Traditional Chinese Medicine and Acupuncture Dr Simon Chan Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong

James Reston Journalist of New York Time Accompanied with Henry A. Kissinger, the then Secretary of State of USA for the official visit to China in 1971 Developed appendicitis while in Beijing Uneventful appendectomy Post-operative pain management with acupuncture Article published on 26 July 1971 about his experience on acupuncture

Richard Nixon Then President of USA First official visit to China in 1972 Expressed interest in TCM/acupuncture and requested for acupuncture demonstration President Nixon and the delegations were shown surgery performed under acupuncture anaesthesia

Traditional Chinese Medicine Practiced more than 2500 years Covers a board range of practice throughout Asia serving for about 75% population worldwide Branches – Herbal medicine – Acupuncture, therapeutic massage and related technique – Bone setting orthopaedic – Qigong

Philosophy of Ancient China Yin and Yang theory – The ancient concept about universe – Two abstract and complimentary aspects every phenomenon in the universe can be divided into – Sun vs moon, hot vs cold, male vs female Five elements – All phenomena of universe and nature can be broken down into five elemental qualities Wood, fire, earth, metal, water – All interdependent and yet restraint each other

Five Elements

TCM Model of Human Body Human body consists of ‘functional’ internal organs which differs from anatomical organs as in Western medicine – Zang (solid organs) – heart, lung, liver, spleen and kidney – Fu (hollow viscus) – stomach, gall bladder, urinary bladder, small and large intestine ‘Zang-Fu’ organs have their own features and related to each others resemble five elements

Wood (Liver) Fire (Heart) Earth (Spleen) Metal (Lung) Water (Kidney)

TCM Model of Human Body “Zang-Fu” organs are connected to each other by channels via the limbs called meridians Meridians are not anatomical structures and allow ‘Qi’ to run through Qi – divine energy flow, regarded as cardinal function of the body but unable to be measured There are 12 bilaterally distributed meridians supplemented by 2 midline channels

Meridians

TCM Model of Disease ‘Pathological’ processes in TCM – Six exogenous factors: Wind, cold, fire, dampness, dryness, summer heat – Emotional factors, improper diet, trauma Pathological factor affects the yin/yang of individual ‘zang-fu’ organ and blockage of Qi flow with resultant symptom

TCM Diagnosis General inspection Listening – take note to symptoms History taking Pulse diagnosis Tongue diagnosis

Principle of TCM Treatment To restore the balance of yin/yang of the body and/or diseased ‘zang-fu’ organ

Acupuncture

Theory of Acupuncture 12 paired and 2 midline meridians distribute throughout the limbs and body surface Meridians are named in accordance to the ‘zang-fu’ organ, limb and anterior/posterior distribution – Lung meridian of hand Tai-yin and Bladder meridian of foot Tai-yang Function of meridian is to regulate and modify the corresponding organ or group of related organs Meridians can be accessed via acupuncture points Acupuncture – insertion and manipulation of needles to unblock the channel and restore Qi flow

Mechanisms of Acupuncture Endorphins theory – Analgesic effect reversed with opioid antagonists and animals with hypophysectomy » Takeshige C. Brain Research Bulletin 1992;27(1):37-44 – Elevated level of CSF  -endorphin and plasma enkephalin in patients after acupuncture » Clement-Jones VL. Lancet 1980;2(8201): » Kiser RS. Lancet 1983;2(8364): Serotonin and descending pathway – Analgesia by high frequency electroacupuncture attenuated by 5-HT antagonist » Tsai HY. Chin Pharmacol J 1989;41: Modulation of nocipcetion – Down regulation of glutamate receptors at spinal interneurons » Choi BTJ. Acta Histochem 2005;

Acupuncture Points The specific sites through which the qi of the ‘zang- fu’ organs is transported to body surface There are 365 classic points along the meridians Nomenclature system developed in accordance to the meridian and number, along side with Chinese name PC6 - Neiguan ST36 - Zusanli LI 4 - Hegu

Acupuncture Points The relationship of acupoints to anatomical landmarks is usually described in terms of Chinese inch Usually tender on pressure compared with surrounding tissue Diameter varies and depends on individual point, patient’s condition, time of day etc Depth – 3-15 mm On needle stimulation, a specific sensation called De-Qi would be elicited – soreness, numbness, warmth, heaviness or distension Manual stimulation of needle until “De-Qi” in order to achieve therapeutic effect

Technique of Acupuncture

Acupuncture and Related Technique Electroacupuncture

Acupuncture and Related Technique Electroacupuncture Acupressure

Acupuncture and Related Technique Electroacupuncture Acupressure Acu-stimulation

Acupuncture and Related Technique Electroacupuncture Acupressure Acu-stimulation Moxibustion

Acupuncture and Related Technique Electroacupuncture Acupressure Acu-stimulation Moxibustion Auricular acupuncture

Clinical Applications of Acupuncture The World Health Organization issued a list of medical conditions that may benefit from acupuncture – Prevention and treatment of PONV or chemotherapy-induced nausea/vomiting – Pain – Alcohol and other drug addiction therapy – Asthma and bronchitis – Rehabilitation from neurological damage

Dimond EG. JAMA 1971;218(10):

12 patients 4 patients required no rescue local anaesthetic 8 patients required supplemental LA of 1-4 ml of 1% lignocaine

Acupuncture Anaesthesia Could not be reproduced Inadequate block lasted for minutes Subjects needed highly motivated Not practiced even in China Used as adjuvant rather than sole anaesthesia

Role of Acupuncture in Anaesthesia Pre-operative preparation – Several randomized control trials with auricular acupuncture have shown the effective treatment for pre-op anxiety » Chernyak GV. Anesthesiology 2005;102: – Use of auricular acupuncture to alleviate parental anxiety in paediatric surgical patients » Wang SM. Anesthesiology 2004; 100:

Intra-operative Use of Acupuncture Acupuncture was not significantly different from placebo acupuncture as an adjunctive analgesia during surgery » Lee H. Pain 2005;114: » Usichenko TI. Pain 2005;114: Electro-acupuncture at ST 36 (Zusanli), GB34 (Yanglingquan) and BL60 (Kunlun) – No reduction in anaesthetic requirement in 14 volunteers » Morioka N el al. Anesth & Analg 2002;95(1):

Post-operative Pain Control Systematic review – 15 RCTs – Surgery types – abdominal, hip arthroplasty, dental, maxillofacial, thoracotomy, knee arthroscopy, spine – Acupuncture – EA, auricular, acupressure – Outcomes – reduced morphine consumption, reduced pain scores, lower incidence of opioid-related side effects – Acupuncture is a useful adjunct for post-op pain management

Post-operative Nausea and Vomiting Systematic review of 40 trials involving 4858 patients Compared with sham treatment, PC6 acupoint stimulation significantly reduced nausea, vomiting and rescue anti-emetic No difference compared with anti-emetics » Lee A. Cochrane DAtabase Sys Rev 2009;15(20:CD003281

However, I was in considerable discomfort if not pain during the second night after the operation, and Li Chang-yuan, doctor of acupuncture at the hospital, with my approval, inserted three long thin needles into the outer part of my right elbow and below my knees and manipulated them in order to stimulate the intestine and relieve the pressure and distension of the stomach. That sent ripples of pain racing through my limbs and, at least, had the effect of diverting my attention from the distress in my stomach. Meanwhile, Doctor Li lit two pieces of an herb called ai, which looked like the burning stumps of a broken cheap cigar, and held them close to my abdomen while occasionally twirling the needles into action. All this took about 20 minutes, during which I remember thinking that it was a rather complicated way to get rid of gas in the stomach, but there was noticeable relaxation of the pressure and distension within an hour and no recurrence of the problem thereafter. James Reston, 1971

Acupuncture in GI Disorders Acupuncture has been shown to reduce acid secretion, reduce GI motility and visceral pain Mechanism – via somatosympathetic pathway

Use of Acupuncture for Colonoscopy Sedation Electroacupuncture to LI4, LI11, ST36 PCA propofol for sedation Preliminary result – reduced propofol requirement for more than 50%

Adverse Events of Acupuncture Adverse events of more than 3000 treatment - 3.2% – Haemorrhange 32% – Haematoma 28%, – needle site pain 13% » Park JE. J Alternative Comp Med 2010;16(9): There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles (National Institute of Health, 2007)

Adverse Events Associated with Acupuncture A survey in China involved 1968 cases 74 patients (3.76%) reportedly to have adverse events Higher risk in elderly and male patients Zhao L. Trials 2011;12:87

Critics on Acupuncture Review on systematic review and meta-analysis Questionable efficacy on pain management Fatal complications can occur

Research on Acupuncture The scientific basis of acupuncture remains unclear Publication bias Difficulties in study design – Blind observers and subjects – True placebo needling impossible – Sham needling was shown to have therapeutic effect – Placebo effect

New Design on Placebo Needles Usichenko TI. Pain 2005;114:

Streitberger Needle Device McManus CA. Acupuncture Med 2007;25(1-2):36-40

Role of Acupuncture in Clinical Practice Despite much skepticism, half of physicians believe acupuncture is efficacious Stable and substantial increase in the use of acupuncture across all socio-demographic groups More than half of surgery patients had a favourable attitude towards the use of complementary and alternative medicine » Chernyak GV et al. Anesthesiology 2005;102(5):

Patient Selection for Acupuncture The practice of acupuncture requires certain skill, experience and theoretical knowledge Patients in general will have poor response – Elderly – Extremely sick patients – Poor attitude and faith towards acupuncture 10% of population are “non-responders’, ie “De- Qi” sensation cannot be elicited – hence, advisable to trial on 1-2 acupuncture points before the decision for treatment

Summary TCM and acupuncture theory is not scientific based and remain philosophical metaphor Mechanism of action of acupuncture is not completely understood No effect of acupuncture on anaesthetic or intra- operative analgesic requirement Acupuncture has been shown to be effective in pre-operative anxiolysis, post-operative pain management, PONV and other GI side effects Further research is needed to define the use of acupuncture in peri-operative period

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