WHERE IS QI!!
Despite inaccurate commentary on the subject, performing acupuncture does influence known analgesic systems. It would seem the discussion becomes murky when people misread studies investigating the importance of needle insertion, and erroneously apply this to the physiological and clinical impact upon pain. So, let’s set the stall out nice and early so the differentiation can be made. If the question were “Is there a single specific component of acupuncture that is the cause of pain relief?”. The answer would be no, and will be discussed in a future blog. However, this is a different question to “Does acupuncture impact on pain relieving physiology?” the answer being yes, very likely. Using a good ol’ superhero analogy through The Dark Knight Rises may help articulate the point. If I were to ask “Does Batman save Gotham?”, the answer is yes, because he kills Talia al Ghul, a bomb wielding, revenge entrenched foe. That is a different question to “Is Batman the sole reason for Gotham being saved?”. Batman is unlikely the only reason, as Catwoman killed Bane and the good people of Gotham rose to fight the corrupt and villainous swarm of bad guys that had descended upon the city. So, for this blog, consider acupuncture as it is found in clinical practice – a combination of variables, some known, some unknown (N.B. like ANY OTHER medical intervention). With that established, let’s consider what it does.
I think of acupuncture as having primarily two roles; first, it provides short to middle term relief, which provides a window of opportunity to use other modalities, and second it changes the threat level associated with symptoms, which is likely to have longer term benefits. The former considers changes to noxious stimulus transmission, the latter a change to limbic area activity. Both have clinical relevance, and both have quantitative studies to support observations made by clinicians over the last zillion years. To begin, let us visit the inhibitory system, which can provide that all important window of opportunity.
Two main contributors to analgesia within the body are endogenous opioids and serotonin. neurotransmitters. Receptors for Opioids can be found in nocioceptor afferent fibres, the spinal cord and regions of the brain such as the Periaquaductal Gray (PAG) and the Nucleus Raphe Magnus (NRM), and when these receptors bind with endorphins, enkephalins or dynorphins, it can result in a reduced capacity to send messages via the ascending tracts. In particular, stimuli that excite nociceptors (thus a potential danger to the local tissue) have less impact upon the stimuli interpreting centre’s within the brain. Opioids do this by either inhibiting CA2+ in the presynaptic space, and / or hyperpolarising the neuron by opening potassium channels. This results in very little or no pain being interpreted by the brain, and therefore, the individual reports reduced / no pain. Similarly, if the PAG is stimulated, causing subsequent modulation of the subcortical nuclei and the spinal cord to produce serotonin, incoming sensory information is inhibited.
It will come as no surprise that acupuncture has been shown to influence opioids and serotonin to activate this system, and thus produce short lived analgesia. So, as Batman edges closer to retirement, he will likely find that his knee will be riddled with OA. In this instance, acupuncture could act as the window of opportunity to get in and do specific exercises designed to strengthen the musculature in his lower limb (or whatever else you deem appropriate!). The acupuncture provides temporary pain relief, allowing previously painful activity to be conducted with only minimal grimacing, which in turn allows him to build up the capacity to build a functionally appropriate rehabilitation regime. If repeated, it could mean he can jump off buildings and beat up Asylum-destined maniacs in a jiffy.
But as we all know, Bruce will enter his twilight years. Without the constant barrage of villains, Hell bent on destroying Gotham, will his attentions be turned closer to home? Will he now feel that knee pain more? Will it start to impact upon his general wellbeing? Will he look back and feel he has made the right career choices? Like all of us, B-dog will be susceptible to long standing pain, and with it, a potential greater emotional attachment to the sensation from his ailments. The limbic system, the most primitive part of our brains which can be found in other animals (such as……bats), is a multi-regional aspect of the brain concerned with emotions and self-preservation. It is important that the limbic system becomes active during (or at the potential threat of) a nociceptive stimuli, as the result of its activation creates defensive behaviour and fear. Therefore, the person is less likely to seek out a nociceptive stimuli again, thus acting as a survival mechanism. So, where as you and I (well maybe not all of you, but at least a couple) would avoid potentially harmful situations (cheers Amygdala), Batman probably has a limbic system that requires a huge stimulus to be considered a threat, as he insists on putting himself in danger (a reckless man, almost as if he is haunted by past heinous events). The opposite to Batman is Overactive-Limbic-System Man, who considers non-threatening stimuli to be noxious, and in essence, is hypervigilant. This is considered to be prevalent in chronic conditions.
Surprise surprise, acupuncture has been found to modulate these areas also. Through functional MRI scans (which aren’t infallible but likely the most accurate, ethical approach to assessing brain activity), a number of studies have observed limbic areas to not only be influenced by acupuncture, but to become downregulated to normal levels. So, when a certain billionaire (or ex-billionaire, depending on which universe you are treating him in) comes calling about a really sore knee, that’s been bothering him for years and is now stopping him from what he wants to do, some cheeky little acupuncture sessions may not only provide a window of opportunity, but help return limbic activity to usual levels. In clinic, this wouldn’t be evidenced by exclamations of reduced Amygdala prominence, but more likely through subtle changes to outlook on life, perception of threat and feelings of wellbeing. In these instances, I have always found mentioning court jester’s, semi aquatic flightless birds, female felines, and duplicitous individuals to hinder adherence to the home advice given.
So in a nutshell, acupuncture does reduce pain, and can have both short and long term benefits. See you next time, same Bat time, same Bat place!