An interview with Angelica Fargas-Babjak, MD and Alejandro Elorriaga Claraco, MD (Spain)

Medical Acupuncture – An effective Hands-On Approach For Pain Management

Angelica Fargas-Babjak, MD, FRCPC is a Professor of Anesthesiology at McMaster University in Hamilton, Ontario, where she is on the Anesthesia staff of the Health Sciences Corporation and is the Director of the Acupuncture/Pain Clinic. She is the Director of the McMaster Continuing Medical Education program, Medical Acupuncture for the Treatment of Pain.

Alejandro Elorriaga Claraco, MD (Spain) is a Sports Medicine specialist trained in Spain. He is the co-director of the McMaster Medical Acupuncture Program and is on regular faculty with the Medical Acupuncture for Physicians program of the University of California at Los Angeles.

Q: What exactly is acupuncture?
A: Acupuncture is a physical form of treatment in which small solid needles are inserted into the skin at specific points, at varying depths, and left in place or manipulated. Originally acupuncture was part of Traditional Chinese Medicine (TCM), an empirically established medical system with more than 2,500 years of documented existence. In western medicine, acupuncture has been adopted and successfully incorporated into medical or allied health practices as medical acupuncture, combining traditional clinical information with knowledge from the biomedical sciences.
Acupuncture is an elegant and gentle treatment approach to activate physiologic adaptive responses of the body. It’s both a systemic and a local therapy, as a variety of biologic effects are triggered by inserting needles into acupuncture points.

Q: What’s the evidence for acupuncture?
A: Considerable evidence supports the claim that opioid peptides are released during acupuncture, explaining at least partially its analgesic effects. Stimulation by acupuncture activates the hypothalamus and the pituitary gland, producing a broad spectrum of systemic effects. Altered secretion of neurotransmitters and neurohormones and changes in the regulation of blood flow, both centrally and peripherally, have been documented. There’s also evidence of alterations in immune function.

During the last 40 years, adding electrical stimulation to the needles has enhanced the analgesic effects of acupuncture treatment. Research has shown that there are at least two clearly defined systems involved in this phenomenon. One is an endorphin-dependent system involving low-frequency, high-intensity electrical stimulation of the acupuncture needle. This response is slow in onset, generalized throughout the body, and cumulative on subsequent stimulation. The other is a monoamine-dependent system involving high-frequency, low-intensity electrical stimulation of the acupuncture needles. This response is rapid in onset, distributed according to the segments of the spinal cord, and isn’t cumulative. The possible mechanism for the other many effects elicited by acupuncture still aren’t known precisely, but promising new research, such as functional magnetic resonance imaging during needling will soon shed new light on this fascinating subject. In addition to the physiologic responses elicited by acupuncture, it’s well-established that acupuncture points are associated with important neurovascular structures and with the motor points of muscles.

Acupuncture has been successfully used in complex treatment of chronic pain syndromes during the last 30 years. In November 1997, after examining the available scientific evidence, an independent panel of experts at the U.S. National Institutes of Health issued a report concluding that acupuncture is effective in treating adult postoperative nausea, chemotherapy nausea and vomiting, and postoperative dental pain. In other situations, such as addiction, stroke, rehabilitation, headaches, migraines, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, lower back pain, carpal tunnel syndrome and asthma, acupuncture is considered useful as an adjunct treatment or an acceptable alternative. This report represents the official validation of the use of acupuncture in the U.S. — but the full range of acupuncture applications is much broader, as has been recognized for years by the World Health Organization (WHO).

Q: What does acupuncture not work for?
A: As a single therapy, acupuncture hasn’t shown itself to be of substantial value in severe, chronic inflammatory and immune-mediated disorders, such as ulcerative colitis, asthma, rheumatoid arthritis and collagen vascular disease, which require systemic corticosteroid medication. Acupuncture isn’t very useful on its own in chronic pain management, but adding the technique to multidisciplinary or multimodal approaches is extremely helpful.

Q: Are there any adverse effects or contraindications?
A: Minor adverse reactions to acupuncture treatment include bruising, post treatment drowsiness, vasovagal effects, such as nausea or syncope, and occasionally transient worsening of the symptoms. More serious complications are limited in practice to infection, broken needles and perforation of a viscus (mainly the pleura, causing a pneumothorax). These turn out to be very rare — less than 200 cases reported worldwide — and are usually related to the skill of the operator. Practitioners using proper insertion technique and sterile disposable needles have never been reported to have serious complications with their patients.
There are no absolute contraindications to acupuncture, although it should be avoided over infectious or wounded areas (surgical or otherwise). Relative contraindications include electrical stimulation over the chest in patients with pacemakers, cranial stimulation in those with epilepsy, avoiding certain points during pregnancy, using caution when needling vascular and intraarticular areas in patients with coagulopathies, and inserting semipermanent needles in patients with valvular heart disease.

Q: Which patients should be considered for acupuncture?
A: The indications for acupuncture include both acute and chronic conditions. For acute conditions, consider any musculoskeletal problem, from sprains and strains to acute lower back pain. In addition, acupuncture can help in the early stages of upper respiratory infections, sinusitis, laryngitis.

Q: How can it help in such infections? With pain?
A: Yes, but not only an infection is an environmental problem, ackupuncture regulates autonomic activity in the mucosa, thus has an effect on permeability. In addition, a direct effect of acupuncture on lymphocytic function has been shown.), indigestion, pain of pyelonephritis, and muscle tension headaches. For chronic conditions, there are three main groups of indications:
• palliative care of nonmalignant pain, including chronic lower back pain, carpal tunnel syndrome, tennis elbow, neck and shoulder pain, and headaches
• functional problems of the digestive, genitourinary, and neuroendocrine systems, such as irritable bowel syndrome, menstrual problems, chronic fatigue, mild depression and frequent respiratory infections
• patients with multiple drug sensitivities or who are on multidrug therapy, and are open to or prefer nonpharmacologic management of their problem

Q: In what other conditions can acupuncture help?
A: One of the greatest strengths of acupuncture intervention is for disorders that are difficult to characterize and treat by conventional medicine. These include ill-defined fatigue or low energy, mild depression, stress-related myofascial symptoms (e.g. muscle tension headaches, neck pain), early functional disturbances (e.g. diminished libido), anxiety, sleep disturbances, bowel dysfunction, and recurrent infectious and inflammatory states without underlying frank immunodeficiency (e.g. sinusitis, gastroenteritis, viral illness).

Q: How can I incorporate acupuncture into my practice?
A: Integrating acupuncture into a conventional medical practice is easier than you may think. As with any other therapeutic intervention you offer to your patients, first inform them thoroughly about all the aspects involved in getting this treatment, explaining in detail the conditions for which acupuncture works better, the expected number of treatments, possible side effects, and typical outcomes for a given condition based on the available evidence from the literature and your personal experience. If you’re the one providing the acupuncture, have a few comfortable treatment rooms where patients can be treated and then remain after the procedure, if they need to rest for a while. The typical acupuncture treatment lasts half an hour. Acute problems can be treated daily, chronic conditions require treatments once or at most twice a week, and maintenance treatment intervals range from three weeks to three months. If you’re referring your patients to another practitioner, you’ll need to coordinate other therapeutic interventions with the acupuncture treatment. For example, on the day of the acupuncture treatment, it’s generally better not to subject the patient to any other physical therapy interventions.

Q: Whom should I refer my patients to?
A: There are many styles of acupuncture and many kinds of training. When looking for a qualified acupuncture practitioner, the first concern should be that he or she also has an appropriate training in conventional biomedical sciences and medicine. Acupuncture should be used as a complementary approach, not a separate medical system. WHO recommends at least 200 hours of training for physicians and other health professionals wanting to use acupuncture as a therapeutic modality. In Canada, there are two university programs in Medical Acupuncture which comply with these guidelines, one based at the University of Alberta and the other at McMaster University. These are comprehensive training programs with rigorous criteria, including examination of the students at the end of the learning process.
Other well-organized programs available in Canada include the Acupuncture Foundation of Canada Institute and the Michener Institute for Applied Health Sciences. Because of the multicultural population in this country, there are other educational possibilities — but keep in mind that some courses are either modular, where people can take a certain number of hours without actually completing their training, or they’re open to non-health professionals. It’s best to find out exactly how many hours of training the practitioner has had and gauge his or her experience in terms of the number of patients treated.

Q: What’s involved in an acupuncture treatment?
A: The acupuncture treatment consists of inserting fine sterile disposable needles into specific body sites in patterns designed to influence the disturbances identified. When appropriate, the needles are further stimulated through manual manipulation, heat or electrical stimulation. In the case of pain problems, local needles are inserted following precise neuroanatomic criteria, while other needles are also inserted on the paravertebral musculature at spinal levels neurologically relevant to the injured area. This combination of classical acupuncture and neuroanatomy leads to superior results in treating pain problems.

Q: What kind of response should I expect?
A: Initially, any change is considered a favourable response — even a transient aggravation of the symptoms, which would mean the stimulation of the needles was too strong or too long and that adjustments should be made in subsequent sessions. Positive responses are fairly individual and range from immediate improvement to a delayed response, anywhere from 24 hours to several days following treatment.
No change after a few treatments means that either the input used isn’t appropriate for the condition, or the condition isn’t responsive to acupuncture. In that case, perform a full reevaluation of the condition and the input, then provide a few more treatments. If no progress is made after six to eight treatments — a maximum of 12 sessions — the condition is unlikely to respond to acupuncture and treatment should be discontinued.

Q: Can I perform acupuncture myself?
A: Certainly — all you need is the proper training and the proper set up. Acupuncture is a manual therapy and requires a certain dexterity, which takes some time to achieve. As with any other hands-on therapy, it can be very rewarding both for the practitioner and the patient. In addition to the therapeutic benefits for the patient, the practice of acupuncture enhances your ability to examine the musculoskeletal system and offers a new physical dimension in the therapeutic relationship between doctor and patient.

Suggested reading:
Filshie J, White A. Medical Acupuncture: A Western Scientific Approach. Churchill Livingstone, Edinburgh, 1998.
Helms JM: Acupuncture energetics: A clinical approach for physicians. Medical Acupuncture Publishers, Berkeley, California, 1995.
Spencer JW, Jacobs JJ. Complementary Alternative Medicine: An Evidence-Based Approach. Mosby Inc, St. Louis, Missouri 1999.
Stux G, Pomeranz B. Acupuncture: Textbook and Atlas. Springer-Verlag, Berlin, 1987.
Wong JY. A Manual of Neuro-Anatomical Acupuncture. Vol 1. Musculo-Skeletal disorders. The Toronto Pain and Stress Clinic Inc., 1999.