, Qi Gong Therapy", rvas clcviscd in lhe early 1970s by cancer patient Cuo Ljn, who until her dealhin the nlid 1gBUs wasthc driving iorce behind 111-a mo.lern fcvival oi Q/ CoDg in lhe People's Repub ic of China tl. In China, Lherapeuti. a.Lrpufctufe js the prim.rry thcrapy lor controllirg chroric benign pain as well as carrcer p.rin. ln the \Vest, it hasachic.ved cofsid erable le3itirnacy ior pain contro in pain clinics. Inspection oi a recent dircctory l8J indicales thal therapeutic acupuncturc is uscd jn l:19oi .177 pain centres in Canada andthc US and lhaL most oi these ' t. ., r'r, , - 'r r- d ir ho-l,,. l. "r d u1i\.r.it ... Pnir]-control modalities uscd in most oi the '177 centres includcdrugs anclnervebloaks as $,ell as physical thcrapy, rclaxalion lrainin8, lrarlgcutaneoLrs stimulatior, biofccdback afd olher therapies sometimcs dcsignaled "Don medi.al". A <)mpte hensive rescafch rcview l9l sLrEigesls lhat the hiBh efficacyof thcsc Lhcrapies "M.1v be atttihutabl-. t)... thc fiatures they share itl aoti|itott, for example, the identiiicatiatl oi psychok;gical iactors \,rhich ex.1c-otbate pain, contacr wiih an empathic proics sional, and iDstallatiotiof htryte frtr relief from Cancer pain Painis one of the most feared aspccts of thc disease ancl indeecl manypatients with advancccl .ancer.lo experience substantia pain al more lhall one sile. Nlost cancer pain is assocratcd with dircct iniillra tion of tumour into nerve, musclc or bonc, but some is the result of trcatrncnt t7al, //1. Whether or not a canccr paticnt becomes clini.ally depressed appears to d..pend on thc scvcrity oi the pain, the nature ot the therap,v, and thc overallqualily of lile of the patieni wjthin his psychosocial milieu 472-74). The Wofld Health Organisation l/51 hasapllysugSested that with rcspccl lo .an.er "Ihe calrcept of'tatal pain' la enconpass all rcl-.\,at1t ,speats /s usefu/. Thisincludesth-. noxious physi(alstinulus and alsa p'r,lnlet, tl L,'t! ' 'l ,,', t '1 t u t,'t' . i J Acupuncturc is chara.lerised in the /nrrr8 I/ Ne/ Chlnt (Ycllow Empelor's Classic ot Intc'rnal Mcdicinc], \a,,hich was pLrl into writtenlorm In the Jrcl ccnlLrryBC and remains the authoritativ.' traditionalChinese nredical (TC:M) text, as the pfimary thcrapy ior suslair)ing phvsical, mental and spiritual yh <->yar8 balance ancl for treating both emergerrl and viftual imbalance, or discasc/illness. PLrl sinrply, acupuncture therapy scrvcs to !nblo.k the llo,,r, ol Ql. Accorcling to TCM thcory, Ql is the sLrbslan.e ol vilal energy and information circulatjng loSelher $'ith blocxl and bodiiy fiuids throughout lhe system oi meridians and collatcrals thal inlenrally link the major intcrnalorgans l/ l). Acuplrnctlrre smooths the florv of Ql by moving it irom locales where it is exccssivc to those \\,here il is delicient- The TCM therapics most often usecl in lhe attempt to cure cancef, cithcr by directly affestinS the canccrous growlh or by stimLrlating the immune systenr to do it, are herbal medicine and Q/ GoDg. Thcrcarc hundreds ol anti-cancer herbal remedies enconrpassjng planl, aniaaal, insect or lish parts as rvell as minerals l.l).To take orlly one exarnple, the inn1n\LinE Zhi ((j. lu.idutn)is nn nncient Chinese -"lixir lhat has beconre a moclern anti canc..r dfug, and biocherrrical research has shown it to producc se(ondary metabolites that havc a tangifJle immunostimulnting effect f-it. M.l l!191 \bl l) No.l 37 A.LpLn.tue nr trle.ti.ine on 21 June 2018 by guest. Protected by copyright. http://aim.bmj.com/ Acupunct Med: first published as 10.1136/aim.12.1.37 on 1 May 1994. Downloaded from
Transcript
The Clinical Use of Acupuncture inOncology: Symptom Control
This paper was presentcd at thc ICMART Syn,pasiurn held at Bath in May 1993
Key wotds/\aupoints, CaDCcr, CaDcer
SummaryMedical acupunctLlrc is exlr-.ntell, useiul itjconttalling thc pain experietl.-.d bv ntaDy canterpatients- lt is a camplei)entaty and aonsetvativetherapJ, that traditionally helps to balant:e the lktwof vital encrty, which in tunt lr-.lps tu relieve tutalpain. Tatal oncological pain includes disease andtherapy rclatcd p.1in, rcla!-.d disaomforL anxtetyand dcprcssion, and lack of eneryy. A number ofacupaints are functionally -.ile.tive in relievingtl1csc syn)ploms, prttiaularlv when stinulated byw,ty ol lhe reiDft)ra-.ntent breathing and nccdling;
Tllere are ir lso hundreds oi Ql Gort rclaxaLion,breathing, posiure, cofccntraLion and mediLationexercises, some of rvhrch have been appliecl Locancer f6l. Perhaps thc bcst krown sel ol af l i-cancer Q/ Cong cxcrciscs, known as lhe "Nevl,
QiGong Therapy", rvas clcviscd in lhe early 1970s bycancer patient Cuo Ljn, who unti l her dealh in thenlid 1gBUs was thc driving iorce behind 111-a mo.lernfcvival oi Q/ CoDg in lhe People's Repub ic ofChina t l .
In China, Lherapeuti. a.Lrpufctufe js the prim.rrythcrapy lor control l irg chroric benign pain as wellas carrcer p.r in. ln the \Vest, i t has achic.ved cofsiderable le3it irnacy ior pain contro in pain cl inics.Inspection oi a recent dircctory l8J indicales thaltherapeutic acupuncturc is uscd jn l :19 oi .177 paincentres in Canada and thc US and lhaL most oi these' t . . , r ' r , , - ' r r - d i r h o - l , , . l . " r d u 1 i \ . r . i t . . .Pnir]-control modalit ies uscd in most oi the '177centres includc drugs ancl nerve bloaks as $,el l asphysical thcrapy, rclaxalion lrainin8, lrarlgcutaneoLrsstimulatior, biofccdback afd olher therapiessometimcs dcsignaled "Don medi.al". A <)mptehensive rescafch rcview l9l sLrEigesls lhat the hiBhefficacy of thcsc Lhcrapies "M.1v be atttihutabl-. t)...thc fiatures they share itl aoti|itott, for example, theidentiiicatiatl oi psychok;gical iactors \,rhichex.1c-otbate pain, contacr wiih an empathic proicssional, and iDstallatioti of htryte frtr relief from
Cancer painPain is one of the most feared aspccts of thc diseaseancl indeecl many patients with advancccl .ancer. loexperience substantia pain al more lhal l one si le.Nlost cancer pain is assocratcd with dircct ini i l l rat ion of tumour into nerve, musclc or bonc, but someis the result of trcatrncnt t7al, / /1. Whether or not acanccr paticnt becomes cl ini.al ly depressed appearsto d..pend on thc scvcrity oi the pain, the nature otthe therap,v, and thc overal l quali ly of l i le of thepatieni wjthin his psychosocial mil ieu 472-74). TheWofld Health Organisation l/51 has aplly sugSestedthat with rcspccl lo .an.er "Ihe calrcept of ' tatalpain' la enconpass all rcl-.\,at1t ,speats /s usefu/.This includes th-. noxious physi(al stinulus and alsap ' r , l n l e t , t l L , ' t ! ' ' l , , ' , t ' 1 t u t , ' t ' .
iJ
Acupuncturc is chara.lerised in the /nrrr8 I/ Ne/Chlnt (Ycllow Empelor's Classic ot Intc'rnalMcdicinc], \a,,hich was pLrl into written lorm In theJrcl ccnlLrry BC and remains the authoritat iv. 'tradit ional Chinese nredical (TC:M) text, as thepfimary thcrapy ior suslair) ing phvsical, mental andspir i tual yh <->yar8 balance ancl for treating bothemergerrl and viftual imbalance, or discasc/i l lness.PLrl sinrply, acupuncture therapy scrvcs to !nblo.kthe llo,,r, ol Ql. Accorcling to TCM thcory, Ql is thesLrbslan.e ol vi lal energy and information circulatjngloSelher $' i th blocxl and bodiiy f iuids throughout lhesystem oi meridians and collatcrals thal inlenral lyl ink the major intcrnal organs l/ l) . Acuplrnctlrresmooths the f lorv of Ql by moving it irom localeswhere it is exccssivc to those \\,here i l is delicient-The TCM therapics most often usecl in lhe attempt
to cure cancef, cithcr by directly affestinS thecanccrous growlh or by st imLrlating the immunesystenr to do it , are herbal medicine and Q/ GoDg.Thcrc arc hundreds ol anti-cancer herbal remediesenconrpassjng planl, aniaaal, insect or l ish parts asrvell as minerals l . l) . To take orl ly one exarnple, theinn1n\ LinE Zhi (( j . lu. idutn) is nn nncient Chinese-"l ixir lhat has beconre a moclern anti canc..r dfug,and biocherrr ical research has shown it to produccse(ondary metaboli tes that havc a tangifJleimmunostimulnting effect f- i t .
M.l l!191 \bl l) No.l 37 A.LpLn.tue nr trle.ti.ine
The concept of "total pain" is compatible with theTCM notion that good health and the absence ofpain entai ls hoJist ic yin < >yang harmony. In TCMterms, cancef, l ike other severe cases of blocked Qrllow, is caused by external or internal "stress" ovefthe l o rg o r . ho l t o rm. and t \ e d i . ea -p na ) bo"ptevented" by the body's defence system (themobil isation ol wel Qi in pan'cular) or byappropriate therapy. The acute phase, marked byyang fQiJ excess and Yin (Qi) deficiency, may befol lowed by a subacute phase and at this point thedisease itseJf is a major internal stressor, marked byYin (Qi) and yang aQ/) deficiency, but with the latterrclat ively more excessive. This is too often fol lowedby a more advanced and l i fe threatening phase.TCM paltefns of cancer correspond in a gcneral
way to varioLrs biomedically-defined canceTs. Forexarnple, "/-/eat Poisor in liver" corresponds lo livercancer and "Liver Kidney Dual Deficiency"encornpasses l iver, colon and uterine/cervicalcancet (16, I7).
The rclevance of medical acupunctureMy own approach lo pain control may be characterised in terms of the cor.plenrenlary nalure ofmedical acupuncture. First, Iarn a professionallytrained and cert i f ied TCM practit ioner (C)MD) aswell as a medical pracl i t ioner (MD) with specialtraininB in geriatr ic medicine, and my practice maybe clefined as a single-modality (acupuncture) paincl inic orientated towafd the elderly f/B)- Second,virtual ly al l my patients are accepted only as formalmcdical rcfcrrais, about I0% of these patients expe-riencing substantial cancer pain. Third, the patientsare diagnosed lrom a Weslern biomedicalperspective (using medical records, x-rays, bloodtests, psychiatr ic assessmenls and so on) as well asfrom a TCM perspective (a comprehensive, holist icprocess encompassing inquiry inspection, pulsetaking and palpation of acupointt. Finally, patientsare ready for a tr ial course of acupuncture consist ingof 6-10 half-hour sessions spread out over a fewweeks. As these sessions proceed, palients areexpected to remain in close communication withtheir own personaJ physicians.
I always attcmpt to control a patientt total pain.M) Serc Jl ' ini, d prolo' ol .nr ompd..a\ lre.r l irB:i . Primary paini i . Related discomforti i i . Anxiety and depressioniv. Lack oi energy.
My typical acupoint prescript ion ior control l inBcancer pain is as follows: L|.4, PC.6, HI.7, 5P.6,CV.2o, C\!.4 (F i gu re 1 ).My cl inical protocol begins wilh primary pain,
since it is the main reason a patient is referred lo themedical acupuncturist. Primary pain inclLrdes direct
A.Dpun.ture in Me.li.lne
inf i l trat ion of lhe lumor into nerve, muscle andbone, as well as the side-effects of radial ion therapyand surgical intervention. Ll.4 (HeBu)is perhaps lhesingle most effective point for control l ing cancerand other types of pain, part icularly in the upperhalf of the body. Indeed, Ll.4 h,as one of the f irst tobe uti i ised for acupuncture anaesthesia, developedin the People's Republic of China in the 1950s.The discomfort that often accompanies cancer and
;t 's therapy generally involves nausea (andvomjting), for which PC.6 fNerguat. l is highlyeffecl ive. Many cancer patients suffer from somedegree of anxiety and depression conccrning theprogress of the disease and outcome oi therapy;stimulatinft HL7 (Shenmen) is most effective in th;sregard. Many cancer patients experience a lack ofenergy. In TCM terms, this pertains to deficienl Qisrimulating SP.6 (Sanyinjiao) is one of the morepowerful remedies.Thus, within the context of the TCM system, 11.4,
PC.6, Hl7 and SP6 are viewed as h;ghly effectivesymptomatic points, and lhey have control ied thephysical, mental and spir i tual suffering of countlesspatients in Asia and elsewhere over the centuries. lnbringing them toSether oncological ly, I am taking aconservative stance. These points, i t rnust be noted,are mult i functional, for example, PC.6 is used notonly for nausea bul also for cancer pain ol the nerveinfi l trat ion type, post-operal ive pain and depression.It must also be noted that the tumour i lself is neverneedled.
Fieure 1. Medi.al a.Dpun.tute aDd totai cancer pain cantrcl: a
ln the interest of total cancef pain control, I alwaysstimlrlate two points on the Covernin8 Vessel fDu)meridian, namel, CV4 lMirgmenr the Cate of Life)and CV20 (Baihui: the Point of 100 Catherings).This is designed to keep /en Qi f lowing smoothly upthe Du and down the Ren meridians. /en (Authentic)
Qi is a synthesis of Wel (Deiensive) Q/, / irg(Nutrient) Qi and vuat (Original) Qi. Takentogether, Du and Ren directly intersecl with the sixyin and six ya,rg regular meridians, and they play acrucial role in smoothing the f low of Qi throlrghoulthe whole person.There is, of course, a wide var;ety of othef relevanl
acupoinls (F/gur"e -? shows the 37 points that I usemost often). CB.34, for example, is effective for paindue to tumour inf i l trat ion of muscles, 81.15 foranx;ety and CV6 for Jack o{ energy. C8.34 is the
lnfluentiaJ Point for muscle and tendon, and al l suchpoints are valuable for cancer pain (the otherInfluentiai points are C8.39: Mafiow, 81.11: Bone,81.17: Blood, LU.9: Pulse/Vessels, Cv.12: YanBOrBans, 1R.13: ) ' lD Organs and CVl7: Qt. 81.15 isthe Back Shu point of the Heart, and each of the 12major organs has a corresponding point (such as81 .15 , BL . lB and 81 .20 ) on the U f ina ry B ladderrneridian. These arc "alarm" points, which aretender when palpated. CV6 (Qlhai: the Sea of Q/,),where al l one's /er Qi acc!mulales, is the bestsingle point fof reinforcing vital energy.Ah Shl points are local or distal tender (tr igger)
points in no set locale. l t is irnportant lo discoversuch points by way of careful palpation and thenstimulate lhem. Microsystem acupoints on the hano,foot, scalp, face and ear, which correspond tovarious locales on the body, are also important incontrol l ing cancer pain. Some auricular needles-d) oc .e l l in o lJ i a b-r$pa1 I roor-c '11 \ .ss ion\ .o
lhat the patient can squeeze them Lo obtain painrel ief. In lhe mor€ severe cases, I apply elec-troacupunclure at relevant points.
Cancer patients general ly require reinforce.nent ofdeficient Ql- Fof miJd reinforcement I applymoxibustion to al l relevant non-rnicrosystem points.For strong reinfofcernent I frequenlly use acombination of needle manipulation and Ql CongbreathinB fF,8{rre 3):As the needle is inserLed LJoth the physician andpatient inhale deeply.This faciJitates the f low of Qi to lhe point ofrnsertron.The breath is then held in ofder to intensify theflow of Qi.The breath is inhaled deeply oncefaci l i tate the f low of Ql.The breath is then exhaled deeply in"l lx" Lhe arrival of Qi at the point.
again to
order to
Bolh Lhe physician and patient must feel De Qi(dist incl ive local sensation of the arrival of vi lalener: ly) for the lreatment to be viable.By the t irne De Qi is altained the needle has beenslowly fotated a ful l tutn clockwise and has beengently but firmly insefted to an inlermediate depth.
My cl inical, non scientif ic results su8Best thal overha l f rhp , a rcc r pd l i en l . l r " . r l ed d p e , e i \ i nB mnrpthan adequate pain relief (Table /.). These results arecompatible with the resulls achieved by others f79-2/.), although it must be noted ihat there is a paucityof data on the use o{ medical acupuncture inoncology. It must also be noted thal cancer patientsrc .po rd to a ' upLn , , J - l t sd lman l r ra r i nu r r , ra t s .i nc lud ing :i. Steady reliei of pain from the first to the lasttreatrnent with periods of worsening inbetween;
Pain SitdPatholosy Patients (N) Response of Patjents (%)Ex. Good Fair Poor
Averase Response (%)
7 1 2 160 284 1 1 51 8 01 5 0
1 2 1 7(N=245) 1 l
t 9243 0202022
2 1 9
1 0 1 93 3 1 720 402 1 4 l29 2925 2521 25
t 9 1 91 9 1 4t 5 l 520 2020 20t 9 t 8
49135 6504029293l4 1
434040404l
PostoperativeNeuralgia 27Posloperative (Cenera ) 21ScarTissue 20Phantom Organ/Limb l6Radiat ion Fibros is 15Av-"rage Response (%) (N=99)
Data ft ,m the SKH AunE ne.lical acupuncture practice,tdnonton, Albe a, Canada, 1987 9t.
Ex. = Patienl repoft and therapist obrerves excellentimprovement after 61 0 sessions of aclrprncture(increased freedom from pain, increased activity,improved mood, less need for dru8s, eic.).
Cood = Cood improvement but patient requircs occasional
Fair = Fair imptuvement but patient requires lrequent
Poor = NeSligible or no improvement: treatment may becontinued, discontinued, or a refetral made-
Steven KH Aung MD OMD PhD(Hon)Cl i n ical Assistant Prcfessol
Deparlment of Family Medicine,University of Alberta
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i i . Rapid improvement after two or three sessionsand then no further improvement or worsening;i i i . lnit ial rel ief of pain fol lowed by a short periodof worsening and then steady improvementjiv. Lack of improvement to the extent that the painintensif ies.
ConclusionThe results imply that acupuncture is a viablecomplement to other therapeutic modalit ies ratherthan an oncological panacea. l t is, in shoft, a usefuloption for helping to control the total pain thatsurrounds cancer While my results are scientif ical lyuncontrolled, the patients have in effect acted astheir own controls since most of them were reterredto my practice after failing to receive adequate painrelief from other therapies. The conservativemedical acupuncture approach I have describedconstitutes a framework from which the physiciancan initiate dynamic treatment of the total vitalenergy imbalance experienced by a substantialnumber of cancer patients,
Acupundurc in Medicine
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