by William Alexander | Apr 4, 2017 | About Acupuncture, Health Benefits of Acupuncture
Why Doctors Approve Acupuncture For Medical Ailments Treatment
The American College of Physicians formally recommends acupuncture for the treatment of back pain. Published in the prestigious Annals of Internal Medicine, clinical guidelines were developed by the American College of Physicians (ACP) to present recommendations based on evidence. Citing quality evidence in modern research, the ACP notes that nonpharmacologic treatment with acupuncture for the treatment of chronic low back pain is recommended. The official grade by the ACP is a “strong recommendation.” [1]
The Medical Goal of Acupuncture
A major goal of the recommendation is for acupuncture and other nonpharmacological therapies to replace drug therapy as a primary source of pain relief. Treatment with opioids is only recommended, with an official “weak recommendation,” when other modalities do not provide adequate relief. A strong recommendation is also made by the American College of Physicians for the treatment of both acute and subacute lower back pain with heat, massage, acupuncture, and spinal manipulation. [2] The recommendations were approved by the ACP Board of Regents and involves evidence based recommendations from doctors at the Penn Health System (Philadelphia, Pennsylvania), Minneapolis Veterans Affairs Medical Center (Minnesota), and the Yale School of Medicine (New Haven, Connecticut).
The American College of Physicians notes that approximately 25% of USA adults have had, at the very minimum, a one day lower back pain episode within the past three months. The socioeconomic impact of lower back pain in the USA was approximately $100 billion in the year 2006 . The costs include medical care and indirect costs due to lost wages and declines in productivity. [3] Recommendations for treatment options, including those for the use of acupuncture, include considerations of positive medical patient outcomes, the total number of back pain episodes, duration between episodes, alleviation of lower back pain, improvement in function of the back, and work disability reductions. Recommendations are for both radicular and nonradicular lower back pain.
The target audience for the American College of Physicians recommendations includes all doctors, other clinicians, and the adult population with lower back pain. The ACP notes, “Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment .” [4] In agreement, the National Institute of Neurological Disorders and Stroke (National Institutes of Health) notes that acupuncture is an effective treatment modality for the relief of chronic lower back pain. [5]
These findings are consistent with those published in Mayo Clinic proceedings finding that acupuncture is effective for the treatment of lower back pain. The same Mayo Clinic report notes that acupuncture does not cause any significant adverse effects. [6] The Mayo Clinic findings apply to both nociceptive and non-nociceptive pain. Nociceptive back pain includes musculoskeletal inflammation and pain involving nerve cells wherein nociceptors are activated. Nociceptors are afferent neurons in the skin, muscles, joints, and other areas. For example, nerve impingement (often referred to as a “pinched nerve”) produces one type of nociceptive pain.
Non-nociceptive pain does not involve inflammation and is more relevant to pain processing in the central nervous system. One type of non-nociceptive pain condition is fibromyalgia and acupuncture has been confirmed as an effective treatment modality for this condition. The Mayo Clinic proceedings note, “Martin et al. found a significant improvement between electroacupuncture vs sham electroacupuncture. Differences were seen on the Fibromyalgia Impact Questionnaire (FIQ) scores for fatigue and anxiety.” [7]
The Mayo Clinic and American College of Physicians findings are consistent with additional quality research. Memorial Sloan Kettering Cancer Center (New York) and University of York (United Kingdom) researchers note “We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed.” [8]
Doctors understand the true need for effective pain management. Nonpharmacological solutions are important for a variety of reasons including prevention of addiction, effective relief of pain, and prevention of adverse effects. This is often of heightened concern during pregnancy and for children. As a result, university hospitals integrate acupuncture into usual care settings to improve patient outcomes. For example, pediatric doctors at the UCSF Benioff Children’s Hospital San Francisco provide acupuncture to children, including non-needle laser acupuncture. At the University of California hospital, acupuncture is made available for both inpatients and outpatients. Dr. Kim notes that acupuncture reduces nausea up to 70%. She adds that acupuncture is also effective for significant reductions in post-surgical pain and chronic headaches. [9]
Recently, researchers have discovered how acupuncture stops pain and provides other forms of relief for patients. Breakthrough research conducted by University of South Florida (Tampa) and Fujian University of Traditional Chinese Medicine (Fuzhou) researchers documents how acupuncture stops pain. The researchers note, “acupuncture exerts a remarkable analgesic effect on SCI [spinal cord injury] by also inhibiting production of microglial cells through attenuation of p38MAPK and ERK activation.” [10]
Microglia are central nervous system immunity cells that secrete proinflammatory and neurotoxic mediators. Acupuncture reduces pain by attenuating this response. The researchers also document that acupuncture provides neuroprotection. The researchers note that acupuncture prevents brain damage in the hippocampus by “preventing microglial activation.” The University of South Florida members of the research team were from the Department of Neurosurgery and Brain Repair and the Department of Pharmaceutical Sciences. Funding was provided by the United States Department of Defense, University of South Florida Neurosurgery and Brain Repair, and the James and Esther King Biomedical Research Foundation.
The aforementioned research reveals an important biochemical mechanism involved in acupuncture’s ability to alleviate pain and reduce harmful inflammation. Researchers focus on other mechanisms activated by administration of acupuncture treatments. For example, laboratory investigations reveal how acupuncture regulates blood pressure.
University of California (Irvine) researchers find acupuncture effective for the treatment of high blood pressure. In a controlled laboratory study, University of California researchers have proven that electroacupuncture at acupoint ST36 (Zusanli) promotes enkephalin production, which dampens proinflammatory excitatory responses from the sympathetic nervous system that cause hypertension. Specifically, electroacupuncture regulates preproenkephalin gene expression, a precursor substance that encodes proenkephalin, which then stimulates the production of enkephalin. [11]
The formal recommendation for the use of acupuncture in cases of lower back pain by the American College of Physicians is based on modern research. Mayo Clinic findings and research from the Memorial Sloan Kettering Cancer Center (New York) and the University of York support this recommendation. In response to the needs of patients, doctors have already implemented acupuncture into several hospitals throughout the USA and both inpatient and outpatient acupuncture treatments are available.
Now, modern scientific investigations reveal how acupuncture works. University of South Florida and Fujian University of Traditional Chinese Medicine researchers confirm acupuncture’s ability to attenuate microglial activation. University of California researchers have quantified acupuncture’s ability to control inflammation by regulating enkephalins. In addition, the NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) provides professional certification for acupuncturists, which ensures standards of excellence for licensed acupuncturists. Given the large body of supportive research and the administrative support for providing safe and effective acupuncture to the general public, expect to see greater implementation of acupuncture into usual care settings.
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References
1. Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain.” Annals of Internal Medicine (2017).
2. Qaseem, et al. Annals of Internal Medicine (2017).
3. Katz J.N. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.J Bone Joint Surg Am200688 Suppl 2214.
4. Lam M. Galvin R. Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.Spine (Philadelphia, Pennsylvania 1976) 201338212438.
5. ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Low Back Pain Fact Sheet, National Institute of Neurological Disorders and Stroke, National Institutes of Health.
6. Nahin, Richard L., Robin Boineau, Partap S. Khalsa, Barbara J. Stussman, and Wendy J. Weber. “Evidence-based evaluation of complementary health approaches for pain management in the United States.” In Mayo Clinic Proceedings, vol. 91, no. 9, pp. 1292-1306. Elsevier, 2016.
7. Martin DP, Sletten CD, Williams BA, Berger IH. Improvement
in fibromyalgia symptoms with acupuncture: results of a randomized
controlled trial. Mayo Clin Proc. 2006;81(6):749-757.
8. MacPherson, H., A. Vickers, M. Bland, D. Torgerson, M. Corbett, E. Spackman, P. Saramago et al. “Acupuncture for chronic pain and depression in primary care: a programme of research.” (2017).
9. Leslie Lingaas. ucsf.edu/news/2014/04/113966/acupuncture-helps-young-patients-manage-pain. Acupuncture Helps Pediatric Patients Manage Pain and Nausea, 2014.
10. Lin, Lili, Nikola Skakavac, Xiaoyang Lin, Dong Lin, Mia C. Borlongan, Cesar V. Borlongan, and Chuanhai Cao. “Acupuncture-induced analgesia: the role of microglial inhibition.” Cell transplantation 25, no. 4 (2016): 621-628.
11. Cevic, C and Iseri, SO. The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. Acupuncture & electro-therapeutics research 2013; 38(1-2): 1-15. ncbi.nlm.nih.gov/pubmed/23724695.
by William Alexander | Sep 6, 2016 | Back Pain
Acupuncture is Leading the Way in Pain Management
Researchers demonstrate excellent clinical results using acupuncture for the treatment of lumbar disc herniations.
Researchers find acupuncture safe and effective for the treatment of lumbar disc herniations across multiple independent clinical trials. A meta-analysis of investigations reveals that Jiaji acupoints yield significant positive patient outcomes when combined with manual and electroacupuncture techniques. Distal and abdominal acupuncture also demonstrated significant positive patient outcomes. This research review covers rare acupuncture points demonstrating clinical efficacy and details a powerful manual acupuncture technique proven effective for relief of lumbar disc herniation symptoms. We’ll start with primary research by Song et al. and then take a close look at a meta-analysis by Wang et al., including specific approaches to clinical care proven to deliver excellent results.
Researchers find both electroacupuncture and manual acupuncture effective for the treatment of lumbar disc herniations. Song et al. conducted a clinical trial at the Xixiang People’s Hospital in Guangdong, China. Electroacupuncture and manual acupuncture significantly reduced patients’ pain levels. Outstanding positive patient outcomes were recorded for the electroacupuncture treatment group. Patients with lumbar disc herniations receiving electroacupuncture had a 91.8% total treatment effective rate. Improvements included pain reductions, increases in range of motion, and improved straight leg lift testing.
A sample size of 123 patients was randomly divided into two groups. In group one, 61 patients received electroacupuncture therapy. In group two, 62 patients received manual acupuncture. For the electroacupuncture patients, the Jiaji acupoints at the specific vertebra corresponding to the herniated lumbar disc, as well as on the two adjacent vertebrae, were selected as the primary acupoints and treated on both sides. Additional secondary acupoints were selected based on individual patient symptoms. For hip pain, the following acupoints were chosen:
Huantiao (GB30)
Chengfu (BL36)
For calf pain:
Weizhong (BL40)
Chengshan (BL57)
For lateral calf pain, the following acupoint were chosen:
Yanglingquan (GB34)
Zusanli (ST36)
Kunlun (BL60)
Xuanzhong (GB39)
Treatment commenced with the patient in a prone position. Upon disinfection, a 0.30 x 40 mm disposable needle was pierced perpendicularly into each acupoint until a deqi sensation was reported. Next, an electroacupuncture device was connected to the needles in the Jiaji acupoints. A continuous waveform was selected at an initial 0.8 Hz frequency. The intensity was then gradually increased until both sides of the lumbar muscle were twitching rhythmically at a tolerable rate for the patient. Subsequently, a 30 minute needle retention time was observed. One electroacupuncture session was conducted once per day for 20 consecutive days with a one day break after the 10th day. For the manual acupuncture patients, the following acupoints were selected according to the affected area:
Ganshu (BL18)
Shenshu (BL23)
Yaoyan (MBW24)
Huantiao (GB30)
Zhibian (BL54)
Chengfu (BL36)
Weizhong (BL40)
Weiyang (BL39)
Yanglingquan (GB34)
Feiyang (BL58)
Guangming (GB37)
Kunlun (BL60)
Tonggu (BL66)
Jinggu (BL64)
Houxi (SI3)
Treatment commenced with the patient in a prone position. Upon disinfection, a 0.30 x 40 mm disposable needle was pierced perpendicularly into each acupoint until a deqi sensation was felt. During the subsequent 30 minute needle retention time, the acupuncture needle was manipulated once every 10 minutes. One acupuncture session was conducted once per day for 20 consecutive days with a one day break after the 10th day. The total treatment efficacy was measured based on the TCM Treatment Efficacy Guidelines issued by the TCM Governing Board. Efficacy was categorized into 1 of 3 possible tiers:
Effective: Waist and leg pain ceased. Straightened leg lift of 70° and above. Normal waist and leg activity regained.
Improvement: Waist and leg pain relieved. Improvement in extent of waist movement.
Not effective: No improvement in symptoms.
The total treatment effective rate was measured as a percentage of patients who achieved at least the “improvement” tier. Electroacupuncture produced a 91.8% total treatment effective rate including pain reductions, increases in range of motion, and improved straight leg lift testing. Song et al. conclude that acupuncture is effective for the treatment of lumbar disc herniations.
The research team prefaced their study with background information. Lumbar disc herniation is a common disease among adults. Pain, numbness, or weakness arises due to damage or compression of the nerve root caused by herniation of the nucleus pulposus. This is the soft inner core of the vertebral disc that helps absorb compression and torsion. A herniation occurs when the soft material from the inner core escapes through the outer rings of the disc. This stubborn disease is usually characterized by an abrupt onset with a prolonged or repetitive course of symptomatic flare-ups. Main symptoms include leg and lumbar region pain, and also lower limb motor dysfunction. Lower limb paralysis is possible in severe cases.
Song et al. note that acupuncture is a relatively non-invasive treatment for disc herniations that dredges meridians, promotes qi circulation, eliminates blood stasis, and expels wind-dampness. Pain is thereby relieved when blood and qi circulation is restored. In modern terms, acupuncture stimulates parasympathetic tone and downregulates excess sympathetic nervous system activity. Resulting decreases in the inflammatory cascade of endogenous biochemicals results from the regulation of the autonomic nervous system.
Song et al. add that acupuncture regulates nerve activity, facilitates muscles relaxation, mitigates muscular spasms, dilates blood vessels, improves blood circulation, and also reduces both edema and inflammation. The Jiaji acupoints, located on the back beside the Du meridian, are used to treat diseases related to the corresponding affected nerve segments. Electroacupuncture utilizes electrical stimulation to facilitate the regeneration of damaged nerves by improving nerve cell metabolism and nerve cell enzyme activity. The basis of this is that electroacupuncture forms a localized, stable, and subtle electric current that boosts the electrophysiological properties of nerve cells (Sun, 1996).
In a related study, Wang et al. conducted a meta-analysis on the efficaciousness of acupuncture for the treatment of lumbar disc herniations. Without exception, the clinical investigations demonstrate that acupuncture is a safe and effective treatment modality for lumbar disc herniation patients. The following are examples of studies included in the meta-analysis.
Liu et al. investigated the efficacy of conventional acupuncture therapy. Conventional acupuncture treatment was administered by first identifying the vertebrae with lumbar disc herniations. Corresponding Du meridian acupoints and the two adjacent Jiaji acupoints were needled. The identified acupoints were treated with the Shao Shan Huo (Setting the Mountain on Fire) needling technique. Patients were treated for 10 consecutive days and achieved a 95% total treatment effective rate.
Shao Shan Huo is a powerful tonification needling technique in Traditional Chinese Medicine (TCM). Needles are inserted and stimulated to elicit the arrival of deqi for purposes of reinforcing qi. When applied properly, the patient feels a warm sensation at the needle region. In addition, the skin will be flush red as a result of enhanced micro-circulation of blood.
Initially, the needle is inserted slowly to superficial depth beneath the skin. During the procedure, lifting and thrusting is applied to three levels of depth beneath the skin, starting with the most superficial level at approximately a 0.5 cun depth. This is followed by lifting and thrusting at the middle level at approximately 1.0 cun and the deep level at approximately 1.5 cun. Depth varies according to patient size and acupoint location.
At each of the three depths of insertion, the needle motion combines quick and forceful thrusting with slow and gentle lifting for a total of nine times. Rotation may also be applied with the same techniques. After stimulation at all three levels is complete, the needle is lifted to the superficial level and the procedure is repeated, often three times, to ensure elicitation of a qi sensation producing heat and redness of the skin. The patient may also sweat in the region of the needle or throughout the body as a result of the heat sensation produced by this tonification method. Liu et al. achieved a 95% total treatment effective rate using the Setting the Mountain on Fire technique using the Du and Jiajia (Huatuojiaji) acupuncture points at correlated regions to lumbar disc herniations. Notably, acupuncture was applied for 10 consecutive days.
Deng and Cai’s investigation also examined application of the Jiaji acupoints for the treatment of lumbar disc herniations. In a different approach to needle stimulation, Deng and Cai applied electroacupuncture stimulation to the needles. They achieved significant levels of positive patient outcomes in their clinical trial. In their investigation, patients were treated every other day. Short-term results and a three month follow-up confirm significant clinical improvements.
He et al. had an entirely different approach to acupuncture therapy for the treatment of lumbar disc herniations. Their approach focused on abdominal acupuncture and anterior acupoints. The clinical investigation yielded significant positive patient outcomes. In their semi-protocolized investigation, a set of primary acupoints were applied plus secondary acupoints were added for specific diagnostic concerns. The primary acupoints for all patients were the following:
Shuifen (CV9)
Qihai (CV6)
Guanyuan (CV4)
Next, secondary acupoints were added based on diagnostic criteria. For acute lumbar disc herniations, the following acupoints were added:
Shuigou (GV26)
Yintang (MHN3)
For prolonged lumbar disc herniation, the following acupuncture point was added:
Qixue (KD13)
For generalized lumbago, the following acupoints were added:
Wailing (ST26)
Qixue (KD13)
Siman (KD14)
For sciatica occurring when sitting, the following acupuncture points were added:
Qipang
Wailing (ST26), affected side only
Xiafengshidian
Xiafengshixiadian
He et al. measured improvement rates after three weeks of acupuncture therapy. Patients achieved significant improvements. The researchers conclude that the protocol is effective for the treatment of lumbar disc herniation symptoms. He et al. used several acupoints termed ‘extra’ points including Xiafengshidian, Xiafengshixiadian, and Qipang. The acupoints demonstrate that the researchers focused on abdominal acupuncture as a means of treating lumbar concerns.
Xia Feng Shi Dian (Xia Feng Shi Dian, Lower Wind-Damp Point) is located 2.5 cun lateral to CV6 and is indicated for the treatment of knee disorders, including postoperative swelling and pain. Xiafengshixiadian (Xia Feng Shi Xia Dian, Below Wind-Damp Point) is located 3 cun lateral to CV5 and is used for leg, ankle, and foot disorders. Qipang (Qi Pang, Beside Qi) is located 0.5 cun lateral to CV6 and is indicated for lower back and leg pain, swelling, and weakness; including postoperative disorders.
The meta-analysis included the clinical research of Zhang et al. Manual acupuncture was applied to acupoints surrounding the afflicted area. All needles were directed towards the center of the afflicted region. Zhang et al. achieved a 97.5% total treatment effective rate.
Overall, the metal-analysis by Wang et al. documents that acupuncture is a safe and effective treatment modality for patients with lumbar disc herniations. Implementation of Jiaji acupoints was common across several studies. Other techniques including abdominal acupuncture and local Ashi acupoint acupuncture also demonstrated clinical effectiveness. Both electroacupuncture and specialized manual acupuncture demonstrated effectiveness as well. As a result of the findings, the researchers conclude that acupuncture is an important treatment option for patients with lumbar disc herniations.
References:
Song YJ, Yu MJ, Li L, Huang WX, Cai ZW, Su DP. (2013). Clinical Observation of Electro-acupuncture in Treatment of Lumbar Disc Herniation. Chinese Manipulation & Rehabilitation Medicne.
Sun ZR. Mechanism of acupuncture in the regeneration of surrounding damaged nerves. 1996(02).
Wang FM, Sun H, Zhang YM. (2014). Advance of Clinical Research in Intervention of Lumbar Disc Herniation（LDH） with Acupuncture Moxibustion. Journal of Clinical Acupuncture and Moxibustion.
30(3).
Deng W & Cai LH. (2011). Electroacupuncture on Jiaji acupoint in treating lumbar disc herniation. Journal of Clinical Acupuncture. (7).
He JX, Lin WR, Chen JQ, Huang Y, Wang SX, Lin HH & Chen HX. Abdominal acupuncture in treating lumbar disc herniation. Shanghai Journal of Acupuncture. 2012. (7).
Liu YZ, Sun XW & Zou W. (2012). Shao Shan Huo acupuncture technique on lumbar Jiaji acupoint in treating lumber disc herniation. Journal of Clinical Acupuncture. (6).
http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1670-acupuncture-found-effective-for-lumbar-disc-herniations
