Book Notes: Pain Free 1-2-3

Chapter 12: Other Modalities- Prolotherapy and Acupuncture

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The following chapter on Prolotherapy was written by two wonderful pain specialists from Texas. In addition to helping you understand a very powerful tool, it also offers a broader perspective on how many different effective approaches there are to pain management. If you’d like, it’s okay to simply skip over the technical details, and leave those to the physicians, who will administer the Prolotherapy injections. Many people receive benefit from the technique discussed in this chapter. I think you’ll enjoy reading it.

Prolotherapy: An Orphaned Medical Intervention Repairing Connective Tissue Weakness to Resolve Chronic Musculoskeletal Pain

By Brad Fullerton, M.D. and David Harris, M.D.

Prolotherapy is a proven, safe, cost-effective treatment that can eliminate chronic pain in approximately 80 to 90 percent of sufferers, yet it has been ignored by mainstream medicine for almost 70 years. C. Everett Koop, M.D., former U.S. Surgeon General, credits Prolotherapy with curing his chronic low back pain in the late 1950s. After receiving training in the technique, he practiced Prolotherapy in his office at the University of Pennsylvania for 20 years and has publicly expressed that Prolotherapy should have a prominent place in the modern treatment of musculoskeletal pain. By the end of this chapter, we hope that you understand why Prolotherapy (or “Prolo”) was orphaned in the first half of the 20th century and why it is now on the leading edge of a revolution in medicine.

The conventional model of pain management has the underlying belief that inflammation is at the root of almost all pain problems. This core belief is so well-established that almost no one bothers to question it any longer. It has become part of the common language that we all use. Patients come into our offices almost everyday complaining of “inflammation” rather than pain. We ask, “Where do you feel the pain?” Patients reply, “Well, my elbow is really inflamed.” or “The inflammation started in my low back, now it’s going down my leg.” They have already decided that what they feel is inflammation, not pain. Often, when they describe “swelling,” this is actually a muscle in spasm.

When new diseases were being identified in the 19th and early 20th centuries, the first clue to the problem often came when doctors would look at tissue under a microscope. They would identify “inflammatory cells” in the tissue; these were often the bodies own white blood cells responding to a virus or bacteria. So, if the infection and thus the inflammation were found in the liver, the disease would be called “hepatitis,” meaning inflammation of the liver. If these inflammatory cells were found in the stomach, the disease was initially called “gastritis” or inflammation of the stomach. But of course, the problem wasn’t really the inflammation, it was the infection. The body’s response to the infection was what the researchers were seeing under the microscope.

In the musculoskeletal system, names like “tendonitis,” “bursitis,” and “arthritis” imply that the problem is inflammation in the tendon, bursa, or joint. However, the most common problem in all these tissues is a degeneration or slow breakdown of the tissue over time. If the body does not adequately respond to this degeneration by making new tissue, we get pain and disability that progresses over a lifetime. Our modern medical model is solely focused on the concept of calming inflammation. There are entire shelves of name-brand and store-brand anti-inflammatory medications waiting for you at your local grocer, drug or variety store. If those don’t work, you can respond to the latest pharmaceutical industry ads and “ask your doctor” about the newest name-brand prescription anti-inflammatory, such as Celebrex®, Mobic®, or Bextra®. Or you can go to your family practice, sports medicine, or pain management physician for any of a variety of steroid injections, such as cortisone. Most of us accept these treatments gladly, because they seem to work so well. They temporarily take away the pain; they stop the inflammation.

Yet, we have an epidemic of chronic pain and degenerative arthritis. There is growing dissatisfaction with the current approach because it only works temporarily. We have to come back again and again for the latest anti-inflammatory prescription or another injection of steroids. Or we are offered a lifetime of treatment with anti-depressants, anti-seizure medications, muscle-relaxants, or slow release opiate medications, such as Oxycontin® or Methadone. These medications have their use but have potential side effects, including tolerance, addiction, stomach irritation, kidney damage, and liver damage. Anti-inflammatory medications have become a standard medical treatment, but many studies have demonstrated that these medications actually inhibit the healing process and eventually weaken tissues in the body.

If you are fortunate, your doctor is willing to refer you to a competent and skilled manual/massage therapist, acupuncturist, or chiropractor. Many of these therapies have grown out of a grass roots response to mainstream failures in treating musculoskeletal pain. As these attempts to control pain begin to fail, the next phase of treatment tends to progress towards destructive, expensive, and riskier procedures, such as surgery, implantation of morphine pumps, implantation of stimulating devices to block the sensation of pain, and procedures to destroy the nerves that conduct the sensation of pain. Surgical procedures such as these have their place, but often may be used before attempts have been made to promote a more natural healing and strengthening process for the underlying tissue weakness and injury that is often causing the pain. Many destructive procedures are performed with minimal recognition of the actual source of the pain. The justification for destructive procedures is “there is nothing else that can be done,” a statement usually made by a physician who has never heard of Prolotherapy or who is not skilled in connective tissue repair with Prolotherapy.

What is Prolotherapy?

A form of Prolotherapy was performed by Hippocrates 2500 years ago, in which an athlete’s shoulder instability was treated by a red-hot needle, initiating healing through inflammation and strengthening of the capsule of the shoulder, and allowing him to ultimately return to his athletic activities. Injections of irritant solutions were performed in the late 1800s to repair hernias and in the early 1900s for TMJ dysfunction before surgery became available. These early attempts at promoting healing were called “sclerotherapy,” implying formation of scar. Older doctors sometimes ask why we would want to create scar tissue around a degenerated spine or joint. The answer is that we don’t. Sclerotherapy is an outdated and inaccurate term. George Hackett, M.D., a surgeon in Ohio, refined the technique and named it Prolotherapy. Over the years it has developed the nickname Prolo. Prolo is short for proliferation, thus Prolotherapy is a series of injections to stimulate proliferation of normal tissue. Since Dr. Hackett’s original work in the 1940s, studies in animals and humans have shown normal tissue formation after Prolotherapy, not scar. High resolution imaging with ultrasound is now confirming Dr. Hackett’s work; the tissue that is regenerated is organized, normal fibrous tissue.

Prolotherapy stimulates the body to repair painful areas. Its effectiveness is wide-ranging and includes pain associated with the back, the neck, all joints throughout the body, arthritis, migraine headaches, fibromyalgia, sciatica, herniated discs, and Temporo Mandibular Joint Dysfunction (TMJ). Chronic musculoskeletal pain is often due to weakness of ligaments and tendons. Joints, such as the knee and shoulder, often develop instability as well as weakening of the internal cartilage surfaces, and these are often improved by intra-articular (inside the joint) injections of dextrose and other irritant solutions.

Prolotherapy involves the injection of a natural solution (something as simple as a sugar or salt solution, cod liver oil, or herbal extract) into the area where the ligaments have either been weakened or damaged through injury or strain. Milder solutions of dextrose (corn syrup, essentially sugar), Lidocaine® (a local anesthetic), and Sarapin® (an herbal extract of the pitcher plant) are often used for the first several sessions. If the response is sluggish, stronger irritants may be used, such as mild concentrations of glucosamine, phenol (an alcohol), glycerin, or cod liver oil extract (known as sodium morrhuate).

The injection is given at the point where the ligament or tendon connects to the bone. Many points may require injection. The injection causes the body to heal itself through the process of controlled inflammation and production of growth factors. In the case of weakened or torn fibrous tissue, this repair results in as much as 30 to 40 percent strengthening of the attachment points.

Prolotherapy treatment sessions are generally given every 3 to 6 weeks to allow time for the growth of the new connective tissue. Patients usually require 4 to 6 treatment sessions for complete recovery, although some experience more immediate results. Many studies over the last fifty years show at least an 80 percent success rate.

Connective Tissue Weakness, Myofascial Pain, Arthritis, and Referred Pain

Pain that fails to respond to the traditional approaches is often caused by an injury to fibrous connective tissues, such as tendons and ligaments. Ligaments connect bone to bone, while tendons connect muscle to bone. Both ligaments and tendons may be damaged by major trauma, or may be exposed to minor repetitive trauma. In most people, these injuries tend to heal over 4 to 8 weeks. However, sometimes the tissue damage is too great, and the repair is not complete. These tissues have poor blood supply and are known to heal poorly compared to other tissues such as muscle. In other cases, patients with conditions such as fibromyalgia and chronic fatigue syndrome have underlying metabolic deficiencies that impair the healing process. These patients will often demonstrate pain and tenderness at the connections of their ligaments and tendons, with referral patterns of pain, numbness, tingling, and other abnormal sensations.

The joints are connected by strong taut ligament tissue, and cartilage lines the joint space. Laxity in the ligament structures may allow too much “play” in the joint, which results in muscle tension as the body attempts to stabilize the weak or loose structures. The muscles become fatigued after a period of time, resulting in myofascial pain. “Myo” refers to muscle; “fascia” is the fibrous tissue that surrounds, supports, and defines muscle and other tissue layers. The muscle may develop small regions of hyperactivity, which on examination show the clinical findings of trigger points and taut bands in the muscle bellies. These trigger points are thought to be neuromuscular junctions, where the smallest nerve fibers connect to the smallest muscle fibers. Normally, the neuromuscular junction is a highly regulated and balanced electrical connection that turns on and off with great precision. However, when trigger points are present, this connection is out of balance as if the neuromuscular junction has a short circuit. So, our muscles go into spasm and/or feel weak. In myofascial pain, some muscles become inhibited from achieving their full strength and become weak. This tends to happen with muscles that move the limbs through space, further away from the center of the body. The muscles closer to the spine whose purpose is to stabilize the body while limb motion is taking place tend to react more with tension and spasm. Thus, it is common to see a combination of weakness and tension in a region of the body, depending on the extent of injury and strain.

In lax joints over time, the body grows larger bony surfaces to support the increased stress and strain, creating the findings of arthritis that the physician notes on x-ray studies. Calcium is deposited in the weakened ligaments. Strengthening the supporting ligaments with Prolotherapy around an arthritic joint does appear to protect the remaining cartilage from further decline in current studies. There is some evidence that cartilage may even be thickened or strengthened, but that is not conclusive. Many physicians believe, and their patients are told, that arthritis is inevitable and irreversible. However, studies show that with Prolotherapy, the supporting ligaments and tendons can be repaired, thus potentially reversing or at least halting this “inevitable” decline.

Myofascial pain also develops from strain at the junction of the muscle tendon where it connects to the bone. There are extensive nerve connections on the outer surface of the bone (the periosteum) where the tendons and ligaments attach, and a strain on the damaged connection points may thus be extremely painful. These nerves provide information to the body regarding the position of the parts of the body, known as proprioception. Pain may be perceived distant from the actual source of the pain, producing the phenomenon of “Referred Pain.” Such pain may not demonstrate abnormalities with nerve testing or any other technique, such as MRI, CT, X-Ray studies, etc., and thus the source of the pain may be difficult to resolve. In such cases, the diagnosis of Reflex Sympathetic Dystrophy (RSD) is often given, when in fact there is a very treatable pain generator in the ligament, tendon, or joint pain generator.

Studies Supporting Prolotherapy

Placebo-controlled, randomized, double-blind studies on Prolotherapy performed with standard techniques have shown statistically significant improvement in pain reduction, stability, increased cartilage growth, improved “arthritic changes” on x-rays, increased range of motion, and greater overall function. It is estimated that over 1,500,000 patients have tried Prolotherapy over the past 70 years, with an extremely low risk and complication rate. Retrospective reviews of large numbers of patients verify a success rate of greater than 80 percent, with success defined as at least an improvement of 50 percent pain reduction. The bibliography attached provides a listing of studies and publications for further review.1

Guidelines for Determining Whether Prolotherapy May Be Useful

Recurrent swelling or fullness involving a joint or muscular region

Popping, clicking, grinding, or catching sensations with movement

A sensation of the “leg giving way” with associated back pain

Temporary benefit from chiropractic manipulation or manual mobilization that fails to ultimately resolve the pain

Distinct tender points along the bone at tendon or ligament attachments

Numbness, tingling, aching, or burning referred into an upper or lower extremity

Recurrent headache, face pain, jaw pain, ear pain

Chest pain with tenderness along the rib attachments on the spine or along the front of the chest

Spine pain that does not respond to surgery or whose origin is not clear from MRI, CT, X-Ray, Myelogram, or other similar studies

Specific Regions Benefiting from Prolotherapy

Spine Pain (Neck, Mid Back, Low Back)

Most back and neck pain results when weak ligaments and tendons cause the spine to become “unstable.” Vertebrae begin to slip, move, and rotate from their proper position, causing the disks to take on the additional load and producing the familiar “disk bulge” or “disk herniation.” The disk is simply a specialized ligament tissue with the same characteristics as other ligamentous tissues. The disk may be the primary source of pain as well, especially with moderate to severe trauma, which may cause an acute tear; this can be very painful and may cause nerve compression. Disk herniations may require treatment with medication, epidural steroid injections, therapy, or surgery, and may not respond well to Prolotherapy. However, the majority of spine pain does not originate in the disks, and thus a focus on disks as the sole source of pain reduces a physician’s “batting average” to far less than 50 percent long-term success. Because current diagnostic studies, such as MRI scans, CT scans, x-rays, bone scans, and myelograms do not reveal abnormalities of the numerous small ligaments, the typical and often unsuccessful focus is on the larger and more noticeable disk structures.

In summary, the disk is one of many potential sources of pain in the spine; however, successful treatment of spine pain requires a practitioner to recognize the numerous other pain generators as well.

Structures frequently treated in the spine and pelvis include the supraspinous ligament, the interspinous ligament, intertransverse process ligaments, facet joint capsules, sacroiliac ligament, sacrotuberous ligament, sacrospinous ligament, sacrococcygeal ligament, among many others.

Prolotherapy strengthens the connections along the spine, providing stability to reduce strain on the other structures. Over 3 to 6 months of treatment, muscle spasm and tenderness resolve, as well as the localized and referred pain. Strengthening the neck segments frequently reduces spasm and pain in the shoulder blade regions. Success often requires injections along the upper and inner aspects of the shoulder blades as well, where the trapezius, levator scapulae, rhomboid, and subscapularis muscles attach.

Headaches

Most headaches originate at weaknesses of the attachments of the suboccipital muscle tendons and fascia at the base of the back of the skull. This form of headache is referred to as tension, suboccipital, or cervicogenic and often refers to the eye, forehead, ear, or temple. The Greater and Lesser Occipital nerves run through this fibrous tissue and appear to contribute to the sensation of headache. Trauma, such as a motor vehicle accident, often causes a “whiplash” injury, creating small tears in this fibrous tissue. Although migraine headaches are thought to have a vascular (blood supply) origin, they are often triggered by the same tissue weaknesses as for tension headaches. Prolotherapy strengthens these tissue attachment weaknesses and usually greatly reduces the intensity and frequency of headaches.

Temporo Mandibular Joint Dysfunction (TMJ)

Popping, clicking, locking, and pain commonly occur in the joints of the lower jaw known as the TMJ. This can occur on one or both sides. The TMJ has been successfully treated for over 75 years with Prolotherapy; it remains the most successful and safest treatment available. Unfortunately, many patients have undergone various unproven surgeries over the last 25 years without attempting, or even being informed, about Prolotherapy first. Most of those surgical procedures are no longer practiced because of widespread failure. Prolotherapy for the TMJ usually involves 3 to 4 intra-articular (inside the joint) injections.

Shoulder, Elbow, Wrist and Hand

The shoulder, elbow, wrist, and hand have numerous ligament and tendon structures. Cartilage within these joints also may become damaged or torn. Repetitive motion of the upper extremity often results in laxity of the supporting joint capsules and ligaments, as well as a weakening of the tendon attachments. Intense athletic activities, such as pitching, golf, or tennis often result in shoulder and elbow pain. Many physicians will often be confused regarding the source of pain, often attributing numbness, tingling, swelling, and burning or achy pain to a nerve injury, which in fact, is fairly uncommon. There are painful conditions involving nerve compression that require surgery, but this is much less common than many believe. The vast majority of such injuries do not require surgery and are treated with very specific Prolotherapy injections into each localized connective tissue attachment and also inside each involved joint.

Instability of the shoulder joint is relatively easy to resolve with Prolotherapy and very difficult and inconsistent to cure with any other technique. Other causes of shoulder pain include: weakened attachments of the trapezius muscles all along the upper border of the shoulder blade and clavicle (collarbone); the attachments of the deltoid muscle tendon at the outer border of the shoulder and also the distal attachment along the outer upper arm; laxity of the acromioclavicular joint; and tears of the rotator cuff tendons. “Tennis elbow” and other elbow pain is usually caused by injury to the annular ligament, the elbow joint, and to the tendon and fascia attachments at the epicondyles, all of which respond well to strengthening with Prolotherapy injections. Wrist pain is frequently the result of ligament tears, cartilage tears, and joint capsular weakness and often is successfully resolved with Prolotherapy. The diagnosis of “Carpal Tunnel Syndrome” is commonly made for generalized wrist pain, when in fact classically this diagnosis should be reserved for true nerve entrapment of the Median nerve. Often, nerve studies, MRI, CT, and X-Rays reveal no clear abnormality, and surgery is contemplated because “there’s nothing else to do.” Although true “Carpal Tunnel Syndrome” may require surgery to decompress the nerve, surgery infrequently improves pain at the wrist, especially if studies do not reveal a significant abnormality of the nerve. All of the above respond very well to Prolotherapy injections to stimulate repair of the injured structures.

Hip, Knee, Ankle, and Foot

Hip and knee pain often are the result of joint capsule or ligamentous laxity, which ultimately may lead to degenerative arthritis if not corrected. Numerous ligaments surround the hip, knee, ankle, and foot, any of which may produce debilitating pain. Another source of pain is the tendon insertions, especially along the head of the femur (thighbone) and at the inner aspect of the knee (“Pes Anserinus”), where the hamstring muscles attach. Young men often develop “Osgood-Schlatter Disease” where the tendon from the patella (kneecap) weakens at the attachment to the tibia bone. Cartilage injury, muscle misalignment, and quadriceps weakness cause pain in the knee and under the kneecap, known as Patellofemoral Syndrome, or Chondromalacia Patellae. Recurrent ankle sprains result in weakness and lengthening of the supporting ligaments of the ankle, and may also cause cartilage injury inside the complex ankle joint. Pain also may occur with chronic tears in the Achilles tendon and in the anterior tibialis attachment on the tibia (“shin splints”). Heel pain commonly occurs along the sole of the foot, originating where the Plantar Fascia connects to the undersurface of the heel, resulting in Plantar Fasciitis. Pain in the forefoot occurs at the toe joints, the metatarsal bones, at bunions, and between the toes with tears of the transmetatarsal ligaments (commonly called “Morton’s Neuroma” or Metatarsalgia).

All of the above structures respond extremely well, permanently, to Prolotherapy, with injections given either inside the involved joints, or into the tendon and ligament attachments outside the joints. Traditional medical practice (medication, steroid injections, surgery, joint replacement) has a fair chance of resolving these problems, but at much greater risk and expense. Surgery may be justified if other less invasive techniques fail to resolve the painful structure. Usually, 4 to 6 treatments with Prolotherapy are required for each of these problems.

Chest Wall and Rib Pain

Obviously, chest pain can be serious. Assuming a more severe problem, such as cancer, heart disease, or lung disease has been ruled out, the primary causes of chest wall pain can be successfully treated with Prolotherapy. The pain is frequently associated with tears or weakness at the rib-breastbone (sternum) attachments, the muscle tendon attachments all along the rim of the ribs, the rib-vertebrae attachments, or the junction of the clavicle (collarbone) at the sternum. Prolotherapy will often reduce or resolve pain from these sites.

Groin, Vaginal, Testicular, or Rectal Pain

Numerous pelvic structures produce pain in these regions. A careful, thorough, and respectful examination of these structures will usually lead to a correct diagnosis and successful treatment. Structures may include the suprapubic joint, inguinal ligament attachments on the anterior pelvis, anterior hip capsule ligaments, sacrococcygeal ligament, iliolumbar ligament, and many others. Cramping during menstruation and back pain during pregnancy are often caused by ligamentous laxity in the pelvic region and can be greatly reduced with Prolotherapy. Prolotherapy often provides permanent relief of the pain over 4 to 6 visits.

Adopting the Orphaned Medical Intervention

To even consider Prolotherapy as an option, your physician has to question whether inflammation is always at the root of pain, or could the problem sometimes be inadequate inflammation? Health is always an act of balance. When our body is in a state of good health, the body is inflaming in a controlled way to fight off intruders and to repair damage from trauma, disease, or the wear and tear of facing gravity over a lifetime. Currently, we are taught that when we sprain our ankle, we must take anti-inflammatory medication as soon as possible. From the perspective of natural healing, this is essentially treating our body’s response to a trauma as if that response were a disease.

As doctors, if we only anti-inflame in response to pain, we are like the captain of a ship who believes the only way to steer a ship across the ocean is to always turn the wheel in one direction. If we appear off course, we just need to turn the wheel farther. But, of course, this will only lead us in circles and we will never reach our patient’s goal of health. Our present way of thinking is very much like the way we used to “care” for forests. For decades, or even centuries, we believed that we must fight all forest fires. As the bigger picture became clearer, we realized that suppressing every fire caused an overgrowth of unhealthy trees and underbrush that actually increased the chance of a devastating forest fire. By trying to help, we were creating imbalance in the ecosystem. Realizing that fires are a healthy event in the life of a forest, the forest service now thinks before acting. Sometimes it is best to suppress a certain fire, sometimes to allow a wildfire to burn itself out, and sometimes it is best to actually start a “prescribed fire.” After a prescribed fire, the unhealthy overgrowth is gone; vibrant, healthy growth begins anew. Then, the entire forest can return to balanced health.

As our health care system has moved toward integrative, complementary medicine, patients are seeking and demanding interventions that help our body do what it is naturally doing for itself. Prolotherapy is just such an intervention; it’s time for adoption has finally arrived.

Brad Fullerton, MD
The Patient-Physician Partnership
2714 Bee Cave Rd, Suite 106
Austin, TX 78746
(512)347-7246
(512)347-7245 FAX

http://www.proloaustin.com/

Dr. Brad Fullerton received his medical degree from the University of Texas, Southwestern Medical School in Dallas. He completed his internship and one year of psychiatric training at the University of Connecticut, then residency training in Physical Medicine and Rehabilitation at the Graduate Hospital of the University of Pennsylvania in Philadelphia. He currently serves as medical director for the Spasticity Clinic at Children’s Hospital of Austin, while maintaining his private practice specializing in the treatment of chronic pain and sports injuries. His research interests include diagnostic musculoskeletal ultrasound imaging in Orthopedic Medicine and its use with Prolotherapy. Dr. Fullerton enjoys hiking along Austin’s beautiful spring-fed creeks and swimming holes with his wife and two daught ers.

David K. Harris, MD
The Lakewood Clinic
7307 Creekbluff Drive
Austin, Texas 78750
512-454-1234
Fax 512-476-0850
http://www.lakewoodclinic.com/

Dr. David Harris specializes in Physical Medicine and Rehabilitation in Austin, Texas. He primarily manages patients with sports and spine injuries at the Lakewood Clinic and at Spine Austin. He has used Dr. Teitelbaum’s approach with his chronic fatigue and fibromyalgia patients with great success, and this has led to the use of many of these techniques with his less “metabolically involved” patients. He has a BS in Electrical Engineering from The University of Texas, is on faculty at the University of Texas, and teaches regularly for the Texas Medical Association. He and his Physical Therapist wife, Michele, have two boys, A.J. and Kyle. He enjoys the outdoors and playing guitar with his local Austin band, Natural Causes.

To find qualified physicians who have been trained in Prolotherapy, please refer to http://www.aaomed.org (American Association of Orthopedic Medicine) and http://www.getprolo.com.

Important Points

1. Prolotherapy is a series of injections of a natural solution (something as simple as a sugar or salt solution, cod liver oil, known as sodium morrhuate, or herbal extract) into the area where the ligaments have either been weakened or damaged through injury or strain. This stimulates proliferation of normal tissue, which helps the body to repair painful areas.

2. Its effectiveness is wide-ranging and includes pain associated with the back, the neck, all joints throughout the body, arthritis, migraine headaches, fibromyalgia, sciatica, herniated discs, and Temporo Mandibular Joint Dysfunction (TMJ).

3. Chronic musculoskeletal pain is often due to weakness of ligaments and tendons. The injection is given at the point where the ligament or tendon connects to the bone. Many points may require injection. The injection causes the body to heal itself through the processes of controlled inflammation and production of growth factors.

Traditional Chinese Medicine— Acupuncture for Coordinated Wellness-Care

By Peter Marinakis, Ph.D., Mac

This chapter on acupuncture is written by Peter Marinakis. He gives an overview of this system of treatment, describes its benefits, and gives details on how you can best use this ancient form of Chinese medicine to treat pain.

Acupuncture is one of the oldest, most commonly used medical procedures in the world. Originating in China more than 3,000 years ago, acupuncture began to become better known in the United States in 1971, when New York Times reporter James Reston wrote about how doctors in China had used needles to ease his abdominal pain after surgery. Research shows that acupuncture is beneficial in treating a variety of health conditions.

The term acupuncture describes a family of procedures involving stimulation of anatomical points on the body by a variety of techniques. American practices of acupuncture incorporate medical traditions from China, Japan, Korea, and other countries. The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

In the past two decades, acupuncture has grown in popularity in the United States. A Harvard University study published in 1998 estimated that Americans made more than 5 million visits per year to acupuncture practitioners.1 The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 stated that acupuncture is being “widely” practiced by thousands of physicians, dentists, acupuncturists, and other practitioners for relief or prevention of pain and for various other health conditions.2

NIH has funded a variety of research projects on acupuncture. These grants have been awarded by the National Center for Complementary and Alternative Medicine (NCCAM), the Office of Alternative Medicine (OAM, NCCAM’s predecessor), and other NIH Institutes and Centers.

This research report provides general information about acupuncture, research summaries, and a resource section. Terms that are underlined are defined at the end of this report.

Acupuncture Theories

Traditional Chinese medicine theorizes that there are more than 2,000 acupuncture points on the human body, and that these connect with 12 main and 8 secondary pathways called meridians. Chinese medicine practitioners believe these meridians conduct energy, or qi (pronounced “chee”), throughout the body.

Qi is believed to regulate spiritual, emotional, mental, and physical balance and to be influenced by the opposing forces of yin and yang. According to traditional Chinese medicine, when yin and yang are balanced, they work together with the natural flow of qi to help the body achieve and maintain health. Acupuncture is believed to balance yin and yang, keep the normal flow of energy unblocked, and maintain or restore health to the body and mind.

Traditional Chinese medicine practices (including acupuncture, herbs, diet, massage, and meditative physical exercise) all are intended to improve the flow of qi.3

Western scientists have found meridians hard to identify because meridians do not directly correspond to nerve or blood circulation pathways. Some researchers believe that meridians are located throughout the body’s connective tissue;4 others do not believe that qi exists at all.5,6 Such differences of opinion have made acupuncture an area of scientific controversy.

Mechanisms of Action

Several processes have been proposed to explain acupuncture’s effects, primarily those on pain. Acupuncture points are believed to stimulate the central nervous system (the brain and spinal cord) to release chemicals into the muscles, spinal cord, and brain. These chemicals either change the experience of pain or release other chemicals, such as hormones, that influence the body’s self-regulating systems. The biochemical changes may stimulate the body’s natural healing abilities and promote physical and emotional well-being.7 There are three main mechanisms:

1. Conduction of electromagnetic signals. Western scientists have found evidence that acupuncture points are strategic conductors of electromagnetic signals. Stimulating points along these pathways through acupuncture enables electromagnetic signals to be relayed at a greater rate than under normal conditions. These signals may start the flow of pain-killing biochemicals, such as endorphins, and of immune system cells to specific sites in the body that are injured or vulnerable to disease.8,9

2. Activation of opioid systems. Research has found that several types of opioids may be released into the central nervous system during acupuncture treatment, thereby reducing pain.10

3. Changes in brain chemistry, sensation, and involuntary body functions. Studies have shown that acupuncture may alter brain chemistry by changing the release of neurotransmitters and neurohormones. Acupuncture also has been documented to affect the parts of the central nervous system related to sensation and involuntary body functions, such as immune reactions and processes whereby a person’s blood pressure, blood flow, and body temperature are regulated.3,11,12

Preclinical studies have documented acupuncture’s effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine.13, 14, 15, 16, 17, 18

According to the NIH Consensus Statement on Acupuncture:

“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.” 7

Increasingly, acupuncture is complementing conventional therapies. For example, doctors may combine acupuncture and drugs to control surgery-related pain in their patients.19 By providing both acupuncture and certain conventional anesthetic drugs, some doctors have found it possible to achieve a state of complete pain relief for some patients. 10 They also have found that using acupuncture lowers the need for conventional pain killing drugs and thus reduces the risk of side effects for patients who take the drugs.20, 21

Currently, one of the main reasons Americans seek acupuncture treatment is to relieve chronic pain, especially from conditions such as arthritis or lower back disorders.22,23 Some clinical studies show that acupuncture is effective in relieving both chronic (long-lasting) and acute or sudden pain, but other research indicates that it provides no relief from chronic pain.24 Additional research is needed to provide definitive answers.

FDA’s Role

The U.S. Food and Drug Administration (FDA) approved acupuncture needles for use by licensed practitioners in 1996. The FDA requires manufacturers of acupuncture needles to label them for single use only.25 Relatively few complications from the use of acupuncture have been reported to the FDA when one considers the millions of people treated each year and the number of acupuncture needles used.

Research Sponsored by NCCAM and OAM

NCCAM and OAM have supported scientific research to find out more about acupuncture. Examples of recent NCCAM-supported projects include:

Studying the safety and effectiveness of acupuncture treatment for osteoarthritis of the knee

Investigating whether electroacupuncture works for chronic pain and inflammation (and, if so, how)

Finding out how acupuncture affects the nervous system by using MRI (magnetic resonance imaging) technology

Bringing together leaders from the Oriental medicine and conventional medicine communities to collaboratively study the safety and effectiveness of acupuncture and further develop the standards for clinical trials

Studying whether acupuncture can decrease the release of adrenalin in heart patients and improve their survival and quality of life. Adrenaline can make the heart beat faster and can thereby contribute to heart failure.

Looking at the effectiveness of acupuncture for treating high blood pressure

Studying the effects of acupuncture on the symptoms of advanced colorectal cancer

Testing the safety and effectiveness of acupuncture for a type of depression called major depression

With regard to earlier findings, researchers at the University of Maryland in Baltimore, with the support of OAM, conducted a randomized controlled clinical trial and found that patients treated with acupuncture after dental surgery had less intense pain than patients who received a placebo.26 Scientists at the university also found that older people with osteoarthritis experienced significantly more pain relief after using conventional drugs and acupuncture together than those using conventional therapy alone.27

OAM also funded several preliminary studies on acupuncture:

In one small randomized controlled clinical trial, more than half of 11 women with a major depressive episode who were treated with acupuncture improved significantly.28

In another controlled clinical trial, nearly half of the seven children with attention deficit hyperactivity disorder who underwent acupuncture treatment showed some improvement in their symptoms. Researchers concluded that acupuncture was a useful alternative to standard medication for some children with this condition.29

In a third small controlled study, eight pregnant women were given a type of acupuncture treatment called moxibustion to reduce the rate of breech births, in which the fetus is positioned for birth feet-first instead of the normal position of head-first. Researchers found the treatment to be safe, but they were uncertain whether it was effective.30 Then, researchers reporting in the November 11, 1998, issue of the Journal of the American Medical Association conducted a larger randomized controlled clinical trial using moxibustion for breech births. They found that moxibustion applied to 130 pregnant women presenting breech significantly increased the number of normal head-first births.31

Acupuncture and You

The use of acupuncture, like the use of many other complementary and alternative medicine (CAM) treatments, has produced a good deal of anecdotal evidence. Much of this evidence comes from people who report their own successful use of the treatment. If a treatment appears to be safe and patients report recovery from their illness or condition after using it, others may decide to use the treatment. However, scientific research may not support the anecdotal reports. Patient outcomes continue to be one of the best forms of feedback to the practitioner, patient, and the health care industry at large. Studies done by state acupuncture societies, such as the Maryland Acupuncture Society, have reported in a January 2000 patient survey that 71 percent of the patients reporting in had a “very satisfied experience with acupuncture and had excellent results.” See www.maryland-acupuncture.org for the full report.

Lifestyle, age, physiology, and other factors combine to make every person different. A treatment that works for one person may not work for another who has the very same condition. You as a health care consumer (especially if you have a preexisting medical condition) should discuss any CAM treatment, including acupuncture, with your health care practitioner. Do not rely on a diagnosis of disease by an acupuncture practitioner who does not have substantial conventional medical training. If you have received a diagnosis from a doctor and have had little or no success using conventional medicine, you may wish to ask your doctor whether acupuncture might help.

Finding a Licensed Acupuncture Practitioner

Health care practitioners can be a resource for referral to practitioners of acupuncture, as more are becoming aware of this CAM therapy. More medical doctors, including neurologists, anesthesiologists, and specialists in physical medicine, are becoming familiar with acupuncture, traditional Chinese medicine, and other CAM therapies. In addition, national organizations (consult your local library or search with a Web browser) may provide referrals to practitioners, although some organizations may encourage the use of their practices.

Check a Practitioner’s Credentials

A practitioner who is licensed and credentialed may provide better care than one who is not. About 47 states have established training standards for acupuncture certification, but States have varied requirements for obtaining a license to practice acupuncture.32 Although proper credentials do not ensure competency, they do indicate that the practitioner has met certain standards to treat patients through the use of acupuncture. See the addendum for a complete list of national and federal organizations.

Check Treatment Cost and Insurance Coverage

A practitioner should inform you about the estimated number of treatments needed and how much each will cost. If this information is not provided, ask for it. Treatment may take place over a few days or for several weeks or more. Physician acupuncturists may charge more than nonphysician practitioners. Check with your insurer before you start treatment as to whether acupuncture will be covered for your condition, and if so, to what extent. Some plans require preauthorization for acupuncture.

Check Treatment Procedures

Ask about the treatment procedures that will be used and their likelihood of success for your condition or disease. You also should make certain that the practitioner uses a new set of disposable needles in a sealed package every time. The FDA requires the use of sterile, nontoxic needles that bear a labeling statement restricting their use to qualified practitioners. The practitioner also should swab the puncture site with alcohol or another disinfectant before inserting the needle.

During your first office visit, the practitioner may ask you at length about your health condition, lifestyle, and behavior. The practitioner will want to obtain a complete picture of your treatment needs and any behaviors that may contribute to the condition. Inform the acupuncturist about all treatments or medications you are taking and all medical conditions you have.

The Sensation of Acupuncture

Acupuncture needles are metallic, solid, and hair-thin. People experience acupuncture differently, but most feel no or minimal pain as the needles are inserted. Some people are energized by treatment, while others feel relaxed.33 Improper needle placement, movement of the patient, or a defect in the needle can cause soreness and pain during treatment.34 This is why it is important to seek treatment from a qualified acupuncture practitioner.

Addendum

For a complete list of National and International Acupuncture and Oriental Medicine Organizations see the http://www.aomalliance.org/ or http://www.who.org/, click health topics, acupuncture, to see a list of health issues treatable with acupuncture.

Peter Marinakis, PhD; Mac, is Director of Full Circle Healing Arts, a multidisciplinary well care clinic in Annapolis, Maryland. Dr. Marinakis was on the faculty of Tai Sophia for the last twenty years and is now a distinguished lecturer at the Institute. He is founder and director of the Community Health Initiative (CHI), a community relationship based drug abuse treatment and wellness care clinic with some 350 clients per day. He is the past president of the Maryland Acupuncture Society, past president of the American Association of Acupuncture and Oriental Medicine (now the AAOM), founding member of the AOM Alliance, and a past Accreditation Commissioner of the Accreditation Commission for Acupuncture and Oriental Medicine. Dr. Marinakis lectures and does workshops throughout the United States on energy medicine and emotion.

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