1. Traditional Chinese Acupuncture
If you want to apply traditional Chinese acupuncture, you must necessarily know that millenary worldview of the person and their environment, which is based on principles of Taoism and Confucianism: Yin and Yang, understood as opposite, complementary and interdependent energies, and the Theory of the Five Movements that classifies nature and its phenomena as belonging to water, wood, fire, earth or metal.
Under these principles, man is an entity between heaven and earth, and health is a state of harmony dependent on his surroundings and his internal world.
In acupuncture, this worldview determines:
1. the categorization and systematization of "acupuncture" points,
2. the vital energy or "Qi" (pronounced chi) and the meridians through which it circulates,
3. the causes of the disease
4. the role of internal organs
5. the diagnostic process
According to traditional Chinese medicine, pain is caused by an imbalance between Yin and Yang and this imbalance can manifest itself at the level of organs, viscera, muscle, skin, vessels, tendons and meridians.
The interrogation, observation, examination of the pulse, the tongue and the areas through which the meridians run allows examining the patient, questioning not only the person verbally but also the effects that the disease produces in them, in their emotional life and relational that generate an enriching context for the consultant and therapist that facilitates a diagnosis, and therefore, an adequate therapy.
Western acupuncture is based on the Western way of looking at the world. That is, choose from all the points used for low back pain, for example, those that are repeated the most or that have had the best results in the treatment of this ailment. It certainly requires general acupuncture knowledge, but it is far from the diagnostic and therapeutic process used in traditional Chinese medicine.
It is important to take into account the differences of these two acupuncture modalities when reading systematic reviews and meta-analyzes of results of acupuncture versus other therapies, whether Western or Eastern. When reviewing these studies, it is obvious that they are not comparable for analysis and differ in the characteristics of the patients and the treatments applied. Due to this, the concluded results have a low level of evidence.
Techniques associated with acupuncture
Along with the insertion of needles, other complementary techniques can be used that can be associated with the therapy. Among these we have:
1. Moxibustion: It consists of the application of heat directly on the needle or by means of cylinders or cones derived from the combustion of the Artemisa Vulgaris plant. It can be applied without the insertion of needles, but following the same points described for acupuncture and according to the required therapy.
2. Electro acupuncture: There is also the possibility of connecting the needles to electrical stimulation equipment, modifying the frequency and amplitude of the applied current.
3. Suction cups: It consists of the use of air suction cups on areas and points, which can be made of ceramic, glass, wood or other related materials.
4. Laser puncture: It is the stimulation of acupuncture points with laser equipment specially designed for this purpose.
3. Variants of acupuncture
Traditional acupuncture uses standard size needles, which have been described for a long time. However, during the evolution of this knowledge, some variants have appeared that, following the belief that certain areas of our body are the abbreviated representation of the cosmos, perform therapy in localized areas of the body, with smaller needles, where they are found. represented all the parts of our organism. Such as auriculotherapy, skull puncture, hand puncture and foot acupuncture.
In auriculotherapy, the pinna is represented by our body. Its therapy requires much smaller needles than traditional ones and has the same objective as traditional acupuncture. Pins or seeds are also used to stimulate the ear points.
A regular acupuncture session involves inserting needles into the body, of different lengths and thicknesses, at painful points (called Ashi points). In addition to the stimulation of these points with needles, other points are stimulated according to the pathology that the patient has. The WHO has classified 409 stimulation points, also distinguishing regional and distal points. During each session no more than 12 needles are inserted.
Obtaining the so-called “De Qi” is considered essential, which is a sensation of pain, numbness and / or heaviness at the insertion point. The needles are held for 20 to 30 minutes, and insertion, mobilization, and removal are based on the underlying pathology. All this in aseptic conditions, and with single-use and disposable material to guarantee maximum patient safety.
In general, 6 to 10 sessions are required with a frequency of one to two times a week, depending on the clinical picture, to achieve a response to treatment. Between the 3rd and 4th session, good results should already be observed. If not, the diagnosis and the points used can be reconsidered.
4. Chronic pain and acupuncture
The use of acupuncture as an auxiliary therapy for the management of chronic pain requires some necessary conditions, as premises of rigor and protocol:
1.There must be a basic diagnosis prior to the start of therapy. Thus, the patient will benefit from effective Western treatments and, above all, it will be avoided to delay the diagnosis of a potentially serious condition, such as a spinal metastasis in the lumbar spine or pain of coronary origin.
If during the course of the sessions symptoms or warning signs appear (persistent, nocturnal pain, etc.), do not hesitate to contact the doctor who referred the patient or request support from the corresponding specialist as it could be a complication.
2. The patient must continue with the pharmacological treatment indicated by his treating physician. It often consists not only of medications, but also of physical therapy, and psychological and / or psychiatric support.
3. All these therapeutic modalities should be understood as adjuvants in the healing process. In addition, in case you are with other complementary therapies and under the principle of “ primum non nocere ” (the first thing is to do no harm), it is convenient to know the reasons for that choice and to be able to make the respective suggestions according to the existing evidence and the own experience.
5. Physiological mechanisms of analgesia in acupuncture
The mere fact of inserting a needle into a muscle determines local effects, such as the release of ATP, the peptide related to the calcitonin gene (CGRP) and substance P and regional effects such as the local increase in blood flow and the release of endorphins.
Segmental inhibition effects at the medullary level are also described, which have been demonstrated in humans. This is similar to what occurs in trigger point dry needling techniques used in physical therapy. Furthermore, a non-negligible percentage of insertion points are shared by both treatment modalities.
However, evidence from studies in experimental animals and in humans shows that traditional acupuncture puncture involves complex mechanisms at different levels of the central and peripheral nervous system, which differ from those obtained with sham acupuncture. Lewith et al. demonstrated an analgesic effect in 40–50% of subjects undergoing sham acupuncture and an effectiveness of 60% in those undergoing true acupuncture.
Neurophysiological studies in animals and humans show that acupuncture increases the pain threshold by activating the endogenous analgesic system, raising the levels of certain endogenous opioids and / or neurotransmitters such as serotonin. In fact, Mayer et al. demonstrated that acupuncture analgesia was antagonized with the use of naloxone in humans, an observation already carried out in animal models. Electro-acupuncture studies indicate that low-frequency stimulation induces the release of enkephalins and beta-endorphin, while high-frequency stimulation releases dynorphins.
Other important conclusions that have been obtained from neurophysiological studies in acupuncture are the following:
-Nociceptive afferent pathways are essential for acupuncture analgesia.
-The acupuncture-induced increase in pain threshold is gradual, with a maximum effect at 20–40 minutes, followed by an exponential drop with a half-life of approximately 16 minutes, even when stimulation is maintained.
-Prolonged acupuncture stimulation over time leads to tolerance, which is mediated through the release of the octapeptide cholecystokinin at the central level.
-Immunocytochemical studies indicate that both pain and acupuncture activate the hypothalamic-pituitary-adrenocortical axis.
-Through the study of neuroimaging (PET, SPECT and functional MRI) performed on volunteers, it has been established that the hypothalamus plays a central role in the analgesia provided by this method; that there is significant overlap between the central nervous system pain and acupuncture pathways, suggesting that acupuncture stimulation could affect central pain processing; that superficial puncture and that of traditional acupuncture activate two different central pathways, yet both generate clinical analgesia.
In 1979 the WHO identified 49 diseases in which the use of acupuncture was recommended. In 1996, at a conference sponsored by the WHO ( WHO Consultation on Acupuncture , Cervia, Italy) its indications were classified according to the degree of evidence for each nosological entity.
The German Acupuncture Society recognizes indications in diseases of the locomotor system, in neurological, cardiovascular, gastrointestinal, gynecological, respiratory, skin, ophthalmological and miscellaneous diseases.
The United States Food and Drug Administration (FDA) considers its indication in pain, allergy and asthma; in the rehabilitation of strokes and drug dependence, while the National Institute of Health (NIH for its acronym in English) of the same country indicates that acupuncture can be used widely in nausea and vomiting associated with chemotherapy, dental pain, headaches (migraine, tension headache), low back pain, asthma, menstrual pain, fibromyalgia, and myofascial pain. Other reviews point to its effectiveness in cervical pain and knee osteoarthritis.
· In the case of non-cancer pain, the main indications are;
· Musculoskeletal diseases.
· Lumbar and lower extremity pain.
· Persistent postsurgical pain.
· Others: Pain associated with the temporomandibular joint, nausea and vomiting (for example, post chemotherapy or in the first trimester of pregnancy) and fatigue associated with malignancy.
7. Pregnancy and acupuncture
Pregnancy is considered a relative contraindication. There are certain points, especially in the abdomen and some distal ones, that are avoided because of the potential capacity to generate uterine contraction. Other authors point out that there are no contraindicated points, as long as an atraumatic puncture technique is used. From a practical point of view, it is recommended to make explicit to the pregnant woman, prior to obtaining informed consent, the potential adverse effects of acupuncture and to obtain authorization from the obstetrician.
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