Successful Treatment of a Resistance Trigeminal Neuralgia Patient By Acupuncture

A 66-year-old woman was referred with a typical TN pain on the left side of her face for 25 years. She was diagnosed with TN after evaluation and work-up by a neurologist. She used medications, including phenytoin (200 mg per day) and carbamazepine (600 mg per day). The pain was triggered by speaking, eating or touching. The pain was evaluated using a visual analog scale (VAS), which ranged from 0 (no pain) to 10 (worst pain imaginable). According to the VAS, the patient rated her pain as 10. She had, to date, experienced no beneficial effects from several therapeutic methods, including medication (carbamazepine, gabapentin and valproic acid), nerve block and radiofrequency rhizotomy of the infraorbital branch of the trigeminal nerve. Acupuncture treatment was initiated without making any change to her drug regime. Acupuncture needles (0.20 × 13 mm needles for the face and 0.25 x 25 mm needles for the other regions) were inserted on the typical areas that are used for trigeminal neuralgia (4). For facial neuralgia, the protocol utilized local points of TH 17 and 21, GB2, SI 18, ST 2, 3 and 7, GV 26 and LI 20; systemic points included TH 5, LI 4, ST 36, ST 44, ST 45 and LIV 3. Auricular acupuncture points were also used (Shen Men, neuro, face and lung points). Needles were not manipulated, and no attempt was made to elicit De-Qi. Every treatment session lasted about forty-five minutes, three times a week. After the fourth session, she reported that she had been relieved almost pain free. By the sixth week (14 sessions), the patient was completely free of pain (VAS = 0) and was still pain free at the end of sixth month.

Clinics (Sao Paulo). 2009 December; 64(12): 1225–1226.

Hüseyin Sert, Burhanettin Usta, Bünyamin Muslu, and Muhammet Gözdemir Department of Anaesthesiology, Fatih University School of Medicine - Ankara, Turkey.Email: drhuseyinsert@yahoo.com

FPIN's clinical inquiries. Acupuncture for migraine headaches.

Clinical Question

Is acupuncture effective in decreasing the frequency of migraine headaches?

Evidence-Based Answer

Acupuncture reduces the frequency of migraine headaches when used as an adjunct to, or in place of, medical management. (Strength of Recommendation: A, based on meta-analyses).

Evidence Summary

Headache is the leading cause of lost work time in the United States.[1] Migraine headaches occur in 18 percent of women and 5 percent of men.[2] More than 2.1 million U.S. adults report use of all-cause acupuncture in the previous 12 months, and 10 percent received acupuncture for migraine headaches.[3] In England, 21.4 percent of physicians perform acupuncture or refer patients for acupuncture.[4] In Germany, acupuncture is the most commonly used preventive treatment for migraine headaches.[5]

The standardized definition of a decrease in migraine headache frequency is a decrease of 50 percent, based on criteria from the International Headache Society. This is in persons who have two to eight migraine attacks per month for at least one year.[6]

A 2009 Cochrane review of acupuncture and prophylaxis for migraine headaches analyzed 22 randomized controlled trials (RCTs) with 4,419 patients.[7] Six trials compared traditional acupuncture with no prophylactic treatment or standard therapy; 14 trials compared traditional acupuncture with sham acupuncture; four trials compared traditional acupuncture with proven drug treatment; and two trials compared traditional acupuncture with relaxation techniques. At four months, traditional acupuncture reduced migraine headache frequency compared with drug treatment (standard mean difference [SMD] = -0.26; 95% confidence interval [CI], -0.41 to -0.11), and compared with no treatment (SMD = -0.43; 95% CI, -0.60 to -0.27). The authors concluded that there is consistent evidence demonstrating that traditional acupuncture is as effective as traditional migraine headache prophylaxis, but not statistically more effective than sham acupuncture (SMD = -0.18; 95% CI, -0.44 to 0.07). This is noteworthy because a 2001 Cochrane review on acupuncture and migraine headaches concluded that traditional acupuncture may have a role in headache treatment; however, the quality and amount of evidence were not convincing at the time.[8]

A critical literature review in 2007 evaluated 10 well-designed RCTs with 2,015 patients.[9] These trials consistently demonstrated that traditional acupuncture was associated with clinically and statistically significant improvement in clinical outcomes compared with no acupuncture. The authors concluded that acupuncture should be incorporated into existing migraine headache therapy protocols.

There is considerable controversy in the acupuncture research community regarding the role of sham acupuncture, which incorporates needle placement in nonacupuncture points. Experientially, sham treatment is not physiologically inert, which makes it difficult to fully control for placebo effects.[10] Traditional acupuncture is not consistently superior to sham acupuncture, but because there may be an analgesic effect with any needling, it can be argued that studies should be designed using traditional acupuncture as the intervention and standard medical therapy as the control.

Recommendations from Others

The American Academy of Medical Acupuncture lists acupuncture as a treatment for migraine headache based on World Health Organization recommendations. [11] , [12] A National Institutes of Health consensus statement determined that acupuncture has considerable value and should be expanded into conventional medicine. The statement encourages further study, but does not specifically address migraine headaches.[13] According to the Institute for Clinical Systems Improvement, controlled studies specifically applied to migraine headache and acupuncture have produced mixed findings based on three older references.[14]

Am Fam Physician. 2010 Apr 15;81(8):1036-7.

Pickett H, Blackwell JC.Nellis Air Force Base Family Medicine Residency, Las Vegas, Nevada, USA. heather.pickett@nellis.af.mil

Acupuncture for pain.

Abstract

Acupuncture is increasingly used as an alternative or complementary therapy for the treatment of pain. It is well tolerated, with a low risk of serious adverse effects. Traditional and modern acupuncture techniques may result in reported improvement in pain patterns. Research on acupuncture has had a number of limitations, including: incomplete understanding of the physiologic effects of acupuncture; ineffective blinding of participants; unclear adequacy of acupuncture "dose;" difficulty in identification of suitable sham or placebo treatments; and the use of standardized treatment regimens rather than the individualized approach that characterizes most acupuncture practice. Controlled trials have been published regarding acupuncture for lumbar, shoulder, and neck pain; headache; arthritis; fibromyalgia; temporomandibular joint pain; and other pain syndromes. Enough data are available for some conditions to allow systematic evaluations or meta-analyses. Based on published evidence, acupuncture is most likely to benefit patients with low back pain, neck pain, chronic idiopathic or tension headache, migraine, and knee osteoarthritis. Promising but less definitive data exist for shoulder pain, fibromyalgia, temporomandibular joint pain, and postoperative pain. Acupuncture has not been proven to improve pain from rheumatoid arthritis. For other pain conditions, there is not enough evidence to draw conclusions.

Am Fam Physician. 2009 Sep 1;80(5):481-4.

Kelly RB.Fairview Hospital/Cleveland Clinic Family Medicine Residency, Cleveland, OH 44111, USA. Robert.Kelly@fairviewhospital.org

Acupuncture for tension-type headache.

Abstract

BACKGROUND: Acupuncture is often used for tension-type headache prophylaxis but its effectiveness is still controversial. This review (along with a companion review on 'Acupuncture for migraine prophylaxis') represents an updated version of a Cochrane review originally published in Issue 1, 2001, of The Cochrane Library.

OBJECTIVES: To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than 'sham' (placebo) acupuncture; and c) as effective as other interventions in reducing headache frequency in patients with episodic or chronic tension-type headache.

SEARCH STRATEGY: The Cochrane Pain, Palliative & Supportive Care Trials Register, CENTRAL, MEDLINE, EMBASE and the Cochrane Complementary Medicine Field Trials Register were searched to January 2008.

SELECTION CRITERIA: We included randomized trials with a post-randomization observation period of at least 8 weeks that compared the clinical effects of an acupuncture intervention with a control (treatment of acute headaches only or routine care), a sham acupuncture intervention or another intervention in patients with episodic or chronic tension-type headache.

DATA COLLECTION AND ANALYSIS: Two reviewers checked eligibility; extracted information on patients, interventions, methods and results; and assessed risk of bias and quality of the acupuncture intervention. Outcomes extracted included response (at least 50% reduction of headache frequency; outcome of primary interest), headache days, pain intensity and analgesic use.

MAIN RESULTS: Eleven trials with 2317 participants (median 62, range 10 to 1265) met the inclusion criteria. Two large trials compared acupuncture to treatment of acute headaches or routine care only. Both found statistically significant and clinically relevant short-term (up to 3 months) benefits of acupuncture over control for response, number of headache days and pain intensity. Long-term effects (beyond 3 months) were not investigated. Six trials compared acupuncture with a sham acupuncture intervention, and five of the six provided data for meta-analyses. Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other outcomes. Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups.

AUTHORS' CONCLUSIONS: In the previous version of this review, evidence in support of acupuncture for tension-type headache was considered insufficient. Now, with six additional trials, the authors conclude that acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches

Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587

Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universitaet Muenchen, Wolfgangstr. 8, Munich, Germany, 81667. Klaus.Linde@lrz.tu-muenchen.de

Influence of comorbidities on improvement of fibromyalgia symptoms when treated with acupuncture: a short report.

Abstract

BACKGROUND: Fibromyalgia syndrome (FMS) is associated with chronic widespread pain, mood alteration, and disability. A definitive treatment plan has not been identified. The genesis of FMS is unclear and generally occurs in women.

PURPOSE: To determine whether patient-identified most disruptive comorbidity (MDC) secondary to FMS may have mediated recovery for individual patients. This is a probative analysis of data from an effectiveness study published in the March 2006 issue of Alternative Therapies in Health and Medicine. (2006;12(2):34-41.)

METHODS: The American College ofRheumatology (ACR) criteria for FMS was used in participant selection; 21 participants completed the study.

RESULTS: The original outcome study indicated significant changes on standardized measures using specific points and numbers of treatment within an 8-week period. The preliminary data on influence ofMDC on improvement were differential related to self-report MDC by patients.

CONCLUSIONS: For all MDCs combined, participants experienced significant improvement at 8 weeks of treatment. Participants with irritable bowel syndrome as their MDC generally had a lower percentage of improvement than other MDC cohort groups. This finding has implications for treatment.

Altern Ther Health Med. 2008 Sep-Oct;14(5):24-5.

Singh BB, Khorsan R, Vinjamury SP.Medicus Research LLC, Midlothian, Virginia, USA

Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study.

Abstract 

OBJECTIVE: The study sought to explore the possibility of using acupuncture and massage therapy for relieving neuropathic pain following spinal cord injury (SCI). Design 30 individuals with SCI and neuropathic pain were assigned to treatment of either massage or acupuncture, with 15 individuals in each group. Both groups received treatment twice weekly for 6 weeks. Treatments were evaluated at the end of treatment and 2 months later (follow-up).

RESULTS: Data were analysed on an intention-to-treat basis. Within the groups, ratings of present pain, general pain, pain unpleasantness and coping improved significantly at the end of treatment after acupuncture compared to baseline values, and following massage therapy ratings of pain interference on the Multidimensional Pain Inventory improved. At follow-up no significant improvements were seen. Between-group differences were seen regarding ratings of worst pain intensity at the end of treatment, and regarding pain unpleasantness and coping with pain at follow-up, both in favour of acupuncture. At the end of treatment, eight of the 15 individuals receiving acupuncture and nine receiving massage reported an improvement on the Patient Global Impression of Change Scale, and at follow-up six patients in the acupuncture group and one patient in the massage group still reported a favourable effect from the treatment. Few side effects were reported and neither dropout from the study did this due to adverse events.

CONCLUSION: Neuropathic pain following SCI is often only partially responsive to most interventions. Results from this study indicate, however, that both acupuncture and massage therapy may relieve SCI neuropathic pain. For this reason, larger randomised controlled trials are warranted for assessing the long-term effects of these treatments.

Acupunct Med. 2011 Apr 6.

Norrbrink C, Lundeberg T.Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden

Acupuncture for pain: an overview of Cochrane reviews.

Abstract

OBJECTIVE: Cochrane reviews have the reputation for being more transparent and rigorous than other reviews. The aim of this overview was to evaluate and summarize Cochrane reviews of acupuncture for the treatment of any type of pain.

METHODS: We searched the Cochrane Database and evaluated the Cochrane reviews that were concerned specifically with the effectiveness of acupuncture for pain. Data were extracted according to pre-defined inclusion criteria by two independent reviewers.

RESULTS: Eight Cochrane reviews were included. They were all of high methodological quality. They related to a wide range of pain syndromes. Four reviews concluded that acupuncture is effective for migraines, neck disorders, tension-type headaches, and peripheral joint osteoarthritis; one review failed to demonstrate type the effectiveness of acupuncture for rheumatoid arthritis; and three reviews were inconclusive for shoulder pain, lateral elbow pain, and low back pain.

CONCLUSION: Several Cochrane reviews of acupuncture for a wide range of pain conditions have recently been published. All of these reviews were of high quality. Their results suggest that acupuncture is effective for some but not all types of pain.

Chin J Integr Med. 2011 Mar;17(3):187-9. Epub 2011 Feb 27.

Lee MS, Ernst E.Brain Disease Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea. drmslee@gmail.com

Subacromial corticosteroid injection or acupuncture with home exercises when treating patients with subacromial impingement in primary care--a randomized clinical trial.

BACKGROUND: Patients with subacromial impingement syndrome (SIS) commonly seek primary care. Subacromial corticosteroid injection is the standard treatment given by GPs, which is supported by earlier studies reporting a positive effect but inconclusive evidence over the long- term. In Sweden, physiotherapists often choose acupuncture combined with exercises to treat SIS, which was reported as probably efficacious. Objective. To compare the efficacy of subacromial corticosteroids injected by a GP with physiotherapy combining acupuncture and home exercises as treatments for SIS. METHODS: A randomized clinical trial was performed in primary health care. Patients diagnosed with SIS were randomized to either subacromial corticosteroid injection (s) or 10 acupuncture treatments combined with home- exercises. The main outcomes were pain and shoulder function (Adolfsson-Lysholm shoulder assessment score). Secondary outcomes were health-related quality of life (HRQL) (EuroQol-five dimension self-report questionnaire) and the patients' global assessment of change. All patients were assessed at baseline and after 6 weeks and 3, 6 and 12 months. Results. One hundred and seventeen patients with SIS were included, of which 91 complied with the study protocol. There were no significant differences between treatments with regard to pain, shoulder function and HRQL in change over time. However, both treatment groups improved significantly from baseline over time. Conclusions. Both subacromial corticosteroid injection and a series of acupuncture treatments combined with home exercises significantly decreased pain and improved shoulder function in patients with SIS, but neither treatment was significantly superior to the other.

Fam Pract. 2011 Mar 4. [Epub ahead of print

Johansson K, Bergström A, Schröder K, Foldevi M.Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, Linköping.

German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) - a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment.

The German Randomized Acupuncture Trial for chronic shoulder pain (GRASP)comprised 424 outpatients with chronic shoulder pain (CSP) > or =6 weeks and an average pain score of VAS > or =50 mm, who were randomly assigned to receive Chinese acupuncture (verum), sham acupuncture (sham) or conventional conservative orthopaedic treatment (COT). The patients were blinded to the type of acupuncture and treated by 31 office-based orthopaedists trained in acupuncture; all received 15 treatments over 6 weeks. The 50% responder rate for pain was measured on a VAS 3 months after the end of treatment (primary endpoint) and directly after the end of the treatment (secondary endpoint). RESULTS: In the ITT (n=424) analysis, percentages of responders for the primary endpoint were verum 65% (95% CI 56-74%) (n=100), sham 24% (95% CI 9-39%) (n=32), and COT 37% (95% CI 24-50%) (n=50); secondary endpoint: verum 68% (95% CI 58-77%) (n=92), sham 40% (95% CI 27-53%) (n=53), and COT 28% (95% CI 14-42%) (n=38). The results are significant for verum over sham and verum over COT (p<0.01) for both the primary and secondary endpoints. The PPP analysis of the primary (n=308) and secondary endpoints (n=360) yields similar responder results for verum over sham and verum over COT (p<0.01). Descriptive statistics showed greater improvement of shoulder mobility (abduction and arm-above-head test) for the verum group versus the control group immediately after treatment and after 3 months. The trial indicates that Chinese acupuncture is an effective alternative to conventional orthopaedic treatment for CSP.

Pain. 2010 Oct;151(1):146-54. Epub 2010 Jul 23.

Molsberger AF, Schneider T, Gotthardt H, Drabik A.Ruhr-University Bochum, Orthopaedic Surgery and Research, 44780 Bochum, Germany. albrechtmolsberger@mac.com

German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups.

BACKGROUND: To our knowledge, verum acupuncture has never been directly compared with sham acupuncture and guideline-based conventional therapy in patients with chronic low back pain.

METHODS: A patient- and observer-blinded randomized controlled trial conducted in Germany involving 340 outpatient practices, including 1162 patients aged 18 to 86 years (mean +/- SD age, 50 +/- 15 years) with a history of chronic low back pain for a mean of 8 years. Patients underwent ten 30-minute sessions, generally 2 sessions per week, of verum acupuncture (n = 387) according to principles of traditional Chinese medicine; sham acupuncture (n = 387) consisting of superficial needling at nonacupuncture points; or conventional therapy, a combination of drugs, physical therapy, and exercise (n = 388). Five additional sessions were offered to patients who had a partial response to treatment (10%-50% reduction in pain intensity). Primary outcome was response after 6 months, defined as 33% improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale questionnaire or 12% improvement or better on the back-specific Hanover Functional Ability Questionnaire. Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement.

RESULTS: At 6 months, response rate was 47.6% in the verum acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group. Differences among groups were as follows: verum vs sham, 3.4% (95% confidence interval, -3.7% to 10.3%; P = .39); verum vs conventional therapy, 20.2% (95% confidence interval, 13.4% to 26.7%; P < .001); and sham vs conventional therapy, 16.8% (95% confidence interval, 10.1% to 23.4%; P < .001.

CONCLUSIONS: Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.

Arch Intern Med. 2007 Sep 24;167(17):1892-8.

Haake M, Müller HH, Schade-Brittinger C, Basler HD, Schäfer H, Maier C, Endres HG, Trampisch HJ, Molsberger A.Orthopaedic Department, University of Regensburg, Bad Abbach, Germany.Erratum in Arch Intern Med. 2007 Oct 22;167(19):2072.

A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.

BACKGROUND: Acupuncture is a popular complementary and alternative treatment for chronic back pain. Recent European trials suggest similar short-term benefits from real and sham acupuncture needling. This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain.

METHODS: A total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary outcomes were back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale). Outcomes were assessed at baseline and after 8, 26, and 52 weeks.

RESULTS: At 8 weeks, mean dysfunction scores for the individualized, standardized, and simulated acupuncture groups improved by 4.4, 4.5, and 4.4 points, respectively, compared with 2.1 points for those receiving usual care (P < .001). Participants receiving real or simulated acupuncture were more likely than those receiving usual care to experience clinically meaningful improvements on the dysfunction scale (60% vs 39%; P < .001). Symptoms improved by 1.6 to 1.9 points in the treatment groups compared with 0.7 points in the usual care group (P < .001). After 1 year, participants in the treatment groups were more likely than those receiving usual care to experience clinically meaningful improvements in dysfunction (59% to 65% vs 50%, respectively; P = .02) but not in symptoms (P > .05).

CONCLUSIONS: Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture's purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.

Arch Intern Med. 2009 May 11;169(9):858-66.

Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA.Center for Health Studies, 1730 Minor Avenue, Seattle, WA 98101, USA. cherkin.d@ghc.org