Acupuncture has been used in China for thousands of years – it’s one of the first ‘alternative’ treatments requested by patients experiencing persistent pain, and one that has been receiving increasing attention from the scientific community as neurobiological research progresses.
This paper by Wang, Kain & White provides an overview of the state of play for acupuncture and analgesia. As a result of this I’m taking another look at acupuncture as a potential modality for people with chronic pain – with a few proviso’s!!
What’s the evidence?
Traditional Chinese acupuncture is a philosophy that focuses more on prevention than treatment of illnesses. The ancient Chinese believed that Qi flows through a network of channels called meridians, which bring Qi from the internal organs to the skin surface. Along these meridians there are acupuncture points that can be stimulated to correct the imbalance and restore the body to normal health.
Western theories are primarily based on the presumption that acupuncture induces signals in afferent nerves that modulate spinal signal transmission and pain perception in the brain.
Over the last decade, advanced imaging technologies have been introduced, including positron emission tomography (PET), single-proton emission computer tomography (SPECT), and functional magnetic resonance imaging (fMRI). These imaging technologies have made it possible to noninvasively visualize the anatomic and functional effects of acupuncture stimulation in the human brain.
PET scanning found that only acupuncture stimulation at LI4 with De Qi sensation activated the hypothalamus – sham or needling in ‘incorrect’ positions didn’t.
In another study, during a PET scanning sequence Biella et al. found that acupuncture, but not sham treatment, activated the left anterior cingulum, superior frontal gyrus, bilateral cerebellum, and insula, as well as the right medial and inferior frontal gyri. These are the same areas activated by acute and chronic pain.
However, just in case you thought it was ‘simple’ – the anticipation and belief of a patient might also affect the level of therapeutic outcome. This has been specifically examined, and findings from Pariente et al. identified that both true and sham acupuncture activated the right dorsolateral prefrontal cortex, anterior cingulated cortex, and midbrain, however only true acupuncture caused a greater activation in insula ipsilateral to the site of stimulation.
SPECT and fMRI studies have also been conducted, with similar findings – only true acupuncture produced activation of specific areas of the cortex that are apparently involved in pain perception.
Physiological and imaging studies are providing insight into the neurophysiological mechanism of acupuncture analgesia. Recent data suggest that acupuncture triggers a sequence of events involving the release of endogenous opioid-like substances, including enkephalin, [beta]-endorphin, and endomorphin, that modulate pain signals processed along the pathway. Imaging studies demonstrate that the limbic system plays an important role in acupuncture-induced analgesia.
Now just because I can, I invite you to consider the place of placebo, or as Dan Moerman calls it ‘meaning response’.
Unless really good randomisation and double blinding (the patient and the assessor are ALL unaware of whether the procedure is ‘real’ or ‘placebo’) we will run into the effect of having treatment (of any kind) can have on an individual. And especially in the case of acupuncture where the practitioner can never be blinded to whether the procedure is ‘real’ or ‘sham’, inadvertent changes of nonverbal (and at times verbal) behaviour can and will be conveyed.
So…. a very fruitful area of study, methinks.
Oh and another concern I have with acupuncture, as I do for any procedure that involves another person rather than self management for a chronic health condition – acupuncture is usually done by someone to someone. The very process of attending a practitioner is a form of pain or illness behaviour. This action by definition means the person has:
- identified that they want help
- need to ask someone else to help them
- can’t manage by themselves
This means the person will inevitably relinquish a degree of self efficacy (confidence that they can manage their problem by themselves and out of their own efforts) to the actions of another person.
As someone who likes my independence, I’m not sure that I want that.
If you’re curious to learn more, trying searching under the term ‘acupuncture’ and ‘chronic pain’, and seeing what comes up. I visited Cochrane Collaboration and found a couple of older reviews of acupuncture, none of them particularly able to identify strong support for its use.
I also visited the Bandolier Oxford Pain Site, and searched under ‘acupuncture’ – again I couldn’t find much support, and most articles were out-dated.
My question is: if fMRI and other studies are demonstrating significant changes in blood flow etc, are they truly controlling for ‘meaning response’, ‘treatment effects’, inadvertent communication of expectations by the practitioner etc, or is this confounding these results? And if it is a ‘meaning response’ – how can we integrate this into our practice?
Dan’s book, by the way, Meaning, Medicine and the Placebo Effect is a really GREAT read – with some good info on pain as well as health care and the sociology of ill health. Good stuff!
If you’ve enjoyed this post, want to know more, want to keep reading – don’t forget you can subscribe using the RSS feed – and do drop me a line! I love mail, and am very happy to reply (even if we don’t agree!!).