ARTICLE IN BRIEF
The US Food and Drug Administration earlier this year recommended that clinicians learn more about acupuncture and other alternate therapies for pain management. Two neurologists, who are both licensed acupuncturists, discuss the ways they incorporate acupuncture in their practice for managing headache and neuropathic pain.
With the opioid crisis fueling increased national interest in finding alternative ways for treating pain, the US Food and Drug Administration published a blueprint for health care providers earlier this year, recommending they learn more about the non-pharmacologic approaches to pain management (https://bit.ly/2nt8fX5). Still, in many practices, there remains a sizable gap between traditional and alternative therapies — as well as who administers each.
At the AAN Annual Meeting in April, several neurologists demonstrated how they were working at their own institutions to bridge that divide and improve treatment options.
“I think that one of the biggest problems in the field is that there are ‘traditional’ and ‘alternative’ methods, whereas in reality both treatment methods have benefits and drawbacks. I really do believe that neurologists are perfectly poised to lead the future of pain management because we understand the nervous system better than any other specialty,” said Jennifer Bickel, MD, FAAN, chief of the headache section in the division of neurology and associate professor of pediatrics at Children's Mercy Kansas City and University of Missouri at Kansas City School of Medicine.
Neurology Today spoke to Dr. Bickel and other neurologists about their holistic approaches to pain treatment through the integration of acupuncture, meditation, and/or other mind-body methods with standard neurological care.
THE ‘NEUROSCIENCE OF COMFORT’
Dr. Bickel admitted she was once a complete skeptic when it came to acupuncture. “I thought acupuncture was all placebo — for years I would say to patients that they could go get it if they want, but I was always concerned that they would come back with a bag of Chinese herbs that I wouldn't know what to do with,” she told Neurology Today.
So how did Dr. Bickel come to lead neurologists through acupuncture demonstrations in the Live Well section of the most recent AAN Annual Meeting in Los Angeles?
“In some ways, I've been a very traditional neurologist and practitioner, but I've seen gaps in the care we provide.”
She began to wonder if neurologists were perhaps “better at managing disease than we are at managing dysfunction?” In 2015, without high expectations, Dr. Bickel enrolled in a 300-hour continuing medical education training course on acupuncture. “I was the worst of students because I didn't think that ultimately it mattered where I put the needles to get good benefit.”
To her surprise, Dr. Bickel said, she was “humbled” by what she observed. “I don't believe in energy channels, but I do believe that acupuncture works in a way that we need to better understand from a neurological perspective.”
For example, she observed that performing acupuncture could elicit symptoms similar to benign migratory paresthesias down the locations of “these ‘channels’ in individuals that had no acupuncture training or preconditioning that would suggest a placebo response.”
Importantly, the role of perception, which she calls “the neuroscience of comfort,” in pain control cannot be ignored, Dr. Bickel said, and there is still a lot we don't know about this area. For example, some of her patients consider acupuncture life-changing despite the fact that they show no objective change on their pain scales, so there are these “benefits, like perhaps resilience,” that are difficult to study.
Acupuncture might benefit more than just the patient, she suggested, as it might also reduce burnout and improve satisfaction among neurologists and practitioners who administer the treatment by enabling them to provide hands-on care and establish a deeper bond with patients. “One of the other reasons I like physicians to be the ones to administer the acupuncture is we can manage patients' expectations better. A neurologist who has learned medical acupuncture is going to be more effective at addressing the underlying neurological condition than a non-neurologically trained acupuncturist.”
In her department, Dr. Bickel said, acupuncture is typically administered for migraine, chronic pain conditions, and musculoskeletal conditions; they use trigger point deactivation, scalp acupuncture, auriculotherapy, electro-acupuncture, and musculoskeletal treatments, including TENS-like treatments. Currently, they are expanding to include basic acupuncture protocol training/privileges for doctors throughout hospital, she added.
“I can tell you that it's not controversial within our neurology department. Everybody embraces it and has been able to see the value in it,” she said. As for the traditional Chinese medicine explanations for acupuncture, she considers them largely allegorical — “very similar to Greek mythology explaining lightning coming from Zeus. But I believe in lightning.”
Alexandra Dimitrova, MD, assistant professor of neurology school of medicine at Oregon Health & Science University (OHSU) in Portland, who is also a medical acupuncturist, told Neurology Today that she recently spoke at a Headache Symposium at her institution comprising about 150 health care practitioners, mostly primary care providers. “I began the talk by asking how many had experienced acupuncture as patients. To my dismay almost all attendees raised their arms. When I asked the same question at the AAN Annual Meeting in Los Angeles this year, less than half the audience raised their hands.”
She suggested the fairly progressive policy for insurance coverage for acupuncture in Oregon might have something to do with these numbers. “Coverage for acupuncture and other integrative treatments is part of our state policy in combatting the opioid epidemic,” Dr. Dimitrova added, whereas other states may not cover the treatment.
Dr. Dimitrova, who is also director of the Neurology Wellness Clinic at OHSU, which works to integrate acupuncture, lifestyle modifications (diet, exercise), and supplements with standard neurologic care, said that when she took over the clinic four years ago, she found it difficult to combine acupuncture treatment with typical neurology outpatient care.
“There were multiple challenges,” she said. For example, they had to change clinic templates to accommodate both regular neurologic visits and acupuncture visits, use comfortable beds for treatments as the standard exam tables are not suited for acupuncture, deal with the insurance pre-authorization process and out-of-pocket cost determination, and determine billing and clinical indications for treatment, she said. Now, the clinic is “thriving.”
“I work with a licensed acupuncturist — Lucy Yeo, MAcOM, who provides indispensable perspective on traditional Chinese medicine approaches, including herbs. We often see patients, for which our clinic is a last resort. As my training in acupuncture was in structural acupuncture, which is anatomy-based and well suited to physicians, I tend to select acupuncture points which are closely associated with peripheral nerves,” she said. She also uses something called “electro-acupuncture,” which involves “attaching small clamps to the acupuncture needles and delivering a targeted low-intensity electrical stimulus for more powerful stimulation.”
Dr. Dimitrova said this has been particularly useful for neuropathic pain (including small fiber neuropathy), cervical radiculopathy, and various muscle spasms (especially involving the paraspinal muscles, neck, and shoulders).
Dr. Dimitrova's main research interests involve “mechanistic studies of acupuncture's effect on the peripheral nervous system, using neurophysiologic techniques such as nerve conduction studies and quantitative sensory testing.” She is studying the local, nerve-specific effects of treatment, as well as the dose-response and duration of treatment effects.
The research-base for complementary and alternative therapies is certainly growing as more patients seek out these types of care. [See “By the Numbers: CAM Therapies for Neurological Conditions” for study highlights.]
For example, Drs. Bickel and Dimitrova cited a 2016 Cochrane review, which found strong evidence for acupuncture for the treatment of migraine. “The authors found that an eight-week or longer course of acupuncture is effective for migraine prophylaxis, with benefits sustained up to 12 months, compared to standard care not involving daily prophylactic medication. Acupuncture was also found comparable to daily preventative medication, with a better side effect profile,” Dr. Dimitrova noted.
Acupuncture poses unique challenges when it comes to research, the clinicians acknowledged. “While recent studies tend to be of better methodological quality, acupuncture research has been plagued by multiple problems such as insufficient blinding of both subjects and outcome assessors, use of subjective outcome measures, improper randomization, lack of power/effect size calculations and a priori statistical plan, use of inappropriate statistical methods and often significant cultural bias in favor of acupuncture, with high drop-out rates in the non-acupuncture arm of the trial, which are usually not addressed,” Dr. Dimitrova said. Another great challenge is that there is no established theory for acupuncture's mechanism of action, she added.
“Unfortunately, on a national level the majority of neurologists and physicians in general know relatively little about acupuncture. They do not know what it is effective for and what to refer patients for,” Dr. Dimitrova said, adding that medical schools present little evidence-based information about acupuncture and integrative medicine modalities so doctors are often uncertain about its benefits. “I hope to play a role in educating my colleagues and plan to participate in a newly formed Outreach Committee of the American Academy of Medical Acupuncture.”
Dr. Jennifer Bickel receives research funding from Pfizer Independent Learning and has a consulting agreement with Theranica. Dr. Mulukutla has nothing to disclose. Dr. Dimitrova receives funding from the National Center for Complementary and Integrative Health.
BY THE NUMBERS: CAM THERAPIES FOR NEUROLOGICAL CONDITIONS
- Ju ZY, Wang K, Cui HS, et al. Acupuncture for neuropathic pain in adults. Cochrane Database Syst Rev 2017; 12:CD012057.
- A review of six clinical trials of manual acupuncture involving 462 adults with chronic peripheral neuropathic pain found insufficient evidence to support or refute acupuncture for neuropathic pain.
- Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev 2016; 6:CDC001218.
- A review of 22 randomized trials of at least eight weeks with a total of 4985 participants with a primary outcome of migraine frequency after acupuncture treatment and at follow-up when compared to a no-acupuncture, sham acupuncture, or prophylactic drug control group. Compared to no treatment, acupuncture moderately reduced headache frequency (standardized mean difference (SMD) -0.56; 95% CI -0.65 to -0.48). After treatment, headache frequency at least halved in 41 percent of participants receiving acupuncture and 17 percent receiving no acupuncture (pooled risk ratio (RR) 2.40; 95% CI 2.08 to 2.76).
- When compared to sham treatment, acupuncture showed a small but statistically significant reduction over sham treatment (SMD= -0.18 (95% CI -0.28 to -0.08) after treatment and -0.19 (95% CI -0.30 to -0.09) at follow-up). Headache frequency at least halved in 50 percent of participants receiving acupuncture and 41% receiving sham acupuncture; at follow-up, in 53% and 42%, respectively.
- When compared with prophylactic drug treatment, acupuncture reduced migraine frequency significantly (SMD -0.25; 95% CI -0.39 to -0.10), but the significance was not maintained at follow-up (SMD -0.13; 95% CI -0.28 to 0.01).