Pain is an unpleasant sensory and/or emotional experience and in most occasions, associated with tissue damage, or inflammation. Acute pain is defined as short-term pain or pain with an identifiable cause. Acute pain is a warning sign of current or underlined tissue damage, or disease and usually responds well to medications. Chronic pain is defined as pain that has lasted 6 months or longer. The pain can be constant or intermittent and has often outlasted its biological purpose, as it does not assist the body to prevent injury. Chronic pain is often more difficult to treat, and therefore, has become one of the most common factors that affect the life quality.
What are NSAIDs?
NSAIDs (non-steroidal anti-inflammatory drugs) are the most frequently used drugs for rheumatoid arthritis and osteoarthritis that cause joints stiffness, motion limit and pain. NSAIDs inhibit the cyclooxygenase enzyme that controls inflammation. NSAIDs also serve as an analgesic (painkiller) and are frequently taken for various types of pain. NSAIDs include a number of drugs (see Appendix: Types of NSAIDs).
What are COX-2 inhibitors?
COX-2 inhibitors are a newer type of NSAIDs that block the COX-2 enzyme at the site of inflammation. The benefit of COX-2 inhibitors is that they do not inhibit COX-1, an enzyme that helps with the production of the protective stomach lining. (Other types of NSAIDs, e.g., aspirin, block both COX-2 and COX-1, which can lead to gastrointestinal side effects such as GI bleeding). The COX-2 inhibitor drugs include Celebrex, Bextra and Vioxx.
Update on COX-2 inhibitor drugs
COX-2 inhibitors are the most commonly prescribed drugs for arthritis and are also prescribed for many forms of back pain. Since the September 30, 2004 recall of Vioxx, a popular COX-2 inhibitor, many questions have arisen regarding the potential side effects and health risks of COX-2 inhibitors and other traditional NSAIDs.
On April 7, 2005 the Food and Drug Administration requested that Pfizer suspend sales of its COX inhibitor drug Bextra (valdecoxib), a pain reliever for osteoarthritis, adult rheumatoid arthritis and severe menstrual cramps, in the United States. Bextra was pulled from the market due to concerns an increased risk of heart attacks, strokes and a potentially fatal skin condition called Stevens-Johnson syndrome. (Please check www.bextra.com for more information.)
FDA stresses its recommendation to choose alternative therapies on pain relief and urges doctors to limit use of Cox-2 inhibitors to patients who can’t take other pain treatments.
Are COX-2 inhibitors and other NSAIDs safe to use?
Generally, elderly patients and those who take the drugs for long periods of time tend to be more susceptible to known side effects, such as gastrointestinal, kidney and liver damage. Also, elderly patients are at higher risk of heart attack and thus are more vulnerable to the extra heart burden of NSAIDs. All patients should avoid the prolonged use of NSAIDs. Based on the FDA recommendation, over-the-counter NSAIDs should not be taken longer than 10 days without checking your doctors. Patients are encouraged to see their doctors to discuss the safer drugs and the best treatment course, based on individual risk factors and needs and talk about the alternative approaches (e.g., acupuncture, Chinese medicine and physical therapy) known to be safe and effective.
Other pain medications
Some commonly used drugs availe for neuropathic pain include N-methyl-D-aspartate antagonists (e.g., dextromethorphan), local anesthetics (e.g., lidocaine), antiepileptic drugs (e.g., carbamazepine, gabapentin), antidepressants, opioids, and tramadol.
While drugs (e.g., steroids, NSAIDs, local anesthetics, antidepressants and anticonvulsants) and surgery remain as the most common options of pain management in mainstream medicine, more people are becoming aware that acupuncture is a natural, safe and effective therapeutic approach to pain relief and related functional recovery. Patients suffering from pain who are not treated effectively or those who have found themselves too dependent upon drugs for pain relief could benefit greatly from acupuncture and other alternative therapies. This is especially true after COX-2 inhibitors and other NSAIDs in the news causing potential life-threatening side-effects.
Acupuncture is part of Traditional Chinese medicine and one of the most popular therapeutic options in pain management. It promotes the body’s natural healing ability and improves physical functioning by restoring Qi (vital energy) flow and Yin-Yang balance. Acupuncture is carried by inserting sterile, disposable fine needles at the well-selected acupuncture points along the Qi meridians (or energy channels) through the body and over its surface.
In Chinese medicine, pain is considered as a result of the block of certain Qi meridians. The obstruction in Qi meridian is like a dam backing up the energy river that produces turbulence in one part of the body and restricts the energy flow irrigating in others. The insertion and manipulation of acupuncture needle unblock the obstructions at the dams and thus reestablish a normal Qi flow through the meridians, which in turn, relieves the symptoms (e.g., pain) and restores the functions of the organs and tissues in the territories nourished by the offended meridians.
In the view of biological medicine, acupuncture involves stimulation of certain points by penetration of the skin with thin, solid needles which are manipulated manually or by electrical stimulation. The relationship between acupuncture points and the nervous system is demonstrated by the following statistic: out of 324 points studied, 99% were within 0.5mm from innervation of cranial spinal nerves, 96% were related to superficial cutaneous nerves, and 86% were beside an artery.
The mechanisms of pain relief accomplished through acupuncture is not fully clear on the scientific base. There are many theories trying to address the issue. Currently, the pain reduction by acupuncture stimulation is thought to relate to the following mechanisms: 1) shutting down the flow of peripheral signals, through a neural mechanism like kind of “gate” in the spinal cord, to the brain that perceives the pain; 2) the release of opioid peptides, the naturally occurring chemicals in the brain that have an analgesic effect; and 3) the stimulation by acupuncture may also activate the hypothalamus and pituitary gland, alter the section of neurotransmitters and neurohormones, change blood flow regulation, and positively affect the immune system (1).
Researches performed in science and medical communities over the world have shown that acupuncture is an effective means of relieving pain, including back pain, headache pain and other types of pain such as arthritis (osteoarthritis and rheumatoid arthritis), neuromuscular injuries, fibromyalgia, carpal tunnel syndrome, labor pain, and cancer-related pain. The following are some examples of the clinical studies on acupuncture treatments of various pain problems.
In December 2004, a landmark study funded by the National Institutes of Health (NIH) was published in the Annals of Internal Medicine, which showed that acupuncture provides pain relief and improves function for people with osteoarthritis of the knee and serves as an effective complement to standard care. The study was the longest and largest randomized, controlled phase III clinical trial of acupuncture ever conducted (2).
A randomized trial published in the Nov. 20 issue (2004) of the British Medical Journal showed that acupuncture, as a complementary therapy to drug treatment for osteoarthritis (OA) of the knee, is more effective than drug treatment alone.
Traditional acupuncturists treat the whole person rather than a disease and therefore attempt to get to the root cause of the problem rather than treating the symptoms. There are several studies suggesting that acupuncture can be very helpful in the treatment of arthritis and more specifically Ankylosing Spondylitis. A study in Russia (3) found that 73% of patients suffering from Ankylosing Spondylitis benefited from acupuncture treatment. When acupuncture was combined with UV light treatment the response rate increased to 93% .
In another study, 54 Rheumatoid Arthritis sufferers were given acupuncture (warm needling) with Zhuifengsu (chinese herb). The effective rate was found to be 100% (4).
A study of auriculo-electropuncture (AEP) – treatment of points on the ear – by a double blind method was conducted in Russia with 16 arthrits patients (5). Not only did they all feel better as a result of the treatment but they all showed “statistically significant” improvement in blood samples.
Back pain, frozen shoulder and tennis elbow
A study on acupuncture for low back pain provided convincing evidence that patients who received acupuncture improved more than patients who received sham acupuncture or no treatment (6). Published studies did not determine whether acupuncture works better than other low back pain treatments or whether acupuncture benefits patients with acute low back pain.
Frozen shoulder (capsulttis) is generally considered to be a spontaneous, progressive pen-arthritis over the shoulder joint. The conventional treatments include cortisone injections and physiotherapy, neither of which are particularly successful in the majority of cases. A stuty conducted by the Department of Anaesthesiology, Taipei Municipal Chung-Hsing Hospital showed that the combined electroacupuncture and RNB had significant high pain control quality, longer duration, and better range of movement of the shoulder joint than that of electroacupuncture or RNB performed alone. The results show how conventional and complementary medicines can work side by side to produce a superior therapeutic effect than either one can by itself.
A controlled study on patients with tennis elbow from a North of England suggested significant success in pain relief when using acupuncture before administering local corticosteroid injection, which allows a much lower dose of steroid to be used, with consequent reduction in the risk of tissue necrosis and inflammatory reaction (7).
The administration of analgesics which used to be their local treatment for migraine can neither give a radical cure nor avoid certain side effects.
Doctors have reported tremendous success with acupuncture treatment of migraine headaches. In contrast to drugs, acupuncture treatment seems to be very effective in preventing the attacks from ever occurring or rendering them much less severe when they do hit.
Researchers in Denmark (8) demonstrated that acupuncture offers significant benefits for migraine sufferers. The researchers monitored 85 patients with a history of migraine in a randomised, double-blind study in which acupuncture treatment (dry needling to acupoints in the neck) was compared to the drug metoprolol in the prevention of migraine attacks. All of the patients, investigators and statisticians were blinded as to treatment, and the therapist was blinded as to results.
Soon after, German researchers continued in this line of study by investigating the effects of acupuncture in preventing migraine attacks (9). The results revealed that there was a statistically significant therapeutic effect and marked decrease in migraine attacks observed in the patients in the acupuncture treatment group which was not observed in the placebo group. The researchers concluded that their results indicated that acupuncture is a useful interval therapeutical agent for migraine sufferers and called for further studies to be carried out to try and identify and understand the exact mechanism or trigger that is responsible for the treatment.
The study by the Department of Family Medicine, School of Medicine, University of Maryland at Baltimore revealed that the average (mean) pain-free postoperative time was significantly longer in the acupuncture group (172.9 minutes) than in the placebo group (93.8 minutes) (P=.01), Average pain medication consumption was significantly less in the treatment group than in the placebo group (P=.05). Outcomes were not associated with psychological factors in multivariate models (10). The investigation concluded that acupuncture is superior to the placebo in preventing postoperative dental pain.
Stomach carcinoma pain
Clinical observation on 48 cases of stomach carcinoma pain indicated that acupuncture including filiform needle group and point-injection group had better therapeutic effects in treatment of stomach carcinoma pain when patient’s mind was concentrated at the site of disease (11).
Pain management in our clinic
As one of the best acupuncture clinics in Houston, Texas, Oriental Art of Healing clinic has accumulated numerous successful stories in pain management with acupuncture and Chinese medicine.
Our acupuncturists have been well trained not only in acupuncture and traditional Chinese medicine (TCM), but also in Western medical sciences and have practiced in both hospital and clinic settings. This allows our acupuncturists to efficiently communicate with a Western physician in interpreting the conventional medical diagnostic data and treatment protocols. Unlike a Western primary physician or specialist, we spend more time to listen to and stay with a patient during a visit. Besides treating symptom (i.e., pain reduction), we focuses on treating the root causes of pain by promoting the body Qi flow, restoring the inner balance, and enhancing self-healing ability according to the TCM etiology for individualized case, which is known a beauty of traditional Chinese medical care.
By Henry D Wu, MD, MS, LAc & Sharon Y Weng, OMD, MS, LAc
The information provided in this article should not be a substitute for
the medical advice from your physician. © All Rights Reserved.
(1) Lexis-Nexis search: NIH Consensus Conference. “Acupuncture”. JAMA (1998); 280(17) :1518-1524.
(2) Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AMK, and Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Annals of Internal Medicine (2004); 141(12):901-910.
(3) Tsarev IuK and Troshina ED. The combined use of acupuncture and UV irradiation in treating the neurological manifestations of lumbar osteochondrosis. Vopr Kurortol Fizioter Lech, Fiz Kult (USSR) May-Jun 1991(3): 25-29.
(4) Liu X, Sun L, Xiao J, Yin S, Liu C, Li Q, Li H, and Jin B. Effect of acupuncture and point-injection treatment on immunologic function in rheumatoid arthritis. General Hospital of PLA, Beijing. J Tradit Chin Med (1993); 13 (3):174-178.
(5) Ruchkin IN. Auriculo-electropuncture in rheumatoid arthritis (a double-blind study). Burdeinyi AP Ter Arkh (1987); 59 (12):26-30.
(6) Manheimer E, White A, Berman B, Forys K, and Ernst E. Meta-Analysis: Acupuncture for Low Back Pain. Annals of Internal Medicine (2005); 142: 651-663.
(7) Chilton SA. Tennis elbow: a combined approach using acupuncture and local corticosteroid injection. Acupuncture in Medicine (1997); 15 (2):77.
(8) Hesse J, Mogelvang B, and Simonsen H. Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation. Pain Clinic and Medical Department, Skodsborg Sanatorium, Denmark: Journal of International Medicine (England) (1994); 235 (5): 451-456.
(9) Weinschutz TK and Niederberger U. Relevance of acupuncture in migraine therapy (Zum Stellenwert der Akupunctur in der Migranetheerapie) Klinik fur Neurologie, Christian-Albrechts-Universitat, Niemannsweg 147, D-24105: Kiel Germany Nervenheilkunde (Germany) (1995); 14/5A:295-301.
(10) Lao L, Bergman S, Hamilton GR, Langenberg P, and Berman B. Department of Family Medicine, School of Medicine, University of Maryland at Baltimore, USA. Arch Otolaryngol Head Neck Surg (1999); 125(5):567-572.
(11) Dang W and Yang J. Chengdu College of Traditional Chinese Medicine, Chengdu, China. J Tradit Chin Med (1998); 18(1):31-38.
Appendix: Types of NSAIDs
The following is a list of different types of NSAIDs: including traditional (non-selective) NSAIDs and COX-2 inhibitors (selective) NSAIDs.
Aspirin (Ascriptin, Bayer, Ecotrin)
Choline magnesium trisate (Trilisate)
Salsalate (Disalcid, Salflex)
Ibuprofen (Advil, Motrin, Nuprin)
Ketoprofen (Actron, Orudis, Oruvail)
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
Sulindac (Clinoril )
Piroxicam (Feldene, Fexicam)
Mefenamic acid (Ponstel)
Valdecoxib (Bextra) (Pulled from the market)
Rofecoxib (Vioxx) (Pulled from the market)