Tag Archives: Pain

Pain

alone-62253_1920Any conversation about acupuncture will usually start involve pain.  Despite the wide spectrum of holistic clinical applications for acupuncture, it is still the most common problem that presents in my clinic.  It is probably what acupuncture is best known for and indeed the most explored and explained condition scientifically.

What is Pain?

The widely accepted definition was developed by a taxonomy task force of the International Association for the Study of Pain: “An unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in such terms.”  Importantly, this definition highlights the fact that it is a subjective sensation.  In other words expressions such as “it can’t be that bad” say more about the frustration of the person saying it than the person suffering.  One persons intolerable discomfort may be very different to the next.  Indeed it may be very different according to a number of external factors like temperature, time of day, mood etc.  In my clinic, it is whatever the patient says it is.

There are a number of ways in which to classify pain but I particularly like those described by Professor G. F. Gebhart who separates into protective and non protective of acute or chronic duration.

_DSC0099Protective pain

This could be likened to my old career as a police officer.  Nobody likes it much but actually its doing an essential job.  In this simplest form, pain is a protective response from our body to prevent more serious injury.  For example, the pain one experiences when touching something hot is a warning shot that prevents a more serious burn.  Without this we’d be in big trouble.  When we injure ourselves and it hurts to move in a particular way its usually to stop us moving and causing more damage. Basically, we need pain.

Non protective pain

By comparison this pain serves no obvious protective function, for example the ongoing discomfort experienced after a nerve injury.

Chronic and Acute

The terms chronic and acute can be ascribed to either of the above classifications and describe the duration of the pain.  The NHS consider pain to be chronic or persistent if it has been suffered for 3 months or more and has failed to respond to standard medical treatment.  This persistent condition is poorly understood. It is believed that in at least some cases, there has been a breakdown in the way in which our complex nervous system processes information.

Alarmingly its not an unusual condition.  The Chronic Pain Policy Coalition in a recent publication reported around 14 million people in the UK living with this condition, 25% of whom have lost their jobs.  This is a significant number of people.

How does acupuncture work?

Picture of acupuncture needlesScientific research for acupuncture is very complex and is much debated (a subject better covered in my talks).  A number of theories are suggested for the mechanism behind acupuncture treatment.  Some studies have found that certain hormones released by the body for anaglesia in response to pain are released in greater quantities during electro-acupucture treatment.  Another explanation is the micro trauma theory which suggests that causing a very small injury in the region of existing trauma re-activates the bodies healing mechanism, “waking it up” so to speak.  All of the current theories/explanations are interesting and plausible but it is fair to say that the exact science is not fully understood.  Never the less, in certain conditions such as migraine, the results of using even very basic acupuncture treatment is so positive that it is recommended by the National Institute for Clinical Excellence.

Traditional Acupuncture

In chronic pain I find it useful to consider the problem in the Traditional Chinese Medicine paradigm.  In basic terms this holds that the usual smooth flow of the bodies energy force, Qi, is disrupted which causes a blockage or stagnation.  This in turn causes pain.  Acupuncture at certain points on the body can get the energy moving in the right way again.

Of course moving Qi is just one part of the problem.  The is to work out why the energy is stagnating in the first place.  In a post trauma injury this may be easy to work out but in long term chronic issues any number of physical and emotional factors could be at work in isolation, or in collusion with one another.  Looking at the wider aspects of your health and wellbeing both physically and mentally helps me to get a clearer picture of your health.  Treatment is then tailored to your specific “holistic” needs.

Help with pain

If you would like more information about how acupuncture could help please contact me to discuss – Contact Details

For more information follow this link to the NHS pain management self help leaflet – Pain Toolkit

A Word about Evidence

The Detective

Photo by paurian on Flickr and used here with Creative Commons license.

The issue of science and evidence based medicine has interested me since I first entered the profession of traditional acupuncture.  I am fascinated by the far reaching capabilities of science, particularly how modern thought correlates with the traditional philosophical concepts of health that still form the main foundation of traditional Chinese Medicine.  It is through this respect however that I have also learnt the limitations of what human beings can explain or understand.

The evidence base for acupuncture is a big subject in which many pitch battles are fought, usually between the relatively niche worlds of scientific skepticism and research savvy complementary therapists.  Its dominated by big brains and personalities and an arena into which I feel intimidated to even dip my toe.  However! The recent episode of BBC’s “Trust me, I’m a Doctor”, in which they tackled the question “does acupuncture work” in about 8 minutes has convinced me to offer some observations that may better equip people to make a more informed decision for themselves.

Historical context

Acupuncture has been researched since the 19th Century and appeared in the first ever issue of the world acclaimed medical journal The Lancet.  The scientific interest however gathered momentum in the 1950’s when Chairman Mao established a number of acupuncture research institutes as part of a “reinvention” of traditional medicine”.  This and an increasing interest in acupuncture from the scientifically minded west led to a substantial amount of acupuncture research.  It is now most likely the most widely researched complementary medicine in common use.

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Photo by Jeremy Shultz on Flickr and used here with Creative Commons license

The Gold Standard of Evidence

When we hear about scientific evidence in medical terms it is really defined by the Randomised Control Trial (RCT) which is considered the Gold Standard of evidenced. In order to establish how well a particular treatment or intervention works it is studied alongside one or more “control groups”. Trial subjects are randomly allocated to one of the groups or “streams” in which they will receive either a treatment or a control treatment.   In the best studies one of the control groups will be treated with a placebo i.e. designed so that the person giving and receiving it cannot differentiate from the active treatment.  In a blind trial they will have no idea which treatment they are getting.  In a double blind study the practitioner will also be blind as to which treatment they are giving.  In its simplest terms a positive outcome would see the tested treatment or intervention outperforming the controls in a statistically significant way.  Sounds simple?  Its not.  Its a complex time and resource intensive process. There are numerous quality indicators within the process and any deviation risks invalidating or at least undermining the entire study.

Difficulties of designing and RCT of Acupuncture

Firstly, there are a lot of poorly designed studies out there and I’m not decrying the ones that say acupuncture doesn’t work.  Actually the opposite.  Some of the early studies of acupuncture that consistently found it to be better than sliced bread aren’t worth the paper they are written on.

There are of course good ones too and it is in some of the larger and better quality studies of acupuncture that we hear one of the commonly cited criticisms that ‘whilst acupuncture outperforms “usual care” with statistical significance, it fails to compare so well to sham acupuncture’.  This is interpreted by many as meaning it is no better than a placebo.  I think we should consider more information before leaping to this conclusion.

Lets be clear, RCTs are designed for and lend themselves to researching drugs.  In this type of research, creating a placebo is a simple matter of handing the subject a pill or liquid without any active ingredients, usually a sugar pill.  The subject takes it as they would any other drug and in the main, this is a direct representation of how a patient would be treated with drugs.

_DSC0027For interventions using holistic therapies like acupuncture it is far more complex.  Typical clinical practise for a traditional acupuncturist involves a great deal more than just needling.  Palpation, case history, lifestyle advice, the list goes on.  And then there’s the needling, tailored individually to the patient and their unique presentation.  Many trials of acupuncture use pre-defined acupuncture points and seek to isolate it from the other parts of treatment like lifestyle advice etc.  You end up with a highly sanitised treatment that bears little if any resemblance to a typical clinical encounter.

The issue of using a placebo control is also highly controversial.  Creating a placebo for acupuncture means designing an “act” for real and false acupuncture that nobody can differentiate. The favoured methods are retractable needles that don’t penetrate the skin or normal needling on “non” acupuncture points.  The latter at least involves needling which arguably activates a bodily response making it far from inert.  The former is also far from infallible.  During a practise sessions with various types of non-penatrative placebo needles I found that in fact they frequently break the skin and this corresponds with the experience of research acupuncturists too.  If they penetrate the skin, can it be considered as a placebo or non-active intervention?

I’d suggest not so what you end up with is a placebo that may not be inert and an intervention that does not represent normal clinical practise.  Yet in spite of this, both still outperform usual care. What does this say?  My interpretation is that even bad acupuncture is better than usual care or no treatment.  Imagine the potential for proper acupuncture!

Other evidence

What really grates on me is not the never ending argument of the wether or not an RCT has proved one thing or another.  Its the hailing of an RCT as the be all and end all of evidence like nothing else in the world matters. I think this is demonstrative of a far larger cultural shift driven by advances in technology, not just our attitude to medical science.  For example, in my previous profession of law and order we used to solve crime long before CCTV and DNA evidence (I hear the cynics amongst you! Lets have that debate another time!)  Now it seems that witness testimony doesn’t really cut it.  We need concrete proof and undisputed computer audit trails.  Does this mean that without them the crime never took place, that the evidence of a witness was wrong?  No, its just that we now have a higher expectation.  The same is true of medical science.  The old evidence is still evidence and actually, if theres enough of it or the “new” evidence is poor evidence it is arguably still “best” evidence!  Thats not to knock progress, just to encourage some humility because our expectations now are so high we seem to forget that in the greater scheme of things we actually still know very little.  Anyone who has suffered a migraine will back me up here.  Drugs may work, they may not, they may work for a time then stop working.  Actually, this commonly occurring but painfully debilitating illness is very poorly understood in spite of countless studies and amazing scientific developments.

Traditional acupuncture does not rely solely on what can and can’t be proved scientifically.  It is built primarily on the collective knowledge of recorded clinical practise over 2,000 years. It is good evidence stood next to science which has only really developed in the last 60 years and still has a long way to go.  I wonder then why some people would be so quick to dismiss it.

Conclusion

Wooden justice gavel and block with brass

Photo by Tori Rector on Flickr and used here with Creative Commons license

I hope that I have been able to give a good overview of the strength and potential weaknesses of scientific evidence in the field of acupuncture.  In my opinion, whilst science has a huge part to play in our future, it still stands very much in support of the historical knowledge and philosophy that is the bed rock of traditional acupuncture.  That doesn’t mean Im not excited about what it can and will bring to my profession as we make more and more advancements .  I simply advocate tempering this with an awareness of our own limitations and the openness of possibilities beyond our own limited knowledge.

In the meantime I will continue to be guided by “all of the evidence” to treat individual health needs with traditional acupuncture for as long as it continues to help people.  I have a feeling I won’t be retiring anytime soon!

Battlefield Acupuncture

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Photo by Mr.TinDC on Flickr and used here with Creative Commons license.

Battlefield acupuncture is an auricular protocol designed in 2001 by Dr Richard Niemtzow, a US air force Colonel, as a treatment for pain relief.

The protocol uses up to 5 points in each ear, though treatment may not include all depending on the pain reduction reported.

It was first used to treat pain patients, including wounded service personnel, in 2008 and reported significant results.  Since then its popularity has grown and it is now being taught more widely to American armed forces as a cheap, easy and safe way of treating acute or chronic pain.

It has also gained in popularity further afield including the UK where this and other auricular acupuncture treatments are used as a stand alone microsystem or as an adjunct to traditional acupuncture.

Though I personally favour a treatment approach that addresses the underlying causes of illness, I am a big proponent of auricular therapy in the management of many symptoms, not just pain, and will often add it in to my standard treatment.

Reference

 

Amaro, J. (2009) Battlefield Acupuncture for the Clinical Practitioner. Acupuncture Today. 10(4)