How Acupuncture Plays a Role in Occupational Medicine

1. How Acupuncture Plays a Role in Occupational Medicine Brent Dauphin, L.Ac., MTCM

2. Most people’s notion of acupuncture…

3. History of Acupuncture Acupuncture has a clearly recorded history of about 2,000 years, but some authorities claim that it has been practiced in China for some 4,000 years. The Chinese believe that the practice of acupuncture began during the Stone Age when stone knives or sharp edged tools were used to puncture and drain abscesses.

4. History of Acupuncture (cont.) Acupuncture, or needle puncture, is a European term invented by Willem Ten Rhyne, a Dutch physician who visited Nagasaki in Japan in the early part of the seventeenth century. The Chinese describe acupuncture by the character 'Zhen/Chen', which literally means 'to prick with a needle', a graphic description of this therapeutic technique.

5. What is Acupuncture? Acupuncture is a system of medicine that has been use for thousands of years to promote healing of injuries and for pain management. Typical acupuncture treatments involve the insertion of several surgical grade sterile, single-use disposable stainless steel needles into specific areas (acupuncture points) on the body.

6. Acupuncture Needles The needles are very thin (about the width of a human hair.) When acupuncture points are needled, they work to help move circulation in the body, reduce pain and improve range of motion at an injured area. Many people think acupuncture sounds scary – until they try it!

7. Is it Painful? • There is usually a sensation with acupuncture. The sensations vary in types and intensity depending on area being treated. • Typically the sensation is quick and is sometimes described as a slight rubber band snap. • This sensation, if experienced, only lasts for about a second or two and afterwards there is usually only a sense of a light weight sensation on the skin while the person rests for about 20 minutes.

8. Acupuncture Pathways • A group of points along a longitudinal pathway in the body is called a meridian. We use points along a meridian to influence other parts of the body that the meridian reaches. • Some meridians reach from head to toe or hand to head, this helps to explain why an acupuncturist may use a point on a person’s hand or wrist to treat a pain they are having in their neck.

9. Acupuncture Pathways (cont.) Patients are often surprised to feel this association when being treated. When a needle is placed in one location they frequently remark that they immediately feel the sensation of pain in the second location has changed/reduced. The reason for the phenomenon is best described by viewing an acupuncture chart.

10. Acupuncture Charts The acupuncture points are organized Into 14 main channels or meridians that are used to coordinate specific areas of treatment

11. Acupuncture and Trigger Points • Acupuncture charts and pathways were developed and refined over thousands of years. Most likely it developed first from massage and acupressure. What they charted is very similar to what modern science now calls Trigger Points and uses for injections. Trigger points are defined as localized areas in which the muscle and connective tissue are highly sensitive to pain when compressed. Pressure on these points can send referred pain to other specific parts of the body.

12. Trigger Point Charts

13. Two Basic Styles of Acupuncture Local – needles are inserted to an area of injury • Ex. Putting needles into local points on the shoulder for a rotator cuff strain. • Creates a local response to foreign object & kicks off a reaction of bringing in similar agents to help heal our body and draw in such things as white blood cells and other inflammatory reaction agents.

14. Two Basic Styles of Acupuncture(cont.) Distal – using acupuncture points at locations other than site of injury. • Ex. Using an acupuncture point on the hand to treat a frontal headache. • Helps to block pain by reducing perception of the pain signal.

15. Obstacles of Acupuncture • I would estimate that at least 90% of the new patients are apprehensive and reluctant to trying acupuncture. This may be due to fear of needles, fear of unknown factors such as what is this acupuncture? Why am I doing this, who is this caucasian Acupuncturist person? (acupuncturists come in all shapes and sizes now in America, similar to the population in general. Chinese is not the majority demographic of acupuncturists coming out of schools now)

16. Side Effects of Acupuncture • SIDE EFFECTS are possible, such as bruising or soreness at the point of needle insertion. These are usually temporary, however there have been rare instances of organ injury reported by incorrect needling technique. Also, just as with any needle technique fainting is a rare but possible occurrence. Usually this is due to a patient having skipped a meal and having low blood sugar at the time or from having extreme needle phobia.

17. Side Effects of Acupuncture (cont.) • Acupuncture is similar to Physical Therapy in that it tends to have fewer side effects and lesser in severity than other forms of pain treatment. The function of acupuncture is to create self healing and is less likely to cause side effects than many other options such pharmaceuticals which require ingesting a foreign substance that needs to be absorbed and metabolized by the body.

18. Treat Yourself Acupuncture Point on the hand • Can be use for frontal headaches and sinus pain • To Find, press the meeting point of bringing the thumb and first finger together. • To Use, push on the muscle until you feel a moderate achy sensation, then continue pushing until the discomfort diminishes.

19. Acupuncture Added to WC • California Adds Acupuncture to Workers' Comp Treatment Guidelines as of June 15, 2007 • Must be prescribed by medically approved provider • Inexpensive and conservative treatment for musculoskeletal injuries promoted by WHO, NIH, Labor Code, and CA Workers Comp System • Acupuncture is supported by RAND evidence based treatment guidelines

20. ACOEM Guidelines for Acupuncture • Indications for acupuncture or acupuncture with electrical stimulation include the following presenting complaints: • Neck and Upper Back Complaints • Elbow Complaints • Forearm, Wrist and Hand Complaints • Low Back Complaints • Knee Complaints • Ankle and Foot Complaints • Pain, Suffering and the Restoration of Function

21. ACOEM Guidelines for Acupuncture (cont.) • Frequency and duration of acupuncture or acupuncture with electrical stimulation may be performed as follows: • Time to produce functional improvement: 3 to 6 treatments. • Frequency: 1 to 3 times per week • Optimum duration: 1 to 2 months • Acupuncture treatments may be extended if functional improvement is documented as defined in Section 9792.20(e).

22. Positive Outcomes of Acupuncture • The positive outcomes of acupuncture in an Injury Rehabilitation & Post Operative Pain Program in Workers Compensation include: • Pain Management • Decrease in Pre-Operative Anxiety • Reduction of Inflammation & Swelling after surgery

23. Positive Outcomes of Acupuncture(cont.) • Reduction of Nausea & Vomiting • Regulation of Digestive function • Reduction of Need for Medication • Reduction of Scar Tissue • Decreased Healing Time • Increased Rates of Full Recovery

24. When is Acupuncture Typically Referred? • Not just when everything else fails! Acupuncture is a conservative treatment. It is optimal to use acupuncture earlier in the course of the condition rather than later. Though acupuncture can be helpful as far down the line as post-operation recovery. Some patients have had physical therapy, cortisone injections and surgeries before they come to see me. These are considered chronic and are certainly harder to return to full work capacity…though some do significantly still improve.

25. When is Acupuncture Typically Referred? (cont.) • Better results and more commonly referrals occur after a round of physical therapy has failed to produce strong enough benefits. Often people have pain that is very strong and they are not able to perform rehabilitative exercises. Other referrals are patients that are either unable or unwilling to take pain medications, injections or surgery and wish to try a more “natural” approach to healing.

26. Use of Acupuncture for CTS Causation of Carpal Tunnel Syndrome Painful neuropathies of the hand and wrist are from nerve compression, most often compression of the median nerve in the carpal tunnel.

27. Use of Acupuncture for CTS (cont.) Etiology of CTS Median nerve compression by tendonitis Usually due to repetitive motion of the wrist and hands.

28. Use of Acupuncture for CTS (cont.) Carpal Tunnel Release Surgery: Carpal ligament is incised… …releasing pressure on median nerve

29. Studies on Acupuncture Mechanisms of Acupuncture: • Stimulates conduction of electromagnetic signals within the muscle and soft tissue fibers causing a relaxing within the soft tissue • Release neurotransmitters and neurohormones that affect body function such as digestion and breathing. • Stimulate blood flow in the body, which is helpful in healing an injury • Reduces pain by causing a release of endogenous opiods, which are pain blockers known as endorphins.

30. Acupuncture Used for Pain Management • There are statistically significant benefits for a variety of types of pain. • An extensive study was published in the past few years of 1,162 patients with chronic low back pain that were treated with acupuncture. • Researcher Heinz Endres, MD concluded, “Patients experienced not only reduced pain intensity, but also reported improvements in the disability that often results from back pain.”

31. Acupuncture Used for Pain Management (cont.) Findings such as these are important in Workers Compensation because our main goal is to return the injured employee to work as quick as possible with the highest capability of function.

32. Not All Studies Are Conclusively Positive • Acupuncture does not cure everything. There is no one cure all magic bullet or magic acupuncture point! Just as there is no one perfect pill or surgery to cure everything. * Also Note – There are difficulties in conducting studies of acupuncture as it does not always fit into our western research model very well due to difficulties in creating a double blind placebo study.

33. Placebo Effect • This is often said of acupuncture because it does not always fit into a western notion of medicine that can be studied. Pills, creams, injections, and other medical procedures, such as ultrasound are also often called placebos. Even the notion of a physician and the way they interact with a patient have been noted as a placebo effect, such as a notably increased healing time when providing a suggestion that the patient, “will be better in a few days” rather than negatively stating “I am not sure if the treatment we are giving you will have an effect.” To that note; many dogs and horses are given acupuncture with noticeably beneficial improvement in conditions such as arthritis, this is obviously not due to their expectations in treatment.

34. Acupuncture vs. Narcotics • 2010 analysis by Accident Fund Holdings reported that the cost of a workplace injury was 9 times higher when a strong narcotic like OxyContin was prescribed when compared to a workplace injury treated with conservative care and no narcotic pain medication. • Prescription of narcotic pain medication has expanded greatly in the last decade, prompting a number of laws now requiring physicians to utilize conservative care in the form of acupuncture & physiotherapies to reduce narcotic addiction, overdose injury and death.

35. Acupuncture vs. Narcotics (cont.) • Accident Fund Holdings reported that the cost of a typical workplace injury, averaged about $13,000, was tripled when a strong narcotic pain medication was prescribed instead of utilization of conservative treatment protocols. • When the strongest narcotic pain medications were prescribed, the average cost of workplace injury increased to 9 times the average.

36. Acupuncture vs. Narcotics (cont.) • A course of acupuncture and physiotherapy of 18 visits would cost roughly $2,000, much less than the $26,000-$114,000 added on average when patients are treated with narcotic pain medications instead.

37. Case Study #1 52 yr. old female process operator developed tennis elbow due to repetitive tasks. Pain was bilateral in nature. Tylenol and round of PT not resolving pain. Pt rated pain 6-8 out of 10 at time of initial acupuncture evaluation with trouble lifting & holding objects. Pt treated with distal acupuncture, infrared heat and given topical herbal patch at each treatment. By 4th tx pt was improving slowly and by 6th/final was more than 50% improved. Because patient continued to gain improvement a second set of acu was requested. By 9th visit pain was reduced drastically. On re-evaluation at last appointment (12th) the patient had 0/10 pain while working full time and had requested release from care. Pt referred coworker in similar position at work who still had pain after cortisone injection for lateral epicondyle region pain.

38. Case Study #2 39 yo M with left Thoracic pain that extended down toward his lumbar area. Patient was injured when moving a large heavy bag, he performed a lifting and twisting motion to the left causing the injury. At time of initial evaluation the patient was very tense and guarded to touch in area from mid thoracic through upper lumbar, he had palpable spasm in area as well. Forward bending and walking provoked pain. He was unable to find a comfortable position to remain in, especially after he finished work as a maintenance worker. His sleep was provoked as well. Patient was trying to continue a full 40 hour work week though even with modifications of reduced lifting, twisting and bending he was having 9/10 pain level. He had a grade 3 tenderness to palpation at the evaluation. By treatment number six the patient’s pain reduced even after working a full day and was sleeping much more comfortably. Objectively I noticed the tenderness to palpation had subsided a grade 1-2 and the patient was much less reactive even when given myofascial release over the injury. By treatment number six he had only slight residual muscle tightness remaining and active range of movement was now much more functional with greater comfort overall in the area.

39. Case Study #3 52 yr F systems analyst injured from keyboarding. Pain at radial wrist. Limited capability of flexion/extension of thumb at time of evaluation. Patient was using thumb and wrist splints to prevent movement of injured area. Swelling at wrist and TTP was at medium high level. After course of PT the patient had gained some improvement though was still sore and had limited ROM. Patient declined cortisone injection and wished to try acupuncture instead. Patient rapidly felt improvement in range of motion capabilities and pain reduction. By 3rd tx active range of motion increased to 90%. At fifth tx the primary physician stated cortisone injection is not warranted and ordered a second set of acupuncture to help the patient strengthen as she remains at full duty in workplace. However approximately twice per year there is a high volume of letter folding and placing into envelopes which is highly provocative for her thumb and wrist. This period just occurred and while it was strenuous to the hands in general patient still has full AROM and much less provocation than the other periods of such intense wrist and hand usage. The patient was advised to continue to use the favorable body mechanics and ergonomics she learned during her treatments to reduce strain in workplace moving forward.

40. Conclusion • Acupuncture can be an effective and less costly way to treat certain work related injuries. Acupuncture can: • decrease pain • decrease inflammation • promote healing • regulate the immune and endocrine systems. • may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten functional recovery.

41. Any Questions? Thank you! Brent Dauphin, L.Ac., MTCM Alliance Occupational Medicine 1901 Monterey Rd. Ste 10 San Jose, CA. 2737 Walsh Ave. Santa Clara, CA. 315 S. Abbott Ave. Milpitas, CA.