Pain Management & Acupuncture

1. Pain Management & Acupuncture Simon Strauss MBBS Monash 1972. Dip. Acupuncture Nanking 1978 This session • Historical Perspective on Acupuncture • Pain Epidemiology - The “Market” • Introduction to Myofascial Pain Theory • The Near and Far Acupuncture Technique

2. AcupuncturePractice - An Established Trend • Growth of Acupuncture Outlets - Brisbane

3. Acupuncture Item 173 (980) • From 1984 to 1995 (National)

4. Attitudes are age related.

5. NHMRC. W.P.Document: Management of Severe Pain Core Curriculum for Medical Practitioners - Identifies a need for Education on: • Acupuncture and Transcutaneous Nerve Stimulation techniques. • The measurement, quantification and recording of pain.

6. International Association for the Study of Pain (IASP) Management of chronic pain: Core Curriculum for Medical Practitioners, Dentists and Physiotherapists - Recommends Education on: 1.Neurostimulation techniques including a. Transcutaneous nerve stimulation b. Acupuncture 2. The measurement, quantification and recording of pain 3. Myofascial Pain

7. What are the Dominant Factors Driving this Acceptance of what only a Decade ago was regarded as Alternative or Fringe? • It Works • The results depend on the practitioner’s skill.(Operator satisfaction) • Its’ mechanisms can be understood from a Western scientific viewpoint • It is cost effective for the consumer • It has a high efficiency index.( +ve effects far outweigh side effects.)

8. ADDITIONALLY There is considerable demand • 1. As Western Countries are experiencing an “Epidemic” of Chronic Pain. • 2. That is poorly managed with our classical techniques!

9. The Epidemiology of Pain: An Australian Study Brisbane. by F. Guthrie, F. Nicolosi and S. L. Strauss. Telephone survey of 265 Households • Household pain prevalence rate, 35.5% • Adult Individual pain prevalence, 19% • Overseas studies, (Canada, USA) have shown similar prevalence rates.

10. Pain Prevalence Increases with Age. • 10% of 30 year olds • 25% of 50 year olds • 45% of >60 year olds • Over the age of 30 females’ pain incidence is higher than that of males. The Epidemiology Pain: An Australian Study

11. Location of most severe painThe Epidemiology Pain: An Australian Study • As % of Pain States declared

12. IntensityThe Epidemiology Pain: An Australian Study45% can be regarded as suffering from severe pain

13. DurationThe Epidemiology Pain: An Australian Study91% have “Chronic Pain” • Time since first occurrence of Pain State

14. FrequencyThe Epidemiology Pain: An Australian Study53% Daily or constant • Frequency of Pain Occurrence as a %

15. Cause of Pain state • Post Surgical = 2.6% • Sports Injury = 3.4% • Accident = 18.8% • Other = 19.7% • Work Related = 21.4% • Spontaneous = 34% The Epidemiology Pain: An Australian Study

16. “Health Professional” Consulted. • 70% visited a “Health Professional” • 30% no treatment or self treatment The Epidemiology Pain: An Australian Study

17. Of those visiting a “Health Professional” • 80% consulted a Medical Practitioner • 8% consulted a Chiropractor • 5% consulted a Physiotherapist • 2% an Acupuncturist (Non-medical) • The remaining 5% - Naturopath, Herbalist, Iridologist etc. The Epidemiology Pain: An Australian Study

18. The Epidemiology Pain: An Australian Study: Summary • Household pain prevalence rate =35.5% • Adult Individual pain prevalence =19% • 91% chronic pain (> 6 months) • 45% severe to unendurable Pain Intensity • 53% constant or daily • Back 33%, head and neck 24%, leg 22% • 70% managed. (80% of managed -Medical)

19. 10 High StreetA Private Practice “Multidisciplinary” Pain Clinic. Core Group: S Strauss, T McCarthy. + Physiotherapist, Psychiatrist, Masseuse • Established 1980 • Research oriented • 10,000 Patients.(25 new patients per week.) • 60% Referred.

20. 10 High Street. Pain State Distribution & Age • Breakdown of 1146 Patient’s Pain Syndromes

21. 10 High Street. Pain Severity97% Could be regarded as having severe pain No Pain Unbearable Pain

22. 10 High Street Compared c General Pain Population Comparison of pain severity

23. 10 High Street. Reason for Presentation • Other forms of treatment had not helped: 63% • “I’d have tried anything if I thought it would help”: 61%

24. 10 High Street Patient’s Profiles. • A picture emerges of desperate patients suffering severe to unendurable pain for several years, who had tried multiple forms of therapy without gaining sustained relief. • The majority of these patients’ syndromes involved the musculoskeletal system. • 10 High Street patient’s had more severe, more prolonged Pain States than those identified as having pain in the general community. • ? Due to referral bias. ( ? Fear of “needles”)

25. 10 High Street. Research Areas of Interest • Initial Aim was to explore Acupuncture's place within Western Medical Practice: Its’ Mechanisms and treatment results. • Led to an in depth investigation into Trigger Points Sympathetic Involvement Pain Measurement Subjective: Pain diagrams, VAS, McGill Pain Questionnaire Pain Measurement Objective: Thermography, Algometry, Axon Flare, Differential Nerve Blocks: Neurotrace, Cryoprobe etc

26. Cold Bi Syndromes: A Starting Point • T.C.M’s Cold Bi syndromes include the majority of chronic pain states where Ah Shi (Oh Yes) points are associated with coldness of the painful area. [ Nanking School TCM.] • T.C.M. characterises this “coldness” as being due to a blockage of the flow of Qi and blood. • The T.C.M. treatment paradigm is to, “Remove the obstruction thus allowing warming and nourishing of the tissues.”

27. Cold Bi Syndromes: A Starting Point • In Western terms this equates to “deactivating” the Trigger Point thereby decreasing the local/regional, aberrantly enhanced, sympathetic outflow activity usually associated with active trigger points.

28. Myofascial Trigger PointsJanet Travell. 1976 “Myofascial Trigger Points are among the most common, yet poorly recognised and inadequately managed, causes of musculoskeletal pain seen in [Western] medical practice.”

29. Myofascial Trigger PointsMostly Missed • The majority of chronic pain patients seen at 10 High Street had active trigger points. • Very few had had their trigger points palpated prior to presentation. • Most expressed surprise when their pain syndrome was reproduced by palpation.

30. Myofascial Trigger PointsMostly Missed, Why? • Nearly all had never filled out a Pain Diagram, McGill Questionnaire, VAS etc. • Many had not been undressed at previous assessments. • Many had accepted being told that their pain had no physical cause. • Contrary to prevailing paradigm.( The Tomato Principal)

31. Recent Studies (IASP’s Journal “PAIN”) • Have shown that the syndrome of “ Chronic Benign Intractable Pain” (previously) defined as pain that has been present for more than six months without known peripheral nociceptive input is nearly always associated with Trigger Points. ( Back 96.7%, Neck 100%) Pain. Vol.37 1989.

32. Recent Studies (IASP’s Journal “PAIN”) • Have shown that Non Specific Low Back Pain in a General Practice setting is usually (80%) associated with Trigger Points. Pain. Vol.37 1989. • More than 50% of patients admitted to chronic pain programs (USA) were found to be suffering from Myofascial Pain Syndromes due to trigger points.*Textbook of Pain; Ed. Melzack and Wall.

33. TRIGGER POINTSThe Emerging [Western] Paradigm Trigger points are increasingly thought to be important in the pathogenesis of many chronic pain syndromes. They can be thought of as ( T. McCarthy 1983) “Pain Amplifiers” where their activity enhances nociceptor input. eg. Osteoarthritis, or augments sympathetic activity. eg Reflex Sympathetic Dystrophy, Post Herpetic Neuralgia etc.

34. TRIGGER POINTSThe Emerging [Western] Paradigm Trigger points are increasingly thought to be important in the pathogenesis of many chronic pain syndromes. They can be thought of as ( T. McCarthy 1983) “Pain Generators” where the trigger point is the actual tissue causing the pain state. i.e. Myofascial Pain Syndromes.

35. TRIGGER POINTSRx’s Directed @ the Trigger Pointin theWest • Spray and Stretch • Ischaemic pressure massage (Shiatsu) • Injection ( Local Anaesthetic, etc. ) • Dry Needling (Superficial +/-Xple, Deep) • Acupuncture

36. The Near and Far Acupuncture Technique • Was historically and still is the most commonly used Acupuncture technique for the resolution of chronic pain syndromes in the Peoples Republic of China. • When Acupuncture is used to treat common pain states the treatment is aimed at resolving the tissue problem or reflex causing or maintaining the pain state.

37. The Near and Far Acupuncture Technique • Two processes are dominant in this “rehabilitation” 1. The Ablation of Trigger Point activity 2. The Restoration of Disordered blood flow • The provision of Analgesia in this context is a secondary consideration. (Electro-Acupuncture stimulation is rarely used in this context.)

38. The Near and Far Acupuncture Technique • Involves the use of both local and distal Acupuncture points.

39. Local Points - AhShi - Oh Yes - Trigger Points • The local points are usually Ah Shi (Oh Yes) Points • “Oh yes” as when palpated they reproduce the patient’s pain syndrome

40. Local Points - AhShi - Oh Yes - Trigger Points • The Western equivalent of the AhShi point is the “Trigger Point” • > 75% of Local Acupuncture Points for Pain correspond to Trigger Points...... R. Melzack

41. Distal Acupuncture Points • Are classical meridian Acupuncture points and are found below the elbow or knee. • They are used for the treatment of many diseases. Distal Acupuncture Points can be used to manipulate 1. the sympathetic nervous system. 2. the various “Pain Gates”

42. Distal Acupuncture Points In the pain Rx context: • Commonly used distal points are characteristically found in muscles often at the motor point. eg. Li 4, Hegu. Li 10, Shousanli. • The “correct” distal point is frequently tender. • Complex “rules” can govern their selection.

43. The Near and Far Technique for Chronic Pain States: Nanking 1978Local Points • A fine 30 - 32 Gauge needle is painlessly inserted through the skin over the active trigger point/points. • The needle is then twirled (900 left-right ) with downwards pressure until the trigger point is penetrated and “needle grasp” Objective - Deqi occurs. • At this stage the patient’s typical pain can/should be replicated. [Qi reaching the pain] -a type of Subjective Deqi or Acupuncture sensation

44. The Near and Far Technique for Chronic Pain States: Modified for Australian conditions. Local points. • Western patients frequently resent feeling Subjective Deqi! • A good result can also be obtained by stopping the needle manipulation immediately following the penetration of the ahshi or trigger point. • Other techniques have also evolved, where the skin over the trigger point is penetrated several times or a “heavy” needle is canter levered in the dermis.

45. The Near and Far Technique for Chronic Pain States: Nanking 1978. Distal Points Distal points are found below the elbow or knee and are used to provide analgesia and or sympatholysis. • The skin over the distal points is painlessly penetrated • The needle is again ‘Twirled’ 90-1800 left - right as well as up and down until needle grasp or subjective Deqi is experienced. • This distal point subjective Deqi can be sensations of numbness, tingling, distension or dull pain. • The “amount” of deqi provided is titrated against the condition. [Acute/Shih heavy, chronic/Xu milder.]

46. The Near and Far Technique for Chronic Pain States: Modified for Australian conditions. Distal points. • Distal points can be selected by experience / formula. • The penetration of the skin over the point should - must be painless. • For acute - severe pain, eg Wry neck, Stuck back, distal points ‘should’ be needled to produce moderate - strong subjective deqi. • For chronic conditions mild subjective deqi or even just needle grasp ( Objective deqi ) is sufficient.

47. “Correct” Needling Technique The Acupuncturist is frequently judged by his ability to painlessly insert the needle through the skin both in China and the West and rightly so.

48. “Incorrect” Needling Technique The consequences of poor / painful needling technique include: • Poor compliance ( First session is the last) • Poor Result due to: 1. Augmented Sympathetic Outflows 2. Not enough Points allowed to be needled / sessions attended. • Iatrogenic / Side Effects.

49. 10 High Street: Treatment Cascade • Acupuncture -Near and Far technique • Relaxation Training, including in order of utilisation; Tapes eg Passive Muscle Relaxation, Biofeedback EMG / GSR, Hypnosis. • Postural Re-education + - Job Task • NSAI’s, Tricyclics, Finalgon, T.N.S. • Nerve Blocks - Local Anaesthetic (Neurotrace) - Cryoprobe (Facet Joints)

50. Results of Acupuncture Rxusing the Near & Far Technique. Survey 1. 100% Referred Survey 3. NHMRC funded Survey 4. Brisbane Medical School ( Very complex, hostile wording. ? reason for low response rate)