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Pain Management & Acupuncture. Simon Strauss MBBS Monash 1972. Dip. Acupuncture Nanking 1978 This session Historical Perspective on Acupuncture Pain Epidemiology - The “Market” Introduction to Myofascial Pain Theory The Near and Far Acupuncture Technique .

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Pain management acupuncture l.jpg
Pain Management & Acupuncture

Simon Strauss MBBS Monash 1972.

Dip. Acupuncture Nanking 1978

This session

  • Historical Perspective on Acupuncture

  • Pain Epidemiology - The “Market”

  • Introduction to Myofascial Pain Theory

  • The Near and Far Acupuncture Technique


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AcupuncturePractice - An Established Trend

  • Growth of Acupuncture Outlets - Brisbane


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Acupuncture Item 173 (980)

  • From 1984 to 1995 (National)


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Attitudes are age related.


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NHMRC. W.P.Document: Management of Severe Pain

Core Curriculum for Medical Practitioners - Identifies a need for Education on:

  • Acupuncture and Transcutaneous Nerve

    Stimulation techniques.

  • The measurement, quantification and

    recording of pain.


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International Association for the Study of Pain (IASP)

Management of chronic pain: Core Curriculum for Medical Practitioners, Dentists and Physiotherapists - Recommends Education on:

1.Neurostimulation techniques including

a. Transcutaneous nerve stimulation

b. Acupuncture

2. The measurement, quantification and

recording of pain

3. Myofascial Pain


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What are the Dominant Factors Driving this Acceptance of what only a Decade ago was regarded as Alternative or Fringe?

  • It Works

  • The results depend on the practitioner’s skill.(Operator satisfaction)

  • Its’ mechanisms can be understood from a Western scientific viewpoint

  • It is cost effective for the consumer

  • It has a high efficiency index.( +ve effects far outweigh side effects.)


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ADDITIONALLY what only a Decade ago was regarded as Alternative or Fringe?

There is considerable demand

  • 1. As Western Countries are experiencing an “Epidemic” of Chronic Pain.

  • 2. That is poorly managed with our classical techniques!


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The Epidemiology of Pain: An Australian Study what only a Decade ago was regarded as Alternative or Fringe?

Brisbane. by F. Guthrie, F. Nicolosi

and S. L. Strauss.

Telephone survey of 265 Households

  • Household pain prevalence rate, 35.5%

  • Adult Individual pain prevalence, 19%

  • Overseas studies, (Canada, USA) have shown similar prevalence rates.


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Pain Prevalence what only a Decade ago was regarded as Alternative or Fringe?Increases with Age.

  • 10% of 30 year olds

  • 25% of 50 year olds

  • 45% of >60 year olds

  • Over the age of 30 females’ pain incidence is higher than that of males.

    The Epidemiology Pain: An Australian Study


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Location of most severe pain what only a Decade ago was regarded as Alternative or Fringe?The Epidemiology Pain: An Australian Study

  • As % of Pain States declared


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Intensity what only a Decade ago was regarded as Alternative or Fringe?The Epidemiology Pain: An Australian Study45% can be regarded as suffering from severe pain


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Duration what only a Decade ago was regarded as Alternative or Fringe?The Epidemiology Pain: An Australian Study91% have “Chronic Pain”

  • Time since first occurrence of Pain State


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Frequency what only a Decade ago was regarded as Alternative or Fringe?The Epidemiology Pain: An Australian Study53% Daily or constant

  • Frequency of Pain Occurrence as a %


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Cause of Pain state what only a Decade ago was regarded as Alternative or Fringe?

  • Post Surgical = 2.6%

  • Sports Injury = 3.4%

  • Accident = 18.8%

  • Other = 19.7%

  • Work Related = 21.4%

  • Spontaneous = 34%

    The Epidemiology Pain: An Australian Study


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what only a Decade ago was regarded as Alternative or Fringe?Health Professional” Consulted.

  • 70% visited a “Health Professional”

  • 30% no treatment or self treatment

    The Epidemiology Pain: An Australian Study


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Of those visiting a what only a Decade ago was regarded as Alternative or Fringe?“Health Professional”

  • 80% consulted a Medical Practitioner

  • 8% consulted a Chiropractor

  • 5% consulted a Physiotherapist

  • 2% an Acupuncturist (Non-medical)

  • The remaining 5% - Naturopath, Herbalist, Iridologist etc.

    The Epidemiology Pain: An Australian Study


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The Epidemiology Pain: An Australian Study: Summary what only a Decade ago was regarded as Alternative or Fringe?

  • Household pain prevalence rate =35.5%

  • Adult Individual pain prevalence =19%

  • 91% chronic pain (> 6 months)

  • 45% severe to unendurable Pain Intensity

  • 53% constant or daily

  • Back 33%, head and neck 24%, leg 22%

  • 70% managed. (80% of managed -Medical)


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10 High Street what only a Decade ago was regarded as Alternative or Fringe?A Private Practice “Multidisciplinary” Pain Clinic.

Core Group: S Strauss, T McCarthy.

+ Physiotherapist, Psychiatrist, Masseuse

  • Established 1980

  • Research oriented

  • 10,000 Patients.(25 new patients per week.)

  • 60% Referred.


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10 High Street what only a Decade ago was regarded as Alternative or Fringe?. Pain State Distribution & Age

  • Breakdown of 1146 Patient’s Pain Syndromes


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10 High Street what only a Decade ago was regarded as Alternative or Fringe?. Pain Severity97% Could be regarded as having severe pain

No Pain Unbearable Pain


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10 High Street Compared c what only a Decade ago was regarded as Alternative or Fringe? General Pain Population

Comparison of pain severity


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10 High Street. Reason for Presentation what only a Decade ago was regarded as Alternative or Fringe?

  • Other forms of treatment had not helped: 63%

  • “I’d have tried anything if I thought it would help”: 61%


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10 High Street Patient’s Profiles. what only a Decade ago was regarded as Alternative or Fringe?

  • A picture emerges of desperate patients suffering severe to unendurable pain for several years, who had tried multiple forms of therapy without gaining sustained relief.

  • The majority of these patients’ syndromes involved the musculoskeletal system.

  • 10 High Street patient’s had more severe, more prolonged Pain States than those identified as having pain in the general community.

  • ? Due to referral bias. ( ? Fear of “needles”)


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10 High Street. what only a Decade ago was regarded as Alternative or Fringe?Research Areas of Interest

  • Initial Aim was to explore Acupuncture's place within Western Medical Practice: Its’ Mechanisms and treatment results.

  • Led to an in depth investigation into

    Trigger Points

    Sympathetic Involvement

    Pain Measurement Subjective: Pain diagrams, VAS, McGill Pain Questionnaire

    Pain Measurement Objective: Thermography, Algometry, Axon Flare,

    Differential Nerve Blocks:

    Neurotrace, Cryoprobe etc


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Cold Bi Syndromes what only a Decade ago was regarded as Alternative or Fringe?: A Starting Point

  • T.C.M’s Cold Bi syndromes include the majority of chronic pain states where Ah Shi (Oh Yes) points are associated with coldness of the painful area. [ Nanking School TCM.]

  • T.C.M. characterises this “coldness” as being due to a blockage of the flow of Qi and blood.

  • The T.C.M. treatment paradigm is to, “Remove the obstruction thus allowing warming and nourishing of the tissues.”


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Cold Bi Syndromes what only a Decade ago was regarded as Alternative or Fringe?: A Starting Point

  • In Western terms this equates to “deactivating” the Trigger Point thereby decreasing the local/regional, aberrantly enhanced, sympathetic outflow activity usually associated with active trigger points.


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Myofascial Trigger Points what only a Decade ago was regarded as Alternative or Fringe?Janet Travell. 1976

“Myofascial Trigger Points are among the most common, yet poorly recognised and inadequately managed, causes of musculoskeletal pain seen in [Western]

medical practice.”


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Myofascial Trigger Points what only a Decade ago was regarded as Alternative or Fringe?Mostly Missed

  • The majority of chronic pain patients seen at 10 High Street had active trigger points.

  • Very few had had their trigger points palpated prior to presentation.

  • Most expressed surprise when their pain syndrome was reproduced by palpation.


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Myofascial Trigger Points what only a Decade ago was regarded as Alternative or Fringe?Mostly Missed, Why?

  • Nearly all had never filled out a Pain Diagram, McGill Questionnaire, VAS etc.

  • Many had not been undressed at previous assessments.

  • Many had accepted being told that their pain had no physical cause.

  • Contrary to prevailing paradigm.( The Tomato Principal)


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Recent Studies what only a Decade ago was regarded as Alternative or Fringe?(IASP’s Journal “PAIN”)

  • Have shown that the syndrome of

    “ Chronic Benign Intractable Pain” (previously) defined as pain that has been present for more than six months without known peripheral nociceptive input is nearly always associated with Trigger Points. ( Back 96.7%, Neck 100%) Pain. Vol.37 1989.


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Recent Studies what only a Decade ago was regarded as Alternative or Fringe?(IASP’s Journal “PAIN”)

  • Have shown that Non Specific Low Back Pain in a General Practice setting is usually (80%) associated with Trigger Points. Pain. Vol.37 1989.

  • More than 50% of patients admitted to chronic pain programs (USA) were found to be suffering from Myofascial Pain Syndromes due to trigger points.*Textbook of Pain; Ed. Melzack and Wall.


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TRIGGER POINTS what only a Decade ago was regarded as Alternative or Fringe?The Emerging [Western] Paradigm

Trigger points are increasingly thought to be important in the pathogenesis of many chronic pain syndromes.

They can be thought of as ( T. McCarthy 1983)

“Pain Amplifiers”

where their activity enhances nociceptor input. eg. Osteoarthritis,

or augments sympathetic activity.

eg Reflex Sympathetic Dystrophy, Post Herpetic Neuralgia etc.


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TRIGGER POINTS what only a Decade ago was regarded as Alternative or Fringe?The Emerging [Western] Paradigm

Trigger points are increasingly thought to be important in the pathogenesis of many chronic pain syndromes.

They can be thought of as ( T. McCarthy 1983)

“Pain Generators”

where the trigger point is the actual tissue causing the pain state.

i.e. Myofascial Pain Syndromes.


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TRIGGER POINTS what only a Decade ago was regarded as Alternative or Fringe?Rx’s Directed @ the Trigger Pointin theWest

  • Spray and Stretch

  • Ischaemic pressure massage (Shiatsu)

  • Injection ( Local Anaesthetic, etc. )

  • Dry Needling (Superficial +/-Xple, Deep)

  • Acupuncture


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The Near and Far Acupuncture Technique what only a Decade ago was regarded as Alternative or Fringe?

  • Was historically and still is the most commonly used Acupuncture technique for the resolution of chronic pain syndromes in the Peoples Republic of China.

  • When Acupuncture is used to treat common pain states the treatment is aimed at resolving the tissue problem or reflex causing or maintaining the pain state.


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The Near and Far Acupuncture Technique what only a Decade ago was regarded as Alternative or Fringe?

  • Two processes are dominant in this “rehabilitation”

    1. The Ablation of Trigger Point activity

    2. The Restoration of Disordered blood flow

  • The provision of Analgesia in this context is a secondary consideration. (Electro-Acupuncture stimulation is rarely used in this context.)


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The Near and Far Acupuncture Technique what only a Decade ago was regarded as Alternative or Fringe?

  • Involves the use of both

    local

    and

    distal

    Acupuncture points.


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Local Points - AhShi - Oh Yes - Trigger Points what only a Decade ago was regarded as Alternative or Fringe?

  • The local points are usually

    Ah Shi (Oh Yes) Points

  • “Oh yes” as when palpated they reproduce the patient’s pain syndrome


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Local Points - AhShi - Oh Yes - Trigger Points what only a Decade ago was regarded as Alternative or Fringe?

  • The Western equivalent of the AhShi point is the “Trigger Point”

  • > 75% of Local Acupuncture Points for Pain correspond to Trigger Points......

    R. Melzack


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Distal Acupuncture Points what only a Decade ago was regarded as Alternative or Fringe?

  • Are classical meridian Acupuncture points

    and are found below the elbow or knee.

  • They are used for the treatment of many

    diseases.

    Distal Acupuncture Points can be used to manipulate

    1. the sympathetic nervous system.

    2. the various “Pain Gates”


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Distal Acupuncture Points what only a Decade ago was regarded as Alternative or Fringe?

In the pain Rx context:

  • Commonly used distal points are characteristically found in muscles often at the motor point. eg. Li 4, Hegu. Li 10, Shousanli.

  • The “correct” distal point is frequently tender.

  • Complex “rules” can govern their selection.


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The Near and Far Technique for Chronic Pain States: Nanking 1978Local Points

  • A fine 30 - 32 Gauge needle is painlessly inserted through the skin over the active trigger point/points.

  • The needle is then twirled (900 left-right ) with downwards pressure until the trigger point is penetrated and “needle grasp” Objective - Deqi occurs.

  • At this stage the patient’s typical pain can/should be replicated. [Qi reaching the pain] -a type of Subjective Deqi or Acupuncture sensation


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The Near and Far Technique for Chronic Pain States: 1978Modified for Australian conditions. Local points.

  • Western patients frequently resent feeling Subjective Deqi!

  • A good result can also be obtained by stopping the needle manipulation immediately following the penetration of the ahshi or trigger point.

  • Other techniques have also evolved, where the skin over the trigger point is penetrated several times or a “heavy” needle is canter levered in the dermis.


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The Near and Far Technique for Chronic Pain States: 1978Nanking 1978. Distal Points

Distal points are found below the elbow or knee and are used to provide analgesia and or sympatholysis.

  • The skin over the distal points is painlessly penetrated

  • The needle is again ‘Twirled’ 90-1800 left - right as well as up and down until needle grasp or subjective Deqi is experienced.

  • This distal point subjective Deqi can be sensations of numbness, tingling, distension or dull pain.

  • The “amount” of deqi provided is titrated against the condition. [Acute/Shih heavy, chronic/Xu milder.]


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The Near and Far Technique for Chronic Pain States: 1978Modified for Australian conditions. Distal points.

  • Distal points can be selected by experience / formula.

  • The penetration of the skin over the point should - must be painless.

  • For acute - severe pain, eg Wry neck, Stuck back, distal points ‘should’ be needled to produce moderate - strong subjective deqi.

  • For chronic conditions mild subjective deqi or even just needle grasp ( Objective deqi ) is sufficient.


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“Correct” Needling Technique 1978

The Acupuncturist is frequently judged by his ability to painlessly insert the needle through the skin both in China and the West and rightly so.


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“Incorrect” Needling Technique 1978

The consequences of poor / painful needling technique include:

  • Poor compliance ( First session is the last)

  • Poor Result due to:

    1. Augmented Sympathetic Outflows

    2. Not enough Points allowed to be needled / sessions attended.

  • Iatrogenic / Side Effects.


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10 High Street: Treatment Cascade 1978

  • Acupuncture -Near and Far technique

  • Relaxation Training, including in order of utilisation; Tapes eg Passive Muscle Relaxation, Biofeedback EMG / GSR, Hypnosis.

  • Postural Re-education + - Job Task

  • NSAI’s, Tricyclics, Finalgon, T.N.S.

  • Nerve Blocks - Local Anaesthetic (Neurotrace)

    - Cryoprobe (Facet Joints)


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Results of Acupuncture Rx 1978using the Near & Far Technique.

Survey 1. 100% Referred

Survey 3. NHMRC funded

Survey 4. Brisbane Medical School

( Very complex, hostile wording. ? reason for low response rate)