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Acupuncture and Pain Management

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Acupuncture and Pain Management IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE) Acupuncture and Pain Management James D. Kenney, DVM There is a large and expanding body of scientific evidence supporting the use of acupuncture in pain management. In the last decade, our understanding of how the brain processes acupuncture anal- gesia has undergone considerable development. Profound studies on neural mechanisms underlying acupuncture analgesia have evolved rapidly and predominately focus on cellular and molecular substrate and functional brain imaging. The currently understood mechanisms of acupuncture analgesia are complex and involve direct and indirect neurohumoral effects that block pain percep- tion, reduce the pain response, relieve muscle spasms, and reduce inflammation. The analgesic mechanisms of acupuncture involve the spinal cord grey matter, hypothalamic-pituitary axis, mid- brain periaqueductal grey matter, medulla oblongata, limbic system, cerebral cortex, and autonomic nervous system. Electroacupuncture (EA) stimulation of these sites results in activation of descend- ing pathways that inhibit pain through endogenous opioid, noradrenergic, and serotonergic sys- tems. There are growing numbers of human trials supporting the use of acupuncture as an evidence- based practice for pain management in human medicine. There are many studies that support the efficacy of acupuncture for low back pain, neck pain, chronic idiopathic and migraine headaches, knee pain, shoulder pain, fibromyalgia, temporomandibular joint pain, and postoperative pain. Although the number of well-designed, controlled clinical research studies in veterinary medicine is lagging behind the number of studies in human medicine, much of the basic science research has been done in animals with neurophysiology that is more similar to veterinary patients than humans. Although there is research to support EA as an evidence-based practice for the control of back pain in horses, additional studies are needed in other clinical situations in veterinary medicine where pain manage- ment is required. Author’s address: PO Box 717, Clarksburg, NJ 08510-0717; e-mail: jdkenneydvm@ msn.com. © 2011 AAEP. 1. Introduction provide relief from low back pain, neck pain, chronic According to the World Health Organization (WHO), idiopathic or tension headaches, migraine head- the effectiveness of acupuncture analgesia has been aches, knee pain, shoulder pain, fibromyalgia, tem- 2 established in controlled clinical trials, and the use peromandibular joint pain, and postoperative pain. of acupuncture to control chronic pain is comparable Acupuncture was more effective for chronic pain with morphine without the risk of drug dependence than placebos (sham acupuncture) based on the re- and other adverse side effects.1 Acupuncture is an sults of systematic reviews of pooled data from high- effective treatment for many types of pain, is well- quality randomized controlled trials.1,3 For short- tolerated by patients, and has a minimal likelihood term outcomes (less than 6 mo), acupuncture was of serious adverse effects.1–3 Modern and tradi- significantly superior to sham treatments for back tional acupuncture techniques have been shown to pain, knee pain, and headache. For longer-term NOTES AAEP PROCEEDINGS ր Vol. 57 ր 2011 121 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE) Table 1. Definitions of Terms Term Definition Neuropathic pain Pain from damage to the nervous system Nociceptive pain Pain from stimulation of nociceptors Peripheral nerve endings in the skin, muscles, ligaments, joints, viscera, and Nociceptors other structures that initially respond to a painful stimulus Nociception Pain sense Mechanical, thermal, or chemical stimulus that alters nociceptors and causes Noxious pain Analgesia Reduced sensitivity to painful stimuli Anti-nociception Analgesia Internuncial neuron Neuron interposed between and connecting two other neurons Inhibit receptors on neurons; examples are serotonin, GABA, Inhibitory neurotransmitters norepinephrine, and epinephrine Excitatory neurotransmitters Activate receptors on neurons; examples are glutamate and aspartate Periaqueductal grey matter that surrounds the cerebral aqueduct in the PAG midbrain Hyperalgesia Increased sensitivity to pain Allodynia Non-noxious stimuli perceived as painful Primary hyperalgesia Hypersensitivity of the peripheral nociceptors Central sensitization and hypersensitivity of CNS neurons associated with Secondary hyperalgesia synaptic plasticity Ability of the connection or synapse between two neurons to change in Synaptic plasticity strength and responsiveness Endogenous opioid polypeptide neurotransmitters that inhibit pain stimuli similar to morphine; includes ␤-endorphins, enkephalins, dynorphins, Endorphins endomorphin-1, and endomorphin-2 Neurons with cell bodies in the spinal cord whose axons form peripheral Lower motor neurons motor nerves and terminate in skeletal, cardiac, and smooth muscles outcomes (6–12 mo), acupuncture was significantly may not be as effective as corticosteroids for pain more effective for knee pain and tension-type head- relief in some patients with rheumatoid arthritis, ache but inconsistent for back pain (one meta-anal- but chronic corticosteroid use may result in gastro- ysis was positive and one meta-analysis was intestinal ulceration, osteopenia, muscle loss, and inconclusive). other adverse effects. Acupuncture not only re- Acupuncture can effectively treat chronic pain of duces pain and inflammation but has positive effects the locomotor system with restricted movements of on the immune system, which directly benefits pa- the joints, because it not only alleviates pain but tients with rheumatoid arthritis, and less conven- also reduces the muscle spasm that causes reduced tional medication may be needed.1 mobility.4,5 Muscle spasm can result in abnormal loads placed on joints, often causing clinical signs of 2. Pain Pathways and Modulation pain before changes are demonstrable on radio- Pain may be classified as acute or chronic, adaptive graphs. In controlled studies of joint pain of un- or maladaptive, and neuropathic or nociceptive, and known etiology, acupuncture was superior to these types of pain have different underlying mech- conventional therapy, delayed-treatment controls, anisms.2 Neuropathic pain occurs from damage to and several other sham acupuncture techniques. the peripheral or central nervous system (PNS or According to the WHO analysis of controlled studies, CNS, respectively). Pain associated with activa- acupuncture can effectively reduce pain from cervi- tion of sensory (afferent) receptors (nociceptors) by cal spondylitis and other causes of neck pain, peri- mechanical, thermal, or chemical stimuli is consid- arthritis of the shoulder, fibromyalgia, fasciitis, ered nociceptive pain and will primarily be reviewed epicondylitis, low back conditions, sciatica, osteoar- here. The pathways involved in nociceptive pain thritis, and radicular and pseudoradicular pain syn- are also involved with the modulation of pain by dromes.1 In some cases, acupuncture integrated acupuncture. Understanding PNS and CNS pain with conventional treatments was more effective pathways is essential to understanding acupuncture than conventional treatments alone. analgesia.6 Terms associated with pain and pain Although acupuncture may not reduce pain to the modulation are defined in Table 1. degree that some conventional treatments reduce Nociception (the sensation of pain) is extremely pain, it is associated with a low incidence of serious complex and involves more than simple transmis- adverse side effects.1 For example, acupuncture sion of pain signals from nociceptors of the PNS to 122 2011 ր Vol. 57 ր AAEP PROCEEDINGS IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE) Fig. 1. The basic three neuron pathways of pain (blue, first-order neurons; red, second-order neurons; green, third-order neurons) of the neo-spinothalmic system and the multisynaptic pathways of the paleo-spinoreticulo-diencephalic system and the bilateral spinothalamic system common in non-primate animals (black broken lines). regions of the CNS for conscious perception. Pain of somatic and visceral first-order afferent nerves. signals are modified by substances released from When a specific threshold of excitation is reached, cells at the site of pain, within the spinal cord grey electrical action potentials transmit along their pe- matter, and by the concomitant stimulation of CNS ripheral processes to cell bodies in the dorsal root inhibitory descending pathways from higher brain ganglia and then into the spinal cord, where they centers. The main neuroanatomic structures in- synapse on second-order neurons in the dorsal horn volved in the complex process of pain perception grey matter. Stimulated second-order neurons include the peripheral sensory receptors (nocicep- propagate electrical signals along their axons, form- tors), afferent peripheral nerve fibers, dorsal horns ing ascending tracts in the spinal cord and brains- of the spinal cord (body) or sensory nucleus of the tem that synapse on third-order neurons in the trigeminal nerve (head), ascending pathways to the thalamus and other brain stem structures. The ac- reticular formation in the medulla oblongata and tivated third-order neurons propagate electrical sig- midbrain, thalamus, hypothalamus, limbic system, nals along their axons that terminate in the and cerebral cortex as well as descending CNS path- somatosensory cortex of the cerebrum
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