Acupuncture and malignant pain
Dr. J. Filshie - M.D.
Royal Marsden NHS Trust, Downs Road, Sutton Surrey SM2 5PT, United Kingdom
In addition to many musculoskeletal and common conditions that have been helped by acupuncture, acupuncture has an increasing role in palliative medicine for both pain and non painful symptoms.
Scientific scrutiny over the last 40 years has provided solid evidence for its action through nerve stimulation and release of multiple endogenous opioids such as b -endorphin, metenkephalin, dynorphin and other neurohumoral transmitters such as serotonin, oxytocin and endogenous steroid release. It also has widespread effects on the autonomic nervous system. It releases C-GRP, nerve growth factor and CCK an endogenous opioid antagonist.
Pain in cancer patients can be caused by the disease itself, its treatment, eg surgery and radiotherapy or can be completely unrelated eg osteoarthritis or migraine.
Cancer pain can be broadly classified into bone pain, nerve pain, visceral pain, soft tissue infiltration, myofacial pain or muscle spasm. There are a number of well recognised cancer pain syndromes. Post surgical pain syndromes include post mastectomy pain, post thoracotomy pain, post radical neck dissection and phantom limb and stump pain. Post radiation syndromes include radiation fibrosis to the brachial plexus, the lumbosacral plexus and radiation myopathy. Post chemotherapy syndromes include peripheral neuropathy, steroid pseudorheumatism, headache and mononeuropathy.
In addition patients are often immunosuppressed and may be susceptible to acute zoster and may develop post herpetic neuralgia.
Patients presenting to a pain clinic in a cancer hospital where most medics are familiar with treatment options are often extremely sensitive to regular medication or they are not helped by large doses of conventional analgesics and may have a combination of pain and emotional problems. These are especially in evidence during stages of denial and anger about the disease.
Naturally, before treatment of any disease is attempted a diagnosis should be made by history, clinical examination and special investigations as necessary.
For pain conditions, a segmental approach to treatment makes the most sense and with the addition of strong analgesic points such as L14. Trigger point treatment can also be very helpful. It is best practice to give a rather gentle treatment on first consultation and the treatment can be tailored and intensified or reduced on a trial and error basis, depending on the individual's response.
Acupuncture can relieve treatment related symptoms as well as those due to active disease. It can permit a reduction in intake of analgesics and also side effects. It can help pain and muscle and visceral spasm. It helps neuropathic and nociceptive pain. Mobility can improve with or without analgesia. Acupuncture can help patients with disabling advanced cancer related breathlessness. Nausea and vomiting can be reduced by acupuncture relief prolonged by TENS. Acute stroke victims have a significant reduction in rehabilitation requirements and costs as a result of treatment in comparison with control patients. Vascular problems and miscellaneous symptoms such as disabling hot flushes due to tamoxifen, radiation rectitis, depression, itch and hiccup can also be helped. Acupuncture is by no means a panacea for treatment of all ills and indeed tolerance to acupuncture can develop with disease progression and is sometimes a marker for advancing disease. Nevertheless it can provide a non-drug method for numerous symptoms with a low side effect profile and considerable efficacy. Further research in this field is welcomed.
In is inadvisable to give treatment around an area of an unstable spine in case removal of protective muscle spasm could give rise to movement which could result in cord transection. One should avoid giving needles into an area of lymphoedema in case of an increased infection risk or persistent leakage from the site of needle insertion. Clotting abnormalities with high INR or platelets less than 20,000 could lead to bruising. (Definitely do not treat patients who spontaneously bruise!) Electroacupuncture is contraindicated for patients with a pacemaker. Do not put needles into an area of broken skin or an area with malignant infiltration.
Thompson, J W and Filshie, J (1997). Transcutaneous Electrical Nerve Stimulation (TENS) and Acupuncture. In Second Edition, Oxford Textbook of Palliative Medicine (eds Doyle, D, Hanks, G and Macdonald, N), pp 421 - 437. Oxford Medical Publications.
Vickers, A J (1996). Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. Journal of the Royal Society of Medicine 89 (6), 303 - 311.
Johansson, K, Lindgren, I, Widner, H, Wiklund, I and Johansson B B (1993). Can sensory stimulation improve the functional outcome in stroke patients? Neurology, 43, 2189 - 2192.
Filshie, J, Penn, K, Ashley, S and Davis, C L (1996). Acupuncture for the relief of cancer-related breathlessness. Palliative Medicine, 10, 145 - 150.