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REFERENCES

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New JCAHO Standard for Pain Management

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Acupunture Facts: Did You Know?

Also see Footnotes at end of article.

As a former Navy Flight Surgeon and civilian occupational medicine physician, I know the frustration of taking care of many occupationally related musculoskeletal injuries. I have never been impressed with the effectiveness of NSAIDs for muscle strains, and medications such as muscle relaxants and narcotics often have side effects that preclude the patient from participating in even modified duty. In this article I will discuss acupuncture, an alternative to these pharmaceutical interventions that I believe is more effective and has fewer side effects than drug therapy.

History
Practiced in mainland China for over 2,000 years, acupuncture is the art and science of achieving a therapeutic effect through the placement of micro-fine needles in specific acupoints throughout the body. Through this technique the Chinese believe the channels through which Qi (the body’s life force) flows are activated. If these channels are blocked, as can happen in cases of pain or acute disease, they can be opened. If the Qi in the channels is depleted, as is the case in chronic disease, it can be tonified or boosted. Both tonification and unblocking are often facilitated by the pumping of ions (electrically charged particles) through the channels, or by application of moxibustion (a gentle, herbal heat) to the needles.

Although acupuncture has its roots in ancient China, it has been in the West longer than most Americans realize. Acupuncture reached the United States via France in the 1800s and was endorsed for the treatment of back pain and sciatica by no less than Sir William Osler, who wrote about it in his epic "The Principles and Practice of Medicine." For unknown reasons—but perhaps because it was confused with many other less successful treatments of the time—interest in acupuncture in the U.S. waned during the early and mid 1900s. During this period, however, its practice and research into its efficacy continued to flourish in France, and to a lesser extent in other parts of Europe. As a result, a "westernized" form of acupuncture developed that attempted to synthesize traditional Chinese concepts with Western scientific understanding. This form of acupuncture, practiced by physicians, is now called "medical acupuncture."

Considering the close ties America enjoys with Europe, it is perhaps ironic that American interest in acupuncture did not rebound sharply until Sino-American ties began to form in the early 1970s. Accompanying the first American ping-pong team to China was a young New York Times reporter named James Reston. After an emergency appendectomy he had his post-operative pain successfully treated with acupuncture. After reading his account, the personal physician of President Nixon witnessed several surgeries performed using acupuncture anesthesia while accompanying the president on his first trip to China in 1972. Since then, interest in and use of acupuncture in the United States has steadily grown.

Physicians in the U.S. have several avenues through which to receive training. To date, over 3,000 have been trained by the UCLA School of Medicine alone. There is also a professional society for physicians, the American Academy of Medical Acupuncture, which publishes a peer-reviewed journal, has annual meetings, and offers continuing medical education (CME) to its members.

Basic Science
Several models exist to explain acupuncture’s mode of action: "energy flow" through meridians, counter-irritation, and neurologic remodulation. Although there is some evidence for the former two of these models, the best substantiated in the laboratory is the latter. Bruce Pomeranz, Ph.D. published several landmark articles in the 1970s, establishing that acupuncture activates the body’s natural painkiller system causing the release of morphine-like compounds called endorphins.¹ He further demonstrated that acupuncture’s analgesic effect could be blocked by naloxone, which blocks the effect of morphine and endorphins.

In subsequent years, much research has been done in animals demonstrating that acupuncture’s analgesic effect involves multiple pathways in the spinal cord and brain. Certain chemical neurotransmitters are turned on and others suppressed in response to acupuncture. The perception of pain is a complex phenomenon involving both ascending (towards the brain) and descending (towards the body) pathways. By modulating these pathways, acupuncture changes the threshold for pain perception. Some of these changes are transient but others are long lasting. Because chronic pain is in some sense a learned perception, sometimes interrupting the signal for a period of time will allow the nervous system to "unlearn" the feeling of pain.

In addition to these animal experiments, the advent of functional MRI (fMRI) has allowed investigators to literally see what is happening in the brain of patients who are undergoing acupuncture. One of the first of these experiments, published in the prestigious Proceedings of the National Academy of Sciences, showed that stimulation of a traditional vision point on the foot stimulated the same portion of the brain stimulated by light. Stimulation of non-vision points on the foot did not show such an effect. ² Since then, other experiments have shown that stimulation of traditional pain-relieving points stimulates the nuclei of the brain heavily involved with endorphin production. ³

Patients often ask me if acupuncture is just covering up pain and not addressing the underlying problem. The answer is definitely no. In addition to some of the clinical mechanisms outlined below, there are numerous studies documenting the effects of acupuncture on circulating hormones such as ACTH⁴, cortisol⁵, and growth hormone⁶. Clearly, changing levels of such hormones can have an effect on inflammation and thus tissue healing. Other studies have shown that acupuncture speeds the healing of surgical wounds.

Clinical Relevance
How do we translate these basic science findings into clinical practice? Fortunately, we have thousands of years of practical experience to fall back on. In the office, some of the points I use are chosen for their traditional indications; in other words, there is still no scientific explanation for them. My personal belief is that these points stimulate neurologic pathways that are at present not understood.

Other points are chosen based on our modern understanding of anatomy. Many acupuncture points coincide with common "trigger points" which are irritable points in muscles that often refer pain to other body parts. The Chinese have long called these trigger points "ah shi" which translates to "that’s it." Studies published by physiatrists have demonstrated that "dry needling" these trigger points works just as well as injecting them with steroids and leads to much less post-injection soreness. ⁷ Allergic reactions and local tissue weakening from steroids are also avoided.

Sciatica, commonly blamed on spinal problems is, in many cases, secondary to trigger points in the muscles of the buttock. Spasm of these muscles can put pressure on the sciatic nerve as it travels through them. Releasing these trigger points with an acupuncture needle can lead to dramatic resolution of otherwise untreatable sciatica. It also saves the patient expensive imaging studies and invasive procedures such as epidural steroids and even surgery.

Trigger points in the forearm muscles similarly cause lateral epicondylitis, a.k.a. tennis elbow. It is the chronic spasm of these muscles that puts tension on the tendons of the elbow, leading to pain and inflammation. If these trigger points are not treated, the tennis elbow will not get better, or will return as soon as the patient returns to regular duty.

No commentary on occupational medicine would be complete without mentioning the bane of all employers—chronic low back pain. This pain is often mysterious in origin and notoriously difficult to treat. These patients can rack up incredibly high medical bills as well as being responsible for the highest percentage of time off work of all occupational injuries. An excellent study published in JAMA demonstrated the superiority of medical acupuncture to both physical therapy and Transcutaneous Electrical Nerve Stimulation (TENS) in the treatment of these patients. Patients treated with acupuncture reported significantly more pain relief, improved functionality, as well as decreased medication use. ⁸

Many of the examples cited above are for conditions that are chronic in nature. Although many of the patients I have treated do present with chronic conditions (often because acupuncture is viewed as a treatment of last resort), I have had some of my most dramatic successes with acute injuries. A good friend of mine, a 40 year old female runner, called my office one day to see if I could help with a hip strain she had sustained while sprinting the day before. She had had this injury before and it had taken months to heal. I treated her once with an application of needles to several piriformis and gluteal trigger points and she was back running the next day.

When I was working in occupational medicine, I had a young man present with a terrible headache one hour after turning his head into a door that was being opened by a co-worker. The headache was one-sided, but there was no sign of trauma to the head or tenderness at his site of pain. What he did have, however, was significant tenderness of his contra-lateral sternocleidomastoid muscle. Treatment of these trigger points with local acupuncture provided him with prompt relief of pain, and he was back to full duty the next day.

Besides the above-stated studies, what other evidence exists for the effectiveness of acupuncture? A Medline search from 1966 to present resulted in 4,577 human studies published in English; 175 of these have been published since 1995 and are represented in such journals as JAMA, Lancet, and Annals of Internal Medicine. While some of these studies have been criticized for poor methodology, a growing number are standing up to critical review.

In 1997 the United States National Institutes of Health gathered a panel of experts to evaluate the research evidence regarding acupuncture. Based on this, a consensus statement was released, the summary of which states:

"Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, 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 placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative 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, in 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." ⁹

Summary
Occupational injuries in large part involve the musculoskeletal system and many current therapies lack the effectiveness desired to promptly get patients back to full duty, with alleviation or resolution of their pain, and in a timeframe that is acceptable to their employer. As insurers, employers, and occupational medicine practitioners search for new and better ways to treat work related injuries, perhaps it is time to take a hard, yet open-minded, look at acupuncture, one of the most ancient of techniques used to address these problems. I believe that, put into practice, acupuncture can be used to accomplish what everyone wants: getting the patient back to work, often at an improved level of functionality, with the least amount of pain and without the negative side effects of many pharmaceuticals currently being used.

Footnotes:

1 Cheng, R.S., Pomeranz, B., "Electroacupuncture analgesia could be mediated by at least two pain-relieving mechanisms: endorphin and non-endorphin systems," Life Sciences 25(23):1957-62 (1979 Dec 3).

2 Cho, Z.H. Chung, S.C., Jones, J.P., Park, J.B., Park, H.J. Lee, H.J., Wong, E.K., Min, B.I., "New findings of the correlation between acupoints and corresponding brain cortices using functional MRI," Proceedings of the National Academy of Sciences of the United States of America 95(5):2670-3 (1998 Mar 3).

3 Fang, B., Hayes, J.C., "Functional MRI explores mysteries of acupuncture," Diagnostic Imaging 21(7):19-21 (1999 Jul).

4 Malizia, E., Andreucci, G., Paolucci, D., Crescenzi, F., Fabbri, A., Fraioli, F., "Electroacupuncture and peripheral beta-endorphin and ACTH levels," [letter] Lancet 2(8141):535-6 (1979 Sep 8).

5 Cheng, R., McKibbin, L., Roy, B., Pomeranz, B., "Electroacupuncture elevates blood cortisol levels in native horses; sham treatment has no effect," International Journal of Neuroscience 10(2-3):95-7 (1980).

6 Finch, P.M., Yuen, R.W., Watson, F.E., "Endogenous opiates modulate release of growth hormone in response to electroacupuncture," Life Sciences 32(15):1705-9 (1983 Apr 11).

7 Garvey, T.A., Marks, M.R., Wiesel, S.W., "A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain," Spine 14(9):962-4 (1989 Sep).

8 Ghoname, E.A., Craig, W.F., White, P.F., Ahmed, H.E., Hamza, M.A., Henderson, B.N., Gajraj, N.M., Huber, P.J., Gatchel, R.J., "Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study," [published erratum appears in JAMA 281(19):1795 (1999 May 19)], JAMA 281(9):818-23 (1999 Mar).

9 "NIH Consensus Conference-Acupuncture," JAMA 280(17):1518-24 (1998 Nov 4).