Acupuncture Therapy in the Treatment of Chronic Head, Neck and Neck-Related Pain
The Patient's Opinion
First Published in the Journal of Traditional Chinese Medicine 5(1): 13-18, 1985
This paper reports the opinions of 174 chronic pain patients' of their outcomes following treatment with traditional Chinese acupuncture in a western setting. The patients, referred and self-referred, following assessment, were divided into four broad categories. Seventy-two complained primarily of cervical brachial syndrome (C.B.S), 46 of headache, 30 of neck pain and 26 of neck pain plus headache. The average duration of pain was 6.8 years, the average number of medical practitioners consulted prior to acupuncture was 3.8. Follow up was carried out at an average of 6 months after the last treatment.
The patients were all treated in private practice and within the limitation of a 75% response to the postal questionnaire# as being consecutive. No presenting patients were refused treatment. All were initially treated twice a week until marked response was noted, treatment was then given once a week until a stable result was reached. Follow-up was at 1 month intervals. On discharge the patients were advised to return on a p.r.n. basis. The needles, usually between 6 and 10, were inserted by the quick method and stimulated to obtain the correct sensations. Tonification or sedation methods were used according to the dictates of traditional Chinese medicine. Moxa was frequently used. In general the near and far method was preferred with needles retained for 20 to 25 mins and restimulated as required.
# Patients were asked to self assess across a range of questions designed to delineate their response across several variables, including:
Amount of pain relief -verbal scale -More Pain, less pain, greatly less pain, no pain.
Frequency of pain and range of movement were similarly assessed.
Sleep and medication changes were also questioned.
Cervical Brachial Syndrome
No. of patients 72; average no. of treatment 7.4; acupuncture benefit Yes 87%
Frequency of pain: Less 18%; none/very much less 70%
Severity of pain: Less 10%; none/very much less 77%
Effective rate: (18%+70%)+(10%+77%) divided by 2 = 87.5%
Limitation of movement: Improved 26%; fully greatly improved 71%
Medication: Decreased 43%; none/greatly decreased 46%
Sleep: Improved 64%; returned to normal 19%
28 cases with secondary complaints of headaches:
Frequency: Less 39%; none/very much less 60%
Severity of Pain: Less 39%; none/very much less 60%
Effective rate: 39%+60% (90%)
Medication: Decreased 35%; none/greatly decreased 64%
Pain duration: Helped group 7.5 years; greatly helped 4.3 years.
Greatly helped less than 5 sessions of treatment, 5.4 years
Of the 3 patients (4%) whose pain worsened, one was a woman of 42 years with bilateral cervical brachial syndrome. She was on high doses of medication and would not discontinue jogging. Another was a 45-year-old man with discogenic pain. He had been referred by a neurologist and was later referred to a neurosurgeon. The third was a patient who remains undiagnosed; a diagnosis of polymyositis is unconfirmed. Of the five patients who did not respond, one was 70 years old and gross C5, C6 degenerative changed with pain for 10 years. Another patients who did not respond had suffered from C.B.S. for 5 years and was given 6 sessions of treatment, Another had C.B.S. secondary to trauma superimposed on chronic severe degenerative changes. This patient had 7 sessions of treatment and was helped only while the treatment was in progress. Another with anxiety plus pain was given one treatment without success. Another failed case, though with no apparent cause, had cervical brachial syndrome of 6 years duration.
The acupuncture treatment of chronic cervical brachial syndrome seems to be quite straightforward. If myelopathy of neuropathy is extreme, the condition becomes more protracted and the first few sessions of treatment must be preformed cautiously to avoid acute exacerbation of pain. revrsal of the muscle changes is not seen. The common cervical brachial syndrome encountered is of the C5, C6, distribution type with deep widespread ache as far as the forearm, frequently associated with parasthenia of the hand.
The common trigger points found in this syndrome are at Small Intestine 11 in the belly of Infraspinatus and Gallbladder 21 in Trapezius. The scalenous trigger point gives a very characteristic pain pattern and is easily distinguishable. The distal points used were Large Intestine 11, Large Intestine 10 if the pain was severe at the time of treatment, Large Intestine 4 plus neuromodulator points such as Heart 7 and Pericardium 6 when anxiety is exacerbating. Moxa can be used, especially if the discomfort is worsened by atmospheric pressure changes or with wet weather or cold.
No. of patients 46. Myogenic 29, vascular/migraine (with aura) 14, mixed 3.
Average no. of treatment 7.8; acupuncture benefit yes 91%.
Frequency of Pain: Less 24%; none/much less frequent 67%.
Severity of Pain: Less 20%; none/very much less 59%
Medication: Less 16%; none/much less 67%
Sleep: Improved 55%; back to normal 35%
Pain duration. Helped group, 7 years duration; greatly-helped, 6 years duration; not helped, 13 yrs. Greatly helped by less than 5 sessions of treatment, 5 years duration; cases greatly helped by more than 5 sessions of treatment, 8.2 years duration.
Of the 5 none-responses to treatment, one had a 30-year history of migraine, which was treated by 7 sessions. Another had myogenic headaches associated with anxiety for 1 year. The cause of the anxiety was not removed. Another with anxiety related to headaches did not respond to 6 sessions of treatment. One had headaches associated with an obsessive compulsive personality disorder for 24 years, while another had mixed headaches for 20 years and was on high doses of opiates.
Vascular headache usually involved multifactorial treatment. Biofeedback and relaxation training are of use. The distal acupuncture points which produce inhibition of the cervical sympathetic outflows are useful.
The common trigger points found in myogenic headaches are at Gallbladder 21- which frequently is associated with postoccipital pain radiating to the parietal and frontal regions, with some reference to the eye. This is a the most common type of headache. The trigger points in splenus capitus is often found in association with vertex headache. Trigger Points in rhomboideus major, frequently produces pain at the postoccipital region when needled and is frequently produces pain at the postoccipital region when needled and is frequently associated with postoccipital headaches. LI 16 at the acromio-clavicular joint also produces postoccipital pain. The trigger points at Large Intestine 18 in sternomostoid can usually be diagnosed from the history, as it produces a very characteristic pain pattern involving the ear, jaw and frontal region plus varied autonomic phenomena including (rarely) one sided nasal discharge, dizzyness and watery eye ipsilaterally. Stomach 7 and the extra meridian point 3 -Taiyang also have characteristic pain patterns.
No. of patients 30; average No. of treatments 6.5; acupuncture benefit Yes 86%
Frequency of pain: Less 23%; none/greatly less 63%
Severity of pain: Less 30% none/very much less 56%
Limitation of movement: Full range 35%; greatly increased 31%; improved 18%; same 13%
Sleep: Returned to normal 32%; improved 47%; same 21%
Greatly helped by less than 5 sessions of treatment, 2.2 years duration
Greatly helped by more than 5 sessions of treatment, 4 years duration.
Of the 4 patients (13%) who were not helped, one was a veteran who had 9 months of neck pain associated with job tension. He was not enjoying his surgery and when he started selling high-rise units he felt greatly improved. Another patient was a female who had 6 years of pain. Her X-rays showed her to have gross degenerative changes, but she would not disist from heavy gardening and had two falls while under treatment. The third patient with 30 years of neck pain associated with anxiety was treated once without response. Another with two years of neck pain was treated by 4 sessions without success but with no apparent cause of failure.
For the Treatment of Chronic Neck Pain
Chronic neck pain can usually be relieved by treating local muscle spasm, ablating trigger points such as Gallbladder 21 and LI 18 and direct needling of involved facet joints, usually found by tenderness. The distal points usually depend on the distribution of pain and mostly involve LI 4, Lung 7 and LI 11 plus other points. For the 26 patients with neck pain and associated headaches, 88% stated acupuncture was beneficial. The effective rate for decrease in frequency and severity of pain was 84% following an average of 8 sessions of treatment, with 62% being very greatly helped and 12% unchanged, while none worsened. 27% reported increased range of movement and 34% greatly improved. The associated headache effective rate was 80%, with 45% being greatly helped. The same frequency of pain occurred in 11% and 28% unchanged. The average age of the greatly helped was 44, the helped group 49; average duration of pain for the greatly helped group was 9 years and the helped group 14 years. The 3 failures to treatment included one with 20 years of migraine, unresolved home conflict and frequent doses of opiates. Another had hypoglycemic headaches which were not responsive to acupuncture but responded to chromium and dietary manipulation. The third had mygoneic neck pain and associated headache. There was no known cause for failure. The treatment of neck pain and associated headaches has already been covered.
The material for this paper, as mentioned, was derived from a multiphasic health questionnaire to which a 75% response was obtained, excluding bad debtors and those with change of address. They can therefore be seen as consecutive patient series within those limitations. The average follow-up was 6 months.
In this paper the results of 174 chronic head, neck and neck-related pain patients have been presents in detail. The average pain duration for the entire group was 6.5 years. The average number of medical practitioners consulted prior to acupuncture was 4. For the majority of patients spontaneous remission was unlikely. Most could be regarded as end-of-the-line patients, having failed to respond to conventional therapies, including anti-inflammatories, drugs, manipulatons, physiotherapy and chiropractice. Double blind method was inappropriate for the following reasons:
Treatment was carried out in private practice.
There is great difficulty in designing an acupuncture double blind trial. Perhaps when laminectomies and nerve blocks have been subjected to double blind evaluation the same methodology could be used.
The duration of pain and the status of these patients would make doubles blind perhaps unnecessary and possibly immoral.
As the follow-up was over a 6 month period, placebo effects could be discounted. For the above reasons patients were used as their own controls.
Acupuncture was taught by the Nanjing School of Traditional Chinese Medicine was utilized. The near and far method, that is ahshi or trigger points or local points coupled with distal points, was most frequently used. This method offers several advantages for work with chronic pain states, it is rarely used. The local points, frequently trigger points, are needled to bring about complex changed as evidenced by (1) immediate muscle relaxation (2) elevation of skin temperature within the dermatome (3) relief of pain. The advantage of the near and far method is the decrease in the number of patients having acute exacerbations following the treatment, the absence of "hyperreactors" and the apparent stability of the result. Electrical stimulation and osteopuncture were not used. Moxa was frequently used to apply heat to the local needles, bringing about C fiber attenuation within the segment.
It is remarkable that acupuncture has an effective rate of 85.6%, with a greatly helped rate of 64% for patients with an average pain duration of 6.8 years. That the results were obtained with an average of 7.7 sessions of treatment shows the effectiveness of the procedure.
Upon analysis of the results, it seems obvious that with earlier presentation a better result can be expected with improvement in the greatly helped and helped ratios and less treatment being required.
This conclusion can be drawn from analysis of the greatly helped and helped groups.
C.B.S.: Greatly helped by less than 5 sessions of treatment; pain duration 2.2 years
Greatly helped by more than 5 sessions of treatment; pain duration 5.4 years
Neck: Greatly helped by less than 5 sessions of treatment; pain duration 2.2 years
Greatly helped by more than 5 sessions of treatment; pain duration 4 years
C.B.S.: Helped group, 7.5 years; greatly helped, 4.3 years.
Headaches: Helped group, 7.3 years; greatly helped, 6 years; not helped, 13,6 years
As mentioned, acupuncture does have other effects apart from relief of pain as evidenced by the 67% with their sleep improved, the 29% who regained normal sleep and the 81% in the C.B.S. group, the 61% in the neck pain and headache group and the 85% in the neck pain group who improved their range of movement. (Recovery of sleep and range of movement in this group usaually occurs before pain diminishes.)
From the above it becomes obvious that acupuncture provides an extremely low-cost, efficient method of dealing with chronic head, neck, and neck-related pain.
As the number of skilled medical acupuncturists increases and the public becomes more aware of their role, it can be anticipated that more patients will present earlier in time with a consequent lowering of the failure rate and improvement in the greatly helped:helped ratios. The widespread use of acupuncture could lead to a dramatic lowering of our health cost. To support this conclusion I have worked out some figures. This is not an attack on Western medicine. The figures I am going to use are based on the response of a population surveyed by the questionnaire. I have averages the cost of 100 patients with acupuncture 100 x $9.05 x 7.8 = $6,300. (The rebate for Acupuncture item 980 at the time this work was carried out = $9.05. With analgesics and anti-inflammatory management the cost is around $22,000 per annum.
Now the group reported on had a pain duration of 6.8 years and so the total cost of drugs and consultations = $149,000 per 100 patients per 6.8 years.
The $149,000 does not include the costs of physiotherapy, chiropractice, surgery and drug related side effects.
The savings made by the community can be calculated by subtracting $6,300 from $149,00 = $142,700 x greatly helped rate of 64%, or approximately $99,000 plus the reduction of medical costs for the 21% who were helped.
In the American Journal Of Acupuncture, Vol. 9. No. 1, March 1981, I presented the results of trial I carried out on chronic pain patients in Auckland at Gerald Gibb's Pain Clinic. The same method and same frequency of treatment were used. The same practitioner, myself, applied the treatments. The patient population was remarkably similar as to pain duration and pathology. When we compare the results of the New Zealand trials to the trials I have just presented, a very interesting thing can be noted. For example, the C.B.S. in New Zealand had the effective rate of 84.5%. The C.B.S. in Australia shows an effective rate of 87%.
The point of interest follows. The greatly helped group in New Zealand was 55%, in Australia 73.5%. Of the headache group in New Zealand the effective rate was 75%, in Australia it was 85%. The greatly helped group in New Zealand was 40%, in Australia 63%. For back pain in New Zealand the effective rate was 73% and that for back pain in Australia it was 87%. The trend of the effective rate and greatly helped groups being higher in Australia is apparent in all the listed conditions. I don't think that this means that New Zealanders are unresponsive. I also don't think that I am a much better acupuncturist now than I was then. The only real variable is the timing of the follow-up. In the New Zealand trials the reassessment was made at 2 months on average; in the Australian trials it was 6 months. From this I would like to refute the frequently made allegation that acupuncture only works as long as it is being used. It would seem that the opposite is true. It is evident that the benefits of acupuncture accrue over a period of time after the treatment has been used.