Friday, July 03, 2009
Here's an article Dr. Brendan Armm wrote a few years ago for his Doctorate in Acupuncture and Oriental Medicine, titled “Opening the Door to Effective Pain Management for Millions of Americans: Acupuncture from a Neuro-Physiological Perspective”.
“Frequently, I have patients coming in with various pain conditions... back pain, neck pain, knee pain, shoulder pain, ankle pain, etc. Many of these people are interested to know how acupuncture works from a western perspective. In essence, inserting acupuncture pins into the body at particular locations sends nerve impulses up to brain to release certain chemicals into the body that have a desired analgesic effect. For example, releasing opiates in the brain can be effective for treating pain. You are welcome to read the essay below for more detail”. - Dr. Brendan Armm
Opening the Door to Effective Pain Management for Millions of Americans:
Acupuncture from a Neuro-Physiological Perspective
by Brendan Armm, DAOM, LAc
One in four U.S. adults has complained of suffering a day-long bout of pain in the past month, and one in ten declared the pain had lasted over a year, according to the U.S. government’s annual, comprehensive report on Americans’ health: Health, United States, 2006, released by the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC).1 Viewing acupuncture from a neuro-physiological standpoint allows Western scientists to determine how this holistic medicine works so well.
Various theories have been posited on the etiology of pain in both Western and Eastern medicine.
According to pain-gate control theory, the swift speed of A-fibers from insertion of cutaneous needles impacts the brain analgesically serving to block muscular pain originating from the slower C-fibers. Thus, the sensation of cutaneous acupuncture blocks muscular pain.
Puncturing the skin introduces foreign bodies subcutaneously. The stimulus causes an immune response in various locations which accounts for the lymphatic system’s role in pain management.
Hilton’s Law states that stimulating skin nerves at joints causes affects deeper in the joint itself. This theory applies to acupuncture points. Placing needles at or around pain points serves to transmit nerve impulses deep beneath the skin giving a therapeutic effect, including alleviating pain and disease.
According to Chinese medical theory, acupuncture points were discovered by comparing given pathology to referred “ashi” or sore points. Treating referred points (local and distal) served to alleviate disease.
The well-known opioid theory for pain has been thoroughly explored in acupuncture by Miltiades Karavis, MD in Athens, Greece. Dr. Karavis specializes in treating pain using conventional biomedical treatment in conjunction with acupuncture. He notes, “We can explain the action of acupuncture in acute and chronic pain syndromes, in addiction, and in psychiatric disease through the role of central neurotransmitters and the modulatory systems that are activated by acupoints: opioid, non-opioid and central sympathetic inhibitory mechanisms.”2
Dr. Karavis states in The Neurophysiology of Acupuncture: a Viewpoint, “Acupuncture is a specialized sensory stimulation that is analyzed through sensory neural pathways. Therefore to understand its action we have to analyze the anatomy, physiology and pharmacology of the nervous system, aided with knowledge of neuroendocrinology and the chemoarchitecture of the brain.”2
According to Deke Kendall, OMD, PhD, LAc, in his book, Dao of Chinese Medicine, needling a therapeutic location creates a beneficial change via the nervous and vasculature systems with consistent and effective results. Dr. Kendall further notes, “The practitioner is in complete control of the treatment for desired effect.”3 He states that acupuncture is evidence-based medicine. These specific nodes (acupuncture points) are slightly warmer than non-nodal sites, are slightly depressed into the skin, and have a lower electrical conductivity. He refers to these points as neurovascular nodes because of the dependency on the nervous system and vasculature.
Research has provided evidence for acupuncture’s efficacy in pain relief in relation to the Central Nervous System (periaqueductal gray, thalamus, and pituitary gland) and the Cardiovascular System (nitrous oxide, vessel control, and blood pressure). Terry Oleson, PhD, researching acupuncture and neurology, explains that acupuncture alters the sense of touch thereby altering feeling by its effect on “somatosensory sympathetic, or somatovisceral reflexes, as well as improved circulation”4 -- yielding pain management. He comments, “if [acupuncture] is not real, then it should not affect the nervous system, excite NTS nucleus to inhibit sympathetic tone, release endorphins, or work with periaqueductal gray – all of which acupuncture does play a role.”4
In Dr. Oleson’s research with periaqueductal gray in the midbrain, it was observed that when a microcurrent excites this part of the brain, animals feel no pain. In the “Tail Flick Test,” rodents’ tails were exposed to a heat lamp. With excitation of their midbrains, the rats did not move their tails off the lamp. More latency is seen with an increase of morphine and with stimulus of periaqueductal gray. This analgesic effect is also seen when using acupuncture. If periaqueductal gray is destroyed, neither acupuncture nor morphine works, suggesting acupuncture uses an opiate system in the brain that needs to sense pain before the pain can be turned off.
Thus, needles inserted into the body activate neural pathways locally, and send impulses to the spinal cord which ascend to the contralateral side of the brain. The signal goes to the centromedian nucleus of the thalamus (for general pain), and into the preoptic area into the pituitary gland (where endorphins are secreted into the general bloodstream). The signal for analgesia travels back down the spinal cord to specific locations having prescribed somatovisceral therapeutic effects.
Other medical practitioners are demystifying acupuncture to better comprehend its potent pain relief. Sheng-Xing Ma, MD, PhD, associate professor at UCLA, David Geffen School of Medicine, summarizes “acupuncture point, ‘St 36’, decreases heart blood pressure and heart rate.”5 He notes “L-arginine derived NO [nitric oxide] in the gracile nucleus and mNTS [medial portion nucleus tractus solitarius] mediates CV reflex responses to electro-stimulation at acupuncture point, ‘St 36’.”5 He describes the dorsal-medulla-thalamic tract to be the important pathway for acupuncture signals. Up-regulation of nNOS-NO [neuronal NO synthase] in the pathways mediates the non-opioid effects of electro-stimulation at acupuncture point, ‘St 36’.6
Dr. Ma’s research shows NO is generated from the skin surface with a high level existence at acupuncture points and possibly at meridians lines. Thus, Dr. Ma concludes NO modifies skin electricity which creates low resistance characteristics for acupuncture points, raises the conductance, increases signal flow and the therapeutic effect.
Peng Li, MD, LAc, staff member at Susan Samueli Center of Integrative Medicine, School of Medicine, UC Irvine, in researching pain control via obtaining “de qi” stated “the effects of acupuncture depend on acupoints, stimulation parameters, and the situation of patients. The effects of acupuncture and ’de qi’ (meaning the patient feels sensation upon needle insertion) working via the central nervous system and the release of neurotransmitters serve to alleviate pain.”7
Acupuncture Today published an article titled, CDC Report: Americans in Pain. The CDC reported remarkable findings in its 2006 National Health Interview release about pain in American patients that raised questions regarding quality of life versus quantity of life.
Investigating life quality, this author was particularly curious to learn what U.S. adults are doing for their pain. The report observed a yardstick through the use of prescription narcotics, with eye-opening findings. "Between 1988-1994 and 1999-2002, the age-adjusted percentage of women reporting narcotic drug use in the month prior to interview increased by almost one-half, from 3.6% to 5.3% . . . rose by almost 75% among women 45-65 years of age, to 5.7%; and by more than 50% among women 65 years and over, to 6.8%.”8
And what are people using pain medication mostly for?
The report tracked low back pain, migraine/severe headache, neck pain, and facial ache in the jaws. For adults 18 years and older, low back pain was the most frequently cited, the most common cause of job-related disability, and a leading contributor to reduced productivity. Also noted was that women across the board reported experiencing low back pain more often than men.
Severe headache/migraine was the second most chronic pain type. “In 2004, 15% of adults reported . . . severe headache and neck pain. Adults 18 to 44 years of age reported migraine/severe headache pain almost three times as frequently as adults 65 years and older.”9 Women in their reproductive years are particularly prone to experiencing severe headaches. Also revealed in the report was the predictable finding that severe joint pain increases with age, with knee joint pain most common, followed by pain in the shoulder, fingers and hips.
In the article titled, CDC Report: Americans in Pain, it was stated:
The impact of pain, particularly chronic pain, is far-reaching. . . . In fact, pain is such a prominent health care issue that the 106th U.S. Congress recently passed Title VI, Sec. 1603, of H.R. 3244, declaring the period between Jan. 1, 2001 and Dec. 31, 2010 the ’Decade of Pain Control and Research.’9
As Americans are living longer, frustration with conventional approaches to pain management is evident. In fact, the CDC report speculates that pain among older adults often goes unreported due to many simply giving up, ’and skepticism about the beneficial effects of potential treatments.’ With so many Americans in pain and dissatisfied with conventional treatment options, acupuncture and other alternative health professions may have a real opportunity to take the lead in a new era of pain management.9
Acupuncture Today’s Associate Editor, Julie Engebretson, notes “While the overall health of the nation seems to be improving or holding steady in many areas, results from the National Health Interview survey highlights the need for appropriate management of one particular condition: pain.”9
It is the opinion of the author, as more research focuses on and documents acupuncture’s effectiveness, Western understanding and acceptance of this ancient art will become widespread. Eastern practitioners functioning alongside their Western medical counterparts will provide the general public with more access to Chinese medicine in conventional healthcare settings -- hospitals, community clinics, and medical offices.
In order for this step to happen, research needs to prove the cost effectiveness of this ancient medical system. One example might be studies designed to show how acupuncture reduces the length of hospital visits which would be well received by insurance companies responsible for paying for exorbitant inpatient care, and by patients, who would prefer to recuperate in the comfort of their own homes.
More research into the efficacy of acupuncture and Chinese medicine is critical for acceptance by U.S. mainstream insurance companies. With billions of dollars annually paid out-of-pocket by Americans for alternative healthcare, this creates a market to modify the current arrangement for insurance-covered modalities.
Two other worthy research subjects include exploring what medical discipline excels in treating specific types of pain, and when is it best to use one discipline over the other. When looking to build something strong and long-lasting, it is wise to begin by examining all of the parts to decide what goes where and in what order.
In conclusion, Eastern and Western medicines have their strengths and weaknesses. When medical practitioners are well educated in both systems, the result can only be positive. Acquiring a neuro-physiological understanding of the mechanics of acupuncture plus comprehension of the nature and etiology of pain through scientific studies and clinical trials in China and elsewhere, a greater perception and acceptance of acupuncture’s effectiveness could be fostered, thereby opening the door to providing millions of Americans with effective pain relief.
1.CDC National Center for Health Statistics. “New Report Finds Pain Affects Millions of Americans.” CDC National Center for Health Statistics Press. 15 November 2006. http://www.cdc.gov/nchs/pressroom/06facts/hus06.htm.
2.Karavis, MD, Miltiades. “The Neurophysiology of Acupuncture: a Viewpoint.” Acupuncture in Medicine, Vol 15, No 1., p. 33. May, 1997. www.acupunctureinmedicine.org.uk/servearticle.php?artid=300.
3.Kendall, LAc, Deke. Dao of Chinese Medicine: Understanding an Ancient Healing Art. New York: Oxford University Press, 2002.
4.Oleson, Terry. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture. Health Care Alternatives; 2nd ed. 1996.
5.Chen S, Ma SX: Nitric oxide on acupuncture (ST 36)-induced depressor response in the gracile nucleus. J Neurophysiol. 2003; 90: 780-785.
6.Ma SX, Ma J, Moise G, Li XY: Responses of Neuronal Nitric Oxide Synthase Expression in the Brainstem to Electroacupuncture Zusanli (ST 36) in Rats. Brain Res 2005; 10:70-77.
7.Li, MD, LAc, Peng. “Biological Basis of Acupuncture.” A transcription from lecture notes. Emperor’s College of Traditional Oriental Medicine, Doctorate of Acupuncture and Oriental Medicine, Santa Monica, California, 20 May 2006.
8.See note 1 above.
9.Engebretson, Julie. “CDC Report: Americans in Pain.” Acupuncture Today, Vol. 08, Issue 01. January 2007.
Brendan Armm, DAOM, LAc is a board-certified Acupuncturist and Chinese Medicinal Herbalist in the state of California and nationally. Dr. Armm completed his clinical Doctorate in Orthopedics, Pain Management and Integrative Medicine at Emperor’s College of Traditional Oriental Medicine in Santa Monica, California. Originally from Connecticut, Dr. Armm has been following in the medical footsteps of his elder family members. In addition to his private practice in Santa Monica, Dr. Armm completed an Advanced Acupuncture Fellowship at Good Samaritan Hospital in Los Angeles; treated at Emperor’s Doctorate level Pain Management Clinic; is a faculty member at Emperor’s, teaching Oriental Medicine and Meditation; and served as Doctorate Student Representative to Emperor’s Board of Directors. Dr. Armm is a member of The American Association of Acupuncture and Oriental Medicine (AAAOM), Acupuncture and Integrated Medicine Specialists (AIMS), and California State Oriental Medical Association (CSOMA). He writes for Acupuncture Today and is politically active in advancing Oriental medicine. Dr. Armm’s passion extends to healing modalities from around the world, including Meditation, Yoga, Nutrition, Ayurvedic and Tibetan Medicines, Tui-na Massage, Homeopathics, Aromatherapy, Flower Essences, and Sound Therapy. Dr. Armm lives in Santa Monica and frequently travels within the United States and to India, Nepal, China, and Tibet to participate in silent meditation retreats. Dr. Armm has recorded several guided meditation albums including a 5 CD set of meditation practices titled “Introduction to Meditation.” For more information, please visit www.lotusew.com or email@example.com.