December/January 2001

Needling the Pain

By Ronald Glick, MD

Incorporating acupuncture into a chronic pain management program.

I began my career in medicine as a psychiatrist. However, I eventually found myself unhappy with the path my practice was taking. Because of managed care constraints, I was becoming more and more removed from my patients.

So, 10 years ago, I left my practice to retrain in physical medicine and rehabilitation. I had become very interested in treating chronic pain, which influenced my decision to go into physical medicine. As I worked with more and more patients, I discovered that many of them were saying the same thing—“I cannot do the physical therapy you are prescribing for me because any type of exercise makes my pain flare up.” While considering how I could manage my patients’ pain well enough to allow their treatment to continue, I thought immediately of acupuncture. Thus, my study of this ancient healing technique began.

During my acupuncture training, I was exposed to various schools of practice. Because I operate from a scientific perspective, I am more comfortable with forms of acupuncture that have a neuroanatomical basis.

The ABCs of Acupuncture

Systems of acupuncture can be broken down into three broad categories that often overlap—energetic, neuroanatomical, and microsystems. The most widely known energetic approach is traditional Chinese medicine (TCM), a system dating back several millennia. Sophisticated Chinese knowledge of anatomy and physiology was well ahead of European medicine.

Two basic concepts are needed for an understanding of the TCM approach. The first is yin and yang, which is the deficiency or excess of energy in a system. In this model, the exhausted patient with chronic fatigue syndrome has a yin or deficiency state and the Type A hypertensive cardiac patient is in a yang state. The second concept is that meridians or channels cover the body through which energy flows. Disruption of flow through these channels can result in disease states. Points on these channels correspond to various organs. By placing needles at strategic points and stimulating them or allowing energy to dissipate, balance can be restored. Approaches using these meridian-based points have been used in the United States and China for neurologic conditions such as hemiplegia, and for a wide array of musculoskeletal problems.¹

Neuroanatomical approaches espouse treatment at the level of the pathology. Theoretically, this involves the gate control theory, a mild noxious stimulation, such as an acupuncture needle, that sends a mild pain message to the brain. The brain responds by sending a pain-relieving message back to the dorsal horn. If this occurs repeatedly, it can turn off the pain message that is coming from the body, like closing the gate at the spinal cord, where the pain message ascends to the brain.

The most basic anatomical technique is the dry needling of a trigger point with the use of an acupuncture needle. A more elaborate system was developed by William F. Craig, MD, of Fort Worth, Tex, called percutaneous electrical nerve stimulation or PENS. Points are selected based on the dermatomal and myotomal levels involved. Needles are placed in these areas in specific montages or patterns and the needles are stimulated with certain electrical frequencies. Empirically, Craig and his associates have had success with the whole gamut of chronic pain conditions. Clinical trials have found benefit for individuals with chronic low back pain,2 sciatica, diabetic neuropathy, and herpes zoster.

There are several approaches that utilize microsystems, ie, systems of diagnosis and treatment that use a representation of the human body. The most famous of these is reflexology—the notion that manual stimulation of points on the sole of the foot can treat various somatic problems. Auricular therapy involves evaluation of the electrical activity of points on the ear followed by electrical stimulation or needling. This has been employed most widely for the treatment of addictions, but it can be helpful for pain. There are charts of the ear with the corresponding body points portrayed as an inverted person in a fetal position. A most promising microsystem for rehabilitation medicine is scalp acupuncture. In China and Japan, this is reported to be effective for treating neurological conditions such as hemiplegia.

The greatest challenge for acupuncture in the United States is to move it from an alternative medicine classification, which implies a lack of scientific validity, to a standard part of our armamentarium. To accomplish this, we need to conduct more scientifically sound, controlled clinical trials, which are difficult to carry out for acupuncture. The National Center for Complementary and Alternative Medicine is helping in getting these projects going.

In addition to trials that demonstrate efficacy, acupuncture can be a tool to further our understanding of pain processing and neurochemistry. Psychoneuroimmunology is a relatively new field that looks at the connections between mood, immune function, and disease. Within the next decade we will likely learn that acupuncture is not strictly a symptomatic treatment, but it may be used to augment the immune system.

Appropriate Uses

When I started out, I anticipated that I would use acupuncture early in the treatment process. However, now I believe that using a passive modality like acupuncture takes the onus away from patients. Currently, I place the greatest emphasis on active involvement in a pain rehabilitation program. After completing their rehab program, patients often ask if there is anything else that will help. I may offer a course of acupuncture treatment with the understanding that the primary change is coming from the patient’s increased activity and pain self-management skills. Often at this point in treatment, I am trying to taper opioid use, and acupuncture can assist with this transition.

Most commonly, I use Craig-PENS as my primary approach, but I often supplement my treatment with auricular- or meridian-based treatment. Although Craig advocates treating two to three times per week initially, the logistics of my practice allow me to see most patients no more than once weekly. I tell patients to expect some fluctuation in pain over the first several weeks and to allow five to six treatments before deciding if it is helpful enough to warrant continuing. I have the greatest success in treating localized myofascial pain, degenerative disc disease, and failed neck and back syndromes. Some of my success relates to patient expectations. For example, if someone has had four surgeries, emerging worse each time, and now expects a total cure, I will not treat him. I have done very well with older adults who have more practical goals, such as the ability to go shopping at the grocery store without having to stop midway.

I am presently involved with a National Institutes of Health-funded study investigating PENS for the treatment of older adults with low back pain associated with degenerative disc disease. Ghoname et al found benefit with the use of PENS in this group.² In addition to confirming the benefit of PENS, we hope to see how long the treatment results last and if improvement carries over to cognitive functioning and physical capabilities.

Case Study

The following case study illustrates this approach: a 47-year-old investment counselor with postlaminectomy syndrome had his first lumbar surgery—a microdiscectomy—at age 40 with a two level laminectomy performed at age 45. With each surgery he experienced a complete resolution of symptoms, allowing return to a busy work schedule and regular outings to his tennis club. Over the past 6 months, his right leg pain returned with a vengeance. MRI showed epidural scarring, and epidural injections gave only transient relief. As with many athletes, he did well with a physical therapy program, although he tended to overdo it with resultant flares. He was hopeful about acupuncture, but wanted to see improvement by 6 weeks, when he had a golf vacation and business trip planned. Consequently, I saw him twice weekly initially.

I utilized the Craig-PENS approach with needles placed in his low back, right buttock, and points in his thigh corresponding to his referral pattern. I also treated the scar area with acupuncture, augmented by a heat lamp. After an initial mild flare, he noted changes including improved sleep, being able to sit longer without having to stretch, increased activity tolerance, and decreased numbness and paresthesias. Following his trip, sessions were decreased to weekly and then biweekly. At this point, he mentioned abdominal discomfort due to irritable bowel syndrome, as well as an exacerbation of his eczema. I shifted to a meridian-based approach, which resulted in a quieting of his bowel and skin symptoms and further decrease in his leg pain. After 3 months, he came in with his pain at a one to two level on a scale of 10 and by mutual agreement we discontinued the acupuncture with a plan to restart if symptoms recurred.

For more information on utilizing acupuncture, visit the American Academy of Medical Acupuncture’s Web site at www.medicalacupuncture.org.

Ronald Glick, MD, is clinical director of the Pain Evaluation and Treatment Institute, at the University of Pittsburgh Medical Center.

References

1. NIH consensus development panel on acupuncture. Acupuncture—NIH Consensus Conference. JAMA. 1998;280:1518-1524.
2. Ghoname EA, Craig WF, White PF, et al. Percutaneous electrical stimulation for low back pain: a randomized crossover study. JAMA. 1999;281:818-823.

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