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    Acuputura en El Manejo Del Dolor Musculoesqueletico y Neurologico

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    richabert

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    (COMPLEMENTARY THERAPIES IN PHYSICAL ‘MEDICINE AND REHABILITATION 1047-9651/99 $80 + 00 ACUPUNCTURE IN THE MANAGEMENT OF PAIN OF MUSCULOSKELETAL AND NEUROLOGIC ORIGIN Joseph Y. Wong, MD, FRCPC, and Linda M. Rapson, MD, CAFCI Acupuncture has been used as a therapeutic treatment for the health of the Chinese people for more than 3000 years, and its use is growing exponentially ‘world-wide for the treatment of a wide range of medical conditions. It is a system for diagnosing and treating disease using fine needles inserted into specific points on the body. Classic acupuncture is a vast body of ancient knowledge collected and ‘compiled over many centuries by the Chinese. The basis fora classic unclerstand ing of acupuncture’s effects is Taoism, an ancient philosophy that has as its frst principle the concept of yin and yang. Taoists believe that these equal and Spposite forces coexist in the universe and must be in balance for harmony to prevail Iiness is thought to result from an imbalance in yin and yang in the Body, and classic acupuncturist insert needles into points on the body in order to either increase or decrease the amount of energy in a given organ system, ‘The objective is to restore a balance of yin and yang and therefore restore health. ‘Classic acupuncture is complicated and may be confusing to western trained medical people because of vast differences in the concepts of disease of the two systems, Tes, however, an holistic system of medical diagnosis and treatment that is used widely throughout the world and has stood the test of time. It should be respected for what it is and what it has given the world in terms of therapy, as well as the stimulation it has offered the western scientific commu rity to further unravel the complex “puzzle of pain From the Acupuncture Foundation of Canada Institute; Medical Acupuncture for Physic ‘ang Program, University of Caforia at Loe Angele, Los Angels, California (YW, {EM; Toronto Pain and Stress Clinic QYW); Acupuncture Cine, Toronto Rehabil tion Institute, Lyndburst Centre (LMR); and the Rapson Pain Clinic (LMR), Toronto, Ontario, Caneda PHYSICAL MEDICINE AND REHABILITATION CLINICS (OF NORTH AMERICA ‘VOLUME. 10- NUMBER 3» AUGUST 1999 531 582 WONG £ RAISON “Anatomic” acupuncture refers to the approach taken today by some west- em trained physicians in China and some parts of the western world wherein ‘one combines knowledge of acupuncture with western learned anatomy, physi- ‘logy, and pathophysiology: This approach has been developed since the 1970s by Dr. Joseph ¥. Wong, co-author ofthis peper, and taught through the Acupunc- ture Foundation of Canada Institute across Canada, Anatomic acupuncture inte- grates knowledge of acupuncture with western medicine in a sophisticated Way, allowing for precise diagnosis and focusing of treatment, It is applicable particularly to the management of pain of musculoskeletal origin, A particular style of acupuncture referred to herwin as a. “one needle” ‘method of acupuncture treatment refers tothe practice of using one acupuncture needle at atime to treat musculoskeletal conditions, examining the patient before and after treatment to diagnose the condition and to assess improvement after 4 few minutes’ stimulation with one needle, Its not meant to imply that only fone needle in total is used for treatment at a given session or that other ‘treatments using several needles with or without the application of electrical stimulation are never used, ‘As noted above, acupuncture can treat a wide range of conditions. The authors believe it has a major role to play in the management of both acute and chronic pain. In this article, however, the authors limit their discussion to the use of acupuncture in the management of pain of musculoskeletal and neuto= logic origin, with a focus on pain in spinal cord injuries (SC). NEUROPHYSIOLOGIC BASIS OF ACUPUNCTURE In the hands of western physicians thus far, acupuncture has serve as a sherapoutc modality mainly Yor the following types of conditions + Control of pain and surgical analgesia + Autonomic nervous system disorders * Control of addictions + Promotion of tissue regeneration and healing, Control of Pain and Surgical Analgesia ‘When acupuncture was introduced to the west in the early 1970s, following. President Richard Nixon's vist to China, western physicians were fascinated by the use of acupuncture for surgical analgesia, Starting in the 1960s, western trained Chinese physicians had begun to esearch the phenomenon of acupunc- ture analgesia, concentrating on physiologic changes in the central nervous, system, particularly the brain. A period of intensive research in Canada, China, Scotlanel, Sweden, the United States, and other countries, beginning, in the 1970s, resulted in the discovery of receptors for opiates, several types of endogenous opiates, pathways of acupuncture analgesia, and a comprehensive hypothesis for the production of acupuncture analgesia. Professor Bruce Pomeranz at the University of Toronto published a compre- hensive theory for the production of acupuncture analgesia (AA) in 1987, based ‘on a review of 228 modem scientific studios on acupuncture.” Further research in many laboratories has corroborated and expanded details of this theory In short, acupuncture needles stimulate type II and type ITI muscle afferent nerves oor A fibers, sending impulses to the anterolateral tract ofthe spinal cord. From, ACUPUNCTURE IN THE MANAGEMENT OFTAIN. 533 there, messages are sent to one or all of three centers: the spinal cord, the ‘midbrain, and the pituitary-hypothalamic complex. At the spinal cord level, pain is blocked presynaptically by the release of enkephalin and dynorphin, preventing pain mnessages from ascending in the spinothalamic tract. Stimulation In the midbrain, through a sequence of excitation and inhibition of cells in the periaqueductal grey matter and the raphe nucleus, sends descending. signals through the dorsolateral tract, causing the release of the monoamines norepi- nephrine and serotonin in the spinal cord. These neurotransmitters can inhibit pain pre- and postsynaptically in the spinal cord by blocking transmission of pain signals through the spinothalamic tract. Finally stimulation inthe pituitary Rypothalamic complex releases G-endorphin into the blood stream from the pituitary gland, Its release is accompanied by the release of adrenocorticotropic formone (ACTH) on an equimolar basis. Both are segments of a 91-amino acid precursor molecule, f-lipotropin ‘Although the fact that acupuncture releases neuropeptides such as enkeph lin, dynorphin, f-endorphin, and endomorphine (a 4-amino acid peptide discov- ered In 1997) gives credibility to acupuncture in the management of pain, it ‘cannot explain every observed effect of acupuncture. A good working know!- ledge of the frequencies that release the various neuropeptides, however, is helpful clinically (as discussed subsequently). ‘Autonomle Nervous System Disorders ‘A western interpretation of the concept of yin and. yang is homeostasis, achieved through the sutonomie nervous system (ANS). Many of the conditions that acupuncture teats well such as migraine headaches and reflex sympathetic dystrophy, involve malfunction of the ANS. A basic concept of acupuncture is that it tends to normalize, rather than overstimulate or reduce physiologic activity below normal. In that respect, it is somewhat like acetylsalicylic acid (ASA), which has an antipyretic effect, but docs not lower normal body tempera ture, (When the authors refer to ASA, they are using it as an unusual example ‘of a drug that has a homeostatic effect rather than a unidirectional effect. For example, if one overdoses on antihypartensives, one’s blood pressure goes ‘below normal.) Control of Addictions. Since the early 1970s, clinical evidence of acupuncture’ ability to reduce withdrawal symptoms and drug,secking behavior in addicts has been amassed, supported by randomized controlled trials* The mechanism of action seems primarily to involve endogenous opioids and dopamine. This application of Acupuncture is useful in the management of chronic pain if drug dependency is fan isstie, since withdrawal symptoms can be alleviated by acupuncture Promotion of Tissue Regeneration and Healing ‘The Chinese belief that acupuncture promotes regeneration and healing is readily understandable fo cinigane who dee iton a regular Basi and integrate Fine the eeiatton process Threat stone contd study he 534 WONG & RAPSON literature that indicates that acupuncture can enhance recovery fom taumatc peripheral nere injury when lesone ate neurogenic and muscles partially dene ‘rated, as demonstrated by electromyography. “Acupuncture, sehen the newdles are connected fo an electrical stimulation device, i a form of electrotherapy. The concept tat it promote healing can be linked to Robert Becker's pioneering work tat showed that theresa hcl felt along acupuncture meridian pathways)” and tat ctrl stimulation promote tissue regeneration and heing of hoy fractures? His work on bone ovr promotion by clcecty has btn cortborated by others!" Elcicl ‘Smulaton for healing has eon esearched in the past tee decades and studies have shown that eleticalsinulation promotes wound healing” CLINICAL APPLICATION iples In clin practic, acupuncture Isa potent analgeste modality, and ani inaninalory effects very commonly are cbverved. These include reduction of erythema and swelling increased singe of motion, decree in tenderness, and ‘elum of normal py fancions Immediately following of tissue injures, inflammation is the body's defen: sive reaction Intated by mast cll activation, including. Immunoglobulin E {IgE flamed supraspinatos tendon ‘Dry needling appears to inte an ant-inlammator reponse in tis. including tendons ligament, prtosteumy synovium, and mule Tis sa physio. Tpgic pienomench that has hot been described adequately or explained jet, but ne hin cared open cna ing ce ‘An empirical observation by anesthesiologist who perform regional nerve blocks and have leaned this acopunctre approach i that when performing 8 Stclate ganglion block the desied efecoften occurs Immediately upon ine Serting the hypodermic needle, pio to ineting any local anesthetic. Chall it appeats fat one can crest profound sutonomc changes by dry needling copunetare point eslced to shmuste relevant sympathetic gana. he key fo success in using this approach specie. Classically acupune- tures performed with multiple needs at each tatment session {commen 6 to l0 or mom) Using mulple neds, the effect of each Individual needle Enno! be easly explsined or rationalized. The "one nde” approach is one ‘way to improve ciical observations and scientific research Evidence for Efficacy of Acupuncture Although the experimental evidence for acupunctre's effects i sro there are fe0 High quality randomized contol tals (RCT) regarding 1 536 WONG& RAPSON effectiveness in acute and chronic pain. Methodological and ethical issues pecu- liar to acupuncture research must be dealt with before this valuable treatment approach will find its proper place in the mainstream of medical practice ™ ‘There are, however, some good RCs that support its eficacy in musculoskeletal painful conditions, such as neck and low back pain, tennis elbow, and osteoar- Unitis °°" These studies show acupuncture to be more effective than standard treatment; one of the studies documented savings of $9000 per patient who avoided knee joint replacement ‘Treating Musculoskeletal Disorders In dealing with musculoskeletal disorders, the outcome of acupuncture treatment depends on the following: Accurate Diagnosis Examination of the patient pre-and post-treatment is critical. A quick result is the rule, not the exception. [tis important to reconsider the diagnosis after a poor rest, Selection of Acupuncture Points Acupuncture stimulus can be applied to: + The painful area, muscle, tendon, nerve ligament, bone, or joint (intr artctaringertion) « Zahtpointa, the Chinese term for tener non-merdlan points + Acupuncture points on the rezoor peripheral nerve + Acupuncture point on the apna neve, using the afoot se + Acupuncture points onthe neuroplenus (eH 1on the brachial ples) + "Sympathetic switches,” which are acupuncture points that are used fo nomnaize sympathetic dysfunction (eg.rST 36,8 3 114, GV 25, and ext point sympathetic) ia + Farasympathetc switches,” which are acupuncture points that are use to normalize parasympathetic dysfoncion (egy, SP 6, HT 7, and er point shen’ men) + "Danie switches” (og, distal poins adjcent to nailbeds and GV 26, a point inthe supralabcl groove) + Distal acupuncture points thot havea generalized effct to produce ac puncture analgesia (eg, LI) + Restpuncture points of the head and fae to stimulate the higher cet rervous system, (eg, Lyndhurst Deafferetation Protocol, whichis de- Sctbed subsequent) + "Proecional™ acupuncture points in the extemal ea, hand, fot, and none These areas of the by contaln "nie system,” oF miniature representations of the body and points that represent every part ofthe bay. in the cso of the eat, the Topreontation i ike an pide down fet, withthe head represented in the lobule, the ternal organ i the concha, the vertebral column on the anterior border ofthe anihel and the libs over the antehalx« Unlike body acupuncture points, which consistently extbit low skin resistance wien using point Finder, he ear ACUPUNCTURE IN THE MANAGEMENTOF PAIN. 587 points become detctabe ether elscralyo by tendemes on palpation Ely when there filles or dysfunction present. The somaloopie map- ping ofthe ear points shoves a 75.2% concordance Betoun the suncuae Eiagnoses and medical dlagnones in the case of acute musculoskeletal injites ina blinded experiment ™ Precision of Needle Placement and Insertion Acupuncture points may be located by the traditional Chinese method! of body proportional units and finger measurement, using surface anatomy land ‘marks a3 well as deeper anatomic landmarks, including bone, muscle, tendon, and so forth. The angle and direction of insertion of the needle are critical with regard to both outcome and safely, as is Uhe depth of insertion. ‘Stimulation Parameters e-Qi Sensation. Traditionally, the technique of acupuncture includes the concept that one mist create a particular sensation upon inserting the needle {the de-gi sensation) inorder fr the treatment tobe slceessul. Qi (pronounced "chie") fs the Chinese term for energy The dev sensation usally fs described as a heavy, numb, aching feeling that is produced when the needle enters an Scupunctire point In clinical practice, the authors’ experience is that itis not necessary t0 create this sensation to achieve the desired result when using Acupuncture on an anatomic basis. ’Needle Manipulation. Traditional manual needle manipulation includes techniques to tonfy and disperse energy a the acupuncture point. Interestingly strong stimulation is used to disperse energy, and milder stmulaton to tory ft Various techniques can be used, such as vigorous stimulation using a vertical ivand-out movement or a strong rotating movement, or weak stimulation by ‘vibrating oF fipping the needle with a finger Using the anatomic acupuncture toprewh ene ees goo ruts wig « mod rede monpulton technique that does not produce pain Electrical Stimolation. Electrical stimulation (ES) can be applied to the needles. The decision to add electrical stimulation is somewhat aibitary and based on the practitioner's experience and syle of practice because thare i iie evidence for the relative efficacy of neues alone versus needles plus FS. The fxdvantages of ES are that it allows for standardization of parameters, the cli San can avoid long period of twsome manual stimulation (eq, during surgical ‘perations), and i less painful forthe patent than manual simulation. High frequency stimulation (100 to 400 Ha) produces a pain-blocking effect that is raph In onset, does not produce cumulative effets, is not blocked Dy naloxone, and usualy does not outlast the treatment?” Ths effect appears (© bbe mediated. by the monoamines serotonin and norepinephrine, az well ab

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