Acupuncture: Integrating An Ancient Technique To Help Your Patients Kirksak Jay Poonkasem, MD, FAAFP, LMT Integrative Palliative Medicine Morton Plant Mease Medical/Surgical Grand Rounds January 9, 2018

Objectives Describe the basics of acupuncture Understand the indications for acupuncture Identify contraindications for acupuncture Discuss methods used in acupuncture treatments Discuss outcomes of acupuncture sessions/treatments Utilize simple acupressure techniques for symptom management

Patient Case 49 year old female with Stage IV Adenocarcinoma of the lungs with mets to the mediastinal lymph nodes, right scapula and right calvarium. Patient complains of excrutiating 10+/10 pain in the neck, shoulder and right arm She cannot move right arm and cannot lay back Patient has been getting chemotherapy and radiation treatments Taking Extended Release Morphine 100mg PO q 8 hrs ATC and Immediate Release Morphine 30mg PO q 3 hrs PRN BTP. Added Neurontin 300mg PO TID and Extended Release Morphine increased to 160mg PO q 8 hrs ATC. Integrated acupuncture in the care of this patient. After a few days inpatient, patient able to regain use of right arm and hand after 2 months of not being able to do so. She also was able to lay down on her back and sleep at night.

What is Acupuncture & Theory? Treatment modality using needles inserted into points along the body to manipulate the flow of Qi (Energy). 12 main paired meridians (energy pathways) in the body that correspond to “organ” systems. 2 unpaired meridians Disease manifests due to obstruction/imbalance of the channels.

Acupuncture History Acupuncture in some form has been around for thousands of years. China, Egypt, Africa, S. America Ice Man – Oetzi – Europe Sharp Stones, bamboo, fishbones used Earliest major acupuncture text “Huang Di Nei Jing (Yellow Emperor’s Inner Classic)” Core was compiled during the first century B.C.

Acupuncture History Qing Dynasty (1644-1911) Gradual Decline in Chinese Medicine 1822, Qing Emperor ordered acupuncture not to be taught at the Imperial Medical College China exposed to Western Medicine due to Missionaries of the 17th Century Success of Western Medicine (drugs, surgery, public hygiene), status of acupuncture declined.

Acupuncture History 1929 – Guomingdang Government tried to outlaw Chinese Medicine Chinese Medicine was brought back when Mao Tse Tung took over in the 1940s. Doctors were trained in Chinese Medicine as well as Western Medicine.

Acupuncture History Popularity in the U.S. 1971 – New York Times Reporter, James Reston, underwent emergency appendectomy in China. Post-op pain managed by 3 acupuncture needles 1972 – President Nixon in China Witnessed surgeries using acupuncture as analgesia

Let’s keep it simple… Breaking it down… Acupuncture Needles Acupuncture Meridians Acupuncture Points This Photo by Unknown Author is licensed under CC BY-SA

Acupuncture Needles Stainless Steel – sterile, disposable Non-beveled, Solid Core Reduced infection risk compared to hypodermic needles Standard Needle 30-40mm length Diameter 0.25mm (Roughly 32 gauge needle) Various styles of needles

Acupuncture Meridians/Channels 14 Channels/Meridians 12 Paired Kidney, Heart, Small Intestine, Bladder Spleen, Lung, Large Intestine, Stomach Liver, Master of the Heart (Pericardium), Triple Heater (San Jiao), Gallbladder 2 Unpaired Conception Vessel Governing Vessel

Acupuncture Meridians/Channels

Acupuncture Points 361 points along the main channels Many, many more not on these channels Most are located in surface depressions and along muscle cleavage planes Can be identified by palpation. Most are hypersensitive Can be trigger points

Acupuncture Points Histologic Sections Bioelectric Properties Points located in vertical columns of loose connective tissue surrounded by thick, dense, connective tissue of the skin. Structural elements at interior of column in loose environment Lymphatic trunk, arteriole, satellite vein, nerves Passage between skin and deeper tissues Bioelectric Properties Lowered electrical resistance at acupoints compared to non- acupoints.

Acupuncture Analgesia Nociceptors in skin and muscles Small Fibers, group III (Skin-Aδ) and IV (Skin-C) fibers Traverses Dorsal horn of spinal tract Dull aching sensation when activated (De Qi). Stimulates endogenous opioids (endorphins, dynorphins, enkephalins) act on CNS to modulate pain. This Photo by Unknown Author is licensed under CC BY-SA

Acupuncture Analgesia Sites of Opioid action in CNS: Hypothalamus, limbic system, basal ganglia, periaqueductal gray, nucleus raphe magnus, reticular activating system, dorsal horn of spinal cord. This Photo by Unknown Author is licensed under CC BY-SA

Acupuncture Analgesia Endogenous opioid peptides in the CNS play an essential role in mediating the effects of electro- acupuncture. Low Frequency (2Hz) Accelerates release of enkephalin, Beta-endorphin, and endomorphin. Mu and delta receptors High Frequency (100Hz) Increases release of Dynorphin Kappa receptors

Acupuncture Analgesia Naloxone Blocks analgesic effect of low frequency stimulation. Does not block analgesic effect of high frequency stimulation.

Acupuncture Microsystems Auricular Scalp Tongue Pulse Hands/Feet

Pulse Diagnosis

Tongue Diagnosis

Auricular Acupuncture Dr. Paul Nogier – 1950s Embryology – Mesoderm, endoderm, ectoderm

Auricular Acupuncture

Auricular Acupuncture Battlefield Acupuncture Richard C. Niemtzow, MD, PHD, MPH, Colonel, USAF Developed in 2001 for rapid pain relief after 911 attacks, eventually for use in the battlefield. Semi-permanent needles used for 3-4 days. (Cingulate gyrus, Thalamus, Omega 2, Point Zero, Shen men)

Auricular Acupuncture National Acupuncture Detoxification Association (NADA) Protocols 1985 – NADA Founded by Dr. Michael Smith, MD, DAc. – Lincoln Hospital, South Bronx, New York Used worldwide now Detox/recover from substance abuse issues Helps with emotional, physical and psychologic attributes in addictions Reduce cravings, anxiety, improve sleep Traumas (Lung 2, Shen men, C. Kidney, Autonomic, Liver)

Chinese Scalp Acupuncture Relatively new – 1970s Utilizes acupuncture techniques and knowledge of neuroanatomy. Pain Movement Stroke/Neurologic

Chinese Scalp Acupuncture

Acupuncture Indications Acute and chronic pain control Postraumatic and postoperative ileus Muscle spasms, tremors, tics, contractures Paresthesia Anxiety, fright, panic Addiction/Drug detoxification Neuralgias (trigemnial , Herpes Zoster, postherpetic, other) Seventh nerve palsy Sequelae of CVA's (aphasia, hemiplegia) Certain functional gastro- intestinal disorders (nausea and vomiting, esophageal spasm, hyperacidity, irritable bowel, etc.) Headache, vertigo (Meniere's), tinnitus Phantom pain Frozen shoulder Cervical and lumbar spine syndromes Plantar fasciitis Arthritis/arthrosis Bursitis, tendonitis, carpal tunnel syndrome

Acupuncture Indications Sprains and contusions Fractures, assisting in pain-control, edema, and enhancing healing process Temporo-mandibular joint derangement, bruxism Dysmenorrhea, pelvic pain Insomnia Anorexia Atypical chest pain (negative work-up) Idiopathic palpitations, sinus tachycardia Allergic sinusitis Persistent hiccups Selected dermatoses (urticaria, pruritus, eczema, psoriasis) Constipation, diarrhea Urinary incontinence. retention (neurogenic. spastic, adverse drug effect) Abdominal distention/flatulence Severe hyperthermia Cough with contraindications for narcotics Acupuncture anesthesia for high risk patients, or patients with previous adverse responses to anesthetics

Acupuncture Benefits/Risks/Contraindications Benefits – Tremendous Pain, Stress Reduction, Anxiety, headaches, symptom management, post op pain, addiction, Length of Stay, etc… Non-pharmacologic symptom management Risks – Minimal Bleeding, infections, pneumothorax (rare) Contraindications: Relative – Case by case Pregnancy Anticoagulation Bleeding disorders Infections

Acupuncture Treatment Points Needled until sensation of “De Qi” Electrical Sensation, dull ache, needle grab Manually or electrically Stimulate needles Moxibustion Herb – Artemisia vulgaris – Mugwort Used to stimulate points

Acupuncture Treatment Electrical Stimulation Positive and Negative leads In general, flow in direction of meridian. Frequency Low: 2-8 Hz High: 70-150 Hz Other treatments Massage Cupping Gua-Sha

Other Treatments Cupping Traditional Chinese Medicine technique, thousands of years old; Egyptians used it in 1550 BC Use of “cups” (plastic, glass, earthen, bamboo, etc) over acupoints and non acupoints on skin. Various types of cupping (retained, wet/bleed, moving, needle, empty, etc) Creates hyperemia, increase blood flow, mobilizes fascia Used for: Various Pain issues, low back pain, neuralgia, musculoskeletal, fibromyalgia, herpes zoster; also used for common cold symptoms, cough, asthma, facial paralysis. Side effects: mild discomfort, bleeding, burns, bruising, infection Majority of studies show potential benefit on pain conditions

Other Treatments Cupping

Other Treatments Gua-sha “Coining, spooning, scraping” Creates therapeutic petechiae. Creates anti-inflammatory effect and immune protective effect Upregulates gene expression for enzyme: Heme oxygenase – 1 Antioxidant, cytoprotective Various pain issues, fever, cough, asthma, respiratory issues, colds

Other Treatments Gua-sha

Acupuncture Treatment Duration Varies according to patients 5-45 minutes Too long of a treatment, risk of depletion of energy from patient. This Photo by Unknown Author is licensed under CC BY-SA

Treatment Complications Needle Shock Vaso-vagal reflex Lightheaded Malaise Cold Perspiration Nausea Loss of consciousness Occurs mainly during first or second visit. This Photo by Unknown Author is licensed under CC BY-SA

Post-Treatment Effects Patient may feel Dizzy, lightheaded, or disoriented Relaxed Exhausted Activated, clear mind, full of will

Post Treatment Effects Instructions Do not over exert for remainder of the day. Strongly discourage Exercise, vigorous physical activity Avoid Heavy meals, excessively rich or sweet food Very hot or very cold food & drinks Alcohol Sexual activity Excesses and Extremes This Photo by Unknown Author is licensed under CC BY-SA

Post Treatment Effects 4 Responses to Treatment Gradual/Progressive improvement Amelioration of symptoms, then gradual return Exacerbation (rebound) of symptoms, then gradual return No change

Number of Treatments? Varies Minimum Trial Patient Response Condition Severity Acute vs. Chronic Minimum Trial 6-8 Treatments 12 is ideal This Photo by Unknown Author is licensed under CC BY-SA

Why Should Acupuncture Be Considered For Your Patients? Integrative Approach to Pain and Symptom management Opiate Crisis U.S. Consumes 80% of Global Opiate Supply FDA proposed that physicians learn about acupuncture for pain management Symptom management Improve quality of life Minimal risks Benefits inpatient and outpatient This Photo by Unknown Author is licensed under CC BY

Patient Case Patient Case No more suicidal ideations due to severe pain “You saved my life…” Patient Case 70-year old male with End Stage COPD & severe chronic neck and leg pain Was on supplemental oxygen 24/7 Could not enjoy any activities; favorite was going to baseball games Very severe pain in legs On morphine ER and oxycodone IR

Acupressure and Your Patients Hold each point for about 30 seconds each with firm pressure. Nausea and Vomiting P6 Pain LI4 – Do NOT use if Pregnant. This Photo by Unknown Author is licensed under CC BY-SA

Acupressure and Your Patients Nausea & Vomiting P6 (Neiguan/MH6) Location: 2 thumb widths above inner wrist crease.

Acupressure and Your Patients Pain LI4 (He Gu) – Do NOT use if Pregnant! Location: Dorsum of the hand, between the 1st and 2nd metacarpal bones, in the middle of the 2nd metacarpal bone, radial side. Fleshy mound.

References “Acupuncture Energetics: A Clinical Approach for Physicians” – Joseph Helms, 2007 Acupunc Med. 2008 Mar; 26 (1):27-32. Manual Acupuncture as an adjunctive treatment of nausea in patients with cancer in palliative care – a prospective, observational pilot study. Nystrom E, Ridderstrom G, Leffler AS. Am J Hosp Palliative Care. 2008 Aug-Sept; 25(4): 298-308. Acupuncture is underutilized in hospice and palliative medicine. Standish LJ, Kozak L, Congdon S. Integrative Cancer Ther. 2010 Jun; 9 (2): 158-167. Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients. Dean-Clower E, Doherty-Gilman AM, Keshaviah A, Baker F, Kaw C, Lu W, Manola J, Penson RT, Matulonis UA, Rosenthal DS. “Getting to Know You” – Joseph Helms, 2007. Phys Med Rehabil Clin N Am. 2004; 749-772. The role of acupuncture in pain management. Audette JF, Ryan AH. http://www.webmd.com/balance/guide/cupping-therapy#2 https://nccih.nih.gov/health/acupuncture/introduction Hinman RS, McCrory P, Pirotta M, et al. Acupuncture for chronic knee pain. A randomized clinical trial. JAMA. 2014;312(13):1313–1322. Pain Med. 2011 Mar;12(3):362-9. doi: 10.1111/j.1526-4637.2011.01053.x. Epub 2011 Jan 28. http://guasha.com/about/what-is-gua-sha/ https://www.pacificcollege.edu/news/press-releases/2015/05/05/science-gua-sha https://www.chinesemedicineliving.com/medicine/gua-sha/

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