Papers Presented

Adding  Life to years with Acupuncture 
Paper presented at XXXIII Annual National Conference of Indian Association of Physical Medicine and Rehabilitation  (IAPMRCON2005),
held at NIMHANS, Bangalore  Jan’05

Background:

           Healthcare is changing rapidly and expectations are rising. Gone are the days when one was expected to suffer pain & other chronic diseases in silence. Everyone desires  to have a better quality of life. Quality of life means different things to different people.  “Quality of Life is an individual’s perception of his position in life in the context of the culture and value system in which he  lives, and in relation to his goals, expectations, standards, and concerns” (WHO, 1994). Physical functioning, psychological well-being, social functioning, freedom from disease symptoms and treatment-related side-effects are the main dimensions to be included in Quality of life.
           Just imagine life of a cerebral palsied child ( and that of the parents too),or life after a stroke with aftereffects, or  life with intractable pains and / or  with chronic musculoskeletal  disorders and so on. These conditions are  not fatal but severe morbidity adds to the woes. It takes away everything from life like looking after oneself, working efficiently, enjoyment, socialization if not life. This I realized as early as in 1979 and added acupuncture & then physical medicine & rehabilitation in a  modest way to improve patients’ quality of life. These all are not curable by only allopathy. But something can be done and should be done. Here comes the real meaning of improvement in quality of life by improving health and quality of life by bringing together the best of West (modern medicine) and East (Acupuncture)  to provide healthcare that is safe, effective, affordable and accessible to individuals, families and communities. This is adding life to years, this is nothing but “rehabilitation”. The term  “adding life to years” is more meaningful  and acceptable rather than “rehabilitation”. I adopted the WHO slogan “adding life to years” (1982). Recently most medical journals, health centers are stressing on offering better “Quality of Life”. That  is why it is said that “ILLNESS  is inevitable but suffering is optional”. So,  What is acupuncture ? How does it help in adding life to years ?  

Introduction & brief history:

           The  word   Acupuncture  is    derived from Latin. In Latin,  acus = needle, pungra = to prick, to prick a needle for treatment is acupuncture. The combination of acupuncture and moxibustion is known in Chinese as  Chen Chiu  [ needle & heat therapy.]  Acupuncture treatment is usually carried out by inserting very fine needles at acupuncture points. Acupuncture point means a specific spot on the body surface where needling is done to get particular therapeutic response.
           Acupuncture is an important prestigious heritage of Chinese people.  Traditional Chinese medicine which includes acupuncture has been largely integrated with Western medicine in China. It is believed that acupuncture developed in both  India and  China, independently of each other. If we go back to the Indian medical classics, known as Vedas, said to have been written about 7000 years ago, we find "needle therapy" mentioned therein. The oldest known Chinese book on acupuncture, Nei Ching, did not appear before fourth century before Christ and historical data indicate that  the Nei Ching was probably written around the second or  Third century B. C. One volume of the Vedas, known as Suchi Veda, translated as the "art of piercing with a needle," was written approximately 3,000 years ago. It deals entirely with acupuncture  and describes  180 points known as "MARMA"  which are said to heal or kill. The whole knowledge of Shalya  Chikitsa or acupuncture is arranged in an orderly manner in eight volumes of the famous ancient Classic SUSHRUTA SAMHITA.(1)  Nevertheless, one cannot argue the fact that the acupuncture was more developed by the Chinese than the Indians, and they presented it to the World in a more complete form. Acupuncture spread through much of Asia and by the sixteenth century Jesuit missionaries had brought the practice to Europe.  As early as 1912, William Osler described its use in the first edition of The Principles and Practice of Medicine.  “For lumbago,” he wrote, “acupuncture is, in acute case, the most efficient treatment.”(2) Acupuncture earned its place in many text books of modern medicine., for e.g. Current Medical Diagnosis & Treatment 2005 which is the world's leading annual textbook in medicine.

Similarly journals in Modern medicine regularly publish articles related to acupuncture which confirms the interest of all health professionals in the subject. For e.g. BMJ – 216 articles,  JAMA 152, The New England Journal of Medicine 45. In 1998 JAMA and its ten affiliated Archives journals published theme issues including more that 80 articles pertaining to the field.

Acupuncture in USA:

           Research and enthusiasm in the United States grew dramatically in 1971 when James Reston of New York Times, wrote an article describing his experience with acupuncture for postoperative analgesia after undergoing an appendectomy   while in China.2 The “magic” cures by acupuncture fascinated the American public and jolted the American organized medicine. The use of complementary and alternative medicine has become common in the United States.  In 1998 a survey by Eisenberg estimated that over 40% of Americans made more than 600 million visits to alternative medicine practitioners and spent over $27 billion for their services. These visits exceeded the total number of visits to all United States primary care physicians, and the out-of-pocket expenditures were about the same as what the American public pays for all physician services. Data from a 2004 U.S. Dept. of Health and Human Services report  that acupuncture is  slightly more popular than homeopathy, four times more popular than naturopathy, and  ten times more popular than ayurveda. The NIH is an agency of the U.S. Department of Health and Human Services the NIH annually invests over $28 billion in medical research.  NIH has more than 17,000 employees on the main campus and at satellite sites across the country. NIH established the Office of Alternative Medicine in 1992 with an annual budget of $2 million in 1998, its role was expanded as the National Center for Complementary and Alternative Medicine (NCCAM). The NIH's budget for research in this field for fiscal year 2004–2005 is $116.2 million.  To maintain effective clinician patient communication and to ensure responsible clinical  practice, it is important that clinicians learn the theory, practice, and scientific evidence associated with these therapies. The FDA approved Acupuncture needles for use by licensed practitioners in 1996. Most significantly, the FDA ruling indicates that acupuncture is a safe and effective medical treatment. There are currently over 10,000 licensed acupuncture practitioners and 3000 physicians acupuncturists in the United States. (2) British Medical Association (BMA)  recognized  acupuncture for  National Health Services as complementary treatment & opined that acupuncture should become more widely available on the National Health Services and family doctors should be trained in some of its techniques. (3)

Mechanisms of acupuncture:

           Originally, the theory of Acupuncture is based upon an ancient  Chinese concept   of (w)holism.  This concept views human beings not only in relation to our own integral totality of body mind, and spirit, but also as  microcosmic expressions of a universe whose characteristics are inherent in every organism & in every process.  Health is viewed as the maintenance of harmony between ourselves and this universe while illness in an expression of disharmony. The most fundamental biologic expression of the  relative balance or imbalance of that primordial energy which the Chinese called  Qi (pronounced Chi ).  A free and balanced flow of Qi in the body expresses harmony and health while a blockage of this energy indicates illness.  Qi travels along certain pathways called meridians.  There are twelve paired & two unpaired meridians,  named pertaining to particular organ. Yin & Yang Theory, Theory of Five Elements, Organ Clock and many more traditional theories not only explain Chinese Philosophy but also dictate the rules to practise the art of acupuncture.  These theories are difficult to digest by others who are trained in the so called Modern Medicine and beyond the scope of this article. But some of these are getting proved  very close to Modern Medicine, for example Organ Clock & Circadian Rhythm .
           Acupuncture is not a drug, it is a complete science or healing system by itself, having several effects to regulate the function of the human body and to increase its resistance by enhancing the immune system and the anti-inflammatory, analgesic, anti-spastic, anti-shock and anti-paralytic abilities of the body. Thus acupuncture improves the speed of natural recovery. Acupuncture  effects cannot be explained by any single theory. Nor is acupuncture simply a trigger for releasing endorphins to create a temporary anesthetic effect by blocking nerves that transmit pain message as currently maintained in medical circles.  It is much more than that.
           Research based on Modern Medicine started in & outside China, only after the US President  Nixon’s visit to China 1971. Acupuncture is the only non-conventional modality subjected to  maximum research & clinical trials.

Basic-Science Evidence:

Electro-analgesia is well established but based on our knowledge of Western medicine, it is difficult to believe that acupuncture treats disorders and diseases by direct control of organs or organ-related disorders and diseases. Numerous surveys show that, of all the complementary medical systems, acupuncture enjoys the highest credibility in the medical community (4) because of data showing that acupuncture in the laboratory has measurable and replicable physiologic effects that offer plausible explanations for the presumed actions. In a review of 228 basic research studies, Pomeranz offered a comprehensive theory proposing that acupuncture activates small myelinated nerve fibers in the muscle, sending impulses to the spinal cord, which then activates centers in the spinal cord, midbrain, and pituitary-hypothalamus to produce analgesia.(5) These responses include changes in plasma or corticospinal fluid levels of endogenous opioids (for example, endorphins and enkephalins) or stress-related hormones (for example, adrenocorticotropic hormone). (6)  In one study, the effects of acupuncture in one rabbit could be transferred to another rabbit by cerebrospinal fluid transfusions(7).  Acupuncture may inhibit early-phase vascular permeability, impair leukocyte adherence to vascular endothelium, and suppress exudative reaction to a degree equivalent to that of orally administered aspirin and indomethacin. Evidence also supports the possibility that one mechanism of acupuncture may be a form of stimulation for the gene expression of neuropeptides.(8) Functional magnetic resonance imaging ( fMRI ) is also beginning to demonstrate that acupuncture has regionally specific, quantifiable effects on relevant structures of the human brain.(9) In another study fMRI  demonstrated the CNS pathway for acupuncture stimulation. Acupuncture at ST.36 and LI.4 activates structures of descending antinociceptive pathway and deactivates multiple limbic areas subserving pain association. An important finding was that the hypothalamus showed a tendency for sustained activation on the fMRI obtained after acupuncture. Such sustained activation of the hypothalamus may have a bearing on the long-lasting analgesic effect of acupuncture in the clinical setting. The finding that acupuncture at LI.4 activated the hypothalamus more extensively than did acupuncture at ST.36 may be in agreement with the clinical observation that acupuncture at the LI.4 acupoint has a stronger analgesic effect. (10) Acupuncture points and meridians have been demonstrated in 1933 by a special technique by name  Kirlian Photography (Kirlian & Kirlian of USSR) and it was confirmed that acupuncture points have low electrical  resistance than surrounding skin surface.  Gunn & associates have correlated the acupuncture points with points of accepted anatomical structures. All motor points of muscles are acupuncture points but all acupuncture points are not  motor points. Despite extensive histologic studies, investigators have been unable to identify unique anatomic structures or physiologic effects at acupuncture points. Despite these shortcomings, our understanding of the mechanism of action of acupuncture for the treatment of pain is superior to our understanding of the mechanism of action for many drugs in widespread use today.(11)

Clinical applications:
Acupuncture may be classified as

1. Symptomatic acupuncture as practised by “Bare Foot Doctors” of China as first line symptomatic treatment for nonspecific short lived illness in rural setup.
2. Classical or Traditional acupuncture  based  on (W)Holistic Approach.  Total person is evaluated before treatment, regardless of the particular treatment.  Acupuncture does not treat a named disease but rather the  cause  of the disease, because symptoms are just signals of a  problem in the body. Herbs may be added. This is better known as Traditional Chinese Medicine (TCM)
3. Acupuncture Anesthesia. 

           Acupuncture Anesthesia  (1958):  is one  of the most recent impressive developments of Chinese medicine. First operation under acupuncture anesthesia was performed at  Shanghai and it was a tonsillectomy.  The term  “acupuncture  anesthesia”  is really a misnomer.  Although pain impulses are  cut    off by raising the pain threshold, other sensations like temperature, balance and vibration sense are found to remain  intact.  Hence it would be more accurate to use the term ‘Acupuncture Analgesia’. While pain threshold is greatly elevated, it may not be always hundred percent complete, and some patients may still experience varying degrees of pain during certain stages of an operation.  In abdominal operations, difficulty is sometimes encountered owing to inadequate muscular relaxation and discomfort from traction on the viscera. So, in recent years Acupuncture assisted Anesthesia is preferred in western countries, wherein muscle relaxants or very low doses of anesthetics are used.

 Recent developments:
“Medical Acupuncture”is the term used to describe acupuncture performed by a doctor trained and licensed in Western medicine who has also had thorough training in acupuncture as a specialty practice. Such a doctor can use one or the other approach, or a combination of both, as the need arises to treat an illness. It may be further sub divided into  (a)  Body Acupuncture (b) Ear Acupuncture (c)  Scalp Acupuncture.  When sound waves are applied instead of needles, it becomes “Sono-acupuncture”, “Laser acupuncture” with  laser beam and so on.

Indications:
           Theoretically it is possible to help or cure by acupuncture any disease that can be affected by a physiological process.  So, acupuncture can be used in many conditions.     In CHINA, 800 diseases are being treated with acupuncture therapy and at least in 140 countries in the world.  We are in the era of Evidence Based Medicine. The "gold standard" methodology to test for efficacy of any therapy is the randomized clinical trial. Acupuncture is no exception.
In an official release report“Acupuncture review and analysis of reports on controlled clinical trials ”of The World Health Organization (WHO) listed  symptoms, diseases and conditions for  treatment by acupuncture:The following is a small part of an official 81 page WHO document. (12)
The diseases or disorders for which acupuncture therapy has been tested in controlled clinical trials reported in the recent literature can be classified into four categories as shown below.

1. Diseases, symptoms or conditions for which acupuncture has been proved through controlled trials—to be an effective treatment: ( total 68; only a few important condition  are listed here )

Adverse reactions to radiotherapy and/or chemotherapy, Allergic rhinitis, Facial pain (including craniomandibular disorders),  Headache, Knee pain, Low back pain, Morning sickness, Nausea and vomiting, Neck pain, Periarthritis of shoulder , Postoperative pain , Rheumatoid arthritis , Sciatica, Sprain , Stroke, Tennis elbow

1. Diseases, symptoms or conditions for which the therapeutic effect of acupuncture has been shown but for which further proof is needed:    (  only a few important condition  are listed here.)

Bell’s palsy , Cancer pain , Facial spasm, Female urethral syndrome , Fibromyalgia and fasciitis, Insomnia, Labor pain,  Male sexual dysfunction, non-organic Neuralgia, post-herpetic, Obesity , Opium, cocaine and heroin dependence, Osteoarthritis, Postoperative convalescence, Prostatitis, chronic Radicular and pseudoradicular pain syndrome, Reflex sympathetic dystrophy, Temporomandibular joint dysfunction.

1. Diseases, symptoms or conditions for which there are only individual controlled trials reporting some therapeutic effects, but for which acupuncture is worth trying because treatment by conventional and other therapies is difficult:

Chloasma,    Colour blindness, Deafness,   Irritable colon syndrome, Neuropathic bladder in spinal cord injury, Pulmonary heart disease, chronic  Small airway obstruction

1. Diseases, symptoms or conditions for which acupuncture may be tried provided the practitioner has special modern medical knowledge and adequate monitoring equipment:

Breathlessness in chronic obstructive pulmonary disease, Coma, Convulsions in infants, Coronary heart disease (angina pectoris),  Diarrhea in infants and young children,  Encephalitis, viral in children - late stage,  Paralysis, progressive bulbar and pseudobulbar.

Scope of Practice of Medical Acupuncture:
           Medical acupuncture is a highly adaptable discipline, and is of potential therapeutic value in many painful and general medical conditions. Whether it is introduced as the primary or the complementary therapy depends on the nature and severity of the presenting problem as well as the training, orientation, and practice environment of the provider. Flexibility and adaptability of acupuncture allow it to be integrated at almost any stage of treatment. The physician trained in medical acupuncture who sees patients early in the course of their disturbances can initiate treatment of a pain or medical problem with acupuncture, and introduce additional therapies if acupuncture proves insufficient as the sole treatment. The physician who receives cases later in their evolution and after conventional treatments have been initiated, can add acupuncture to assist, or possibly replace  conventional treatments.(13)

Most Useful as Primary Therapy: Musculoskeletal Pain

           In the United States, acupuncture has found its greatest acceptance and success in the management of musculoskeletal pains. Acute musculoskeletal lesions such as soft tissue contusions, acute muscle spasms, musculotendinous sprains and strains, and the pain of acute nerve entrapments are among the problems most frequently and successfully addressed by acupuncture. In such cases, acupuncture can legitimately serve as the initiating therapy. Chronic musculoskeletal pain problems are also commonly and appropriately treated with acupuncture, although not usually as the only approach. Those problems likely to be responsive to acupuncture intervention include repetitive strain disorders (eg, carpal tunnel syndrome, tennis elbow, plantar fasciitis), myofascial pain patterns (eg, temporomandibular joint pain, muscle tension headaches, cervical and thoracic soft tissue pain, regional shoulder pain), arthralgias (particularly osteoarthritic in nature), degenerative disc disease with or without radicular pain, and pain following surgical intervention (both musculoskeletal and visceral). In the management of chronic musculoskeletal pain, acupuncture offers a broad range of potential value between the conventional therapy poles of pharmaceuticals and invasive procedures. Other chronic pain problems commonly responsive to acupuncture include postherpetic neuralgia, peripheral neuropathic pain, and headaches from other causes.(13)

Evidenced Based Medicine: Randomised Control Trials

           Please note that RCTs ( by modern medicine)  are about 50 years old, while Chinese Medicine is 4500 years old, and there have only been adequate funding sources for alternative medicine research in only  the last 4 or 5 years. Few very important RCTs are mentioned here for your kind perusal as we are in the era of EBM.

1. A study conducted by Orthopedic Surgery and Research, Dusseldorf, Germany, by Molsberger AF concluded  that acupuncture can be an important supplement of conservative orthopedic treatment in the management of chronic LBP.(14)

Acupuncture Safety

           In the hands of a medically trained practitioner, acupuncture is a fairly safe and forgiving discipline. The possible risks and complications of an acupuncture treatment are the undesirable consequences of penetrating the body with a sharp instrument: syncope, puncture of an organ, infection, a retained needle. These risks can be reduced by scrupulous sterilizing of needles, acquiring good clinical skills, understanding surface and internal anatomy, and executing responsible clinical judgment.(13) One of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same conditions. As examples, musculoskeletal conditions, such as fibromyalgia, myofascial pain, and tennis elbow, or epicondylitis, are conditions for which acupuncture may be beneficial. These painful conditions are often treated with, among other things, anti-inflammatory medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical interventions have a potential for deleterious side effects but are still widely used and are considered acceptable treatments. The evidence supporting these therapies is no better than that for acupuncture. Studies of safety of acupuncture as appeared in BMJ   reported 43 minor adverse events associated with 34,407 acupuncture treatments; 91 minor events in 31,822 acupuncture treatments. If combined with the other study above = total of 121,520 treatments with 198 minor adverse events (0.16% incidence), and no pneumothoraxes (in the conclusion they are considered to be "extremely rare")(24).  In my 25 years of acupuncture practice at Anand Pain Relief & Rehabilitation institute wherein  more than  2 lacs acupuncture treatments  were given ( i.e. more than  30 lacs  “acupuncture needling”)   no major adverse effects were noticed.
           Acupuncture therapy is not miraculous. It has its appropriate range of applications  and, like any other medical intervention, yields good results in well-selected early problems and less successful results when chronicity and complexity of the presenting problems increase. The World Health Organization has adopted guidelines on basic training for physician and nonphysician providers, standards for safe practice, and clinical indications for acupuncture. The training guidelines reflect the minimum hours expected in most member nations and are consistent with regulations enacted in the United States: 2500 hours for nonphysician acupuncturists and 200 hours for physicians.

Prospects For The Future
The potential for medical acupuncture is just beginning to be understood. Future clinical research and utilization evaluations should clarify as too  how best to integrate acupuncture into the conventional healthcare system. Medical acupuncture offers the opportunity to expand contemporary medicine to treat conditions for which current interventions are either ineffective or have undesirable secondary effects. It is likely that because of its usefulness and adaptability to so many aspects of allopathic medicine, medical acupuncture will be integrated with increasing frequency into private and institutional practices.(13)

Conclusion:
In conclusion it is clear that research on acupuncture will not only be significant for the health and welfare of the people but also important for the progress of medical science. Acupuncture is a complete healing system by itself. It is  an anti-inflammatory & analgesic,  anti-spastic,  enhances the immune system and hastens the speed of natural recovery. It generates the feeling of well-being. When acupuncture  is combined with modern medicine, the patient benefits which is clearly described in this article. Acupuncture relieves intractable pains to bring a smile back; helps in avoiding surgery in cases of backpain, helps arthritics to have life with a smile and  helps the stroke & cerebral palsied to lead a self-sufficient life. Helps in minimizing side effects of potent chemotherapy and so on. This is adding life to years.  As we learn more about it, the possibilities of using acupuncture alongside 'orthodox' medicine will increase. Combining Western medicine and Acupuncture  is what Dr Vinay Varma has been    practising since 25 years  to bring a smile back by relieving pains and thus adding life to years.

References:

1. Archimedes A , Energetic concepts of classical Chinese acupuncture,  Am J acupuncture, no. 1, vol. 7, Jan-March , 1979 , page 41
2. Mark Silvert, Acupuncture wins BMA  approval,  BMJ 2000;321:11 ( 1 July )
3. Ellen F. Hughes, Bradly P. Jacobs, Brian M. Berman,  Complementary & Alternative Medicine, Current Medical Diagnosis & Treatment 2005, Online Eds,  The McGraw-Hill Companies . See www.current-med.com/ch44.html
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5. Pomeranz B, Nyguyen P. Naloxone blocks acupuncture analgesia and causes hyperalgesia: endorphin is implicated. Life Science. 1979;191:1757-
6. Pomeranz B, Stux G, eds. Scientific Bases of Acupuncture. New York: Springer-Verlag; 1989.
7. Han JS. Physiology of acupuncture: review of thirty years of research. J Altern Complement Med. 1997;(Suppl 1):S101-8.
8. Guo HF, Tian J, Wang X, Fang Y, Hou Y, Han J. Brain substrates activated by electroacupuncture (EA) of different frequencies (II): Role of Fos/Jun proteins in EA-induced transcription of preproenkephalin and preprodynorphin genes. [PMID: 9037530] Brain Res Mol Brain Res. 1996;43:167-73.[Medline]
9. Cho ZH, Chung SC, Jones JP, Park JB, Park HJ, Lee HJ, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. [PMID: 9482945] Proc Natl Acad Sci U S A. 1998;95:2670-3.[Abstract/Free Full Text]
10. Wu MT, Hsieh JC, Xiong J, Yang CF, Pan HB, Chen YC, et al. Central nervous pathway for acupuncture stimulation: localization of processing with functional MR imaging of the brain—preliminary experience. [PMID: 10405732] Radiology. 1999;212:133-41.[Abstract/Free Full Text]
11. Stux G,Hammerschlag R (editors): Clinical Acupuncture: Scientific Basis. Springer, 2000.
12. John A. Amaro, What conditions does Acupuncture treat according to The World Health Organization (WHO), Today Archives - October 2004
13. Joseph M Helms,  An overview of Medical Acupuncture, American Academy of Medical Acupuncture, online:

             http://www.medicalacupuncture.org/acu_info/articles/helmsarticle.html