Acupuncture in the treatment of Chronic Pain in Children
Acupuncture involves the insertion of needles in the body both near the site of pain and at a distance from the site of pain on lines of acupuncture points called “meridians”. What is important when considering acupuncture for children and adolescents is that these needles are extremely fine and unlike an injection or having blood drawn, they are not hollow and do not cut the skin or blood vessels. The insertion is practically painless neither leaving a mark nor causing bleeding.
Treated conditions: Historically, acupuncture has been used to treat a wide variety of common conditions. The National Institutes for Health consensus conference on acupuncture concluded that it was effective in the treatment of; headaches, menstrual cramps, elbow tendonitis, fibromyalgia, myofascial pain, osteoarthritis, lower back and neck pain, carpal tunnel syndrome and post operative or chemotherapy caused nausea and vomiting (1). Additionally acupuncture has been used to treat chronic abdominal pain, IBS, mild anxiety and depression, post operative and post procedural pain (2) and increasingly PTSD (3,4). Chronic pain seems to be best treated by a combined approach using a mix of modalities including western medication, relaxation therapies (biofeedback, guided imagery), PT, psychological counseling and acupuncture.
Mechanisms of action: The traditional idea for how acupuncture works is that it balances the energy (“Qi”) that flows through the meridians and unblocks stagnation that is the cause of pain. Particularly in cases of chronic pain the purpose of treatment is to balance all the systems of the body (the cooling calming Yin energy and the hot metabolic Yang energy) which enables the body to heal itself. Traditional concepts such as Qi and Yin/Yang are unfamiliar and perhaps even off putting to the Westerner. Interestingly, modern research provides a window to understanding the mechanisms of acupuncture action. Acupuncture points are generally points of low electrical resistance on the surface of the skin; these can be measured with an Ohm-meter. When a needle is inserted into an acupuncture point in an area of pain (local needling) there is not only an increase in blood flow to the area but also an increase in the low amperage current that flows down the outside of the nerve sheaths (Glial cells); this causes cell membranes to become more permeable allowing inflammatory material to leave the cells and nutrients to enter. Additionally, by needling tight local muscles, it releases “trigger” points that causes the muscles to relax. Acupuncture appears to have a homeostatic or normalizing effect on the body. It has been observed that needling the same acupuncture point has the effect of decreasing heart rate when it is rapid and increasing the rate when it is slow, similar results have been observed in gastric activity. One can see how acupuncture balances the sympathetic (fright and flight) and the parasympathetic nervous system which influences chronic pain syndromes where sympathetic arousal is a major contributing factor.
Scientific studies: By needling acupuncture points, the brain releases both endogenous opioids and various neurotransmitters. Acupuncture immediately increases serum enkephalins and endorphins but even more importantly it enables the brain to increase opioid production on its own, over time when acupuncture is not being applied. The increase in production of neurotransmitters such as serotonin and dopamine is important in that it enhances mood and allows those substances to calm down the pain receptor sites in the brain. By using modern imaging techniques (fMRI and PET scans), scientists have shown that by needling acupuncture points traditionally used for say vision problems it caused observable increase in activity in the visual cortex of the brain, as if a flashlight had been shone into the eye of the subject; such an effect was not observed when needling points only a few centimeters away from the traditional point. This gives credibility to the traditional indications of the point and demonstrates the need for accurate needling!
Treatment of children by acupuncture: It was first discussed in the Han dynasty (200 C.E.). By the Song dynasty (11th – 13th century) the first textbook specifically dealing with Pediatrics was written. Acupuncture has always been part of Traditional Chinese Medicine and includes herbal medicine, therapeutic exercise (Tai Chi, Qi Gong), massage (Tui Na) and nutritional medicine. Today acupuncture has demonstrated its efficacy not only as a stand alone therapy but also as an adjunct to modern Western bio-medicine.
Side Effects: This long history of the use of acupuncture is a testament not only to its efficacy but also its safety. As previously mentioned the homeostatic effect means that the worst that can happen is nothing. The incidence of minor bruising is rare. A 2011 review of eighteen data bases world wide on the use of acupuncture in children concluded that their results supported results from other adult studies that found that acupuncture was an extremely safe modality when performed by appropriately trained practitioners (5). An occasional feeling of lightheadedness after treatment is transitory and probably due to the endorphin release. This review of acupuncture safety in children concluded that acupuncture is one of the safest modalities available.
Licensing: Most states in the U.S. have their own acupuncture licensing exam to qualify practitioners, usually carrying the designate L.Ac (Licenced Acupuncturist) or D.O.M. (Doctor of Oriental Medicine). There is also the National Certification Commission for Acupuncture and Oriental Medicine which administers exams to qualify practitioners with a Dipl. Ac. Certification. There is also a Physician’s organization, the American Association of Medical Acupuncture, that can be contacted for a list of doctors trained in acupuncture in your area. Very often the best referrals are by word of mouth from providers or acquaintances that have had beneficial experiences with local practitioners. I recommend calling the acupuncturist to determine their level of experience in treating the needs of your child.
When, how often to use Acupuncture?: Acupuncture is not considered as a primary option in treating children, perhaps because of perceived safety issues or more likely concerns that the child would be too afraid of needles. Our experience at the UCLA Pediatric Pain Clinic suggests otherwise. We have found that when approached delicately, the majority of children tolerate the treatment with ease. It is important that the practitioner relates comfortably with the patient and takes time explain that these needles are “hair like” and do not cut the skin like getting a shot or getting blood drawn. It is also important to acknowledge that even grown ups get a little apprehensive before a treatment and that is normal to feel that way. I explain that if a needle feels uncomfortable, then they should say so and it will be adjusted or removed, so that while they lie with the needles in for 15 to 20 minutes it should be a pain-free experience. Due to the release of endorphins patients often feel very relaxed and consider it enjoyable rather than terrifying. From 6-15 needles can be inserted in one treatment, however if a patient is showing hesitancy about being needled, it is advisable to agree to use one needle then see how the child feels, which is usually nothing or just a mild sensation, and then with their consent proceed.
There is no standard for the number of acupuncture treatments needed for a therapeutic result. The more chronic a condition is, the more treatment is likely to be required. Treatments act cumulatively on one another and it is generally considered necessary to treat two times per week for six treatments in order to see if acupuncture is going to be effective, if a significant improvement is observed in this initial series of treatments then depending on the situation anywhere between six and twenty more treatments may be prescribed to achieve maximum benefit. Recently acupuncture points have been stimulated by using a cold Laser which has the obvious benefit of not being invasive and therefore more acceptable to children. Although not considered as powerful as needling, it can be used in conjunction with conventional acupuncture or as a stand alone modality.
A case history: Three years prior to his first visit, “Gary” a 15 year old male had been in a serious car accident, with his father driving. He sustained major injuries to his facial bones and a fracture of his right orbit. His chief complaint was chronic and debilitating right eye pain; this became so bad that one year previously his right eye was removed which did not help the pain. He reported the eye pain to be a 7-8/ 10. The pain got worse with stress and fatigue. Sleep maintenance was poor and he reported feeling unrefreshed on waking. Since the accident, he experienced generalized anxiety particularly when in a car, and was hyper vigilant about safety in general. He preferred to be with family members only; his affect was flat and depressed. His chronic pain was a significant family stressor and his father in particular had guilt about the accident.
Gary was treated with a combination of therapies which included medication changes, relaxation techniques, psychological counseling and a course of acupuncture treatment, additionally he was encouraged to continue swimming which was an activity that he enjoyed and excelled at. This approach addressed both the physical pain and the psychological stressors that increased his sympathetic arousal. This combination caused a 50% decrease in his pain over a period of two to three months and enabled him to integrate himself socially with greater ease.
N.I.H. Consensus Development Conference, Acupuncture. JAMA. 1998; 280:
W.H.O. Acupuncture: Review and Analysis of Reports on Controlled Trials: 1996.
Hallifield M. et al. Acupuncture for PTSD, A randomized controlled pilot trial. J. Nerv. Ment. Dis. 2007; 195(6): 504-513.
Wambeh. H. et al. CAM for PTSD symptoms; a systematic review. Jnl of Evidence based CAM. July 2014 19: 3. 161-175.
Adams. D. et al. The Safety of Pediatric Acupuncture: a systematic review. Pediatrics. Dec 2011; 128 (6) 1575-87.
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