General Practitioners, Pain and Acupuncture: an established trend

Simon Strauss M.D.
e-mail: simons@atnet.net.au

Australia along with other Western countries is experiencing an epidemic of chronic pain. 
Studies carried out in Canada, United States Of America and Sweden reveal similar patterns of pain epidemiology as those recently found in Australia.

Many Australian GPs have responded to their patients' needs by adding pain management tools to their practices. These tools frequently include, pain assessment techniques, Acupuncture, Manipulation, Relaxation training and Re-education of job task and posture. Virtually none of Australia's medical undergraduate curricula include courses on pain management and as a consequence, most practitioners have acquired their skills in this area outside mainstream medical educational facilities.

Medical acupuncture in particular is one of general practice's growth areas. 

From the early 1970s when only a few medical practitioners used acupuncture, there is now widespread use and integration of afferent stimulation techniques developed from Traditional Chinese Acupuncture. (Stimulation techniques developed from Traditional Chinese Acupuncture include Dry needling, Electro-acupuncture and TNS, Trigger point injection and dorsal column stimulation.)

This integration of Acupuncture into Australian medical practice has not been easy.
 
During the mid 1970s the Australian Health Department actively sought to discourage medical practitioners from using Acupuncture by introducing substantial financial disincentives. If a single acupuncture point was stimulated, then all services including long consultations, home or hospital visits, and associated consultations reverted to the level of a standard consultation. These rulings are still in force.
 
Additionally the practice of acupuncture entails substantial costs. For high quality medical acupuncture the working rule is one room per patient hour. Younger patients may take less time but older patients tend to take longer because of undressing and dressing times. Needles for most chronic conditions should be left in situ for 20 minutes or more. For most practitioners with limited space this means that only a few patients / hour can be serviced. Patients with needles in situ, having electrical stimulation or moxibustion, also require close monitoring. Despite these negative factors evidence of the growth of acupuncture is easily found. 
 
 
 
The Australian Medical Acupuncture Society (AMAS) founded in 1974 has over 600 members and is the Australian Medical Association's second largest affiliate body. At present, well over 2000 of Australia's 18,000 general practitioners have used the Medicare acupuncture item number and the numbers continue to increase.
 
There is also an increasing willingness from the wider General Practice community to refer patients for Acupuncture treatment. This acceptance seems to be age related as shown below.
 
Why is it then that Acupuncture has become so wide spread? 
What is the driving force behind this acceptance of what only a decade ago was thought of as fringe or alternative?

The dominant factors seem to be:
That it works.

What is the Evidence that Acupuncture Works?

The results of acupuncture depend on a close knowledge of the technique and the functional status of the patient. Consequently there is no valid "shotgun" method of needling that applies to all patients with the same condition and so it is impossible to design a satisfactory double-blind trial.
When a valid double-blind evaluation technique is developed for laminectomies, nerve blocks, cognitive psychotherapy etc., this will provide a suitable model for acupuncture.

The results of controlled studies which have been extensively reviewed [ 1 ] show good evidence for the short term effectiveness of acupuncture in many pain states. The long term studies, particularly where the well trained acupuncturist has been given the freedom of ( traditional ) normal practice profiles, have been encouraging, with success rates far higher than those associated with placebo response.

How Does It Work?


The close correlation between local acupuncture points for pain and trigger points as noted by R. Melzack [2], co-author of the gate theory of pain, represents a major convergence of Western and Eastern knowledge. The traditional Chinese "Ah Shi" (translates to 'Oh yes') points are frequently equivalent to trigger points at which the application of pressure reproduces the pain syndrome. The near-and-far acupuncture technique, where needles are placed at the Ah Shi / Trigger points as well as distal points is the most commonly used technique in modern China today. The neurophysiological effects of needling of trigger points are currently being explored. Relaxation of "stuck" myofibrils, increased local blood supply, the release of spinal dynorphin and encephalin have all been postulated to explain the rehabilitative effects of trigger point needling. The distal points usually below the elbow or knee which are used to modulate the sympathetic nervous system and the various 'pain gates' represent another meeting point between modern neurophysiology and ancient traditional Chinese acupuncture. Trigger points or ahshi points can be analysed clinically by using a tissue sensitivity gauge [3]. How trigger points are involved in the pathogenesis and maintenance of commonly encountered pain states and their involvement with the Autonomic Nervous System remains occult and is an important area of research that may well resolve many of the questions involving common pain states. Melzack, in a recent article on the role of compensation in chronic pain states, appears to support the importance of these concepts. " Patients who failed to respond to conventional forms of therapy were sometimes cured if the physician recognised that abnormal autonomic nervous system activity may persist indefinitely after a brief injury or that trigger spots may develop at the site of even relatively minor injury. Major procedures such as cordotomies may fail, but simple ones such as trigger point injections, may produce sudden remarkable recovery and subsequent return to work."

An Epidemic of Chronic Pain.

A survey of 265 randomly selected households in Brisbane, found that, 19% percent of individuals over the age of eighteen reported that they were "currently experiencing pain or were regularly troubled with pain." Over 35% of households included one or more persons who were "currently experiencing pain or were regularly troubled with pain". Females had a higher pain prevalence than males. Pain prevalence rates increased with age for both sexes. 

The pain conditions were typically: located in the back (33%), followed by head and neck (24%); leg (22%) and was described as discomforting by 40% and as either distressing, horrible or excruciating by 45%.  70% had suffered for more than three years with 60% reporting either daily or continuous pain. The most common cause for the pain was spontaneous or unknown (55%) or work related ( 21%). The most popular form of management was by the medical profession ( 80%), Chiropractors (5%) and Physiotherapists (3%). [ 4 ]


Conclusion.

Australia along with other western countries is facing an epidemic of chronic pain that will escalate with the greying of our population. At present around one in six Australian adults has a chronic pain syndrome, with one in 12 adults experiencing unacceptable levels of severe pain for many years. The majority of sufferers attend their G.P's for management, which has usually entailed the prescription of NSAI's and analgesics. Many Australian General Practitioners have acquired pain assessment and management skills to augment their more traditional therapies. They have done so in the face of considerable difficulties. However the sheer volume of patient demand and the recent changes in attitudes towards Acupuncture will ensure that many more GPs will embrace this cost effective and usually side effect free therapy.

References.

1.Richardson PH, Vincent PA. Acupuncture for the treatment of pain: a review of evaluative research. Pain 24: 15, 1986.

2. Melzack R. et al. Trigger points and acupuncture points for pain: correlations and implications. Pain 3: 3, 1977.
3. Reeves JL et al. Reliability of the Pressure algometer as a measure of myofascial trigger point sensitivity. Pain 24: 313, 1986.

4. Guthrie F, Nicolosi F, Strauss S. The prevalence of pain complaints in a general population; An Australian Study. Australian Association of Musculoskeletal Medicine
Bulletin Vol 9: 3 December 1993.