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The Electro Acupuncture: a Mode of Analgesia

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The Electro Acupuncture: a Mode of Analgesia Pak Armed Forces Med J 2005; 55(1): 50-55 Electro Acupuncture THE ELECTRO ACUPUNCTURE: A MODE OF ANALGESIA Sadia Salim, *Ahsin Manzoor, M Mazhar Hussain, Idrees Farooq Butt, Muhammad Aslam Dept of Physiology Army Medical College Rawalpindi, *Dept of Surgery CMH Malir INTRODUCTION perception. In 1960’s, Prof. Melzack and Wall explained the mechanism of analgesia by bringing The role of electroanalgesic modalities in forward the “Gate control theory”, which treatment of chronic pain syndromes has long been suggested that stimulation of large-diameter questioned by medical practitioners because of the afferent nerve fibers may inhibit second-order lack of adequate randomized, double-blind sham- neurons in the dorsal horn of spinal cord to controlled studies to support their use in clinical suppress the conduction of pain impulses through practice [1-3]. Earlier few sham-controlled studies the small-diameter fibers to the higher brain involving the use of electroacupuncture reflected centers [12]. It is the most commonly used some significant benefits in terms of lowering pain hypothesis to explain the relief of pain on using scores, improvement in sense of well-being, high-frequency Transcutaneous Electrical Nerve physical activity, and quality of sleep, and Stimulation (TENS) therapy [13,14]. During reduction in need for oral analgesic medication [4- 1970’s the raphe spinal structures were identified 6]. Recently, Sator-Katzenschlager and co workers as part of brain analgesia system along with the described a prospective, randomized sham- discovery of endogenous opioids [15] which controlled study by using auricular acupuncture. opened the avenues of research on The study involved electrical stimulation of an electroacupuncture mechanisms. During 1980’s, auricular acupuncture point which resulted in Prof. Jisheng Han at Beijing Medical University enhancement of analgesic benefits of acupuncture China demonstrated that electroacupuncture in patients with chronic low back pain. This study stimulation at the rate of 4 pulses per second (pps) has contributed the growing body of scientific data in rabbits releases enkephalins and endorphins in supporting the use of electro analgesic modalities the brain and spinal cord. He injected antibodies to in the management of chronic pain [7]. Some endogenous opiates intrathecally into the spinal studies have also documented the long term cord of rabbits before the administration of benefits of electroanalgesia in chronic pain and electroacupuncture, which resulted in blockade of significant benefits to patients receiving electroacupuncture analgesia [16]. Richard Cheng electrostimulation by accelerating their ability to of Toronto Canada in addition to the same return earlier to full-time work as well as observation, also showed that stimulation at the improved quality of life [8-11]. Therefore, we rate of 200 pps would lead to the release of have reviewed the role of electrotherapy as one of monoamines, serotonin and nor epinephrine [17]. the modes of analgesia for the management of Prof. Pomeranz and Stux proposed that analgesia chronic pain. by needles through the peripheral nerve stimulation might send signals to brain and release PROPOSED MECHANISMS OF endorphins. He and his co- workers were the first ELECTROANALGESIA ones to experiment on the spinal cord of anaesthetized animals and found that acupuncture The physiological mechanisms of analgesia was mediated by endorphins. They electroanalgesia have not clearly explained that identified that the electroacupuncture blocked the how different modalities of electrical therapy transmission of the noxious stimuli to brain which induce analgesia?. The survey of literature reveals could have also been blocked by giving pre- the paucity of work that could lead to assess the electroacupuncture naloxone; an opiate receptor mechanism and efficacy of electrotherapies antagonist [18]. Different studies have shown that compared to placebo treatments. Most studies blockade of opioid receptors with naloxone in the indicate both reduction in pain threshold and its habenula, nucleus accumbens, amygdala, or periaqueductal gray matter had prevented the Correspondence: Dr Sadia Saleem, Department of analgesia produced by the electroacupuncture [19- Physiology, Army Medical College, Rawalpindi. 22]. 50 Electro Acupuncture It has also been suggested that acupuncture b. In pregnancy, electrical therapies may needle directly stimulates A delta nerve fibers, induce premature labor. which have an inhibitory feedback effect on pain c. It may result in laryngospam if the transmission mechanisms. Therefore, central and electrodes or needles are placed on the peripheral nervous systems work together in anterior neck. acupuncture to establish local anaesthesia and deep general anaesthesia, whereas naloxone can d. It should be used cautiously in patients with inhibit the effect of acupuncture [23-25]. spinal cord stimulator or intrathecal pump [30,38,39]. The functional magnetic resonance imaging (fMRI) shows that how acupuncture stimulation MODES OF ELECTRO can have the specific effect on the nervous system THERAPIES [26]. A study using fMRI in human subjects, has suggested that electroacupuncture stimulation There are different ways to administer desensitizes or reduces the activation of central electrical therapy to achieve desired therapeutic areas of the cortex that are believed to be involved effects. It is possible that by changing frequency, in pain signal processing and perception [27]. waveform, pulse duration, electrode configuration, and duration of stimulation, one can produce a The currently proposed scientific bases for range of therapeutic effects including relief of the mechanisms of analgesia produced by various chronic pain and induction of sensory effects or to electrical therapies include: facilitate motor functions [40,41]. a. Presynaptic inhibition in the spinal cord. The most popular electrical therapies are b. Endogenous pain control by the release of endorphins, enkephalins and dynorphins. a. Electroacupuncture c. Direct Inhibition of an abnormally excited b. Conventional TENS nerve. c. Acupuncture like TENS(ALTENS) INDICATIONS FOR THE USE OF d. Pulse (burst) TENS ELECTRICAL THERAPIES e. Interferential Current Therapy a. Musculoskeletal pain including Tennis f. Percutaneous electrical nerve elbow, fibromyalgia, chronic backache stimulation (PENS) osteoarthritis, rheumatoid arthritis, Electro Acupuncture myofascial pain, tension headaches [28-33]. b. Neurogenic pain including phantom pain, Specific acupuncture points are pricked on sympathetically mediated pain, post herpetic the surface of the body by means of needles. These neuralgia, trigeminal neuralgia, atypical needles are electrically stimulated through flexible facial pain, brachial plexus avulsion, pain wires, via small crocodile clips, attached to a pulse after spinal cord injury [30,34,35]. generator. Usually 4-8 needles can be stimulated at one time via parallel channels on the stimulator c. Visceral pain and dysmenorrhea [36]. [42,43]. In order to achieve maximum benefit from electroacupuncture treatment, the strongest d. Miscellaneous conditions including tolerable current intensity is recommended by migraine headache, dental pain, recurrent Pomeranz [18]. jaw pain, post operative nausea and vomiting, angina pectoris [30,37]. Conventional TENS CONTRAINDICATIONS FOR One of the most commonly used forms of THE USE OF ELECTRICAL electroanalgesia is Transcutaneous Electrical THERAPIES Nerve Stimulation (TENS). A TENS unit consists of one or more electric generators, a battery, and a a. In patients with pace maker. set of electrodes. These units are small which are 51 Pak Armed Forces Med J 2005; 55(1): 50-55 Electro Acupuncture programmed to deliver stimuli of variable current EFFICACY strengths, pulse rates and pulse widths. The usual settings for the stimulus parameters are as follows: Most of the studies represent electro therapy as a useful and effective therapeutic modality in Amplitude: Low intensity, just above patient the management of pain [50]. In general, the threshold. Pulse Width: 10- 1000 microseconds. response rates for various pain syndromes have Frequency: 80-100 pulses/sec. The optimal been documented between 50-80% [28]. settings of the stimulus parameters are subjective According to the National institute of health and determined by the trial and error [44]. consensus panel of researchers, electrotherapy is not only useful alone but can be successfully Acupuncture Like TENS (ALTENS) combined with conventional therapies to treat various pain disorders [29]. The combination of In ALTENS, the treatment is given without electro therapy and conventional medicine can using needles; instead, small flexible pads are bring the state of complete relief from pain or, applied on the acupuncture points. The current is reduction in dosage of drugs along with of high intensity and low frequency. This method minimizing their risk of side effects [29,50-52]. In is often considered for those patients who do not a study, acupuncture was used for the treatment of respond to conventional TENS [22, 45]. rheumatoid arthritis that proved more effective Pulse (Burst) TENS than intra-articular steroids [53]. The electro acupuncture treatment for chronic low back pain This is also one of the options used in was found better long term pain relieving therapeutic settings of TENS. In this method low modality, compared to placebo treatment [9]. In intensity stimuli are used which fire in
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