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PainManagementwithAuricularTherapy/AuricularAcupuncture

KarenWilliams, MSN,RN, FNP-BCTempleVA

Neurology/Headache Clinic

Objectives

• Overviewofhistoryofacupuncture• Reviewoftypesofacupuncture• Discuss history andsignificance ofAuricularAcupuncture

• Reviewparticulars ofauricular therapy• Casepresentations

Disclosures

• Theviewsexpressed inthis presentation arethose ofthe author anddonot reflect theofficial policy oftheDepartment oftheVeterans Affairs,Department ofDefense,orU.S.Government.

TraditionalChinese Acupuncture(TCM)

• First developed in China over2000yearsago• Yellow Emperor’s InnerClassic- earliest major

medical source datingback to206BC- 220AD1

• Meridian based - Seeks torestore harmony andbalance- Qi, orenergy, travels along 12mainpathways ormeridians within thebody

• Health is influenced by thequality, quantity andbalance

• Diagnosis madeby takingpulses, observing patient’sappearance, demeanor and tongue andphysicalexam

• Qi is profoundly disturbed by traumatic stress

Loss andgainofacupuncture

• 1822- Qing Emperor ordered tostop teachingacupuncture atImperialMedical college

• China was exposed to theadvancesofwestern medicine

• 1949- Rise ofMao Zedong- pushed out“Barefoot Doctors” - theyweretaughtbasic Chinese andwestern medicine to treatemergencies, simpleillness and injuries/provided inexpensive medical careto rural china 1

ResurgenceofacupunctureintheU.S.

• 1971- Front pageofNYTimes, JamesReston reported onhisemergencyappendectomy in China- postop pain relieved by3needles2

• 3months latera report in Journal ofAmerican Medical Association- gaveafavorable report on theuseofacupuncture for surgical anesthesia3

• NIHsponsored physicians tostudyChinese health careand researchacupuncture4

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DifferentTypesofAcupuncture

• Traditional Chinese Acupuncture (TCM)

• Medical Acupuncture

• Japanese Acupuncture

• Korean Hand Acupuncture

• Scalp Acupuncture

• Auricular Acupuncture andAuriculotherapy

• Veterinary Acupuncture

MedicalAcupuncture• Simplified version ofTCM frequently addresses more acuteissues.

• 300-500 hours of training.

• Physician, Nurse Practitioners andPhysician Assistants using this modality.

• Added treatment modality inWestern medicine – gaining momentum inmilitary andVA facilities forpain treatment, PTSD/mood disorders, headinjury

AdditionalTypes ofAcupuncture

• Japanese Acupuncture: uses thinner, fewer needles sometimes onlytouching needle toskin surfaceand/or only using oneneedle

• Korean HandAcupuncture: utilizes thehand asahomunculus/microcosm representation of theentire body.Usesneedlesor taping of specificpoints

• Chinese ScalpAcupuncture (CSA):uses thescalp as themicrocosm –especially effective formotor andspinal impairment

• Veterinary Acupuncture: used onanimals ofall kinds – requires specialtraining, veryeffective

HistoryofAuriculotherapy Earliestuse• Egypt, Greeceand Rome500BC to100AD- Hippocrates andGalen used

ear rings andother formsofear stimulation

• Persians in200AD after the fallofRome, recorded cauterization forsciatica pain

• 1500 to1700 theDutchEast IndiaCompany, brought Chinese acupuncturebacktoEurope, to include earacupuncture and thedevelopment ofthehypodermic needle (fromtheacupuncture needle)

• 1957Dr PaulNogier (French)noticed scarring on patients ears, which wasfor the treatment of sciatica.His research lead tohis development of thesomatotopic map (based on the idea ofa inverted fetus)on the ear.Hisworkwas presented inFrance,published in Germanand then inChinese5

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Earliestuse(continued)• 1958 the Chinese learned ofDRNogiers chartsandverified the accuracy

of thepoints. The “Barefoot Doctors”were taught these skills tobringhealth care tothe Chinese population5

• 1980-DrTerry Oleson fromUCLAverified thescientific accuracyoftheauricular diagnosis- had75% accuracyofdiagnosing thedisease byevaluating theear 6

• 1990WHO standardized the terminology5

Auriculotherapy/Auricular Acupuncture

• Utilizes theearasahomunculus/microcosm representation ofhumanbodywith specific corresponding acupuncture points onear

• Embryological development of theearallows access tobrainandsubsequently thebody organs– Ectoderm-superficial tissue/skin, hair, teeth, peripheral nerves, spinal

cord– Mesoderm- middle tissue/ muscle, bones, joints, blood vessels– Endoderm- deep tissue/ GItract, lungs, internal organs

• Stimulation ofnerveendings sends signals to thebrain and then to thebody

• Byobserving theearonecan identify specific issues/disease processes5

Auriculotherapy/Auricular Acupuncture

With permiss ion from Terry Oleson, Ph.D

AuricularPoints

Auriculotherapy/Auricular Acupuncture(continued)

• Gained momentum with successful useasa treatment for substanceabuse (NADA protocol) andmore recently forPTSD,TBI,andbattlefielduse

• These points canbeneedled, seeded, electrically stimulated• Canbe learned inamatter ofweeks• Allows quick andeasyaccess for treatment without patient needing to

removeclothing• Treatments takeas little as20minutes andprovide relief fordays to

weeks, sometimes resolving theproblem• Wide rangeofdisorders to include headache, chronic backpain, asthma,

allergic rhinitis, dental pain, anxiety, insomnia5

EasyAuricularAcupunctureProtocols

• National Acupuncture Detoxification Association (NADA)– Lung,Liver, Kidney,ShenMen, AutonomicPoint

• Battlefield Acupuncture (BFA)– Cingulate gyrus,Thalamus, Omega 2,PointZero,ShenMen

• Auricular TraumaProtocol (ATP)– Master Cerebral, Amygdala, Hypothalamus,Hippocampus,Insula, Vagus,PointZero,

ShenMen

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Howbigaretheneedles? Research• Efficacyinpain management: Meta–analysis of13studies on Auricular

Therapy (Acupressure, Acupuncture andelectroacupuncture)showed agreaterdecrease inpain score than shamorcontrol group (1.59standarddeviations greater than themeandecrease for thesham control)7

• Pilot study of87activeduty military personnel with acutepain- theacupuncture group showed a23% reduction inpain verses thestandardmedical caregroup8

• Randomized exploratory studyevaluated usual care,TCMandAuricularAcupuncture in the treatment ofpost concussive headaches onactivedutyservice members. Both types ofacupuncture improved headacherelated quality of lifemore thanusual care9

Research• Asub groupof ratswere stressed inorder to induce depression- then

divided intoacupuncture, antidepressant, no treatment.The acupuncturegroup andantidepressant groups showed reduced glutamate in thehippocampus, prevented damage tohippocampal neurons and improvedbehavior10

• Clinical observation in the Temple VAheadache clinic- I donotwritenarcotics, I useacupuncture onadaily basis tostop theheadachepain,improve moodand help withsleep. Resulting in someveryhappyVeterans

• Further research isdefinitely needed, someof thedifficulty is havingacontrol group

"WithPermission fromDr RichardC.Niemtzow"

BFAScience

AnteriorCingulateCortexandThalamicNuclei

Painstimulation Painstimulation w/acupuncture

Precautions• Know whatyouare treating

• Donot relieve pain if it isneeded to limit thepatients activity

• Donotuse during pregnancy

• Needle cautiously with bleeding disorders

• Donotuse electric current with acardiacpacemaker

• NoETOH,drugs before treatment

Precautions(continued)• Avoid treating those thatareextremelyweak, anemic, tired, hungryor

haveeatenabigmeal- treatment will not beeffective

• Those thatareweakafter, need to restbefore leaving

• Needle shock- vasovagal reaction (uncommon, butcanhappen)

• Treatwith antibiotics if infection develops (very rare)

• Most commonside effect is redor tender ear

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CostofAcupuncture• Thecostactuallyvariesbythetypeofprovider(physicianvs"other"(NP))andthe

typeofPatient.ThePriceQuote:asofJan17th 2013.Theratetablesarechanged1-2timeseachyearandratesdogoupanddown,usuallyonlyslightly.

• Pricequoteforacupuncturewithoutstimulation

• 97810- $35.74(Physician)$30.38(ExtraMedical/NP)-first15minutes

• 97811- $26.89(Physician)$22.86(ExtraMedical/NP)-additional15minutes

• Pricequoteforacupuncturewithstimulation

• 97813- $38.12(Physician)$32.40(ExtraMedical/NP)-first15minutes

• 97814- $30.63(Physician)$26.04(ExtraMedical/NP)-additional15minutes

GreatNews!• TheTexasBoard ofNursing has grantedapproval foruse ofAuricular

acupuncture, if youhavetaken theappropriate courses.Theuse ofauricular acupuncture does notoverlap into the territory of theLicensedAcupuncturist, according toTexasMedical Board definition ofacupuncturist.

• Possibility for learning this valuable skillTheAuriculotherapy Certification Institute www.auriculotherapy.org*This certificate does not replace the need for state licensure inaspecific health carefield, but itdoes acknowledge specialty oftraining in this particular health caremodality.

CasePresentations

Occipitalneuralgiaandneckpain

Chronic pain

History• 40yearoldmale with ahistory ofmultiple concussions, neckand low back

pain related tomultiple deployments: toinclude hard landings withparachute jumps, headstrikes onvehicles andmultiple blasts fromIdentified explosive devices (IED)

• Chronic posterior occipital painwith jab and jolt forward behind theeyes.Occurring 2-3 times perweek lasting 2hours, ratedas7/10.Headacheshavebeenoccurring since 2006 (10years)

• Prior treatments with acupuncture andmassage tobackhelpful, nottolerant ofTopamax, Robaxin- would prefer to stayaway frommedications

• Pastmedical history- Migraines, PTSD,Sleep Apnea, Insomnia, Lowbackpain, Neckpain, Tinnitus, GERD

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AuricularAcupuncture treatment• Placement ofneedles at the following points:• Shenmen, Amygdala, Master Cerebral, Vagus, Hypothalamus,

Hippocampus, Thalamus, Cingulate gyrus, point zero, Cervical (Sensory&Motor), Lumbar (Motor)

• Pain prior to treatment:7/10 neckandshoulders, mild occipital pain• Anxiety prior to treatment:6/10

• Needles left in for20minutes

• Pain aftertreatment: 4/10 neckand shoulders, occipital pain resolved• Anxiety after treatment:3/10

Occipitalneuralgiaandanxiety

Pre-procedure pain

History• 38yr old femalewith ahx ofoccipital neuralgia/tension headaches

occurring since 1998- unsure of trigger other than wason activeduty asamedicat timeofonset. Inaddition hadamedication overuse componenttohercurrent headaches (takingdaily excedrin/Imitrex for3weeks)

• failed multiple medications to include paxil, celexa, nortriptyline, topamax,depakote, motrin

• Medical history- PTSD,Sexualassault inadolescence/ MST, Anxiety,Insomnia, Constipation, Allergic rhinitis, Asthma, GERD, Lowbackpain,Dizziness, Polyarthralgia

• Seen inclinic for trial ofbotox- attime ofappt hada5/10 headachelocated in the leftoccipital area radiating tobehind her left eye.Inaddition she wasextremely anxious about theadministration ofBotox.Rated anxietyas10/10

Treatment• Auricular acupuncture administered at the following sites: Tranquilizer,

Shenmen, Point zero, Amygdala, Hypothalamus, Hippocampus, MasterCerebral, Insula, Lesser occipital – needles left in for20minutes

• Alpha-stim AID(micro-current applied bywayofear tabs) wasapplied tohelp with anxiety

• Herheadache resolved after10minutes andanxietywas reduced to3/10

• Shewasable tocomplete theadministration ofBotoxwithout issue, herheadache didnot return thatdayand heranxiety remained low

Dentalpain

Acutepain

HistoryandTreatment• 51yr old malewith 3dayhistory of right sided jawpain following root

canal. Ratespain as8/10, constant throbbing anddistracting him fromworking

• Acupuncture needle placed atDental analgesia point• Pain resolved beforemyhandwas away fromhisear- pain did not return

• 75yr old malewith 2dayhistory left jaw pain following toothextraction,“drysocket”.Rated pain as9/10, unable toeatorevenbrush his teeth

• Acupuncture needle placed atDental Analgesia point x2, Thalamus, ShenMen

• Pain resolved over5minutes- pain did not return

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DentalPain(continued)• 35yr old femalewith 10daysof left facialpain. Found tohave infection in

tooth, now needing dental surgery as the infection hadsurpassed theability todoa rootcanal. Inaddition she wasdxwith sinus infection astooth rootwas into the sinus cavity.TakingT&C#3every4hours- reducedherpain to5/10

• Placed auricular needles atDental Analgesia, JawandThalamus- painresolved over3minutes. Needles removedand goldstuds placed.

• Patient leftpain freeandhappy, afterbeing in theofficeatotal of10minutes. Pain 0-2/10 for3days, noneed to takeT&C#3.Paincamebackwhen goldstuds fellout, needed togobackonT&C#3 until surgery as shecould notgetbackin to theoffice.

Words ofWisdom

"Anyone who is trained and licensed togive injections ordosutures couldlearn tousea fewsimple acupuncture protocols inamatterofweeks, andcould relieve anenormous amount of suffering." 11

‘AcupunctureislikeChinese noodles’:communitybasedacupunctureconcept

References1. Helms J. Acupuncture Energetics Aclinical Approach forPhysicians. New

York:Thieme publishers, 2007:3-17.2. Reston J. Now aboutmyoperation inPiking.The NewYorkTimes, July

26,1991: 1,6.3. Diamond EG.Acupuncture Anesthesia: western medicine and Chinese

traditional medicine. Journal ofthe American Medical Association, 2181971:1558-1563.

4. Chen JYP.Acupuncture. InMedicine andPublic Health in thePeople’sRepublic ofChina. Edited by J.R.Quinn. U.S.Dept.ofHealth, EducationandWelfare: National Institutes ofHealth, John S.FogartyInternationalCenter. 1972:65-90.

5. Oleson T.Auriculotherapy Manual: Chinese andWestern SystemsofEarAcupuncture, 3rd edition. NewYork:Churchill Livingston, 2003:2-19.

References6. Oleson T,Kroening R,Bresler D.Anexperimental evaluation ofauricular

diagnosis: thesomatotpic mapping of themusculoskeletal pain atearacupuncture points. Pain 1980;8:217-229

7. Yeh CH,etal. EfficacyofAuricular Therapy forPainManagement: ASystematicReview and Meta- Analysis. Evidence-Based ComplimentaryandAlternative Medicine 2014;2014 1-14.

8. Goertz CM, Niemtzow R,Burns SM, Fritts MJ,Crawford CC, Jonas WB.Auricular acupuncture in the treatment ofacutepain syndromes: A pilotstudy.Mil Med2006 Oct171(10):1010-4.

9. Jonas WB, etal. ARandomized Exploratory Study toevaluate TwoAcupuncture Methods for the treatment ofHeadaches Associated withtraumatic Brain Injury.Medical Acupuncture 2016;28:113-130.

References10. FanL,etal. Glutamate ofHippocampus Involved inRemission of

Depression byAcupuncture inRats.Medical Acupuncture 2016; 28:71-78.

11. Rohleder L,EtAl. Acupuncture is likenoodles. Oregon:Working ClassAcupuncture, 2009:122.

KarenWilliams,MSNRN FNP-BC

karen.williams1@VA.gov254-743-2759