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Pain Management






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Pain Management Pain Management Document Transcript

  • Pain ManagementCase StudyIntroduction: an 84-year old retired female presented with undiagnosed peripheral neuropathy in both feet that begun more than 25 years before she sought acupuncture treatment. Diagnosis: local qi and blood stagnation due to bone bi syndrome acquired after decades of working many hours every day without adequate rest. Treatment: ten weekly sessions of electroacupuncture using a 2/100Hz dense-dispersed current on local points for 30 minutes. Outcome: the patient reported a 66.6% reduction in pain after eight weeks. Pain in the right foot had completely resolved, although it persisted in the left. Conclusion: EA may be partially effective for the treatment of PN due to unknown aetiology. The use of alternating 2/100Hz frequency on a dense disperse setting appears to be effective in reducing the degree of pain experienced. Prioritisation of treatment principles according to the rapidity with which a significant amelioration of the condition may be achieved may increase patient retention, confidence and satisfaction.2009Word Count: 27455/21/2009<br />INTRODUCTION<br />Peripheral neuropathy (PN) may be defined as the deranged function and structure of peripheral motor, sensory, and autonomic neurons, involving either the entire neuron or selected levels, and which varies greatly in its range of clinical manifestations (Dyck, 1982). <br />Common features tend to include symmetrical and distally graded sensations of tingling, prickling, burning, or band-like dysesthesia in the balls of the feet, tips of the toes, or distributed over the soles of the feet (Simpson, Wolfe, 1991).<br />Western medicine does not have any truly effective treatments for this PN and Amitriptyline, an antidepressant, is often prescribed. As a result, many PN patients will seek alternative methods of treatment such as acupuncture, which has recently received increased attention in the international media (Flaws, 2000).<br />There is sufficient evidence to support the short-term effectiveness of acupuncture when used for the treatment of pain, with the proportion of patients who may benefit ranging from 50 percent to 80 percent (Birch, Hammerschlag, Berman, 1996). The clinical and cost effectiveness of acupuncture in comparison to conventional treatments for chronic pain management have been confirmed in large trials over the past 10 years, particularly by health insurance funded trials on acupuncture conducted in Germany. These trials provided the necessary evidence for the integration of acupuncture into the management of osteoarthritis of the knee and back pain. However, there was insufficient evidence to support a similar policy for the treatment of tension headaches and migraines with acupuncture (Cummings, 2009). <br />Greten, et al, conducted a pilot study in 2007 to evaluate the possible therapeutic benefit of acupuncture on peripheral neuropathy (PN) in 47 patients who were diagnosed with PN of undefined aetiology by nerve conduction studies (NCS). They aimed to provide objective results by measuring changes in nerve conduction, as well by assessment of subjective symptoms, over a period of treatment lasting one year. In the acupuncture group, 76% improved symptomatically and objectively when measured by NCS, while only 15% of patients in the control group did so. Of the acupuncture group, 14% showed no change, while the symptoms were aggravated in 10% of this group. In the control group, 27% showed no change and 58% showed an aggravation. In all cases, the subjective improvement correlated directly with improvement in NCS in both groups, suggesting that there is a positive effect of acupuncture on PN of undefined etiology as measured by objective parameters. However, the small sample size of this study remains as a stimulus for further research using larger subject numbers, preferably in gold standard RCTs, although only single-blind may be possible, thereby limiting its overall conclusiveness. The type of acupuncture used, and if electroacupuncture is used, the specific parameters involved, must also be more clearly defined and standardized. This is possible as treatment of PN with acupuncture can possibly be conducted without individualized TCM pattern diagnosis, using standardized acupoints on all subjects.<br />A systematic review identified an RCT for post-herpetic neuropathy that reported no analgesic benefit associated with acupuncture when compared with sham transcutaneous electrical nerve stimulation. For peripheral neuropathy related to HIV, an RCT found no significant evidence that acupuncture or amitriptyline were more effective than placebo. Another RCT consisting of 90 patients compared the effectiveness of deep needling and shallow routine needling both at local and distal acupuncture points for the treatment primary trigeminal neuralgia and found that only deep needling increased the therapeutic effect (Ernst, 2008). <br />Sagar and Wong (2006) conducted a pilot study consisting of five patients to determine of the effectiveness of acupuncture, as well as the associated, individualized diagnosis according to the paradigm of traditional Chinese medicine, for the treatment of chemotherapy induced peripheral neuropathy. According to this study, the pathogenesis is related to the poor circulation of Qi and Blood to the extremities, and is often associated with Qi, Blood, Yang and/or Kidney deficiencies. This study produced several positive results that would warrant further, more extensive studies in this direction, ideally employing a much larger RCT of a similar construction. <br />A growing body of research suggests that electro-acupuncture is an effective method of treatment from peripheral neuropathy related to varying conditions such as diabetes, alcoholism and hypothyroidism. However, the definition of “peripheral neuropathy” often included a number of neuralgias (Mayor, 2007).<br />SUMMARY OF INFORMATION<br />Please refer to Appendix A for a detailed account of the diagnostic information collected during the initial consultation. For the full case notes, please refer to Appendix B.<br />Although this patient has a wide range of accompanying symptoms, within the TCM diagnostic system these are not directly related to pain in the feet and will therefore not be discussed in detail here. However, the following information may facilitate the formulation of a viable TCM diagnosis. <br />The patient was an 84-year-old retired female whose main complaint was pain in the feet. This pain began 25 years before with no apparent cause and was described as follows: a constant and mild, but sharp pain along the line of the metatarsal-phalangeal joints of both feet, but which became accentuated by regular severe, sharp, stabbing, needle-like pain when standing or walking for a prolonged period of time. The pain was better for taking pressure off the feet; worse when standing or walking. The pain did not affect her mood or psyche in a negative way, nor did it affect her sleep or social interaction.<br />The patient’s feet appeared to be contorted; the toes were bent at approximately 30 degrees towards the midline and flexed in a superior direction at a similar angle. Palpation of the soles of the feet produced soreness and tenderness, but not at any particular points, i.e. no ashi points were located. The tendons across the soles of the feet seemed tense and hard. The feet were neither cold nor hot to the touch, nor were they swollen. The feet were slightly purple, with purple veins and spots.<br />The patient had been diagnosed with hypothyroidism and high blood pressure six years prior to the consultation, for which she was prescribed thyroxine and cardamol respectively. There was no history of any major diseases or complications in her family. The patient worked on her feet for more than 50 years, both as the owner of a small pub and in her later career as a nurse.<br /> The patient had not seen her doctor regarding the pain her feet which remains undiagnosed.<br />Her tongue was thin and dry, with a reddish-purple body covered in small red dots, and a brown coating at the rear (had drunk coffee that morning).<br />All pulse positions were rapid and choppy. Individual pulses positions are described in the table below:<br />PositionLeftRightFrontFullFull-ShortMiddleSlightly fullFull-ShortRearHiddenShort<br />AETIOLOGY AND PATHOLOGY<br />The patient was diagnosed with the following patterns in connection with the peripheral neuropathy (with supporting evidence):<br />
    • Bone Bi or Chronic Painful Obstruction Syndrome
    • Chronic pain with deformity of the affected joints
    • Sharp, severe, stabbing pain
    • Choppy pulse
    • Purple discolouration of the feet and veins of the feet
    • Purple tongue
    • Kidney Deficiency with Empty-Heat
    • Dizziness when standing
    • Lower back ache
    • Low-pitched tinnitus
    • Night-time urination
    • Difficulty falling and staying asleep
    • Malar flush
    • Weak proximal/Kidney pulses
    Figure 1 summarises the diagnosed patterns of disharmony:<br />Overwork – Physical StrainOld Age<br />Malnourishment of ChannelsKidney Deficiency<br />Invasion of Pathogenic Factors<br />Qi and Blood Stagnation<br />Bone Bi<br />Figure 1. Graphic representation of Zangfu Diagnosis<br />According to TCM theory, pain, soreness or numbness of muscles, tendons and joints may be caused by localised qi and blood stagnation due to the obstruction of the affected channel or channels by an invasion of external Wind, Cold and Dampness, or by trauma to or overuse of the channel. This condition is called "Painful Obstruction Syndrome" or “Bi Syndrome”. Joints are areas of convergence of Qi and Blood, through which Yin- and Yang-Qi meet, Exterior and Interior converge, and Qi and Blood enter and exit. Pathogenic factors converge at the joints after penetrating the channels, thereby causing obstruction and local stagnation of Qi and Blood. Any invasion by pathogenic factors is made easier if the body is in a weakened condition or if the joints are weakened by overuse, such as by standing and working on one’s feet for many years. Another important predisposing factor is an underlying deficiency of Blood or Yin. These may lead to malnourishment of the channels, making them prone to invasion by external pathogenic factors, especially in chronic Painful Obstruction Syndrome and/or in elderly patients (Maciocia, 1994).<br />Bone Bi only occurs in chronic cases and develops from any of the previous four types. Chronic obstruction of the joints by pathogenic factors causes retention of body fluids which transform into Phlegm, further obstructing the joints and channels. This extreme form of Phlegm causes deformity of the bones in the joints (Maciocia, 1994). The obstruction caused by Phlegm may lead to stasis of Blood further obstructs proper circulation, leading to a constant, severe ache and pronounced stiffness of the sinews which are no longer adequately moistened and nourished by the blood (Flaws, 1996). Liver-Blood and –Yin nourish the sinews. A deficiency of either Liver –Blood or –Yin leads to the malnourishment of the sinews and tendons which produces aches and stiffness of joints (Maciocia, 2005). The Kidneys govern the bones (Flaws, 2008). When the Kidneys are deficient the bones fail to receive nourishment and Phlegm builds up in the joints in the form of swellings (Maciocia, 1994). In addition, if there is yin deficiency of Liver and/or Kidneys, the movement of blood will become difficult and choppy or stagnant (Flaws, 2000).<br />TREATMENT<br />The patient had already been undergoing treatment for 7 weeks to help with her insomnia and night-sweats, although no attention had been paid to her feet until the aforementioned symptoms had been resolved. All of the subsequent treatments focused on the following treatment principles: <br />
    • Move the stagnation of qi and blood in the local area
    • Tonify and Move Qi and Blood
    • Clear Phlegm from the Lungs
    Please see Appendix C for detailed notes of each individual treatment and the points used. For the treatment of the pain, the initial 5 sessions employed electro-acupuncture to Bafeng of both feet, the electrodes being connected to the most medial and distal points. Sessions 12-15 involved electro-acupuncture to Dadu SP-2 and Zutonggu BL-66. The EA device was set to an alternating current strength of 2/100Hz for 30 minutes on the dense-disperse frequency setting. Bafeng was initially selected due to close proximity of these points to the area of pain. However, these were later substituted for Dadu SP-2 and Zutongu BL-66 after the patient described the pain has being becoming concentrated deep within the joints. The application of electroacupuncture to these aforementioned points was intended to distribute the current through the joints, rather than across the superior surface of the foot as may have occurred with the stimulation of Bafeng. A dense-disperse, or alternating, current strength-frequency setting was employed as this program facilitates the simultaneous release of both endogenous enkephalin and dynorphin opioid peptides (Han, 2004). Low frequency stimulation at 2Hz produces only enkephalin while high frequency stimulation at 100Hz produces only dynorphin (Han, 2003). Therefore, the use of either one of these settings utilizes only half of the endogenous opioid peptide production potential. The simultaneous, non-alternating (i.e. constant) frequency using two separate electrodes employing stimulation at 2Hz and 100Hz does produce both opioid peptides, but only activates the κ-, and not the μ- and δ-opioid receptors. However, alternating 2Hz and 100Hz frequencies on a dense-disperse setting stimulates the release of both enkephalin and dynorphin while activating μ-, δ-, and κ-opioid receptors, making full synergistic use of this endogenous analgesic system (Han, 2004). This view is not universally held, as many acupuncturists consider regular-consistent (Bensky, 1981) or burst frequencies (Han, 2003) set to a low frequency of 1-10Hz (Mayor, 2007) to be the most effective for the treatment of pain. The duration of treatment was set at 30 minutes as this has been shown to be the effective period of time at which the skin pain threshold of the patient begins to decrease exponentially, indicating the activation of endogenous pain reducing mechanisms (Han, 2004).<br />At the beginning of each session the patient was asked to describe the intensity of the pain during the previous week using a numerical rating scale (NRS). This scale began at “0”, which equated to “no pain”, and ended at “10”, meaning “no change”. The NRS was used as it was more sensitive to changes in pain intensity than verbal rating scales (VRS) as does not involve the same degree of assumption or possible misinterpretation of the definition of certain descriptive words used in VRS, while providing results that are easier to evaluate than those obtained from a visual analogue scale (VAS) due to inclusion of the demarcated numeral values instead of the unmarked gradient common to VAS. NRS was also easier to administer, was less time consuming, and involved higher patient compliance than the short-form McGill pain questionnaire, which was rejected when presented to the patient on the grounds of being “too much effort”. The short-form McGill pain questionnaire would have been the preferred option, however, as it includes a greater number of response categories. The Roland and Morris Disability Questionnaire and the West Haven-Yale Multidimensional Pain Inventory were not considered as the patient was not disabled by the condition nor did she confess to be under any psychological stress as a result of her condition. <br />A ten session treatment duration was agreed upon by both the practitioner and patient, with the following outcomes being mentioned as useful indicators of the success of the treatment after this period: the successful outcome of treatment was defined as the complete cessation of pain in both feet; a substantially beneficial outcome was defined as an improvement of 70-99%; a moderately beneficial result was defined as a 50-69% improvement; a less than moderately beneficial result was defined as 30-49% improvement; an slightly beneficial result was defined as 1-29%; no result meant there was no reported change in symptoms.<br />DISCUSSION<br />The result of this weekly investigation can be tabulated as follows and represented in figure 2:<br />Week 86/10Week 94/10Week 105/10Week 114/10Week 123/10Week 133/10Week 143/10Week 152/10<br />Figure 2. Weekly NRS values<br />By the end of the 15th treatment, the patient no longer experienced any pain in her right foot and only occasional pain in the left after prolonged standing or walking.<br />According to the predefined categories of success, the final rating of 2/10 meant that the patient’s symptoms had been reduced by approximately 66.6%. Therefore, the outcome of the treatments after 8 sessions was considered as having been moderately beneficial. <br />In hindsight, no effort was made to expel phlegm in the joints or any pathogenic factors leading to obstruction. Better results may have been obtained if these principles had been addressed. Additional information regarding the underlying causes of the PN from a western medical perspective may also have been useful for the further refinement of the settings used on the EA device, as well as prompting the possible inclusion of additional acupuncture points, thereby further increasing the potential therapeutic outcome of the treatment. <br />As a matter of self-reflection, the low priority that the treatment of the pain took in relation to the treatment of the patient’s other symptoms, especially her insomnia, which were treated with seven sessions of acupuncture before the pain was addressed, should be considered here. While this particular patient was content to treat the insomnia before progressing to, or including, treating the pain in her feet, not all patients would behave this way. Broadly speaking, excess conditions, such as local qi and blood stagnation and bi syndromes, often resolve themselves more quickly than symptoms caused by chronic deficiencies, particular yin deficiencies. In clinical practice, a therapist would benefit more by treating both the deficiency conditions and any pain symptoms simultaneously, or even initially focusing on the pain, as this would provide rapid and easily observable results that would increase the patient’s confidence in the efficacy of the treatment, thereby making them less likely to end the treatment prematurely. By doing this, the practitioner will retain clients longer and will also increase the number of possible new patients due to the relation of such positive experiences of treatment that are inevitable in such cases. <br />Conclusion<br />EA may be partially effective for the treatment of PN due to unknown aetiology. The use of alternating 2/100Hz frequency on a dense disperse setting appears to be effective in reducing the degree of pain experienced. Prioritisation of treatment principles according to the rapidity with which a significant amelioration of the condition may be achieved may increase patient retention, confidence and satisfaction. The treatment may have been more successful had the patient determined the root cause of the pain by visiting an appropriately trained healthcare professional, such as a podiatrist.<br />REFERENCES<br />BENSKY, D., O’CONNOR, J., 1981. Acupuncture. Seattle: Eastland Press.<br />BIRCH, S., BERMAN, B. M., HAMMERSCHLAG, R., 1996. Acupuncture in the treatment of pain. Journal of Alternative Complementary Medicine, 2(1), 101-124.<br />CUMMINGS, M., WHITE, A., 2009. Does acupuncture relieve pain? BMJ [online] 338 (a2760). Available from: http://www.bmj.com/cgi/content/full/338/jan27_2/a2760 [Accessed 12 April 2009].<br />DYCK, P. J., 1982. Current concepts in neurology: the causes, classification, and treatment of peripheral neuropathy. New England Journal of Medicine, 307(5), 283-86.<br />ERNST, E., PITTLER, M. H., 2008. Complementary Therapies for Neuropathic<br />and Neuralgic Pain. Clinical Journal of Pain, 24, 731-733.<br />FLAWS, B., 1996. A Handbook of TCM Patterns & Their Treatment. Seventh Edition. Boulder: Blue Poppy Press.<br />FLAWS, 2008. Statements of fact in Traditional Chinese Medicine. Third Edition. Boulder: Blue Poppy Press.<br />FLAWS, 2000. Blue Poppy Press Recent Research Report #227. Boulder: Blue Poppy Press.<br />GRETEN, J. H., LIEPERT, J., REMPPIS, A., SCRHŐDER, S., 2007. Acupuncture treatment improves nerve conduction in peripheral neuropathy. European Journal of Neurology, 14, 276–281.<br />HAN, J., 2003. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends in Neurosciences, 26, 17-22.<br />HAN, J., 2004. Acupuncture and endorphins. Neuroscience Letters, 361, 258-261.<br />MACIOCIA, G., 2005. The Foundations of Chinese Medicine. Second Edition. London: Churchill Livingstone.<br />MACIOCIA, G., 1994. The Practice of Chinese Medicine. First Edition. New York: Churchill Livingstone.<br />MAYOR, 2007. Electroacupuncture. New York: Churchill Livingstone.<br />SAGAR, S., WONG, R., 2006. Acupuncture treatment for chemotherapy-induced peripheral neuropathy--a case series. Acupuncture in Medicine, 24(2), 87.<br />SIMPSON D. M, WOLFE D. E., 1991. Neuromuscular complications of HIV infection and its treatment. AIDS, 5, 917-926.<br />