Sunday, 31 July 2016

Acupuncture and pain-management

Recently I read an article that Acupuncture is as effective as drugs in treating pain. This was from an Acupuncture trial in four Melbourne Emergency Departments.  This could open the way for more hospitals to offer Acupuncture as an effective (and low-cost) healthcare intervention.

Great to see such a successful and practical result with Acupuncture.  We have know for some time (since early research in the 1970s) that Acupuncture can be highly effective in pain management when it was shown to release naturally occurring opiod peptides, and B endorpin plays an important role in Acupuncture analgesia.  Han 2004 (Acupuncture and Endorphins. Neuroscience Letter 361: 258-261) found that Acupuncture releases both enkephalin in the spinal cord and B-endorphin in the brain.   There are no doubt other mechanisms that may be involved (e.g. Melzac's Gate Control theory, Central inhibitory effects, etc) but whatever the mechanisms, it seems to work.  Great for the patients (perhaps not so great for the pharmaceutical companies - but hey, there's a lot of chronic pain patients, who will still take a lot of medication).  But at least, more help is available, and acupuncture may become more a part of this.

If you wan to read more,  please look at:

Inflammation and Ice (which is counterproductive - and wrong) Acupuncture and tissue healing. Osteopathy and Lymphatic drainage.

Recently I was reading an article on why Ice is wrong (Icing Injuries is Wrong) see:

Josh and Shagra Stone list, in a well-researched review list several reasons for this.  Among them are:

 " Ice does not facilitate proper collagen alignment. Diagnostic imaging of chronic tendon injuries like Achilles tendinopathy, jumper’s knee, runner’s knee, and plantar fasciitis show poor collagen arrangement of connective tissue." 

"Ice impedes cellular signaling and inhibits the proper development of new cells. The processes of mechanobiology and cellular signaling take progenitor cells—infant cells who do not know what they are going to be—and makes them into rebuilding cells like myocytes, osteocytes, tenocytes, chondrocytes, etc."

There are several reasons why Ice is ineffective and counterproductive, in that it inhibits the inflammatory process which is essential for tissue repair.  (The authors, in the above article, cite inflammatory cells as releasing the hormone Insulin like Growth Factor, a primary mediator of the effects of growth hormone, a stimulator of cell growth and proliferation, and potent inhibitor of programmed cell death).

Essentially the inflammatory process is a necessary part of tissue repair.  When receiving osteopathy and acupuncture treatment, I often tell my patients this - and make an analogy to the almost constant road-works here in Christchurch.  Yes, a drag, and causes traffic congestion, and slows everything down - yet an essential part of the city's repair process.

I have also speculated that the effectiveness of Acupuncture in treatment and pain-relief, may, at least in part, be due to the changes in blood flow and platelets secreting cytokines, and possibly release of insulin like grown factor also.  Admittedly this is an area for further research.  Certainly, cytokines and other metabolites can promote a healing cascade and stimulation for collagen regeneration.  
For more on this, please see:

Clinically, Acupuncture, does seem to effect blood flow around the area being needles (with local endorphin release, and more far reaching effects  -   enkephalin in the spinal cord and B-endorphin in the brain. ( Han 2004 Acupuncture and Endorphins. Neuroscience Letter 361: 258-261).  We also know that the nervous system can be senstised to pain by the presence of inflammation, either peripherally, where the responsiveness of nerves is increased by the presence of inflammatory mediators, or centrally where additional receptors are recruited that amplify the nociceptive (pain) signal.

In their article, Josh and Shagra Stone, also mention (as evidence against the use of Ice):
"Swelling—a byproduct of the inflammatory process—must be removed from the injured area. Swelling does not accumulate at an injured part because there is excessive swelling, rather it accumulates because lymphatic drainage is slowed. The lymphatic system does this through muscle contraction and compression. Ice has been shown to reverse lymphatic flow."

In my early training as an Osteopath  (at the Institute for Classical Osteopathy, with John Wernham - who studied with John Martin Littlejohn in the 1930s, who in turn studied with Andrew Still in the 1890s, the original founder of Osteopathy) great emphasis was placed on lymphatic drainage in osteopathic treatment.  Yes, of course, bio-mechanics, alignment, joint range of motion are also all important, yet the treatment and principles taught by Wernham always placed great emphasis on lymphatic drainage, from the lower extremities (calf pump) to the diaphragm (cysterna cylii) and finally the clavicles and return to the superior vena cava, via the thoracic ducts.  (Littlejohn, whilst a brilliant physiologist, was also an anatomist, and made a life long study of these disciplines, which were still in their infancy at the beginning of the twentieth century).

For more around this you could look at see:

So interesting how modern research and observation, bears out Osteopathic knowledge over a century old.  The more of this the better.

In summary (for I have gone far beyond "Why Ice is bad') it begs the question, so how then should we treat injuries?  Elevation may still be good (effective elevation needs to raise the injured area above the level of the heart, for optimal drainage.  Easy for an arm, less so for a leg.)

Well, just to be practical (for patients and clinicians) I've always found a combination of acupuncture and gentle osteopathy to be excellent, and bring good results, both in the short and long term.  And the reasons why, are easy to see, if we think of this basic physiology, and the cellular and inflammatory processes underpinning it.  Research and Evidenced based medicine are helpful here, as it will give us much greater understanding of what is most effective.

For more on this you might want to see: