Acupuncture and Physical Disability
Acupuncture, a key element of Traditional Chinese Medicine, has become a widely popular alternative medicine with the American public in recent years. This treatment has considerable potential for treating problems associated with physical disability, including spinal cord injury (SCI) and multiple sclerosis. Acupuncture's potential includes the intriguing possibility of restored function. History Although acupuncture has a 5,000-year tradition, the transition to the west has been slow. Sixteenth century Jesuit missionaries first reported the procedure. Troops from far-east military invasions brought the procedure back to France in the 1800s. In 1825, Benjamin Franklin's great-grandson translated French work on acupuncture. However, after a flurry of interest, acupuncture receded into oblivion in the United States until President Nixon went to China in the early 1970s. Soon after Nixon's visit, the American Medical Association (AMA) pressured the Food and Drug Administration (FDA) to ban acupuncture needles unless used in an investigation. In turn, the ban provided the justification to deny health-insurance coverage. Nevertheless, acupuncture's popularity grew. In spite of technically violating federal law, many states authorized its use, and schools and accrediting organizations were established. In 1996, after a million Americans used the procedure every year, FDA finally reclassified acupuncture needles, and insurance began to covered the treatment. Last year, a prestigious National Institutes of Health (NIH) Consensus Conference endorsed specific acupuncture applications. Treatment and Diagnosis: Acupuncture-related therapies consist of stimulating specific points on the skin by inserting needles or applying heat, pressure, or massage. Acupuncture usually is combined with a variety of other Eastern therapies, such as herbal treatments, food and nutrition therapy, exercise, and meditation. The thin, usually disposable, needles rarely draw blood, and any discomfort is mild. The World Health Organization (WHO) has listed over 100 disorders that may be amenable to acupuncture treatment, including respiratory, eye, mouth gastrointestinal, neurological, orthopedic, bronchopulmonary, reproductive, hypertension, insomnia, skin, arthritic, allergic, and addictive disorders. It is rarely used to treat infectious disease. Acupuncture seems to work better at early stages before impaired body function progresses into organic or tissue damage. It is often a preventive measure to preserve good health. Adverse reactions are rare, especially compared to drugs or other medical treatments. Acupuncture emphasizes diagnosis. The Western name for a disorder (for example, asthma) has little diagnostic relevance. Two patients with the identical disorder may receive very different treatments according to their specific energy imbalances. Diagnostic methods include patient observation, history taking, and touch. Examining the tongue and feeling the pulse are especially important. Evaluating the pulse is much more involved than in Western medicine. A yin and yang pulse is at three locations on each wrist, measured by deep and light-touch pressure. Each of these 12 different pulses corresponds to a specific organ. When the pulse of both wrists are taken simultaneously, the relative differences indicate the body's energy balance with respect to specific organs. Although both medical doctors (MDs) and non-MDs can practice acupuncture, non-physician practitioners usually have had much more extensive training. Physicians can pefrorm acupuncture after 200 hours of training; non-MDs must train over three years in an accredited school of oriental medicine. Dr. Claire Cassidy, of the Traditional Acupuncture Institute in Columbia, Md., recently surveyed approximately 600 Chinese-medicine patients from six U.S. clinics. According to her study's data, acupuncture appears to be doing something right compared to Western medicine. This survey indicated that 87% of the people who used acupuncture and oriental medicine were very satisfied with their care, 91% with their practitioner, 70% were happy with the cost, and 91% report that their presenting problem has improved. In comparison, only 30 % were satisfied with conventional biomedical care, 43% satisfied with their physician, and 26% satisfied with the price. Eastern Origins: With origins in Taoist philosophy, acupuncture evolved from observing that a disorder was associated with an increased sensitivity in specific areas of skin. These were consistently linked to a specific organ and followed a defined topographical pattern. These patterns or meridians serve as pathways for life-force energy called qi (pronounced chee). The body is endowed at birth with a fixed amount of qi which is then depleted through activities of daily living and supplemented by energy obtained from food or air. Energy imbalance, whether excessive or lacking, is the cause of all illness; the absence of qi is death. qi circulates throughout the body in a well-defined cycle, moving from meridian to meridian and from organ to organ. Qi is characterized by the dynamic interaction of two antagonistic, yet complimentary energy forces called yin and yang, each of which includes a portion of the other (see figure). Yin, the feminine, is associated with cold, dark, passive, and that which is deep or hidden. In contrast, yang, the masculine, represents heat, light, active, and that which is on the surface. Yin and Yang are constantly interacting and changing, and one never exists in isolation from the other. According to Chinese tradition, all substances are formed from fire, water, earth, metal, and wood. Fire contains the most yang and water the most yin. The elements are created or destroyed by specific cyclical interactions. For example, fire melts metal, metal cuts down wood, wood covers earth, earth absorbs water, and water puts out fire. To each element is assigned one yin and one yang organ. Under this model, a bad heart (a fire organ) will adversely affect the lungs (a metal organ), which will in turn affect the liver (wood). Each organ has a meridian associated with it containing a series of acupuncture points. Stimulating these points regulates energy flow in the meridians. Overall, it is a closed system in which the excess of energy in one area reduces the energy in another area. Eastern medicine is interactive and holistic - everything affects everything. In contrast, western medicine emphasizes component parts (e.g., kidney) without seeing a relationship to the whole. The focus is on the symptoms, which according to Eastern medicine are merely the "footprints" left by energy imbalances. Scientific Basis: Although the theory behind acupuncture is based on centuries of empirical, clinical observations, it was developed without the benefit of modern physiological and anatomical insights. Because the idea of an intangible life-force qi flowing through anatomically undefined meridians seemed far-fetched to those trained in western medicine, it was dismissed for many years. Any effects were often attributed to heightened suggestibility, although the critics could not explain how such suggestibility would work in animals and young children. Scientists have now proposed a number of physiological mechanisms for acupuncture: · The procedure stimulates neural pathways and mediates a variety of neurotransmitter systems. For example, acupuncture has been shown to stimulate muscle sensory nerves, which send messages to the spinal cord, midbrain, and pituitary. This stimulation releases pain-reducing molecules called endorphins and cortisol-producing hormones that help conditions such as arthritis. · Acupuncture points often correspond to skin areas with unique anatomical and electrical properties. · Through the release of specific molecules, it appears that acupuncture can dilate blood vessels, thereby improving circulation. Since Eastern medicine assumes that physiological and molecular alterations are based on changes in energy flow, are acupuncture-induced hormonal and neurotransmitter changes secondary to a still scientifically undefined "qi" mechanism? Some investigators now believe this is so. They propose that the body's qi energy may correspond to very subtle bioelectromagnetic fields. Acupuncture perturbs these fields; the perturbation is then magnified through more traditional physiological mechanisms. Most living systems are sensitive to such low fields. The contribution of these fields to our biological understanding has been minimal due to difficulties measuring them and the traditional emphasis on molecular mechanisms. Some people suggest that integrating molecular and energy-field approaches would greatly reduce the division between Eastern and Western medicine. Like yin and yang, harmoniously integrating Eastern and Western medicine may represent a more balanced approach to health care. Clinical Trials: A key difficulty in proving acupuncture's effectiveness is the FDA requirement to use double-blind, randomized clinical trials. In such a trial, neither the patient nor doctor knows who is receiving treatment as opposed to a placebo control. Although these trials generally work well for drugs, they do not for acupuncture. As a placebo control, many clinical studies attempted to insert needles in "sham" acupuncture points (i.e., wrong points). Because the results of such studies were ambiguous at best, they reinforced the skeptics. However, these studies were fundamentally flawed for a number of reasons. A major one was that the sham acupuncture points were not neutral controls. Although not as effective as true acupuncture points, sham points also evoked a physiological response. Overall, criticism leveled at acupuncture should be placed within the context of the following NIH Consensus Conference statement: "While it is often thought that there is substantial research evidence to support conventional medical practices, this is frequently not the case…the data in support of acupuncture are as strong as those for many accepted western medical therapies." Acupuncture and Spinal Cord Dysfunction: People with spinal cord dysfunction can benefit from most acupuncture applications just as readily as able-bodied individuals can. Given the health problems common to those with spinal cord dysfunction, some of these applications may provide a valuable treatment option in addition to more conventional approaches, such as drugs. In spite of acupuncture's potential, the procedure is not well appreciated by the spinal cord injury health-care community. In preparation for this article, I observed acupuncturist Kelly Haggerty treating Paralyzed Veterans of America (PVA) member Artie Guerrero for the first time. As is the case with many PVA members who have used wheelchairs for a long time, Artie had several chronic, problems with his shoulders and other areas due to overuse. An athlete, who recently rode across Vietnam in a hand cycle, he was a little bit apprehensive at first. This feeling soon dissipated. "After years of being treated and analyzed by detached medical professionals, I was amazed how relaxed I quickly became. Kelly had a gentle, soothing style with an intuitive appreciation and understanding of the body. I didn't have to tell her; she quickly identified my sore-point areas. Furthermore, I was surprised that half the time, I didn't even know that the needles had been inserted. That night, my bad arm had no pain; I didn't even have to take my usual pills." Some evidence suggests that acupuncture may even restore some function. For example, Dr. Gao and his colleagues (Journal of Traditional Chinese Medicine Vol. 16 (2), 1996, pp. 134-137), report on the results of treating 261 individuals with traumatic spinal cord injury. Of these cases, 79% had been injured at least one year. According to traditional Chinese theory, traumatic SCI is the conse damages, in turn, affect the yang qi energy of the entire body. The goal of treatment is to clear and activate meridian channels, reversing the stagnation of qi. The authors claim that among the 261 SCI cases treated, 95% had some degree of improvement (e.g., improved sensation, bowel and bladder function, spasms, and walking). They quote a case in which a T-9 paraplegic, two years post injury, after 10 days of treatment no longer needed a catheter to urinate. After an additional three-month treatment a year later, he was able to walk with crutches. The authors speculate that acupuncture improves circulation surrounding the spinal cord; this, in turn, promotes regeneration. They believe that patients should be treated with acupuncture as soon as possible after injury. Dr. Naeser (Journal of Alternative and Complementary Medicine,Vol. 2, 1996, pp.211-248) has summarized the results of various acupuncture studies involving the treatment central nervous system paralysis, including spinal cord injury and multiple sclerosis (MS). The SCI studies basically parallel the results reported above. For MS, the studies, involving 42 people, indicated that acupuncture improved muscle spasms, vision, sleep, sexual functioning, and bladder control. In one case, a woman, who had not been able to walk unassisted in 15 years, was able to walk unaided 100 feet after one-year of treatment.
P: The NIH Consensus Development Panel on Acupuncture concluded that the use of acupuncture should be expanded into conventional medicine and further studies encouraged. I believe the same may be said regarding acupuncture and spinal cord medicine. Directions for such further studies might include, for example, the role of acupuncture 1) in the acute phase of SCI; 2) in the prevention and treatment of autonomic dysreflexia; 3) in the management of areflexic bladder and detrusor-sphincter dyssynergia; and 4) in the management of neurogenic bowel. Additionally, more work is needed on the role of acupuncture in the management of SCI-related chronic pain and spasticity and in the management of pressure ulcers. Because of the heterogeneity of acupuncture, these research trials should be designed to assess the absolute and relative efficacy of competing acupuncture approaches (e.g., traditional Chinese, Japanese meridian, French energetics, Korean hand, Five Elements, auriculomedicine, scalp acupuncture, and neuroanatomic) in the treatment of SCI patients.