Migraines: Preventative Care with Acupuncture

Acupuncture is the technique of piercing the body with a solid needle for therapeutic purposes. Acupuncture was developed in China and the first textbook describing the use of acupuncture is thought to date back to about 200BC. Western interest in acupuncture grew in the 1970’s with President Nixon’s visit to China and has steadily increased since then. The majority of acupuncture treatment in the UK is provided in private practice by professional (lay) acupuncturists who are not from an orthodox medical background. However, acupuncture is provided in almost all NHS pain clinics and by increasing numbers of GPs and physiotherapists.

Types of acupuncture

Two main philosophical approaches are usually recognised. Traditional Chinese medical concepts describe illness and disease as a disturbance of qi (a form of energy or ‘vital force’) within the body. Qi is said to flow along fourteen meridians on the body surface on which the acupuncture points are situated (rather like stations on the lines of the London Underground map). Acupuncture aims to re-establish the correct flow of qi throughout the meridians. Diagnosis may include detailed examination of the pulse and tongue. Needle placement is individualised, so each patient with migraine might receive a different number and distribution of needles. This is often combined with dietary advice and Chinese herbal treatment.

Western medical acupuncture is a modern scientific approach which is based on the biological effects of needling and on clinical and laboratory research. Acupuncture has been found to have effects on the nervous system, including locally where the needles are placed, in the spinal cord and brainstem, where a ‘damping effect’ occurs on pain transmission, and in areas of the brain which regulate the emotional aspects of pain. This may explain beneficial effects from ‘distant’ acupuncture points of traditional practice. Western medical acupuncture uses both local points (for instance on the head and neck) and distant points (such as hands and feet). A related approach is ‘trigger point’ acupuncture, in which tender points in muscles are needled to release muscle spasm contributing to the condition, for example in the neck and scalp.

Evidence for acupuncture

A major problem in acupuncture research is that most clinical trials in headache are ‘randomised, double-blind placebo-controlled trials’, which means that the treatment (typically a drug) is compared with a ‘placebo’ or dummy tablet of identical appearance so that neither the patients nor the researchers know which is which. This is done to minimise treatment expectations affecting the outcome. However, it is much more difficult to devise a ‘placebo’ acupuncture technique with which patients and researchers can be ‘blinded’. One method is called ‘sham’ acupuncture, in which the needles are inserted less deeply into the skin and away from classic acupuncture points. This relies upon the patient not knowing where the true points are and works best in those who have never had acupuncture before. The second method is to use a special needle held in a sheath, which hides it from the patient. The needle can then be made to enter the skin as usual, or to ‘prick’ the skin but not penetrate it (placebo). This has been shown to mimic the sensation of acupuncture effectively. There is much controversy about whether either of these methods are truly inactive like a drug placebo or may have specific effects because they stimulate nerve fibres lying under the skin. The other issue is that practitioners can never be ‘blinded’; they always know which treatment they are giving. For this reason the results of treatment must be assessed by another researcher unaware of which patients got which treatment, or by the patients themselves.

Acupuncture studies in headache have concentrated almost entirely on the prevention of headache rather than acute treatment. A Cochrane systematic review first published in 2001 analysed 16 studies involving 1151 patients and concluded that ‘the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches’, but called for further large-scale studies. Large, randomised controlled clinical trials involving several thousand patients have now been conducted, funded by German health insurance companies. These studies have compared acupuncture with standard treatment (drugs and advice given by physicians) and demonstrate persistent and clinically relevant benefits under real-life conditions and equivalence to specialist drug management. However, no convincing evidence of superiority to ‘sham’ acupuncture has been shown for headache. To skeptics, this suggests that ‘acupuncture doesn’t work’ (i.e. ‘it is no better than placebo’). To supporters of acupuncture, it suggests that while the studies show that it may not matter quite so much how the acupuncture is done, i.e. where the needles are placed or how deeply, acupuncture is much better than no treatment and equivalent to conventional treatment options, with considerably fewer side-effects.

In so-called ‘pragmatic’ studies, the real-world effectiveness of acupuncture has been assessed when given in addition to usual treatment. Patients are randomized to ‘acupuncture’ or ‘no additional treatment (standard GP management) without the use of a placebo. In one such study, patients suffering with chronic headache (80% with migraine) were given 12 sessions of acupuncture over 3 months. This resulted in 34% fewer headache days, 15% less medication, 15% fewer days off work and 25% fewer GP visits after one year. The cost-effectiveness, expressed per ‘quality-adjusted life year’ (QALY), the recommended measure, was £9000 per QALY, well under the threshold of £20-30 000 per QALY) required by the National Institute of Clinical Effectiveness (NICE). These results have been repeated in Europe.

The National Institute for Health and Care Excellence (NICE) include in their headache guideline(2012, updated 2015) that a course of up to 10 sessions of acupuncture may be offered by a healthcare professional if neither topiramate or propranolol are suitable or work well for a particular patient. However, there is no mandate for health professionals to prescribe acupuncture. In practice its availability on the NHS is inconsistent.

Safety of acupuncture

Acupuncture is extremely safe if delivered by adequately trained practitioners. The most frequent side-effects are mild and include: minor bruising or bleeding, usually on needle withdrawal (3%), worsening of existing symptoms (1%) which usually lasts no more than two days and is sometimes associated with a good overall outcome; drowsiness, relaxation, or euphoria (3%) which is often experienced as pleasurable (and if so is not an adverse event!), and pain at the needling site (1%). Severe, extremely rare side-effects include a puncture lung or heart membrane (this is avoided by correct technique); transmission of blood-borne diseases (e.g. hepatitis C), avoided by using single-use, sterile, disposable needles, and skin infection (which is possible with ear acupuncture, particularly if indwelling studs are used).

Acupuncture at the Royal London Homeopathic Hospital

The Royal London Homeopathic Hospital, part of University College Hospital NHS Trust, introduced acupuncture into the NHS in 1977. It is the largest provider of acupuncture services to NHS patients, providing several thousand patient sessions per year. All treatment is provided by conventionally qualified doctors, nurses and physiotherapists who are additionally trained in acupuncture.  Both Western and traditional Chinese techniques are used. With increasing scientific evidence for the effectiveness of acupuncture, the RLHH has concentrated on the challenge of providing NHS acupuncture on the scale and frequency required to treat the large number of sufferers with chronic painful conditions including headache and migraine, facial pain, back and neck pain and knee osteoarthritis. It has set up a number of pioneering group treatment services, where patients are treated up to six at a time initially on a weekly or two-weekly basis, followed by monthly maintenance treatment for those who respond. Clinical audit has demonstrated that the results compare with those from clinical trials.

References

• Linde K et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD001218.

• Diener HC. et al. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol. 2006 Apr;5(4):310-6.

• Linde K, Streng A, Jurgens S, Hoppe A, Brinkhaus B, Witt C et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA 2005;293(17):2118-25.

• Vickers A. et al. Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial BMJ 2004;328;744-9.

• Wonderling D et al. Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. BMJ 2004;328;747.

• National Institute for Health and Care Excellence.  Headaches in over 12s: diagnosis and management (NICE guidelines [CG 150]).  2012 (updated 2015).

this article originally appeared on migrainetrust.org, with contribution by Dr Saul Berkovitz MRCP

How Does Yoga Relieve Chronic Pain?

Chronic pain triggers changes in brain structure that are linked to depression, anxiety, and impaired cognitive function. New research shows that practicing yoga has the opposite effect on the brain and can relieve chronic pain.

Chronic pain alters brain structure. Brain imaging studies have shown that chronic pain leads to changes in gray matter volume and the integrity of white matter connectivity. Gray matter is home to the neurons in specific brain regions, while white matter creates communication lines between your various brain regions.

In a recent lecture, “Effect of Environment on the Long-Term Consequences of Chronic Pain,” at the American Pain Society's(link is external) annual May 2015 meeting in Palm Springs, M. Catherine Bushnell, presented findings from cutting edge research on the ability of yoga to counteract chronic pain that she's spearheading at NIH/NCCIH.

Catherine Bushnell(link is external), PhD, is scientific director of the National Center for Complementary and Integrative Health (NCCIH) at the U.S. National Institutes of Health (NIH) where she oversees a program on the brain’s role in perceiving, modifying, and managing pain. In a press release, Bushnell summed up the findings of her research by saying, "Practicing yoga has the opposite effect on the brain as does chronic pain." 

Bushnell and her colleagues are conducting research aimed at discovering non-pharmacological treatments for pain. They've found that chronic pain can be prevented or reversed through mind-body practices. Lifestyle choices—such as practicing yoga or meditation—have been shown to reduce pain perception and offset the effects of age-related decreases in gray matter volume while helping to maintain white matter integrity. 

Reduced gray matter volume can lead to memory impairment, emotional problems, and decreased cognitive functioning. Hyper-connectivity of white matter tracts between brain areas associated with negative emotions and pain perception can hardwire these corresponding states of mind.

The researchers used diffusion tensor brain imaging to analyze gray matter volume and the integrity of white matter tracts. Bushnell hypothesizes that increased size and connectivity of the insular cortex is probably the most important brain factor regarding changes in an individual's pain tolerance and thresholds.

Yoga appears to bulk up gray matter through neurogenesis and strengthen white matter connectivity through neuroplasticity. After assessing the impact of brain anatomy on pain reduction, Bushnell believes that gray matter changes in the insula or internal structures of the cerebral cortex are the most significant players involved in chronic pain.

"Insula gray matter size correlates with pain tolerance, and increases in insula gray matter can result from ongoing yoga practice," said Bushnell. Yoga practitioners have more gray matter than controls in multiple brain regions, including those involved in pain modulation. Bushnell stated, 

Brain anatomy changes may contribute to mood disorders and other affective and cognitive comorbidities of chronic pain. The encouraging news for people with chronic pain is mind-body practices seem to exert a protective effect on brain gray matter that counteracts the neuroanatomical effects of chronic pain. Some gray matter increases in yogis correspond to duration of yoga practice, which suggests there is a causative link between yoga and gray matter increases.

Rodent studies have shown that increased levels of stress alters pain behaviors, whereas socially and physically enriched environments reduce reduce pain-related brain changes. These findings in both humans and animals indicate that the adverse effects of chronic pain can be reduced, or prevented, by altering environmental factors and making lifestyle choices that improve the pain modulatory systems in the brain.

Yoga Increases Gray Matter Brain Volume and White Matter Connectivity

Bushnell has been working with Chantal Villemure to study the benefits of yoga on chronic pain. In their recent study, they focused on people who had been practicing yoga regularly for at least six years and compared the "yogis(link is external)" to healthy people who didn't practice yoga but were matched for age, sex, education, and other exercise.

Bushnell and Villemure found dramatic differences in gray and white matter between the general population and the yoga practitioners. As Bushnell explains,

We found from brain anatomy studies that the people practicing yoga had more gray matter in a number of regions; as we get older, we lose gray matter, but we didn’t see that decrease in the yoga practitioners, which suggests that yoga may have a neuroprotective effect. When we looked at pain perception, there was a significant increase in pain tolerance in the yoga practitioners, and there was a change in pain thresholds, too.

Villemure has a theory that many of the benefits of yoga might be related to autonomic nervous system and stress reduction as it relates to chronic pain. The autonomic nervous system has two branches: the sympathetic nervous system(link is external) and the parasympathetic nervous system(link is external). Villemure is also examining how yoga practitioners might have a different method of coping with the anticipation of pain.

When most people are expecting pain, it triggers the “fight-or-flight" response of the sympathetic nervous system which causes cortisol levels to skyrocket. On the flip side, Villemure observed that when yogis anticipate pain, their parasympathetic nervous system activates. This creates a "tend-and-befriend" or "rest-and-digest" response, as opposed to a "fight-or-flight" response.

Conclusion: Yoga Is a Viable Drug-Free Treatment Option for Chronic Pain

Most of the pharmacological treatments for chronic pain are opioid based and are highly addictive. Luckily, the effectiveness of non-pharmacological interventions such as yoga and meditation have been shown to have potent pain-relieving effects on the brain. In the long run, alternative treatments for pain, such as yoga, could be more effective than pharmaceutical treatments for relieving chronic pain. 

This article originally appeared on psychologytoday.com and was written by Christopher Bergland.

It's Official: Yoga Helps Depression

Evidence keeps stacking up that yoga is a boon for both physical and mental health conditions. Now, a small new study from Boston University finds that taking yoga classes twice a week may help ease depression, thanks in part to deep breathing.

The study, which was published in the Journal of Alternative and Complementary Medicine, included 30 people from ages 18 to 64 with clinical depression, who either were not taking antidepressants or had been on a steady dose for at least three months. Half of the participants were assigned to take a 90-minute Iyengar yoga class three times per week, as well as four 30-minute sessions at home each week. People in the other group took two group classes and three at-home sessions every week.

Iyengar yoga classes emphasize alignment, precise postures and controlled breathing. The classes taught in the study also included 20 minutes of slow, gentle breathing, at a rate of five inhales exhales through the nose per minute.

After about three months, most of the people in both groups had lowered their scores on a depression-screening questionnaire by at least 50%. Not surprisingly, more yoga was better; those who took three classes per week had lower depression scores than those who took two per week.

But since many participants mentioned that the larger time commitment was challenging, the researchers actually recommend two classes per week, saying that the regimen still comes with meaningful benefits.

That yoga seems to be effective is good news for people struggling with depression. Lead author Dr. Chris Streeter, associate professor of psychiatry and neurology at Boston University School of Medicine, says that the practice has far fewer side effects and potential drug interactions than mood-altering medications. The most common complaint reported in the study was a small one—temporary muscle soreness—and one participant experienced distressing thoughts while practicing breathing exercises at home.

Some people who haven’t responded to traditional treatments might do well with yoga, because unlike antidepressant drugs, yoga and deep breathing target the autonomic nervous system, Streeter says. “If your autonomic nervous system is balanced out, then the rest of the brain works better,” she says. Research shows that 40% of people on antidepressants do not recover fully from depression, says Streeter, which puts them at increased risk for a relapse. “Getting that 40% all the way better is a really important goal. Instead of adding another drug, I would argue that yoga is another thing you can add to the treatment regimen that might help.”

More research is needed to determine how yoga stacks up against other treatments. (A larger trial comparing yoga to walking is underway, the study notes.)

While Iyengar yoga is generally considered to be a safe practice for people of all levels, it’s not the only type with health benefits, Streeter adds. “It depends on who the person is and what they’re looking for,” she says. For now, what’s clear is that the type with the most health benefits will be whichever kind you stick with.

This article originally appeared on time.com and was written by AMANDA MACMILLAN.

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Getting the Right Massage for Low Back Pain

Massage therapy can provide substantial healing and pain relief for people suffering from low back pain caused by muscle tension and strain, if the correct muscles are targeted.

I asked certified massage therapist Kate Fish, who works at in a chiropractor's office, to explain how she helps heal her clients' pain with massage.

See Chiropractic Treatments for Lower Back Pain

She explained that isolating and rejuvenating the main back muscles that can have the biggest effect on low back pain caused by stressed muscles.

See Pulled Back Muscle and Lower Back Strain

Kate stresses that two important muscles, the quadratus lumborum (QL) and the gluteus medius, may play a bigger role in causing pain than most people realize, saying, "If you strain either of these muscles, the pain can be severe and debilitating.

Dysfunction in these muscles (the QL and the gluteus medius) can lead to severe and debilitating low back pain." Tweet this to share on Twitter.

Kate recommends that you specifically ask your massage therapist to spend 60 minutes on these two muscles.

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1. Quadratus lumborum (QL) muscle massage

Ask your therapist to massage the QL muscle while you lie on your side for 20 minutes on each side (40 minutes total).

The QL muscle, which connects the last rib to the pelvis, is responsible for pelvic stability and structural alignment. It is a common source of low back pain.

See Back Muscles and Low Back Pain

The muscle can become irritated when the lower body is engaged while the upper body is still. For example, activities that could irritate the QL muscle are:

See Office Chair, Posture, and Driving Ergonomics

See Running and Lower Back Pain

• Lifting that requires leaning over something (such as getting groceries out of a trunk)
• Leaning over a sink while doing dishes
• Sitting slumped in a chair
• Running on uneven pavement

Sharp, stabbing pain, urgent pain in the low back is a symptom of a hypertonic (tight) QL.

This muscle must be stretched and massaged simultaneously by your therapist in order to reduce lower back pain. Typically, clients can get relief by combining treatment of the QL muscle with 20 minutes of massage on the gluteus medias.

Back Strains and Sprains Video

2. Gluteus medius massage

After working on the QL muscle, ask your therapist to focus on the gluteus medius for 20 minutes.

The gluteus medius is a posterior hip (or buttocks) muscle that frequently causes pain when the QL muscle is irritated. The gluteus medius becomes inflamed as it tries to compensate for the QL’s dysfunction. Your massage therapist should focus on simultaneously stretching and massaging the gluteus medius as you lie on your stomach.

Kate has been able to provide significant pain relief to numerous clients by using these massage techniques in only one session. She recalls,

"One of my clients had experienced severe low back pain for 3 months. After his doctor ordered an MRI, he was worried he would have to have surgery. He visited the chiropractor where I worked as a massage therapist, and I assessed that his QL was ischemic (so tight that the blood supply got cut off). Working on these specific muscles, I loosened them and increased their blood flow, and the client was pain-free after one session."

See Pulled Back Muscle Treatment

Most likely, your massage therapist is well-versed in the muscles that cause back pain, but don’t hesitate to speak up and specifically request this type of massage if you suspect your pain is due to muscle dysfunction.

This article originally appeared on Spine-Health.com and was written by Allison Walsh.