Auricular acupuncture in treatment of pain

Taras Usichenko

Department of Anaesthesiology and Intensive Care Medicine Ernst Moritz Arndt University of Greifswald

Outline

•  Intoduction

– Potential mechanisms

–  Indications for treatment of acute pain & chronic pain

– How to avoid side effects and complications

• Demonstration with practice

–  Identification of AA points

– Needling

Auricular acupuncture ≈ stimulation of cranial & cervical nerves

Greater occipital n.

Auriculo- temporal n.

Auricular branch of vagal n.

Peuker Dtsch Z Akupunktur 2003

Innervation of external auricle

fMRI-investigation of electric stimulation applied to auricular concha

Increase of neuronal activity in brain stem (locus coeruleus)

Dietrich et al Biomed Techn 2008

Trigeminal Vagal Cervical

Sources of afferent nerve supply

Potential analgesic mechanisms of auricular stimulation - summary

Activation of:

- descending noxious inhibitory system (DNIC) including

- antinociceptive endogeneous opioid system of brain stem

- cholinergic anti-inflammatory pathway via vagal nuclei

Clinical indications for auricular stimulation in treatment of pain

•  auriculotherapy reduced analgesic use for perioperative pain

•  for acute pain and chronic pain, auriculotherapy reduced pain intensity

Patients, who received PERIOPERATIVE auriculotherapy, required less analgesics than those from the control group

Asher et al J Alternat Compl Med 2010

Auriculotherapy vs. control condition in treatment of POSTOPERATIVE PAIN after: • molar extraction • hip arthroplasty • knee arthroscopy

Outcome: analgesic requirement

Auricular acupuncture reduced opioid requirement after hip arthroplasty by 36%

Main Result

Indwelling AA needles

Asher et al J Alternat Compl Med 2010

Patients with CHRONIC PAIN, who received auriculotherapy, reported less pain than the patients from the control group

Auriculotherapy vs. control condition in treatment of CHRONIC PAIN: • cancer pain • chronic pain in patients with TMD • distal arm chronic pain • cervical pain • low-back pain

Outcome: analgesic requirement

Auricular electroacupuncture in patients with CHRONIC low-back pain

Sator-Katzenschlager et al Anesth Analg 2004

Patients with chronic low back pain randomised to: - auricular electroacupuncture (EA) - auricular acupuncture (CO) Intervention: - stimulation P-StimTM 48 hours weekly for 6 weeks - rectangular pulse 0.1 ms, 1Hz, max. 4 mA

Methods

P-Stim device at acupuncture points: lumbar spine (40), shen 6 men (55) and cushion (29)

Results

•  Female, 77 yrs old, 45 kg

•  Chronic low-back pain because of

lumbal stenosis L4/5 due to spondylolisthesis

•  coronary artery disease, 2 myocardial infarction

Dorsal & ventral osteosynthesis, spondylodesis & hemilaminektomy

Case of chronic low-back pain treated with transcutaneous fentanyl

History Surgery

•  Fentanyl-patch 75 mcg/h

since 1 yr

FNT t.c. 75 ~ 31,88 EUR

Auricular acupuncture to assist opioid reduction for chronic low-back pain

Acupuncture using indwelling fixed needles to support fentanyl reduction

White AR Acupunct Med 2004

It is expedient to take care because of known ADVERSE EFFECTS and COMPLICATIONS of AA

•  The most common complication of AA is infection

•  Vasovagal reactions are possible

•  Recommendations:

- puncture in supine (or at least sitting) position

- desinfection

- avoid needling, choose acupressure in patients with

cardiac valve disease, diabetes mellitus, suppressed immunity

Acute perichondritis of the ear. From: Manual of ENT surgery, Thieme, 1989.

•  Inspection

•  acute inflammation: discolorations (red or brown)

•  chronic conditions: flaky white dry areas

•  Palpation

•  Detection of skin areas with lower impedance

Search for stimulation points,

when you already know the diagnosis

Ogal 1998

Palpation and detection of areas with lower skin impedance

Usichenko et al Acupunct & Electrother Res 2003

Palpation only

It is assumed that the skin impedance of acupuncture

point is lower compared to surrounding tissues

Electrical resistance in dependence from distance to acupuncture point

Hyvarinen & Karlsson 1977

•  Clean with C2H5OH

•  Auricular acupuncture points vs. body points:

–  smaller

–  closer to surface

–  have lower resistance

Even small lesions of epidermis lead to strong

reduction of skin impedance at lesion points

Bossy Am J Acupunct 1983

Stratum corneum has the highest resistivity

McCarroll & Rowley IEEE Trans Biomed Eng 1979

Even minimal lesions of stratum corneum lead to dramatic reduction of skin resistance

•  Analgesic effects of auricular stimulation can be explained

using the modern data from neurophysiology research

•  AA can be recommended for treatment of:

- chronic pain of various origin

- postoperative pain as complementary method

•  Serious side effects can be easily avoided

Conclusions