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Acupuncture

  • Acupuncture is a clinical modality which is frequently offered to pain patients.
  • Acupuncture is traditionally part of a number of traditional East Asian medical systems including: Traditional Chinese Medicine (TCM) and Korean Traditional Medicine (KTOM). Additionally, acupuncture has been an integral part of health care in Japan, Vietnam and other regions of Asia.
  • Since the seventies acupuncture has been a licensed profession in the United States and today 47 states (and the District of Columbia) license acupuncturists. Additionally, physicians, and other professionals may also practice acupuncture.

Acupuncture: Needling

  • Involves the insertion of specialized needles into regions of the body determined on the basis of traditional theory, bioscience based anatomy and physiology, and clinical assessment.
  • Needles range from .4 to .12 mm in diameter and may be from 15mm to 150 mm in length.
  • Needles are typically retained for 20 minutes, and in some cases up to 45 minutes. However, retention time and the stimulus applied to the needles can vary according to the treatment plan.
  • Needle insertion and stimulation elicits both local and central responses and has been demonstrated to reduce pain.

Acupuncture Ideas: Qi

  • Traditional Chinese Medicine conceives of a body in which qi and blood are rhythmically circulated throughout the organs to the periphery, traveling through channels that allow qi and blood to reach every part of the body. While acupuncture is sometimes characterized as "energy medicine" it is clear that the Chinese originators were very careful observers of human anatomy and physiology, particularly of the vascular system.
  • The idea of "qi" is often translated as energy, but for the Chinese, qi was the unseen, but critical part of human physiology that traveled with blood. Qi is closely linked with respiration and it is not unreasonable to think of qi and blood traveling together as the circulation of oxygenated blood.

Acupuncture Assessment

  • Diagnostic procedures used by acupuncturists include taking a patient history and conducting a physical examination. Distinctively traditional elements distinctive elements such as pulse palpation, abdominal palpation, channel palpation, and inspection of tongue and skin can form part of the physical examination.
  • The video segment presents a focused history and palpation during physical examination.

Acupuncture Ideas: Qi Dynamic

  • Qi is understood in Chinese medicine as the source of physiologic activity. Qi is derived from food and air and is necessary for all bodily activity. When the qi is abundant and its movement normal the body functions normally and pain is absent.
  • The normal movement of qi in the body, that is the normal functioning of the body: breathing in and out, the movement of peristalsis, etc. is referred to as the qi dynamic.
  • The qi dynamic can be disrupted by disease processes, life-style, emotional states etc. leading to pain and dysfunction.

Pattern Diagnosis

  • Diagnostic patterns are heuristic in traditional Chinese medicine and are identified using findings from the history and examination.
  • Pattern diagnosis is considered an important and distinctive feature of traditional Chinese medicine.
  • A traditional clinical aphorism is: "One disease has many treatments; one treatment can address many diseases."
  • For example a specific clinical instance of "headache" would be considered to have a distinct pathomechanism that would be revealed through the diagnostic process and characterized by a pattern. That pattern might also be applicable to other conditions.

Acupuncture and Headache

  • Traditional Chinese Medicine characterizes headache as both a disease entity and as a symptom of pathological processes. Headache is extensively differentiated according to the pain presentation, pain distribution, and accompanying symptoms.
  • For example, a standard reference describes 23 distinct headache patterns that are used to differentially diagnose headache.
  • Biomedically informed approaches to Chinese medicine diagnosis associate migraine with a more limited set of patterns.
    • Liver depression – Qi & Blood Vacuity Pattern
    • Ascendant Liver Yang Hyperactivity Pattern
    • Cold Reversal Pattern
    • Blood Stasis Obstructing the Network Vessels Pattern

Morgan's Assessment

  • Clinically Morgan presents with signs that are associated with two specific patterns:
    • Liver depression – Qi & Blood Vacuity Pattern
    • Blood Stasis Obstructing the Network Vessels Pattern

Morgan's Assessment: Liver Depression

  • Specific patterns are suggested by specific findings
    • Liver depression – Qi & Blood Vacuity Pattern
      • Stress and mood are migraine triggers
      • Other triggers: not eating, strong odors
      • Greater likelihood of h/a on 1st day of menses or immediately before
      • Stooling can temporarily relieve migraine symptoms
      • Childhood history of stomach qi counter flow (vomiting) with food stagnation suggesting a weakened spleen stomach and impaired free coursing
      • On palpation abdomen is tender at "alarm point" Ren 12 (on midline midway between the xiphoid process and the umbilicus).

Liver Depression

  • In Chinese medicine the liver is considered very important in maintaining the qi dynamic. When it is constrained or when digestive function (governed by the spleen and stomach) is weakened the liver can be said to "overact on the spleen" producing signs such as irritability, digestive upset, loose stool, menstrual irregularity, and headache. These comparatively mild signs can be worsened by other conditions or through chronicity.

Morgan's Assessment: Blood Stasis

  • Specific patterns are suggested by specific findings
    • Blood Stasis Obstructing the Network Vessels Pattern
      • History of head injury
      • headache more likely on 1st day of menses or immediately before
      • menses painful with clots and darker blood
      • pulse rough and fine
      • tongue stasis signs at edge and center, some heat signs at tip

Blood Stasis

  • In Morgan's case her early history of cyclic vomiting, as well as her history of headaches prior to the concussion suggest a disruption of the qi dynamic. Subsequent to the concussion, signs of blood stasis are clearly in evidence. The head trauma and resulting blood stasis exacerbated the problems that Morgan was already experiencing.

Treatment Planning

  • Acupuncture point selection is an important part of treatment planning.
  • In this case points would be selected
    • Based on the diagnostic patterns
    • Based on the regionalization of headache pain
      • According to channel distribution
    • Based on the tenderness of established acupuncture points
    • Based on the presence of transiently reactive points on the channel sinews.
  • Treatment would be revised based on the patient’s response.

Treatment Planning: Channel Palpation

The palpation of channel pathways as well as their associated acupuncture points can be an important part of both assessment and treatment planning. Depending on the condition points and regions that are tender may be important clinical signs and loci for needling. Channel theory posits relationships between different regions of the body that are established by channel pathways (as roughly depicted in the adjacent image). Thus a distal point on the arm might be relevant to the assessment or treatment of a pain associated with a specific area of the head.

Acupuncture and Evidence

  • The quality of the evidence base for the use of acupuncture in a range of painful conditions is steadily improving (Vickers et al. 2102, 2014, Hempel et al. 2014).
  • The evidence base for the use of acupuncture in headache pain in general is improving a recent Cochrane review (Linde et al. 2016) concluded:
    • "The available results suggest that acupuncture is effective for treating frequent episodic or chronic tension-type headaches, but further trials - particularly comparing acupuncture with other treatment options - are needed."

Acupuncture and Pediatric Migraine

  • The evidence base for the use of acupuncture in pediatric migraine headache pain is quite limited. One prospective interventional cohort study (case series) examined acupuncture as treatment for emergent pediatric migraine in the ED. No RCTs are available.
  • The study authors concluded "With all subjects showing improvement or resolution of migraine headache, this pilot study introduces an alternative intervention to pediatric migraine management. Further studies are needed to evaluate the duration of symptom resolution and comparative effectiveness; auricular acupuncture seems to be a valid alternative."
    • Graff et al. 2016

Acupuncture and Evidence

  • The evidence base for the use of acupuncture in managing migraine headache is improving, a recent Cochrane review (Linde et al. 2016) concluded:
    • "The available evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. Contrary to the previous findings, the updated evidence also suggests that there is an effect over sham, but this effect is small. The available trials also suggest that acupuncture may be at least similarly effective as treatment with prophylactic drugs. Acupuncture can be considered a treatment option for patients willing to undergo this treatment. As for other migraine treatments, long-term studies, more than one year in duration, are lacking."

Acupuncture Adverse Events

  • Minor risks
    • Pain on needle insertion (commonly experienced)
    • Bleeding, and bruising (commonly experienced)
    • Transient nerve damage (relatively rare)
  • Infection is typically rare when appropriate aseptic technique is used
    • Sterile single use disposable needles, appropriate skin cleansing and handwashing substantial reduce risk
  • Organ puncture and damage to tissue
    • Pneumothorax: comparatively rare, but possibly underreported
    • Damage to heart, liver, kidney, spinal cord, spinal nerves, brain stem are rare

When to Refer for Acupuncture

  • Acupuncture referral is often triggered by clinician experience or patient preference. Assessing the evidence base for acupuncture in relation to the presenting complaint is an appropriate first step.
  • Acupuncture is suitable for referral in the context of a wide range of pain conditions. For adult patients the evidence base is strong in headache. It is less so for pediatric patients.
  • Consider referral when limiting, reducing or avoiding pharmacological intervention is desirable.

How to Refer for Acupuncture

  • Alternatively, if time and resources permit requesting consultation and a report from a qualified acupuncturist may be more helpful.
  • Refer with the expectation of reporting and trialing of acupuncture. Depending on the complexity and chronicity of the case appropriate time for evaluating clinical outcomes range from 8 to 12 visits.

The Acupuncture Referral

  • Acupuncture regulations and licensure can vary from state to state. As is the case with any referral, it is appropriate to be familiar with applicable laws and regulations in the state in which you practice.
  • Licensed Acupuncturists: Acupuncture is an independently licensed profession in 47 states including the District of Columbia. Licensed Acupuncturists typically complete the equivalent of 4 academic years of training after completing college requirements and pass a nationally recognized examination.
  • Physicians: In most jurisdictions, physicians may practice acupuncture with no documentation of additional training. However, most physician acupuncturists will have completed at least 300 hours of acupuncture training.
  • In some jurisdiction providers such as Doctors of Chiropractic, Physical Therapists, Naturopathic Doctors, and Nurses may also be permitted to practice acupuncture. Licensing and training standards vary by jurisdiction.

Finding an Acupuncturist

  • National Commission for the Certification of Acupuncture and Oriental Medicine (NCCAOM) provides a national listing of Diplomates and the states in which they practice. NCCAOM Diplomates have had their education independently verified, has passed a rigorous multipart examination, participate in continuing education, and are bound by a code of ethical practice. The "find a practitioner" button can identify a qualified acupuncturist in your area.
  • American Academy of Medical Acupuncture (AAMA)
    • "the professional society of physicians (MDs and DOs) in North America who have incorporated acupuncture into their traditional medical practice." This site can be used to locate physicians in your area who practice acupuncture.
    • http://www.medicalacupuncture.org/
  • State professional associations may be a helpful resource.
  • As is the case with many referrals, both colleagues and patients may provide useful guidance or recommendations concerning local practitioners who may be suitable for referral.
  • State licensing agencies generally provide an online resource for checking the license and credentials of any individual holding themselves out as an acupuncturist. It is good practice to verify a referees license to practice their profession in any given state.

Acupuncture Referral: Communication

  • Communication around referral can vary widely from a brief informal recommendation to a detailed letter of referral. In institutional settings with electronic health records, the referral, report of consultation and follow up are easily managed.
  • A written letter of referral, providing a brief history, findings, problem list, and the clinical goal of the referral is ideal. A less formal approach may also be appropriate since the Licensed Acupuncturist will take a detailed history and request records they may need.
  • Depending on the condition, its complexity and chronicity duration and frequency of treatment may vary. A trial of 8 to 12 treatments should provide a basis for both referrer and clinician to assess the potential clinical benefit.
  • It is appropriate for the referring clinician to follow up with the patient to assess their impression of acupuncture's helpfulness

References

  • American Academy of Medical Acupuncture. Conditions for which Medical Acupuncture May Be Indicated in a Hospital Setting. http://www.medicalacupuncture.org/ForPatients/GeneralInformation/
    HealthConditions.aspx
    . Downloaded 11/09/2015
  • Ergil M, Ergil K. Pocket Atlas of Chinese Medicine. Thieme: New York. 2009
  • Graff, D. M., & McDonald, M. J. (2016). Auricular Acupuncture for the Treatment of Pediatric Migraines in the Emergency Department. Pediatric Emergency Care. https://doi.org/10.1097/PEC.0000000000000789
  • Hempel, S., Taylor, S. L., Solloway, M., Miake-Lye, I. M., Beroes, J. M., Shanman, R., Booth, M. J., Siroka, A. M., Shekelle, P. G. Evidence Map of Acupuncture. VAESP Project #05-226; 2013
  • Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, Vickers A, White AR. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016 Jun 28;(6):CD001218.
  • Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews. 2009;(1):CD001218. Accessed at http://www.thecochranelibrary.com on July 2, 2014.
  • Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews. 2009;(1):CD007587. Accessed at http://www.thecochranelibrary.com on July 2, 2014.
  • Sackett, David 2000 Evidence-based medicine: How to practice and teach EBM. Edinburgh.
  • Seshia, Wang SJ, Abu-Arafeh I, Hershey AD, Guidetti V, Winner P, Wöber-Bingöl C. Chronic daily headache in children and adolescents: a multi-faceted syndrome. Can J Neurol Sci. 2010 Nov;37(6):769-78.
  • Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine. 2012;172(19):1444–1453.
  • Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA. 2014;311(9):955–956.
  • World Health Organization 2003 Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials WHO, Geneva
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