Acupuncture Integrated Into Anesthesia Pain Medicine

2. Acupuncture Integrated Into Anesthesia Pain Medicine James D. Colson, M.S., M.D. Clinical Assistant Professor University of Michigan

3. Overview • Complementary and alternative medicine (CAM) therapies have become more prominent in our healthcare system. • 34-42% of patients in the U.S. seek nontraditional types of medical care.

4. CAM Therapies • Acupuncture • Chiropractic care • Reflexology • Reiki • Qigong • Polarity therapy

5. Acupuncture is the One CAM Therapy • Highest rate of referrals. • Garners the most credibility.

6. NIH Consensus Conference on Acupuncture 1997, Endorsed Acupunctures Effectiveness • Postoperative and chemotherapy-induced nausea/vomiting. • Postoperative dental pain.

7. Historical Perspective • Acupuncture therapy dates back to the Chinese Han dynasty 206 BC-220 AD. • Term “acupuncture” coined by French Jesuit missionaries in the 17th century. • First documented use of acupuncture in Europe, a French physician in 1810. • American medical journals published articles on acupuncture in the 1820s.

8. Historical Perspective • Sir William Osler recommended acupuncture for treating lumbago in his 1892 text. • President Nixon’s visit to China in 1972. • NIH Consensus Conference on Acupuncture in 1997.

9. Classic Concepts • Acupuncture originated from Taoist philosophy • The yin and yang, two opposing, yet balancing forces • Sum of yin and yang forces is manifested in the flow of qi • Qi is a vital energy or essence of life force

10. Classic Concepts • Qi flows along the energy channels of the body • Obstruction to the flow of qi is manifested as disease or pain • Meridians emerge at the body’s surface at sites- acupuncture points • Needling at acupuncture points facilitates the flow of qi

11. Yin and Yang exemplified as physiological processes Yin Anabolism Weight gain Conserve energy Hypoglycemia Hypotension Parasympathetic Yang Catabolism Weight loss Expand energy Hyperglycemia Hypertension Sympathetic

12. Classic Concepts • 14 Principle meridians- 12 paired and 2 unpaired • 365 classic acupuncture points

14. Neurophysiologic Basis • Gate control theory of neuromodulation. • Neurohumeral response involving the descending inhibitory system.

15. Neurophysiologic Basis • Acupuncture needling activates large nerve fibers to inhibit afferent nociceptive transmission by smaller fibers. • Fibers transmit impulses to the spinal cord - activation of centers in the midbrain and hypothalamic-pituitary axis triggering release of neuropeptides

16. Neurophysiologic Basis • Acupuncture activation leads to the release of endorphins enkephalin and dynorphin which block incoming afferent nociceptive input. • Release of monoamines serotonin and norepinephrine block spinal cord nociceptive transmission

17. Cho et al: fMRI Neurophysiological Evidence of Acupuncture Mechanisms. Medical Acupuncture 2002; 14:16-22.

18. Previous studies have shown a correlation between specific acupoints and a corresponding functional cortical area. • Stimulation of acupoints results in cortical activation in a corresponding functional region of the brain. • Hypothesized that acupuncture signals are projected to higher brain centers via the spinal cord. • Acupuncture mechanisms are mediated through higher centers of the brain.

19. Interventions: • Pain stimulation was achieved by hot water immersion of subject’s index finger. • Meridian acupuncture needling at a specific acupoint. • Sham acupuncture needling at an arbitrary point.

20. Outcome measure: Findings on fMRI imaging in the anterior cingulated cortex and thalamic areas.

22. Conclusions: Acupuncture appears to inactivate brain regions involved in the transmission and perceptions of pain.

23. Acupuncture Methodology Varied approaches to practice of Acupuncture Meridians and points are universally accepted Each approach differs in choice of points and method of stimulation Goal: To restore the flow of qi

24. Acupuncture Methodology Classical acupuncture is the traditional practice according to the principles of Taoism. • French/Vietnamese meridian energetics • Auricular acupuncture • Korean hand acupuncture • Japanese acupuncture • Scalp acupuncture • Tendinomuscular acupuncture • Electroacupuncture

28. Acupuncture Technique Acupuncture needling evokes a sensation termed “de qi” • Energy moving needles in the extremities. • Energy focusing needles at truncal or local points. • Passive needling for dispersion • Needle stimulation for tonification.

29. Techniques Tonification for deficient energy requires some form of needle stimulation: • Manually by intermittent twirling, rotation or up and down thrusting of the needle • Electrical stimulation • Moxibustion • Cupping

33. Treatment Precautions Acupuncture, like any other invasive treatment, has its own specific set of contraindications, commonly observed side effects, as well as potential for serious adverse complications

34. Contraindications • Pregnancy • Bleeding diathesis • Anticoagulation therapy • Rheumatic/valvular heart disease

35. Side Effects • Local needle pain • Vasovagal reactions • Psychological responses • Bleeding, ecchymosis, hematoma

36. Complications • Organ injury • Infection • Pacemaker suppression • Needle breakage • Skin burns • Contact dermatitis

37. Acupuncture Indications In Western medical practice, acupuncture is most applicable in treating pain. • In a review of acupuncture studies for chronic pain, Pomeranz (1983) reported a 55 to 85% positive response with a 30 to 33% placebo response • Richardson and Vincent (1986) found good evidence from controlled studies that acupuncture provided effective short-term pain relief ranging from 50 to 80%. • Lewith and Machin (1996) concluded that a positive response to acupuncture was noted in 70% of chronic pain patients with a placebo response in 30%.

38. Kotani et al: Preoperative Intradermal Acupuncture Reduces Postoperative Pain, Nausea and Vomiting, Analgesic Requirement, and Sympathoadrenal Responses. Anesthesiology 2001; 95:349-356.

39. Interventions: • Acupuncture needles placed along the bladder meridian for upper abdominal (n=50) and lower abdominal surgery (n=39); • Control- no needle placement for upper abdominal (n=48) and lower abdominal surgery (n=38); • All patients received morphine and bupivacaine epidurally, with IV boluses of morphine.

40. Outcome measures: Pain intensity; supplemental IV opioid requirement; side effect profile; and stress hormone responses, 4 days postoperatively.

43. Acupuncture for Postoperative Pain □ Control ● Acupuncture

44. Conclusions: Acupuncture used preoperatively significantly decreased postoperative pain scores, reduced supplemental analgesic requirements up to 50%, lowered the incidence of postoperative nausea and vomiting 20 to 30%, and reduced stress hormone concentrations 30 to 50%, compared to controls.

45. Wang et al: Narcotic Sparing Effect of Acupuncture during Lithotripsy: A Double Blinded RCT. Anesthesiology 2004; 101:A31

46. Interventions: • Acupuncture group received auricular acupuncture and electroacupuncture to the Four Gates. • Sham acupuncture applied auricular and to Four Gates. • All received a bolus of midazolam and alfentanil, then IV PCA alfentanil during the procedure.

47. Outcome measures: Alfentanil usage; PACU discharge; physical recovery score.

48. Conclusions: Alfentanil usage in the acupuncture group was significantly lower. No differences in time to home discharge. Physical recovery scores showed a trend toward improvement with acupuncture.

49. Skilnand et al: Acupuncture in the management of pain in labor. Acta Obstet Gynecol Scand 2002; 81:943-948.

50. Interventions: • Acupuncture group (n=106); • Sham acupuncture (n=104)