Does acupuncture rewire the brain?

What an absolutely amazing blog post by an acupuncture researcher, Vitaly Napadow. In it, he talks about some recent research, published in the journal Brain, he participated in. What is remarkable is it seems to answer two really big questions.

The first question is “does acupuncture really do anything centrally?” Over the years there has been a lot of research that has associated various point functions with stimulation of certain areas of the brain associated with that function using functional MRI. For example, some of this early research showed that points on the foot that are supposed to help the eyes actually stimulated visual areas in the occipital region of the brain. Wow! Same thing with points to help the ears and hearing. The only problem is this research was later retracted. And while there does seem to be this connection with other points, it has never been as clear cut.

Enter Maeda and the research team. They found that patients using “real” (verum) acupuncture locally and distally (on the leg), showed changes in the somatosensory areas of the cortex in the brain. And these were connected to improvements in median nerve function.

The second question revolves around the difference between sham and verum acupuncture. While there are many forms of sham acupuncture, they generally involve using needles in slightly different locations and/or depths than the real acupuncture. And there have been lots and lots of recent studies that show sham and verum acupuncture are better for various conditions than other interventions. But there has not been a big difference between the two.

Generally, I believe there hasn’t been a difference because sham really isn’t sham. If one uses the same point but at a shallower depth, this is very similar to Japanese style acupuncture, and therefore not sham. Researchers have used this similarity of results between sham and verum acupuncture to imply that acupuncture’s strength lies in its placebo effect.

Once again, enter the research team. What they found was that sham and verum acupuncture did have similar effects right after treatment. However, sham acupuncture did not cause changes in the somatosensory cortex, nor did it show long term benefit. Verum acupuncture did both.

So, this research showed two things: acupuncture affects the brain and can actually rewire it and verum acupuncture is different and better than sham acupuncture. These are really amazing results. And this was a good study: it was randomly controlled, involved 80 patients, and was well constructed. Of course more research is always needed…

Does acupuncture affect stem cells?

Picture By Robert M. Hunt [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons
very interesting study in the journal Stem Cells looked at the affect of acupuncture to mobilize mesenchymal stem cells. In both humans and rats it showed increased mobilization of these cells when the acupuncture points Large Intestine 4 and 11 on the arm, and Du 14, on the spine, and 20, on the top of the head, were needled. It also showed increased functional connectivity between the hypothalamus, the master controller of hormones, and the amygdala, the emotional part of the brain. It found reduced pain and increased tendon remodeling in the rats undergoing partial rupture of the Achilles tendon. This again shows central nervous system involvement in the affects of acupuncture, but adds the novel idea of stem cell involvement.

Low Back Pain

I have suffered from low back pain most of my life. I was diagnosed at age 18 with several healed compression fractures. My first experience with acupuncture was when I was in a car accident at age 22. It was the only thing that helped the pain (medication and physical therapy didn’t). To round off my litany of back pain, in my last year of medical school, I developed a fast-growing spinal cord tumor, a schwannoma, and by graduation, I couldn’t sleep and had trouble walking. And no, I am not going to say acupuncture solved that; major surgery did. Though regular acupuncture and herbs helped me recover.

I understand the unique nature of low back pain…a little too intimately.

The opioid epidemic has been in the news a lot lately. And low back pain in the most common form of chronic pain. This is not a good combination. Many studies are under way right now to determine if acupuncture is an appropriate alternative to opioids, especially in cases of chronic low back pain. While the results of these trials may be a few years away, there is plenty of evidence to show how effective acupuncture can be in treating low back pain.

This evidence shows efficacy in treating low back sprain/strain, lumbar facet syndrome, lumbar disc herniation, unspecified low back pain/myofascial pain, sciatic neuralgia, spondylolisthesis, low back pain in pregnancy, and sacroiliac sprain/strain among other conditions.

clinical practice guideline from the American College of Physicians and the American Pain Society states “For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain” including acupuncture. The same societies in a systematic review, state “We found fair evidence that acupuncture… [is] also effective for chronic low back pain.

A relatively large (638 patients) 2009 randomized trial concludes “acupuncture was found effective for chronic low back pain.”

Cochrane review, often considered to be of high evidence, states “For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment” and “The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain.”

While there are skeptics of the use of acupuncture in low back pain, they generally fall into two categories. One category of skeptics is against acupuncture in general and ignores and attacks any positive research. The other category disregards most studies because “sham” acupuncture shows similar results to verum or true acupuncture. As I have summarized in other articles (and will eventually write a specific article) “sham” acupuncture is usually not sham and is a form of true acupuncture. The bottom line is there is a ton of evidence supporting the use of acupuncture in low back pain.

Of special note: I use a technique particularly useful for herniated disks and I have seen lots of clinical efficacy using it. If you suffer from a herniated disk, and you are being told surgery is your only option, why not try acupuncture first?

Here is some additional research supporting the use of acupuncture in low back pain:
Acupuncture for back pain: a meta-analysis of randomized controlled trials.
Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up.
Acupuncture for chronic low back pain in older patients: a randomized, controlled trial.
Does acupuncture improve the orthopedic management of chronic low back pain–a randomized, blinded, controlled trial with 3 months follow up.
Efficacy of electroacupuncture and TENS in the rehabilitation of chronic low back pain patients.
The use of electro-acupuncture in conjunction with exercise for the treatment of chronic low-backpain.
Acupuncture relieves pelvic and low-back pain in late pregnancy.
Acupuncture for low back pain in pregnancy–a prospective, quasi-randomised, controlled study.

Neck Pain

Neck pain, known technically as cervicalgia, is very common and can cause lots of other conditions such as headaches. Evidence shows that acupuncture can help many neck conditions including cervical strain and whiplash, cervical radiculopathy, cervical stenosis and spondlyosis, herniated cervical disc, torticolis, and unspecified neck pain. Here is some research that supports the use of acupuncture in neck conditions:

Effect of acupuncture treatment on chronic neck and shoulder pain in sedentary female workers: a 6-month and 3-year follow-up study.

Randomised trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain.

Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham- controlled crossover trial. 

The acupuncture treatment of neck pain: a randomized controlled study.

Chronic neck pain: a comparison of acupuncture treatment and physiotherapy.

[Randomized trial of acupuncture compared with conventional massage and “sham” laser acupuncture for treatment of chronic neck pain – range of motion analysis]. [While the abstract is in English, the full article is in German]

Relief of chronic neck and shoulder pain by manual acupuncture to tender points–a sham-controlled randomized trial.

Vertigo and Dizziness

Circular Stairway

Vertigo, which includes dizziness and nausea, is very disconcerting and can prevent many normal activities. Acupuncture can help many causes. Acupuncturists are trained to assess patients and refer them to doctors and specialists as needed. In other words, we may be an excellent stop in treating vertigo before more invasive techniques are used.

Vertigo can have many causes including benign paroxysmal positional vertigo (BPPV, the most common cause), Meniere’s disease, vestibular neuritis or labyrinthitis, stroke, tumor, migraines, reduced blood flow to a certain areas of the brain (vertebrobasilar ischemia), head or neck injury. Acupuncture may be able to help many of these conditions, though some better than others. Here are some studies that support this:

Modulation of cerebellar activities by acupuncture stimulation: evidence from fMRI study
Penetrating needling on head points for vertigo caused by vertebral-basilar arterial blood-supply insufficiency
Efficacy and safety of acupuncture for dizziness and vertigo in emergency department: a pilot cohort study
Fifty Cases of Vertebrobasilar Ischemic Vertigo Treated by Acupuncture

Tension Headaches

Headache

Tension headaches, also known as stress headaches, occur in up to 80% of the population at some point. Causes can vary from stress, poor rest, bad posture, anxiety, and even low iron levels. Unlike migraine headaches there are no neurological symptoms such as muscle weakness or vision issues. They generally do not cause nausea and vomiting. Occasional tension headaches affect the vast majority of people and are usually treated with rest or over-the-counter medications such as acetaminophen, ibuprofen, aspirin, and others. Acupuncture can help reduce stress and minimize the occurrence of occasional tension headaches.

Chronic tension headaches are a different matter. First, not all chronic headaches are tension headaches and more serious conditions such as fractures, hypertension (high blood pressure), bleeding in the brain, and other conditions should be ruled out. Any severe headache that comes on suddenly, should be assessed immediately by a medical professional.

So the big question here is: does acupuncture help chronic tension headaches? Lots of studies have looked at this. Most are not well constructed. A recent meta-study (a study that analyzes the results from other studies) shows the evidence supports the effectiveness of acupuncture treating tension headaches. However, the studies were of low to moderate quality and more studies are necessary. For those that don’t read research frequently, this last part is very common; there are few studies that do not end with the phrase “more studies are necessary.”

Current research provides evidence that acupuncture can help tension headaches. That evidence is not extensive, but it is moderately strong.

Acupuncture may reduce coronary heart disease in fibromyalgia patients

A very interesting Taiwanese study was just published. It is a large retrospective, epidemiological study looking at the incidence of coronary heart disease (CHD) in fibromyalgia patients. Using sophisticated statistics, they looked at paired patients who had fibromyalgia; approximately 58,000 who had had acupuncture and 58,000 who did not. What they found was the incidence of CHD was much lower in those having had acupuncture, approximately 43% lower. This is a significant population based study. Now other studies need to show why there is this effect and if acupuncture can help reduce CHD in those who have no or other conditions.

Fibromyalgia

Fibromyalgia

This one is close to my heart. I have a very close family member who suffers from fibromyalgia. And I see the pain and struggle she goes through every day. We have tried a lot of different things. She has gone gluten free, which has helped a lot (though I don’t think this is for everyone) [she has, since this was published, started eating gluten again without consequences]. Her primary therapy is attempting to keep stress at bay through various means including exercise, hobbies, and relaxing. In addition, she tries to stay away from drama and stressful situations and benefited from healthy eating, cognitive therapy (often, a primary recommendation of treatment guidelines) and tries to honor her symptoms: she rests when she needs to.

When she allows me to perform acupuncture, it does help the pain quite a bit…but there are many times when she just doesn’t want to be touched in any way. The one thing she doesn’t want to do, for various legitimate reasons including chemical sensitivities, is herbs. And, of course, that is the thing I have seen which produces the best results long term. I have treated many fibro patients…they have all gotten better but to various degrees. Some have no pain so long as they get regular herbs and acupuncture. Some feel better for a short while after treatment while herbs reduces the number of exacerbations. In other words, I have seen Chinese medicine do wonders for fibromyalgia. It does take a little while to dial in the right treatment for each individual patient, like needing to use very thin needles and a light touch in my loved one. But once dialed in, it can be help substantially. But as is all conditions, individuals respond differently to acupuncture and herbs and differently to various other interventions.

There has been a lot of research on fibromyalgia and Chinese medicine, primarily because Western medicine’s approach is to use heavy pharmaceuticals: effective, but with lots of side effects.

Here is a great, recent randomized controlled trial (RCT). It was a little small (50 patients), but was statistically significant and followed the patients for 7 months after treatment. They concluded, “We found that acupuncture significantly improved symptoms of fibromyalgia,” including pain, fatigue, and anxiety.

Here is a similar RCT comparing real versus sham acupuncture. They concluded, “real acupuncture treatment seems to be effective in treatment of” fibromyalgia.

Here is a systematic review of using Chinese medicine for fibromyalgia. It concludes Chinese medicine “therapies appear to be effective for treating” fibromyalgia. However, this was published in a relatively less recognized journal than others.

A Cochrane Library review (considered by many to be the gold standard of reviews) concludes “there is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia.” It does go on to discuss real versus sham acupuncture, which is a real issue and a big debate happening in acupuncture research.

And to be completely fair, here are two reviews that are negative on acupuncture and fibromyalgia. Both were in the well-regarded journal, Rheumatology, one was published in 2007 and the other in 2010. Both emphasize the sham versus real acupuncture debate. In a quick summary, some researchers believe sham acupuncture is a great control for these studies, while others, myself included, believe that sham acupuncture protocols are not actually sham and therefore make poor controls.

Check out my short article on how acupuncture may reduce coronary heart disease in fibromyalgia patients.

Update:

My loved one, after a longer than usual bout of pain and after talking with one of my mentors, decided to try herbs. The results were immediate and dramatic: her pain almost disappeared. Overnight. She has had some pain since starting the herbs, but it has been a lot less intense and for much, much shorter periods of time (and almost always during periods of stress). In other words, the herbs have been almost as successful as possible. And it continues…she found the herbs were not working quite as well, but a little tweak to them, restored their full effectiveness. She has been going really, really strong for about 6 months as I am writing this.

Disk Herniations

 

Spinal disk herniation

I was first introduced (probably in 2005 or so) to a very different acupuncture technique: Pachi Pachi. I was introduced to it by my classmate, Dr. Don Snow, but it was originally written about and taught by Kiiko Matsumoto.

Pachi Pachi and Disk Herniations

In disk herniations (also known as a slipped disk), I will apply three needles at the vertebrae affected by the herniation, on either side of the spine and one central. I will do the same either at the level below or both the levels above and below. I will then spark the central needle every five minutes four times. A few body points, that change on the location of the herniation, round out the treatment.

Currently, I am using it on two patients. One has had a disk herniation in the low back. She has had debilitating pain affecting most of her activities for about a year. After 5 visits, she was completely pain free. We are currently extending out the visits to make sure the pain is truly gone.

My second patient, I have only seen twice as I am writing this. She was in a car accident and was diagnosed with a disk herniation in the lower neck. She has had severe headaches since the accident and her medical doctor wanted to do cortisone injections to help the pain. She was uncomfortable with that prospect and sought out acupuncture. After her first visit she had one headache (a great improvement in frequency) and it went away quickly (again, much better than before). She said she is very happy with the treatment and knows she chose the right path. I am really happy with her progress and expect her to be completely pain free in a few more visits.

What is Pachi Pachi?

It involves three things: acupuncture needles, triple bypass cords, and a pachi pachi sparker. There are variations of this that may eliminate either the cords or needles. Basically the sparker uses similar electrical aspects as TENS (transcutaneous electroneuro stimulation) or PENS (percutaneous electroneuro stimulation), but has higher voltage and is used intermittently rather than continuously for a set period of time. Basically, my protocol involves inserting at least three needles, applying the triple bypass cords, and sparking the middle needle every five minutes four times. Patients have described the sensation as “surprising” but not painful.

Triple bypass cords are specially made cords, from what I am told, that include a diode. What this does is allow for electricity to flow in a very specific direction around its three clips. This sets up a unidirectional circulation of electricity.

Does Pachi Pachi work?

I have tried to find research on this technique for over a decade. Without luck. It is a very niche acupuncture technique and I have had no luck in finding any literature on it. But I have been using it for all that time and have seen amazing results. I first started using it because it was almost miraculous on a patient with a lower back disk herniation. I was working with Dr. Don Snow and he applied the technique and this patient with debilitating back pain was uttterly pain free in four visits. Disk herniations are just not that easy to work with using any technique including acupuncture, surgery, or cortisone injections. That patient never came back. I have now used Pachi Pachi scores of times in disk herniations and other troubling situations and have seen this “miracle” in most of them. Not all of them. I do believe, and research on acupuncture supports this belief, that about 10% of the population does not respond to acupuncture. But way more often than not, my patients become pain free.

How does Pachi Pachi Work?

As I said earlier, there is no research on this technique, so there are no definitive answers to this question. I have thought about it a lot and have a theory as to it effectiveness. But first, here is a discussion of it.

I was revisiting Australia many years after I graduated medical school there. I was sitting around having beers (a very common occasion in Australia) with a couple of old classmates. One was on his way to becoming a maxillofacial surgeon, the other was almost finished with his orthopedic surgical training. I told them about this technique and asked their opinion on what could be the mechanism of action. In other words, how does it work? We thought about several possible mechanisms. The ortho surgeon thought that it ablats (destroys) the local nerves and therefore eliminates pain. I did not think this was the case because there would be local numbness and longer term side effects, neither of which I had seen in my patients. My other friend offered a few thoughts but nothing coherent.

I think what it does is electrochemically shuts down the inflammatory process. Without inflammation, pain will go away. It may also allow for some level of healing of the herniation. The flaw in this theory is that minor injuries to the area (even a “wrong” stretch) would reactivate the inflammation. And I just do not see patients coming back for treatment of their herniation very often. The support in this position is that I have used in many other conditions where there is inflammation and it works almost as well as with disk herniations.

The downside to this technique is that for many conditions (not usually disk herniations), it can be quite uncomfortable. I am currently effectively using it on a patient with carpal tunnel syndrome, but it is quite jarring. She endures it because she lost feeling in part of her hand years ago and this is the only thing bringing it back.

Bottom line is we do not know how it works. My experience clearly shows that it does work and it is very odd for me to employ something that I do not fully understand. But the results speak for themselves…

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