Pain Management
& Acupuncture
Simon Strauss MBBS Monash 1972.
Dip. Acupuncture Nanking 1978
This session
 Historical Perspective on Acupuncture
 Pain Epidemiology - The “Market”
 Introduction to Myofascial Pain Theory
 The Near and Far Acupuncture Technique
Acupuncture Practice An Established Trend
 Growth
of Acupuncture Outlets - Brisbane
120
100
80
60
40
20
0
1974 1976 1978 1980 1982 1984 1986 1988
Medical
Non medical
Acupuncture
Item 173 (980)

From 1984 to 1995 (National)
1,000,000
900,000
800,000
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
Item 173
84/85 86/87 88/89 90/91 92/93 94/95
Attitudes are age related.
76
80
68
70
54
60
50
% 50
Practicing Ac.
Recommending Ac.
40
30
18
14
20
10
10
2
4
6
0
<1960
60's
70's
80's
Total
Decade Registered
NHMRC. W.P.Document:
Management of Severe Pain
Core Curriculum for Medical Practitioners Identifies a need for Education on:
Acupuncture and Transcutaneous Nerve
Stimulation techniques.
 The measurement, quantification and
recording of pain.

International Association for
the Study of Pain (IASP)
Management of chronic pain: Core Curriculum for
Medical Practitioners, Dentists and Physiotherapists Recommends Education on:
1.Neurostimulation techniques including
a. Transcutaneous nerve
stimulation
b. Acupuncture
2. The measurement, quantification and
recording of pain
3. Myofascial Pain
What are the Dominant Factors Driving
this Acceptance of what only a Decade
ago was regarded as Alternative or
Fringe?

It Works

The results depend on the practitioner’s
skill.(Operator satisfaction)

Its’ mechanisms can be understood from a
Western scientific viewpoint

It is cost effective for the consumer

It has a high efficiency index.( +ve effects
far outweigh side effects.)
ADDITIONALLY
There is considerable demand
 1.

As Western Countries are
experiencing an “Epidemic” of Chronic
Pain.
2. That is poorly managed with our
classical techniques!
The Epidemiology of Pain: An
Australian Study
Brisbane. by F. Guthrie, F. Nicolosi
and S. L. Strauss.
Telephone survey of 265 Households

Household pain prevalence rate, 35.5%

Adult Individual pain prevalence, 19%

Overseas studies, (Canada, USA) have
shown similar prevalence rates.
Pain Prevalence
Increases with Age.

10% of 30 year olds

25% of 50 year olds

45% of >60 year olds

Over the age of 30 females’ pain incidence
is higher than that of males.
The Epidemiology Pain: An Australian Study
Location of most severe pain
The Epidemiology Pain: An Australian Study

As % of Pain States declared
Arm
4
5
Other
Chest
%
%
%
8
22
Leg
Head & Neck
24
33
Back
0
5
10
15
20
25
30
35
Intensity
The Epidemiology Pain: An Australian Study
45% can be regarded as suffering from
severe pain
Intensity
9
Excruciating
13
Horrible
23
Distressing
40
Discomforting
15
Mild
0
10
%
%
20
30
40
Duration
The Epidemiology Pain: An Australian Study
91% have “Chronic Pain”

Time since first occurrence of Pain State
67
>3Years
17.1
1-3 years
6.8
6-12 Months
3-6 Months
2.6
1-3 Months
3.3
Percentage
3
<I Month
0
20
40
60
80
Frequency
The Epidemiology Pain: An Australian Study
53% Daily or constant

Frequency of Pain Occurrence as a %
18.8
Variable
0.9
Yearly
Percentage
12.8
Monthly
14.5
Weekly
30
Daily
23
Constant
0
5
10
15
20
25
30
Cause of Pain state
Post Surgical = 2.6%
 Sports Injury = 3.4%
 Accident
= 18.8%
 Other = 19.7%
 Work Related = 21.4%
 Spontaneous = 34%

The Epidemiology Pain: An Australian Study
“Health Professional”
Consulted.

70% visited a “Health Professional”

30% no treatment or self treatment
The Epidemiology Pain: An Australian Study
Of those visiting a
“Health Professional”

80% consulted a Medical
Practitioner
 8% consulted a Chiropractor
5% consulted a Physiotherapist
 2% an Acupuncturist (Non-medical)
 The remaining 5% - Naturopath, Herbalist,

Iridologist etc.
The Epidemiology Pain: An Australian Study
The Epidemiology Pain: An
Australian Study: Summary

Household pain prevalence rate =35.5%

Adult Individual pain prevalence =19%

91% chronic pain (> 6 months)

45% severe to unendurable Pain Intensity

53% constant or daily

Back 33%, head and neck 24%, leg 22%

70% managed. (80% of managed -Medical)
10 High Street
A Private Practice “Multidisciplinary” Pain
Clinic.
Core Group: S Strauss, T McCarthy.
+ Physiotherapist, Psychiatrist, Masseuse

Established 1980

Research oriented

10,000 Patients.(25 new patients per week.)

60% Referred.
10 High Street. Pain State
Distribution & Age
 Breakdown of 1146 Patient’s Pain Syndromes
58
Sciatica
184
58
CBS
239
52
Headache
240
56
Shoulder
297
61
Back
393
58
Neck
0
100
Age
Number
398
200
300
400
10 High Street. Pain
Severity
97% Could be regarded as having severe pain
No Pain
Pain
Unbearable
30
25
20
15
%
10
5
0
1
2
3
4
5 Unbearable
10 High Street Compared c
General Pain Population
Comparison of pain severity
40
%
35
30
25
10 High St.
Gen. Pain P.
20
15
10
5
0
1
2
3
4
5 Unendurable
10 High Street. Reason for
Presentation
 Other
forms of treatment had not
helped: 63%
 “I’d
have tried anything if I thought it
would help”: 61%
10 High Street Patient’s
Profiles.

A picture emerges of desperate patients
suffering severe to unendurable pain for several
years, who had tried multiple forms of therapy
without gaining sustained relief.

The majority of these patients’ syndromes
involved the musculoskeletal system.

10 High Street patient’s had more severe, more
prolonged Pain States than those identified as
having pain in the general community.

? Due to referral bias. ( ? Fear of “needles”)
10 High Street. Research
Areas of Interest
Initial Aim was to explore Acupuncture's place within
Western Medical Practice: Its’ Mechanisms and
treatment results.
Led to an in depth investigation into
Trigger Points
Sympathetic Involvement
Pain Measurement Subjective: Pain diagrams,


VAS, McGill Pain Questionnaire
Pain Measurement Objective: Thermography,
Algometry, Axon Flare,
Differential Nerve Blocks:
Neurotrace, Cryoprobe etc
Cold Bi Syndromes:
A Starting Point

T.C.M’s Cold Bi syndromes include the majority
of chronic pain states where Ah Shi (Oh Yes)
points are associated with coldness of the
painful area. [ Nanking School TCM.]

T.C.M. characterises this “coldness” as being
due to a blockage of the flow of Qi and blood.

The T.C.M. treatment paradigm is to, “Remove
the obstruction thus allowing warming and
nourishing of the tissues.”
Cold Bi Syndromes:
A Starting Point

In Western terms this equates to “deactivating”
the Trigger Point thereby decreasing the
local/regional, aberrantly enhanced, sympathetic
outflow activity usually associated with active
trigger points.
Myofascial Trigger Points
Janet Travell. 1976
“ Myofascial Trigger Points are among the
most common, yet poorly recognised and
inadequately managed, causes of
musculoskeletal pain seen in [Western]
medical practice.”
Myofascial Trigger Points
Mostly Missed

The majority of chronic pain patients seen at 10
High Street had active trigger points.

Very few had had their trigger points palpated
prior to presentation.

Most expressed surprise when their pain
syndrome was reproduced by palpation.
Myofascial Trigger Points
Mostly Missed,
Why?

Nearly all had never filled out a Pain Diagram, McGill
Questionnaire, VAS etc.

Many had not been undressed at previous
assessments.

Many had accepted being told that their pain had no
physical cause.

Contrary to prevailing paradigm.( The Tomato Principal)
Recent Studies
(IASP’s Journal “PAIN”)
 Have
shown that the syndrome of
“ Chronic Benign Intractable Pain”
(previously) defined as pain that has
been present for more than six months
without known peripheral nociceptive
input is nearly always associated with
Trigger Points. ( Back 96.7%, Neck
100%) Pain. Vol.37 1989.
Recent Studies
(IASP’s Journal “PAIN”)

Have shown that Non Specific Low Back Pain
in a General Practice setting is usually (80%)
associated with Trigger Points. Pain. Vol.37
1989.

More than 50% of patients admitted to chronic
pain programs (USA) were found to be
suffering from Myofascial Pain Syndromes due
to trigger points.*Textbook of Pain; Ed.
Melzack and Wall.
TRIGGER POINTS
The Emerging [Western] Paradigm
Trigger points are increasingly thought to be important
in the pathogenesis of many chronic pain syndromes.
They can be thought of as ( T. McCarthy 1983)
“Pain Amplifiers”
where their activity enhances nociceptor
input. eg. Osteoarthritis,
or augments sympathetic activity.
eg Reflex Sympathetic Dystrophy, Post
Herpetic Neuralgia etc.
TRIGGER POINTS
The Emerging [Western] Paradigm
Trigger points are increasingly thought to be important
in the pathogenesis of many chronic pain syndromes.
They can be thought of as ( T. McCarthy 1983)
“Pain Generators”
where the trigger point is the actual tissue
causing the pain state.
i.e. Myofascial Pain Syndromes.
TRIGGER POINTS
Rx’s Directed @ the Trigger Point
in theWest
 Spray
and Stretch
 Ischaemic
 Injection
 Dry
pressure massage (Shiatsu)
( Local Anaesthetic, etc. )
Needling (Superficial +/-Xple, Deep)
 Acupuncture
The Near and Far
Acupuncture Technique

Was historically and still is the most
commonly used Acupuncture technique
for the resolution of chronic pain
syndromes in the Peoples Republic of
China.

When Acupuncture is used to treat common pain
states the treatment is aimed at resolving the
tissue problem or reflex causing or maintaining
the pain state.
The Near and Far
Acupuncture Technique

Two processes are dominant in this
“rehabilitation”
1. The Ablation of Trigger Point activity
2. The Restoration of Disordered blood
flow

The provision of Analgesia in this context is a
secondary consideration. (Electro-Acupuncture
The Near and Far
Acupuncture Technique
 Involves
the use of both
local
and
distal
Acupuncture points.
Local Points - AhShi - Oh
Yes - Trigger Points
 The
 “Oh
local points are usually
Ah Shi (Oh Yes) Points
yes” as when palpated they
reproduce the patient’s pain
syndrome
Local Points - AhShi - Oh
Yes - Trigger Points
 The
Western equivalent of the AhShi
point is the
“Trigger Point”
>
75% of Local Acupuncture Points for
Pain correspond to Trigger Points......
R. Melzack
Distal Acupuncture Points
Are classical meridian Acupuncture points
and are found below the elbow or knee.
 They are used for the treatment of many
diseases.
Distal Acupuncture Points can be used to
manipulate
1. the sympathetic nervous system.
2. the various “Pain Gates”

Distal Acupuncture Points
In the pain Rx context:
 Commonly used distal points are
characteristically found in muscles often at the
motor point. eg. Li 4, Hegu. Li 10, Shousanli.

The “correct” distal point is frequently tender.

Complex “rules” can govern their selection.
The Near and Far Technique for
Chronic Pain States: Nanking 1978
Local Points
A fine 30 - 32 Gauge needle is painlessly inserted
through the skin over the active trigger
point/points.
 The needle is then twirled (900 left-right ) with
downwards pressure until the trigger point is
penetrated and “needle grasp” Objective - Deqi
occurs.
 At this stage the patient’s typical pain
can/should be replicated. [Qi reaching the pain] a type of Subjective Deqi or Acupuncture
sensation

The Near and Far Technique for
Chronic Pain States: Modified for
Australian conditions.
Local points.

Western patients frequently resent feeling Subjective
Deqi!

A good result can also be obtained by stopping the
needle manipulation immediately following the
penetration of the ahshi or trigger point.

Other techniques have also evolved, where the skin
over the trigger point is penetrated several times or a
“heavy” needle is canter levered in the dermis.
The Near and Far Technique for
Chronic Pain States: Nanking 1978.
Distal Points
Distal points are found below the elbow or knee and are
used to provide analgesia and or sympatholysis.
The skin over the distal points is painlessly penetrated
0
 The needle is again ‘Twirled’ 90-180 left - right as well as up
and down until needle grasp or subjective Deqi is
experienced.
 This distal point subjective Deqi can be sensations of
numbness, tingling, distension or dull pain.
 The “amount” of deqi provided is titrated against the
condition. [Acute/Shih heavy, chronic/Xu milder.]

The Near and Far Technique for
Chronic Pain States: Modified for
Australian conditions. Distal points.
Distal points can be selected by experience / formula.
 The penetration of the skin over the point should - must
be painless.
 For acute - severe pain, eg Wry neck, Stuck back, distal
points ‘should’ be needled to produce moderate - strong
subjective deqi.
 For chronic conditions mild subjective deqi or even just
needle grasp ( Objective deqi ) is sufficient.

“Correct” Needling
Technique
The Acupuncturist is frequently
judged by his ability to
painlessly insert the needle
through the skin both in China
and the West and rightly so.
“Incorrect” Needling
Technique
The consequences of poor / painful
needling technique include:
 Poor
compliance ( First session is the last)
 Poor Result due to:
1. Augmented Sympathetic Outflows
2. Not enough Points allowed to be
needled / sessions attended.
 Iatrogenic
/ Side Effects.
10 High Street: Treatment
Cascade
Acupuncture -Near and Far
technique
Relaxation
Training, including in order of
utilisation; Tapes eg Passive Muscle Relaxation,
Biofeedback EMG / GSR, Hypnosis.
Postural Re-education + - Job Task

NSAI’s, Tricyclics, Finalgon, T.N.S.

Nerve Blocks - Local Anaesthetic (Neurotrace)
- Cryoprobe (Facet Joints)
Results of Acupuncture Rx
using the Near & Far
Technique.
Survey Number of % Of Responders
Responders
1
124
100%
2
478
75%
3
1146
55%
4
128
35%
Length of
Follow up
6 Weeks
6 Months
One year
1-4 years
Method
Ac. of
Benefit?
Telephone Yes! 84%
Mail
Yes! 88%
Mail
Yes! 87%
Mail
Yes! 85%
Survey 1. 100% Referred
Survey 3. NHMRC funded
Survey 4. Brisbane Medical School
( Very complex, hostile wording. ? reason for low response rate)