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

What is Pain and What is Happening When We feel It?

What is pain? It might seem like an easy question. The answer, however, depends on who you ask.

Pain doesn’t originate at the site as most think, it’s created by the brain so we protect the area that’s in danger.

Some say pain is a warning signal that something is damaged, but what about pain-free major trauma? Some say pain is the body’s way of telling you something is wrong, but what about phantom limb pain, where the painful body part is not even there?

Pain scientists are reasonably agreed that pain is an unpleasant feeling in our body that makes us want to stop and change our behaviour. We no longer think of pain as a measure of tissue damage – it doesn’t actually work that way even in highly controlled experiments. We now think of pain as a complex and highly sophisticated protective mechanism.

How does pain work?

Our body contains specialised nerves that detect potentially dangerous changes in temperature, chemical balance or pressure. These “danger detectors” (or “nociceptors”) send alerts to the brain, but they cannot send pain to the brain because all pain is made by the brain.

When you’re injured, the brain makes an educated guess which part of the body is in danger and produces the pain there.

Pain is not actually coming from the wrist you broke, or the ankle you sprained. Pain is the result of the brain evaluating information, including danger data from the danger detection system, cognitive data such as expectations, previous exposure, cultural and social norms and beliefs, and other sensory data such as what you see, hear and otherwise sense.

The brain produces pain. Where in the body the brain produces the pain is a “best guess scenario”, based on all the incoming data and stored information. Usually the brain gets it right, but sometimes it doesn’t. An example is referred pain in your leg when it is your back that might need the protecting.

It is pain that tells us not to do things – for example, not to lift with an injured hand, or not to walk with an injured foot. It is pain, too, that tells us to do things – see a physio, visit a GP, sit still and rest.

We now know that pain can be “turned on” or “turned up” by anything that provides the brain with credible evidence that the body is in danger and needs protecting.

All in your head?

So is pain all about the brain and not at all about the body? No, these “danger detectors” are distributed across almost all of our body tissues and act as the eyes of the brain.

When there is a sudden change in tissue environment – for example, it heats up, gets acidic (cyclists, imagine the lactic acid burn at the end of a sprint), is squashed, squeezed, pulled or pinched – these danger detectors are our first line of defence.

They alert the brain and mobilise inflammatory mechanisms that increase blood flow and cause the release of healing molecules from nearby tissue, thus triggering the repair process.

Local anaesthetic renders these danger detectors useless, so danger messages are not triggered. As such, we can be pain-free despite major tissue trauma, such as being cut into for an operation.

Just because pain comes from the brain, it doesn’t mean it’s all in your head. 

Inflammation, on the other hand, renders these danger detectors more sensitive, so they respond to situations that are not actually dangerous. For example, when you move an inflamed joint, it hurts a long way before the tissues of the joint are actually stressed.

Danger messages travel to the brain and are highly processed along the way, with the brain itself taking part in the processing. The danger transmission neurones that run up the spinal cord to the brain are under real-time control from the brain, increasing and decreasing their sensitivity according to what the brain suggests would be helpful.

So, if the brain’s evaluation of all available information leads it to conclude that things are truly dangerous, then the danger transmission system becomes more sensitive (called descending facilitation). If the brain concludes things are not truly dangerous, then the danger transmission system becomes less sensitive (called descending inhibition).

Danger evaluation in the brain is mindbogglingly complex. Many brain regions are involved, some more commonly that others, but the exact mix of brain regions varies between individuals and, in fact, between moments within individuals.

To understand how pain emerges into consciousness requires us to understand how consciousness itself emerges, and that is proving to be very tricky.

To understand how pain works in real-life people with real-life pain, we can apply a reasonably easy principle: any credible evidence that the body is in danger and protective behaviour would be helpful will increase the likelihood and intensity of pain. Any credible evidence that the body is safe will decrease the likelihood and intensity of pain. It is as simple and as difficult as that.

Implications

To reduce pain, we need to reduce credible evidence of danger and increase credible evidence of safety. Danger detectors can be turned off by local anaesthetic, and we can also stimulate the body’s own danger-reduction pathways and mechanisms. This can be done by anything that is associated with safety – most obviously accurate understanding of how pain really works, exercise, active coping strategies, safe people and places.

A very effective way to reduce pain is to make something else seem more important to the brain – this is called distraction. Only being unconscious or dead provide greater pain relief than distraction.

In chronic pain the sensitivity of the hardware (the biological structures) increases so the relationship between pain and the true need for protection becomes distorted: we become over-protected by pain.

This is one significant reason there is no quick fix for nearly all persistent pains. Recovery requires a journey of patience, persistence, courage and good coaching. The best interventions focus on slowly training our body and brain to be less protective.

This article was originally posted on https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040

For more information and audio recordings discussing pain, follow this link.

Optimizing Results With Electro-Acupuncture

Electroacupuncture is an acupuncture technique that, comparatively speaking, has only recently come into use. Some scholars believe electroacupuncture was first used by physicians in France and Italy as far back as the early 1800s. Others attribute its discovery to Japanese scientists in the 1940s who were interested in making bone fractures heal more quickly. Still others claim that electroacupuncture wasn't really developed until 1958, when acupuncturists in China began experimenting with it as a form of pain relief. Whatever the case, electroacupuncture is an increasingly popular form of treatment, and is used by practitioners of traditional Chinese medicine for a wide array of conditions.

What's the difference?

Electroacupuncture is quite similar to traditional acupuncture in that the same points are stimulated during treatment. As with traditional acupuncture, needles are inserted on specific points along the body. The needles are then attached to a device that generates continuous electric pulses using small clips. These devices are used to adjust the frequency and intensity of the impulse being delivered, depending on the condition being treated. Electroacupuncture uses two needles at time so that the impulses can pass from one needle to the other. Several pairs of needles can be stimulated simultaneously, usually for no more than 30 minutes at a time.

One advantage of electroacupuncture is that a practitioner does not have to be as precise with the insertion of needles. This is because the current delivered through the needle stimulates a larger area than the needle itself. Another advantage is that electroacupuncture can be employed without using needles. A similar technique called transcutaneous electrical nerve stimulation, or TENS, uses electrodes that are taped to the surface of the skin instead of being inserted. The advantage of this procedure is that it can be used by people who have a fear of needles or a condition that prohibits them from being needled.

What conditions can electroacupuncture treat?

According to the principles of traditional Chinese medicine, illness is caused when qi does not flow properly throughout the body. Acupuncturists determine whether qi is weak, stagnant or otherwise out of balance, which indicates the points to be stimulated. Electroacupuncture is considered to be especially useful for conditions in which there is an accumulation of qi, such as in chronic pain syndromes, or in cases where the qi is difficult to stimulate.

In the United States, electroacupuncture has been studied for a variety of conditions. It has been effectively used as a form of anesthesia; as a pain reliever for muscle spasms; and a treatment for neurological disorders. Other studies have examined the role of electroacupuncture in treating skin conditions such as acne, renal colic, and acute nausea caused by cancer medications. There is also some evidence that electrical stimulation of acupuncture points activates the endorphin system, which could lower blood pressure and reduce heart disease.

Does electroacupuncture hurt?

Patients may experience a tingling sensation while being treated with electroacupuncture, which is most likely due to the electric current. In most cases, however, the effect produced by the current is subsational; in other words, the tingling sensation will not be felt. Some minor bruising or bleeding may occur, which is the result of a needle hitting small blood vessels.

Are there any risks involved?

Electroacupuncture should not be used on patients who have a history of seizures, epilepsy, heart disease or strokes, or on patients with pacemakers. It should also not be performed on a patient's head or throat, or directly over the heart. Another recommendation is that when needles are being connected to an electric current, the current should not travel across the midline of the body (an imaginary line running from the bridge of the nose to the bellybutton).

Before trying electroacupuncture, patients should make sure to discuss the potential risks and benefits with their practitioner.

This article originally appeared on acupuncturetoday.com

Understanding Gua Sha: Benefits and Side Effects

What is gua sha?

Gua sha is a natural, alternative therapy that involves scraping your skin with a massage tool to improve your circulation. This ancient Chinese healing technique may offer a unique approach to better health, addressing issues like chronic pain.

In gua sha, a technician scrapes your skin with short or long strokes to stimulate microcirculation of the soft tissue, which increases blood flow. They make these strokes with a smooth-edged instrument known as a gua massage tool. The technician applies massage oil to your skin, and then uses the tool to repeatedly scrape your skin in a downward motion.

Gua sha is intended to address stagnant energy, called chi, in the body that practitioners believe may be responsible for inflammation. Inflammation is the underlying cause of several conditions associated with chronic pain. Rubbing the skin’s surface is thought to help break up this energy, reduce inflammation, and promote healing.

Gua sha is generally performed on a person’s back, buttocks, neck, arms, and legs. A gentle version of it is even used on the face as a facial technique. Your technician may apply mild pressure, and gradually increase intensity to determine how much force you can handle.

BENEFITS

What are the benefits of gua sha?

Gua sha may reduce inflammation, so it’s often used to treat ailments that cause chronic pain, such as arthritis and fibromyalgia, as well as those that trigger muscle and joint pain.

Gua sha may also relieve symptoms of other conditions:

1. Hepatitis B

Hepatitis B is a viral infection that causes liver inflammation, liver damage, and liver scarring. Research suggests that gua sha may reduce chronic liver inflammation.

One case study followed a man with high liver enzymes, an indicator of liver inflammation. He was given gua sha, and after 48 hours of treatment he experienced a decline in liver enzymes. This leads researchers to believe that gua sha has the ability to improve liver inflammation, thus decreasing the likelihood of liver damage. More research is underway.

2. Migraine headaches

If your migraine headaches don’t respond to over-the-counter medications, gua sha may help. In one study, a 72-year-old woman living with chronic headaches received gua sha over a 14-day period. Her migraines improved during this time, suggesting that this ancient healing technique may be an effective remedy for headaches. More research is needed.

3. Breast engorgement

Breast engorgement is a condition experienced by many breastfeeding women. This is when the breasts overfill with milk. It usually occurs in the first weeks of breastfeeding or if the mother is away from the infant for any reason. Breasts become swollen and painful, making it difficult for babies to latch. This is usually a temporary condition.

In one study, women were given gua sha from the second day after giving birth up until leaving the hospital. The hospital followed up with these women in the weeks after giving birth and found that many had fewer reports of engorgement, breast fullness, and discomfort. This made it easier for them to breastfeed.

4. Neck pain

Gua sha technique may also prove effective for remedying chronic neck pain. To determine the effectiveness of this therapy, 48 study participants were split into two groups. One group was given gua sha and the other used a thermal heating pad to treat neck pain. After one week, participants who received gua sha reported less pain compared to the group that didn’t receive gua sha.

5. Tourette syndrome

Tourette syndrome involves involuntary movements such as facial tics, throat clearing, and vocal outbursts. According to a single case study, gua sha combined with other therapies may have helped to reduce symptoms of Tourette syndrome in the study participant.

The study involved a 33-year-old male who had Tourette syndrome since the age of 9. He received acupuncture, herbs, gua sha, and modified his lifestyle. After 35 once-a-week treatments, his symptoms improved by 70 percent. Even though this man had positive results, further research is needed.

6. Perimenopausal syndrome

Perimenopause occurs as women move closer to menopause. Symptoms include:

• insomnia

• irregular periods

• anxiety

• fatigue

• hot flashes

One study, however, found that gua sha may reduce symptoms of perimenopause in some women.

The study examined 80 women with perimenopausal symptoms. The intervention group received 15 minute gua sha treatments once a week in conjunction with conventional therapy for eight weeks. The control group only received conventional therapy.

Upon completion of the study, the intervention group reported greater reduction of symptoms such as insomnia, anxiety, fatigue, headaches, and hot flashes compared to the control group. Researchers believe gua sha therapy might be a safe, effective remedy for this syndrome.

SIDE EFFECTS

Does gua sha have side effects?

As a natural healing remedy, gua sha is safe. It’s not supposed to be painful, but the procedure may change the appearance of your skin. Because it involves rubbing or scraping skin with a massage tool, tiny blood vessels known as capillaries near the surface of your skin can burst. This can result in skin bruising and minor bleeding. Bruising usually disappears within a couple of days.

Some people also experience temporary indentation of their skin after a gua sha treatment.

If any bleeding occurs, there’s also the risk of transferring bloodborne illnesses with gua sha therapy, so it’s important for technicians to disinfect their tools after each person.

Avoid this technique if you’ve had any surgery in the last six weeks.

People who are taking blood thinners or have clotting disorders aren’t good candidates for gua sha.

TAKEAWAY

When conventional therapies don’t improve your symptoms, research suggests that gua sha may be able to provide relief.

This technique may appear straightforward and simple, but it should only be performed by a licensed acupuncturist or practitioner of Chinese medicine. This ensures a safe, proper treatment. More research is needed, but there are few risks associated with this massage technique.

Whoever you choose, make sure that person has a certification in gua sha. Certification confirms they have basic knowledge of this healing practice. Using a professional improves the effectiveness of the treatment and reduces the risk of pain or severe bruising from excessive force.

This article originally appeared on healthline.com