1. Acupuncture Sarah K. Ayers, M.D. Capt, USAF 21 March 2012

2. Outline Slide  What is Acupuncture?  Indications for Acupuncture  Mechanisms of Action  Evidence  Military Considerations  Resources

3. Types of Acupuncture  Traditional Chinese  Electrical stimulation  Chinese Scalp  Auricular—Battlefield Acupuncture

4. Patient #1  31yo female s/p MVA  5 days later, still having 5/10 neck and shoulder pain (L > R)  Ibuprofen insufficient, cyclobenzaprine makes her too sleepy to work  15-20 needles total, no electricity, pain cut to almost 0/10  Next day—still mild aches, much better overall

5.  Chronic Pain/Fatigue Syndromes  Osteoarthritis  Joint disease/back pain  Acute Pain--Sprains, Strains, Post- Operative Pain  Migraines  Fibromyalgia  Depression, Anxiety  PTSD Indications

6. Indications Continued  Insomnia  Addictions– nicotine, cocaine, heroin  Upper respiratory symptoms  Strokes  Nausea & vomiting

7. Soo…How does this work?  fMRI with blood oxygen level-dependent (BOLD) measurements  Acupuncture points: rich in neuroreceptors  Modulates pain network via analgesic effects  CNS hormones release in hypothalamus and limbic system  Causes changes in interpretation of pain

8. Electroacupuncture  Fascia is bath of conductive fluid  General tx (2-8 Hz)  Enkephalin released from periaqueductal gray  Endorphin released from the hypothalamus  May be reversed/blocked by Naloxone  Local tx (above 10 Hz)  Dynorphin released in spinal cord  Activates low-threshold skin and muscle receptors  Serotonin/Norepinephrine released in midbrain

9. Chronic Issues  Electroacupuncture with exercise vs. exercise alone, 2003  No changes in objective ROM findings  Quality of life – significantly improved  2003 Rheumatology paper  over 60yo, >12wk back pain  Quality of life/disability - significantly improved  Some patients able to decrease pain medications

10. Migraines  Korean Hand Therapy  Study demo’d changes in blood velocity and volume in carotids and vertebrals arteries  Significant efficacy between triptans, acupuncture and control  Auricular acupuncture  Annals of Internal Medicine Jan 2009  Reduced frequency/pain of primary migraine or tension-type headaches.

11. Military issues…  Flight Status-Now teaching Battlefield Acupuncture  Allergic rhinitis and sinusitis  Avoids opiate use  Mission Readiness, Capability  Battlefield Conditions  Alternative to sedating medications  Stress/PTSD  TBI/Phantom Pain

12. Injuries  2 Battlefield points  23% reduction of pain in ER patients in initial 24h  Results equivocal after 24h  5 Battlefield points  9 chronic pain patients who had no relief with Western therapies  1 st 24h: pain completely relieved  2 nd 24h: pain attenuated from baseline

13. Deployment Considerations…  Tested at Andrews, Landstuhl, and at Echelon I & II in Al Asad, Iraq  432 Treatments  Average RTD 2.2 days sooner  $0.06-$0.50 per needle  Relative cost, complication risk of Ibuprofen

14. Patient #2  31yo AD EOD male  Subjected to three blasts where other coworkers died  Now with insomnia/chronic fatigue, TBI, migraines, neck/back pain, inability to run  Chronic narcotic use  About to get a Medical Board (MEB)

15. Patient 2 Treatment…  Battlefield Acupuncture  Traditional Acupuncture, treated every 2-3wks  Improved headaches/insomnia  Decreased narcotic use  Started hyperbaric oxygen therapy  Now back to running, better concentration, and MEB has been delayed

16. Summary  Types of acupuncture  Indications  Mechanism of action  Evidence  Clinic/military applications

17. Questions & Resources  “Acupuncture for Chronic Low Back Pain in Patients: A Randomized, Controlled Trial” CF Meng, Rheumatology, 42: 1508-1517  “Combining Spatial and Temporal information to explore functionality- guided action of Acupuncture using fMRI” Journal of Magnetic Resonance Imaging, (2009) V30: 41-46  “An fMRI Study of Somatosensory-Implicated Acupuncture points in stable…stroke pts” Journal of MR Imaging, 24: 1018-1024 (2006)  “Efficacy of Acupuncture for Treating Knee Arthritis” Alternative Medicine Alert Vol 8, p49-60 (May 2005)  “Randomized Control Trial: An Assessment of Acupuncture on Specific Meridian or Specific Acupoint vs sham acupuncture for treatment of functional dyspepsia” Alimentary Pharmacology & Therapeutics (2012) V35: 552-561  “Traditional Acupuncture in Migraines: A controlled, randomized study” Headache, Mar2008, V48 p398-401  “The use of Electro-Acupuncture in Conjunction with Exercise for the Treatment of Lower Back Pain” Yeang, Journal of Alternative and Complimentary Medicine, 2003 V9 p 479-490