Transcript Traditional Chinese Medicine

Traditional Chinese Medicine and
Acupuncture
Dr Simon Chan
Department of Anaesthesia and Intensive Care
Prince of Wales Hospital
Hong Kong
James Reston
• Journalist of New York Time
• Accompanied with Henry A. Kissinger, the then
Secretary of State of USA for the official visit to
China in 1971
• Developed appendicitis while in Beijing
• Uneventful appendectomy
• Post-operative pain management with
acupuncture
• Article published on 26 July 1971 about his
experience on acupuncture
Richard Nixon
• Then President of USA
• First official visit to China in 1972
• Expressed interest in TCM/acupuncture and
requested for acupuncture demonstration
• President Nixon and the delegations were
shown surgery performed under acupuncture
anaesthesia
Traditional Chinese Medicine
• Practiced more than 2500 years
• Covers a board range of practice throughout Asia
serving for about 75% population worldwide
• Branches
– Herbal medicine
– Acupuncture, therapeutic massage and related
technique
– Bone setting orthopaedic
– Qigong
Philosophy of Ancient China
• Yin and Yang theory
– The ancient concept about universe
– Two abstract and complimentary aspects every
phenomenon in the universe can be divided into
– Sun vs moon, hot vs cold, male vs female
• Five elements
– All phenomena of universe and nature can be broken
down into five elemental qualities
• Wood, fire, earth, metal, water
– All interdependent and yet restraint each other
Five Elements
TCM Model of Human Body
• Human body consists of ‘functional’ internal
organs which differs from anatomical organs
as in Western medicine
– Zang (solid organs) – heart, lung, liver, spleen and
kidney
– Fu (hollow viscus) – stomach, gall bladder, urinary
bladder, small and large intestine
• ‘Zang-Fu’ organs have their own features and
related to each others resemble five elements
Wood
(Liver)
Water
(Kidney)
Metal
(Lung)
Fire
(Heart)
Earth
(Spleen)
TCM Model of Human Body
• “Zang-Fu” organs are connected to each other
by channels via the limbs called meridians
• Meridians are not anatomical structures and
allow ‘Qi’ to run through
• Qi – divine energy flow, regarded as cardinal
function of the body but unable to be
measured
• There are 12 bilaterally distributed meridians
supplemented by 2 midline channels
Meridians
TCM Model of Disease
• ‘Pathological’ processes in TCM
– Six exogenous factors: Wind, cold, fire, dampness,
dryness, summer heat
– Emotional factors, improper diet, trauma
• Pathological factor affects the yin/yang of
individual ‘zang-fu’ organ and blockage of Qi
flow with resultant symptom
TCM Diagnosis
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General inspection
Listening – take note to symptoms
History taking
Pulse diagnosis
Tongue diagnosis
Principle of TCM Treatment
• To restore the balance of yin/yang of the body
and/or diseased ‘zang-fu’ organ
Acupuncture
Theory of Acupuncture
• 12 paired and 2 midline meridians distribute
throughout the limbs and body surface
• Meridians are named in accordance to the ‘zang-fu’
organ, limb and anterior/posterior distribution
– Lung meridian of hand Tai-yin and Bladder meridian of foot
Tai-yang
• Function of meridian is to regulate and modify the
corresponding organ or group of related organs
• Meridians can be accessed via acupuncture points
• Acupuncture – insertion and manipulation of needles
to unblock the channel and restore Qi flow
Mechanisms of Acupuncture
• Endorphins theory
– Analgesic effect reversed with opioid antagonists and animals
with hypophysectomy
» Takeshige C. Brain Research Bulletin 1992;27(1):37-44
– Elevated level of CSF -endorphin and plasma enkephalin in
patients after acupuncture
» Clement-Jones VL. Lancet 1980;2(8201):946-949
» Kiser RS. Lancet 1983;2(8364):1394-1396
• Serotonin and descending pathway
– Analgesia by high frequency electroacupuncture attenuated by
5-HT antagonist
» Tsai HY. Chin Pharmacol J 1989;41:123-126
• Modulation of nocipcetion
– Down regulation of glutamate receptors at spinal interneurons
» Choi BTJ. Acta Histochem 2005;107-67-76
Acupuncture Points
• The specific sites through
which the qi of the ‘zangfu’ organs is transported
to body surface
• There are 365 classic
points along the
meridians
• Nomenclature system
developed in accordance
to the meridian and
number, along side with
Chinese name
PC6 - Neiguan
ST36 - Zusanli
LI 4 - Hegu
Acupuncture Points
• The relationship of acupoints to anatomical landmarks
is usually described in terms of Chinese inch
• Usually tender on pressure compared with surrounding
tissue
• Diameter varies and depends on individual point,
patient’s condition, time of day etc
• Depth – 3-15 mm
• On needle stimulation, a specific sensation called De-Qi
would be elicited – soreness, numbness, warmth,
heaviness or distension
• Manual stimulation of needle until “De-Qi” in order to
achieve therapeutic effect
Technique of Acupuncture
Acupuncture and Related Technique
• Electroacupuncture
Acupuncture and Related Technique
• Electroacupuncture
• Acupressure
Acupuncture and Related Technique
• Electroacupuncture
• Acupressure
• Acu-stimulation
Acupuncture and Related Technique
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Electroacupuncture
Acupressure
Acu-stimulation
Moxibustion
Acupuncture and Related Technique
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Electroacupuncture
Acupressure
Acu-stimulation
Moxibustion
Auricular acupuncture
Clinical Applications of Acupuncture
• The World Health Organization issued a list of
medical conditions that may benefit from
acupuncture
– Prevention and treatment of PONV or
chemotherapy-induced nausea/vomiting
– Pain
– Alcohol and other drug addiction therapy
– Asthma and bronchitis
– Rehabilitation from neurological damage
Dimond EG. JAMA 1971;218(10):1558-1563
• 12 patients
• 4 patients required no
rescue local anaesthetic
• 8 patients required
supplemental LA of 1-4
ml of 1% lignocaine
Acupuncture
Anaesthesia
• Could not be reproduced
• Inadequate block lasted
for 10-15 minutes
• Subjects needed highly
motivated
• Not practiced even in
China
• Used as adjuvant rather
than sole anaesthesia
Role of Acupuncture in Anaesthesia
• Pre-operative preparation
– Several randomized control trials with auricular
acupuncture have shown the effective treatment
for pre-op anxiety
» Chernyak GV. Anesthesiology 2005;102:1031-1049
– Use of auricular acupuncture to alleviate parental
anxiety in paediatric surgical patients
» Wang SM. Anesthesiology 2004; 100:1399-1404
Intra-operative Use of Acupuncture
• Acupuncture was not significantly different
from placebo acupuncture as an adjunctive
analgesia during surgery
» Lee H. Pain 2005;114:511-517
» Usichenko TI. Pain 2005;114:320-327
• Electro-acupuncture at ST 36 (Zusanli), GB34
(Yanglingquan) and BL60 (Kunlun)
– No reduction in anaesthetic requirement in 14
volunteers
» Morioka N el al. Anesth & Analg 2002;95(1):98-102.
Post-operative Pain Control
• Systematic review – 15 RCTs
– Surgery types – abdominal, hip arthroplasty, dental,
maxillofacial, thoracotomy, knee arthroscopy, spine
– Acupuncture – EA, auricular, acupressure
– Outcomes – reduced morphine consumption, reduced pain
scores, lower incidence of opioid-related side effects
– Acupuncture is a useful adjunct for post-op pain
management
Post-operative Nausea and Vomiting
• Systematic review of 40 trials involving 4858
patients
• Compared with sham treatment, PC6 acupoint
stimulation significantly reduced nausea,
vomiting and rescue anti-emetic
• No difference compared with anti-emetics
» Lee A. Cochrane DAtabase Sys Rev 2009;15(20:CD003281
However, I was in considerable discomfort if not pain during the second
night after the operation, and Li Chang-yuan, doctor of acupuncture at the
hospital, with my approval, inserted three long thin needles into the outer
part of my right elbow and below my knees and manipulated them in order
to stimulate the intestine and relieve the pressure and distension of the
stomach.
That sent ripples of pain racing through my limbs and, at least, had the
effect of diverting my attention from the distress in my stomach.
Meanwhile, Doctor Li lit two pieces of an herb called ai, which looked like
the burning stumps of a broken cheap cigar, and held them close to my
abdomen while occasionally twirling the needles into action.
All this took about 20 minutes, during which I remember thinking that it
was a rather complicated way to get rid of gas in the stomach, but there
was noticeable relaxation of the pressure and distension within an hour
and no recurrence of the problem thereafter.
James Reston, 1971
Acupuncture in GI Disorders
• Acupuncture has been shown to reduce acid
secretion, reduce GI motility and visceral pain
• Mechanism – via somatosympathetic pathway
Use of Acupuncture for Colonoscopy
Sedation
• Electroacupuncture
to LI4, LI11, ST36
• PCA propofol for
sedation
• Preliminary result –
reduced propofol
requirement for
more than 50%
Adverse Events of Acupuncture
• Adverse events of more than 3000 treatment 3.2%
– Haemorrhange 32%
– Haematoma 28%,
– needle site pain 13%
» Park JE. J Alternative Comp Med 2010;16(9):959-963
• There is general agreement that acupuncture is
safe when administered by well-trained
practitioners using sterile needles (National
Institute of Health, 2007)
Adverse Events Associated with
Acupuncture
• A survey in China
involved 1968 cases
• 74 patients (3.76%)
reportedly to have
adverse events
• Higher risk in elderly
and male patients
Zhao L. Trials 2011;12:87
Critics on Acupuncture
• Review on systematic review and meta-analysis
• Questionable efficacy on pain management
• Fatal complications can occur
Research on Acupuncture
• The scientific basis of acupuncture remains
unclear
• Publication bias
• Difficulties in study design
– Blind observers and subjects
– True placebo needling impossible
– Sham needling was shown to have therapeutic
effect
– Placebo effect
New Design on Placebo Needles
Usichenko TI. Pain 2005;114:320-327
Streitberger Needle Device
McManus CA. Acupuncture Med
2007;25(1-2):36-40
Role of Acupuncture in Clinical Practice
• Despite much skepticism, half of physicians
believe acupuncture is efficacious
• Stable and substantial increase in the use of
acupuncture across all socio-demographic
groups
• More than half of surgery patients had a
favourable attitude towards the use of
complementary and alternative medicine
» Chernyak GV et al. Anesthesiology 2005;102(5):1031-1078
Patient Selection for Acupuncture
• The practice of acupuncture requires certain skill,
experience and theoretical knowledge
• Patients in general will have poor response
– Elderly
– Extremely sick patients
– Poor attitude and faith towards acupuncture
• 10% of population are “non-responders’, ie “DeQi” sensation cannot be elicited – hence,
advisable to trial on 1-2 acupuncture points
before the decision for treatment
Summary
• TCM and acupuncture theory is not scientific
based and remain philosophical metaphor
• Mechanism of action of acupuncture is not
completely understood
• No effect of acupuncture on anaesthetic or intraoperative analgesic requirement
• Acupuncture has been shown to be effective in
pre-operative anxiolysis, post-operative pain
management, PONV and other GI side effects
• Further research is needed to define the use of
acupuncture in peri-operative period
Thank you