jussara regiane de barros ladeia effects of acupuncture … - eff… · including postoperative...
TRANSCRIPT
JUSSARA REGIANE DE BARROS LADEIA
EFFECTS OF ACUPUNCTURE THERAPY IN PAIN
MANAGEMENT IN PATIENTS UNDERGOING THORACIC
SURGERY
São Paulo
2018
Monograph presented to Erich Fromm University –
Florida, United States – to obtain the title of
specialist in acupuncture.
Teacher advisor: Dr. Alfredo Alexander Raspa
i
Abstract
LADEIA, Jussara R. Barros. Effects of acupuncture therapy in pain
management in patients undergoing thoracic surgery. Monograph, Erich
Fromm University – Florida, United States – São Paulo, 2018.
Objective: The aim of this study was to review recent literature about the
effects of acupuncture therapy in pain management in patients undergoing
thoracic surgery.
Methods: This is an integrated review, performed from the online Pubmed
and Scielo databases. The terms "acupuncture therapy", "pain" and "thoracic
surgery" were used.
Results: Were found 18 articles in the Pubmed database. Four clinical
studies were selected for analysis after applying the inclusion and exclusion
criteria. These were randomized and controlled trials.
Conclusion: There is a lack of studies in literature involving acupuncture
therapy as an analgesic method in patients undergoing thoracic surgery,
especially in the West. In this review, acupuncture-associated
electrostimulation was shown to reduce postoperative dosage of opioids.
Key-words: acupuncture therapy; pain; thoracic surgery.
ii
Summary
ABSTRACT .............................................................................................................................. I
1. INTRODUCTION .............................................................................................................. 3
2. OBJECTIVE......................................................................................................................... 4
3. LITERATURE REVIEW ................................................................................................... 5
3.1 THE ORIGIN OF DISEASES BY TCM.......................................................................................... 5
3.1.1 Internal Causes .................................................................................................................... 5
3.1.2 External Causes ................................................................................................................... 5
3.1.3 Other Causes ......................................................................................................................... 5
3.2 ACUPUNCTURE ........................................................................................................................... 5
3.2.1 Effects of Acupuncture ..................................................................................................... 6
3.2.2 Pain and Acupuncture ..................................................................................................... 6
3.3 THORACIC SURGERIES .............................................................................................................11
3.3.1 Postoperative pain ...........................................................................................................11
3.3.2 Pain assessment ................................................................................................................14
4. METHODS ....................................................................................................................... 16
4.1 PUBMED SEARCH STRATEGY ...................................................................................................17
4.2 SCIELO SEARCH STRATEGY ......................................................................................................17
4.3 INCLUSION CRITERIA ...............................................................................................................17
4.4 EXCLUSION CRITERIA ...............................................................................................................17
5. RESULTS ......................................................................................................................... 17
6. DISCUSSION ................................................................................................................... 20
7. CONCLUSION ................................................................................................................. 22
8. BIBLIOGRAPHIC REFERENCES ................................................................................ 23
3
1. Introduction
Acupuncture belongs to Traditional Chinese Medicine (TCM) and is
used for prevention and also treatment of several diseases and disorders.
Through insertion of needles, the technique acts on the energy channels,
known as acupuncture points, or acupoints, reaching homeostasis,
reestablishing the free circulation of vital energy and promoting health
(Dulcetti Jr, 2001).
Acupuncture has been widely used in Asian countries for the treatment
of pain. The National Institutes of Health suggest that acupuncture can be
used as a complementary or alternative treatment for many diseases,
including postoperative pain. Clinical studies have shown that acupuncture
can help relieve postoperative pain, reduce the dosage of opioid analgesics
and other related side effects and is a low-cost, easily applied and accepted
method (Wu et al., 2016; Xiong et al., 2018).
Thoracotomy is associated with elevated pain levels in the immediate
postoperative period. Some patients experience continuous pain lasting over
60 days, and this pain may persist for years. Karmakar & Ho (2004),
demonstrated that about 30% of patients still feel pain up to four to five years
after surgery. Post-thoracotomy pain causes distress, impaired lung function
and mobility, leading to increased morbidity. Treating post-thoracotomy
chronic pain is more difficult (Karmakar & Ho, 2004; Deng et al., 2008).
Therefore, due to the deleterious effects of postoperative pain of
thoracic surgeries and the potential analgesic effect of acupuncture, it is
important to review the evidences presented in literature supporting the use of
this technique in such scenario.
4
2. Objective
The aim of this study was to review recent literature about the effects of
acupuncture therapy in pain management in patients undergoing thoracic
surgery.
5
3. Literature Review
3.1 The Origin of Diseases by TCM
Identifying the cause of patient disharmony is one of the most
important parts of Chinese medical practice.
3.1.1 Internal Causes
The view of TCM is different from Western medicine. In TCM, the mind-
body is not a pyramid, but a circle of interaction between internal systems and
their emotional aspects (Maciocia, 1996).
Emotions only become pathological causes when they are particularly
intense and prolonged and if not expressed or recognized. Physical
symptoms are caused by their emotions: fury, joy, sadness, worry and
abstraction, fear, shock (Maciocia, 1996).
3.1.2 External Causes
They are due to climatic factors: wind, cold, summer heat, humidity,
dryness, fire (Maciocia, 1996).
3.1.3 Other Causes
Other causes can be: debilitated complexion (depends on the health of
the parents); excessive physical exercise; excessive sexual activity; irregular
diet; trauma - physical trauma causes local stagnation of Qi or blood (Xue),
causing pain, edema and hematoma; parasites and poisons; inadequate
treatment (Maciocia, 1996).
3.2 Acupuncture
Acupuncture has been widely practiced in China for over four thousand
years. According to TCM theories, the human body has an energy system in
6
which a vital energy (Qi) circulates and is responsible for the functioning of all
organs. The structures of the organism are balanced by the energies of Yin
and Yang. That way, if the energies of Yin and Yang are in perfect harmony,
surely the body will be healthy. Needles are inserted at specific spots in the
body in order to rebalance the flow of energy along the meridians, transmitting
specific health benefits (Silva, 2004; Wong et al., 2006; Wen, 2014).
3.2.1 Effects of Acupuncture
The effects of acupuncture are related to the origin of our energy body
and our physical form. We have the junction of two essences through the
mental and physical body, the Lin Tai and the Yin Chao, which generate the
Essential Ancestral Qi and which will successively form the energies: Zang
Fu, Xue Qi (Blood), Jing Luo (Energy Channels and Collaterals), Mental
energy and physical form (Yamamura, 2001).
Acupuncture changes the blood circulation. Through the stimulation of
certain points, the dynamics of regional circulation from micro-dilatations can
be changed. And other points promote muscle relaxation, healing spasms,
reducing inflammation and pain (Wen, 2014).
3.2.2 Pain and Acupuncture
3.2.2.1 Physiology of pain
According to the International Association for the Study of Pain (IASP),
pain is defined as "an unpleasant sensory and emotional experience
associated with or related to actual or potential tissue injury. Each individual
learns to use this term through their previous experiences" (International
Association for the Study of Pain, 2011).
Nociception is the term used to describe how pain becomes a
conscious experience. Nociceptors are a highly specialized subset of primary
sensory neurons that respond only to pain stimuli, converting these stimuli
into nerve impulses, which the brain interprets to produce pain sensation
7
(Rosenquist et al., 2017). They are categorized as either myelinated or non-
myelinated, indicating the type of stimulation they respond to: chemical,
mechanical and thermal (Ellison, Rosenquist et al., 2017).
A-delta fibers are large, myelinated, and fast-conducting. They are
responsible for immediate acute pain. The activation of these fibers causes
the medullar reflex of withdrawal, before the pain sensation is perceived
(Ellison; Rosenquist et al., 2017).
Type C fibers are non-myelinated, smaller, and constitute the majority
of peripheral nociceptors. They are located in the tendons of muscles, in
organs and on the skin. They transmit uncomfortable, painful or burning
sensations that are poorly located and often present as constant pain. They
can respond to thermal, mechanical and chemical stimuli. In relation to the A
delta fibers, the C fibers are slow conducting and recover from fatigue more
slowly, in addition to producing a longer lasting pain. (Ellison; Rosenquist et
al., 2017).
There are four stages in pain nociception: (1) transduction, (2)
transmission, (3) perception and (4) modulation (Figure 1).
Transduction is the first process of nociception. It refers to the
conversion of a noxious stimulus, which may be thermal, mechanical or
chemical, into electrical activity at the peripheral terminals of sensory fibers of
the nociceptor (Ellison; Rosenquist et al., 2017).
When nociceptors are stimulated, they release chemical mediators
that activate more nociceptors (histamine, bradykinin, acetylcholine, serotonin
and substance P). These chemical mediators may increase pain sensitivity,
reduce or inhibit pain perception. For example, prostaglandins are believed to
increase the sensitivity of pain receptors, enhancing the bradykinin-triggering
effect. Substance P, found in C fibers, amplifies the pain signal. However,
endorphins and enkephalins, which are natural opioids, inhibit the
transmission or perception of pain (Ellison, 2017).
Endorphins produce effects by linking the receptors to opioids, which
can be stimulated by afferent nerve activity. The release system of this
substance covers the hypothalamus and a neural network that protrudes into
the nuclei of the midbrain and brainstem. Through this pathway it has the
property of influencing pain sensitivity. Increased production of endorphins
8
promotes pain relief and can also provide a sense of satisfaction. Enkephalins
are substances considered as neurotransmitters. They have analgesic action
and are capable of reversibly binding to opioid receptors (Silva, 2004).
Transmission is the second process of nociception. Transmission
refers to the passage of peripheral terminal action potentials along the axons
to the central nociceptor terminal in the central nervous system (CNS). It is
during this process that pain control can occur. Opioids block the release of
neurotransmitters, particularly substance P, which disrupts pain at the marrow
level. The impulses then synapse with the projection neurons (tertiary
neurons), cross the midline of the spinal cord and ascend to the brain through
two different spinothalamic tracts. The neospinothalamic tract transmits rapid
impulses of strong and acute pain. The paleoespinothalamic tract transmits
slow impulses of low and chronic pain. The rapid and acute pain is first
noticed, followed by a throbbing and low pain. These tracts connect to the
reticular formation, hypothalamus, thalamus, and limbic system. The impulses
are then projected to the somatosensory cortex for interpretation and for other
areas of the brain for an integrated response to pain stimuli (Ellison;
Rosenquist et al., 2017).
Perception is the third process of nociception. Perception refers to the
"decoding" or interpretation of the afferent input into the brain that gives rise to
the individual's specific sensory experience. It is the conscious perception of
pain. The transmission of stimuli ends in the reticular and limbic systems and
in the cerebral cortex, which is where perception occurs. Pain interpretation
can be influenced by many factors, including genetics, cultural preferences,
gender roles, life experience, past pain experiences, health condition, etc.
(Ellison, Rosenquist et al., 2017).
Modulation is the last process of nociception. Modulation refers to the
change (e.g.: increase or suppression) of the sensory input. The modulation
of the pain stimulus prior to the perception of pain is made either by inhibition
or augmentation through supraspinal influences emerging from the bridge,
marrow and midbrain (Lome, 2005; Elisson, 2017). Supra-spinal inhibition
leads to the release of endogenous opioids that limit the release of
neurotransmitters from the primary neuron and hyperpolarize the secondary
neuron, so that greater pain stimuli are required for action potential to be
attained. Norepinephrine and serotonin can be released from the dorsal horn
of the marrow, both inhibitory substances. Supra
the release of additional neurotransmitters to increase the progression of
stimuli from the primary neurons to the secondary ones (Lome, 2005; Elisson,
2017).
3.2.2.2 Analgesia Mechanism of
Scientific studies show that the action of acupuncture is clearly related
to the nervous system (Yamamura, 2001).
the release of hormones, such as cortisol and endorphins, promoting
analgesia. There is internal regulatio
Acupuncture exacerbates these mechanisms to restore balance and health in
less time. Research shows that the stimulation of the hypothalamus, pituitary
gland and other glands acts to hasten recovery of metabolism, whic
important in the healing process (Wen, 2014).
Figure 1Physiology of Pain. Dec;29(4):397
attained. Norepinephrine and serotonin can be released from the dorsal horn
of the marrow, both inhibitory substances. Supra-spinal stimulation occurs by
the release of additional neurotransmitters to increase the progression of
primary neurons to the secondary ones (Lome, 2005; Elisson,
Mechanism of Acupuncture
Scientific studies show that the action of acupuncture is clearly related
to the nervous system (Yamamura, 2001). Stimulating certain points promotes
the release of hormones, such as cortisol and endorphins, promoting
analgesia. There is internal regulation to offer resistance to the disease.
Acupuncture exacerbates these mechanisms to restore balance and health in
less time. Research shows that the stimulation of the hypothalamus, pituitary
gland and other glands acts to hasten recovery of metabolism, whic
important in the healing process (Wen, 2014).
1. Four stages in nociception. (From: Ellison DL. Physiology of Pain. Crit Care Nurs Clin North Am. 2017 Dec;29(4):397-406).
9
attained. Norepinephrine and serotonin can be released from the dorsal horn
spinal stimulation occurs by
the release of additional neurotransmitters to increase the progression of
primary neurons to the secondary ones (Lome, 2005; Elisson,
Scientific studies show that the action of acupuncture is clearly related
Stimulating certain points promotes
the release of hormones, such as cortisol and endorphins, promoting
n to offer resistance to the disease.
Acupuncture exacerbates these mechanisms to restore balance and health in
less time. Research shows that the stimulation of the hypothalamus, pituitary
gland and other glands acts to hasten recovery of metabolism, which is
Ellison DL. Crit Care Nurs Clin North Am. 2017
10
The analgesic action of acupuncture requires integrity of the superficial
and deep primary afferent peripheral discriminatory pathways and is blocked
by the action of local anesthetics on the peripheral nervous system. It occurs
by stimulation of the physiological systems of pain suppression, specifically
the segmental block at medullar level, the descending suppressor system and
also through the opioid system of the brain from the introduction of needles at
specific points (Silva, 2004).
The electrical potential of acupuncture needles acts on the free nerve
terminations at these points, altering the cell membrane potential, triggering
action potential and conducting nerve stimulation (Yamamura, 2001).
A-delta and C-fibers are the main types of fibers related to conduction
of the acupuncture needle stimulation. Studies mention that A-delta fibers are
dominant, followed by C fibers (Yamamura, 2001). Activation of A-delta fibers
by acupuncture or electroacupuncture blocks the afferent impulses from C
fibers at the medullar level through the release of enkephalin (Silva, 2004).
The effect of the needle depends on the depth of its insertion, since the
types of nerve receptors are distributed differently. The superficial ones will
reach the nerve receptors associated to the A-delta fibers (acute pains and
thermoception). The insertion of needles determines three local effects:
electric, neurochemical (by mechanical action, the needle damages the
tissues and releases substances) and mixed (Yamamura, 2001).
During the last decades, there has been a growing appreciation of
acupuncture in the West. One of the main potential benefits of acupuncture
was its application in regional anesthesia for the treatment of several forms of
pain. Studies have shown promising results of the use of acupuncture in the
management of early postoperative pain in several types of surgery
(Pohodenko-Chudakova, 2005; Usichenko et al., 2005; Lin et al., 2002).
Electroacupuncture (EA) began to be used as a complement to pain
management as early as the 1970s (Pongratz et al., 1977) and it is possible to
reduce the amount of medication administered in patients after general
surgery (Wong et al. , 2006). EA is performed by inserting small needles into
the skin at specific acupuncture points and stimulating them with electric
current (Karavis, 1997; Han, 2003).
Clinical studies from the 1980s have revealed that acupuncture may be
11
an effective and safe alternative method of anesthesia for lung resection.
Later, the combined application of acupuncture and general anesthesia was
shown to be beneficial in pneumonectomy (Fu et al., 2011). A meta-analysis
of 2012 provided clear evidence that acupuncture is favorable in the treatment
of chronic pain (Vickers et al., 2012). In addition, the method was
recommended by the American College of Chest Physicians as
complementary therapy in lung cancer patients suffering from post-
chemotherapy nausea and post-thoracotomy pain (Cassileth et al., 2007).
3.3 Thoracic Surgeries
Thoracic surgeries may be performed through large cuts (thoracotomy)
or by video (video-assisted). Some conditions treated by thoracic surgery are:
pleural diseases, tumors, congenital lung defects, lung/heart transplants,
cardiac surgeries, lung diseases (abscess, bronchiectasis), etc.
Surgeries can be approached by different incisions (Figure 2), for
example: longitudinal sternotomy, anterior intercostal thoracotomy, side
intercostal thoracotomy, posterolateral intercostal thoracotomy, posterior
intercostal thoracotomy, and ministernotomy (Bento, 2004).
3.3.1 Postoperative pain
Postoperative pain is somewhat unavoidable due to intense surgical
trauma (Coura et al., 2011). Postoperative analgesia must be adequate for
different types of operations, and it is more difficult to treat pain after surgery
in the thoracic and upper abdominal regions than on the face and extremities
(SBED, 2006).
Multiple nociceptive stimuli occur in thoracotomy procedures such as
surgical incision, insertion of thoracic and mediastinal tubes and stimulation of
the parietal pleura, making the prescription of analgesia quite complex and
requiring a combination of techniques and medication (Coura et al., 2011). A
series of studies suggest that patients after cardiac surgery have significant
postoperative pain in the intensive care unit (ICU) and after transfer to the
12
ward (Meehan et al .; Valdix & Puntillo, 1995). An Australian study of 102 ICU
patients after cardiac surgery showed that patients who had worse pain were
women, patients with internal mammary artery grafts and younger individuals
(York et al., 2004).
Figure 2 . Types of incision for approach in thoracic surgeries. (Adapted from: Mattox KL, Wall Jr. MJ, Tsai P. Trauma Thoracotomy: Principles and Techniques. 2017. Thoracic Key [internet homepage]. Available in: <https://thoracickey.com/trauma-thoracotomy-principles-and-techniques>).
Most cardiac surgeries are performed through median sternotomy and
many patients experience significantly greater pain than expected after this
type of incision. Typically, acute pain is most intense on the first postoperative
day at the surgical incision spot and the worst pain is experienced when
moving or coughing. Often, pain continues increasing up to one week after
surgery, and the location may change during this time away from the incision
site and towards the shoulders (Mazzeffi & Khelemsky, 2011). In
cardiothoracic surgery, posterolateral thoracotomy is the gold standard of
MEDIAN STERNOTOMY ANTEROLATERAL THORACOTOMY
TRANSESTERNAL ANTEROLATERAL THORACOTOMY
PARTIAL ANTERIOR THORACOTOMY
13
surgical access to the chest for anatomical resection of the lung.
Unfortunately, standard thoracotomy is also arguably the most painful incision
of all surgeries (Wong et al., 2006).
Some studies comparing median sternotomy with thoracotomy have
shown that sternotomy is a relatively better procedure than thoracotomy due
to lower thoracic cavity trauma (Barnas et al., 1994; Ranieri et al., 1999).
Following the same reasoning, Guizilini et al. (2010) showed that patients
submitted to ministernotomy (eight centimeter incision) had better
preservation of lung function when compared to standard median sternotomy
(20 centimeters). In addition, previous studies have shown that patients
submitted to ministernotomy had less painful sensation than those submitted
to conventional median sternotomy (Grossi et al., 1999; Moustafa et al.,
2007).
Median sternotomy impairs thoracic stability, worsens its expandability,
reduces forced vital capacity and forced expiratory volume in the first second
for days or even weeks (Ragnarsdottir et al., 2004). Good pain management
relieves post-surgical stress response and may improve clinical outcomes
(Mazzeffi & Khelemsky, 2011). Several studies have shown that poorly
controlled postoperative pain is associated with impaired pulmonary function,
causing a decrease in vital capacity and spirometric values by up to 33%,
leading to a restrictive deficit especially in the first three postoperative days.
There is also an increase in intrapulmonary shunt and alveolar-arterial oxygen
pressure gradient, and reduction of partial oxygen blood pressure (Sasseron
et al., 2009; Gust et al .; OConnor et al., 1999). Better control of pain may also
shorten hospital stay, reducing costs (Mazzeffi & Khelemsky, 2011).
Pain mechanisms in the postoperative period are complex. There is
damage to the skin, subcutaneous tissues, bones and cartilage. In addition to
the nociceptive inputs caused by direct tissue trauma, the inflammatory
response generated leads to sensitization of peripheral and central pathways
that result in the experience of pain. A number of inflammatory mediators
(prostaglandins, histamines, substance P, bradykinins, serotonin, adenosine
triphosphate, nitric oxide, leukotrienes) and ions (e.g.: sodium, potassium and
calcium) spread on the spot (Coura et al., Mazzeffi & Khelemsky, 2011).
Some of these molecules directly activate the nociceptors, while others work
14
through indirect mechanisms. These inflammatory molecules also play an
important role in sensitizing both central neurons. The presence of chest and
mediastinal drains, which irritate the parietal pleura and pericardium, are also
a significant source of pain for patients. The intercostal nerves that emerge
from the roots of the thoracic nerve innervate the sternum, the ribs, and the
surrounding subcutaneous tissue. The parietal pleura is also richly innervated
with nociceptive fibers that can be activated by mechanical or chemical
stimuli. The pericardium is innervated with pain fibers from the vagus nerve,
phrenic nerve and sympathetic trunks (Jammes et al., 2005; Mazzeffi &
Khelemsky, 2011).
In most cases, pain control is achieved through administration of
opioids, a substance that may cause several undesirable side effects such as
nausea, vomiting, constipation, decreased consciousness, and respiratory
depression (Wong et al., 2006; et al., 2011). Some personalized strategies
may be used to minimize side effects due to reduced opioid dose such as
patient controlled analgesia (PCA). However, even so, the incidence of
adverse effects is still high (Coura et al., 2011).
Poor pain control is associated with the activation of the nervous
system and the increase of the hormonal response to stress. This response
may contribute to multiple post-operative adverse effects, including increased
blood pressure with consequent increase in left ventricular post-load and
myocardial oxygen consumption, myocardial ischemia, cardiac arrhythmias,
hypercoagulability, atelectasis and other pulmonary complications, increased
rates of delirium, higher risk of infection, especially of sternum, venous
thrombosis and hyperglycemia (Coura et al., Mazzeffi & Khelemsky, 2011).
Studies have shown that better pain control is associated with lower rates of
cardiovascular complications, pneumonia and hypercoagulability in the
postoperative period (Liu & Wu, 2007).
3.3.2 Pain assessment
The assessment and recording of pain intensity by health professionals
15
has to be performed in a continuous and regular way, in the same way as vital
signs, in order to optimize therapy, provide safety to the health care team and
improve the quality of life of the individual. The intensity of the pain is always
that referred by the patient. The scale used must always be the same. For a
correct assessment of pain intensity it is necessary to use a common
language between the health professional and the assessed individual, which
is translated by a standardization of the scale to be used and by the teaching
prior to its use. It is essential that the patient correctly understands the
meaning and use of the scale used.
Pain assessment must include: a detailed history, physical
examination, laboratory and imaging exams and, if possible, a differential
diagnosis must be remembered. Regional, anatomical, etiological,
pathological and functional diagnosis must be obtained. Postoperative pain
may be measured by the patient's report, using the scales (Figure 3), the
amount of analgesic the patient requests and the need for analgesic
supplementation (SBED, 2006).
The verbal scale commonly uses words to describe pain intensity.
Usually the following words are used: absent, mild, moderate and intense,
which are scored as: absent = 0; mild = 1; moderate = 2 and intense = 3. The
visual analogue scale (VAS) is an extremely simple, sensitive and
reproducible instrument to assess pain, since it allows its continuous analysis.
The verbal numerical scale is an alternative for the verbal and visual analogue
Visual Analogue Scale (VAS)
No pain Most intense pain
Facial Expression Scale
Figure 3. Pain scales. (Adapted from de PORTUGAL. Ministério da Saúde. Direcção-Geral da Saúde. Circular Normativa nº 9/DGCG de 14/6/2003. Available in: <http://www.dgsaude.pt>)
16
scales. The patient suggests a number to represent his pain intensity, where
zero means no pain and ten the most intense pain possible. The facial
expression scale is mainly used for children, but may also be used to assess
the pain of illiterate or mentally ill patients (SBED, 2006).
4. Methods
This is an integrated review, performed from the online Pubmed and
Scielo databases.
17
4.1 Pubmed search strategy
The terms "acupuncture therapy", "pain" and "thoracic surgery"
(acupuncture therapy[MeSH Terms]) AND Pain[MeSH Terms]) AND Thoracic
Surgery[MeSH Terms]) were used.
4.2 Scielo search strategy
The terms in Portuguese and their equivalent in English have been
used: “acupuncture therapy/ terapia por acupuntura”, “pain/ dor” and “thoracic
surgery/ cirurgia torácica” in the "all indexes" field.
4.3 Inclusion criteria
Clinical studies were chosen in which the method involved the use of
acupuncture analgesia for acute pain of patients undergoing thoracic surgery.
The search was limited to English, Portuguese and Spanish languages.
4.4 Exclusion criteria
Articles not available online have been deleted.
5. Results
Pubmed: From the terms and combinations used 18 articles were
found. Nine studies were deleted because they were from different languages
(two in French; four in Chinese; two in Italian; one
were outside the proposed topic; one study was not a clinica
was not available online.
(Figure 4).
Figure
Scielo: no articles were found fro
Chart 1 presents the
as well as the types of intervention and results obtained in each one
different languages (n=9)
outside proposed topic
not available on
Sistematic Review
Total =
found. Nine studies were deleted because they were from different languages
two in French; four in Chinese; two in Italian; one in Russian);
were outside the proposed topic; one study was not a clinical trial and one
was not available online. Four clinical studies were selected for analysis
Figure 4. Flowchart for searching the analyzed articles
Scielo: no articles were found from any combination of terms
Chart 1 presents the characteristics of the selected studies' population,
as well as the types of intervention and results obtained in each one
Pubmed(n=18)
Analyzed(n=4)
different languages (n=9)
outside proposed topic (n= 3)
not available on-line (n=1)
Sistematic Review (n=1)
Total = 14
Scielo (n=0)
18
found. Nine studies were deleted because they were from different languages
); three studies
l trial and one
Four clinical studies were selected for analysis
the analyzed articles.
m any combination of terms.
characteristics of the selected studies' population,
as well as the types of intervention and results obtained in each one
19
Author , year Population Intervention Results
Wong et al., 2006
Patients with lung cancer undergoing video-assisted thoracic surgery.
Controlled Randomized Double-Blind Study Intervention Group: EA 30 min/day for 7 days (IG4, VB36, TA8, VB34 - on the same side of the thoracotomy) Control Group: the same protocol simulating therapy
EA decreased dosage of analgesics.
Deng et al., 2008
Patients with lung cancer undergoing unilateral thoracotomy.
Blind Randomized Controlled Study Intervention Group: 2 days prior to surgery, intradermal needles were inserted at points of the spine (B12 to B19), E36 and at the auricular Shenmen and replaced 1 week later. The needles remained at points E36 and Shenmen for 1 week and in the spine for 3 weeks after the replacement. Control Group: not performed on acupoints, or with real needles.
There was no reduction of either pain or dosage of analgesic after thoracotomy.
Coura et al., 2011
Patients undergoing elective cardiac surgery.
Randomized Controlled Study Treatment group: EA (IG4, IG11, F3, E36, CS6, TA5) - 30 min (12-18 hours prior to surgery) + PCA in PO Control Group: electrostimulation with electrodes at the same spots - 30min (12-18 hours prior to surgery) + PCA at PO
Treatment group had a reduction in the postoperative opioid dosage.
Huang et al., 2015
Patients submitted to video-assisted lobectomy.
Controlled Randomized Double-Blind Study Points: CS6, IG4, P7, IG11 Transcutaneous stimulation on the acupoints (TEAS) for 30 min; before anesthetic induction/during surgery/24 hours and 48 hours after surgery. Group "2/100": stimulation with frequency alternating between 2 to 100Hz every 3 seconds. Group "2": stimulation with frequency 2Hz Group "100": stimulation with frequency 100Hz Control Group: no stimulation, only electrodes positioned
TEAS groups had a decrease in intraoperative opioid dosage; decrease in anesthetic recovery time and time for extubation; improved PaO2 during unilateral ventilation; decrease in pain score.
Chart 1. Characteristics and results of the analyzed studies.
EA: Electroacupuncture; PCA: patient controlled analgesia; PO: posteoperative period; TEAS: transcutaneous electrical acupoint stimulation); PaO2: partial pressure of oxygen.
20
6. Discussion
In the present study, the results show the scarcity of studies on the use
of acupuncture in pain control in patients undergoing thoracic surgery. Most of
them used the electrostimulation associated with acupuncture and obtained
good results in relation to the reduction in the dosage of analgesics in the
postoperative period. We also observed that some articles were not included
in the analysis because they were not available in English or Spanish. The
technique is mostly used in the East and research in Western countries is still
growing.
Out of the analyzed articles, all were randomized controlled clinical
trials, two of them double-blind. However, the methodologies were very
different from each other. This may be a reflection of the difficulty in
establishing a good control group model, making it challenging to isolate the
placebo effect from the actual effect of acupuncture.
There is no standardization of the acupoints used in the therapies.
Good results were observed in studies with IG4 point stimulation. There is
also recurrence of the use of points IG11 and CS6. IG4 (Hegu - Junction
Valley) is located on the radial side, in the middle of the second metacarpal
and its actions include analgesia, tonification and harmonization of Qi
increase and decrease (Wen, 2014). IG11 (Quchi - Crooked Pond) is located
at the lateral end of the elbow fold and its actions include analgesia, cooling
the blood (internal heat), removing heat in the canal (Wen, 2014). CS6
(Neiguan - Inner Gate) is located 2 cun above the wrist, in the center of the
anterior side of the forearm, between the tendons and its actions include
moving Qi and Xue in the thorax. Also ideal for pain control, distension in the
thorax and abdomen, nausea, vomiting and anxiety (Wen, 2014).
Regarding electrostimulation, the frequency used was not similar
among the studies. Authors have already demonstrated that low frequency
and high frequency EA induced the release of different opioid peptides. For
example, 2Hz induces the release of endorphins and enkephalins and 100Hz
induces the release of dynorphins. Therefore, using alternating frequencies in
the same therapy may have a more efficient analgesic effect (Han et al.,
21
1991; Zhao et al., 2004; Huang et al., 2015).
The study that obtained better results in the control of pain after
thoracic surgery was that of Huang et al., 2015, who performed
electrostimulation with electrodes in the acupoints at different moments (pre,
intra and postoperative). This corroborates with the recommendation of the
Brazilian Society for the Study of Pain. It is recommended that postoperative
pain control be started before the start of the operation, with pre-emptive or
preventive analgesia consisting of administering drugs and/or using analgesic
techniques before the incision. Preemptive analgesia aims to reduce pain
intensity and avoid central sensitization, consisting of the use of analgesic
therapy before injury until resolution of the acute inflammatory phase.
Preemptive analgesia may be performed on any part of the painful pathway,
such as the periphery, the conduction pathway, the marrow and upper centers
(SBED, 2006). That is, acupuncture has the potential to be used in all phases
of surgery.
Due to the analgesic effect provided by acupuncture, the results
obtained in the studies show that it is possible to reduce the dosage of opioids
and, consequently, the adverse reactions caused by the use of such
substances, such as nausea and vomiting, in addition to promoting early
extubation, minimizing postoperative pulmonary complications.
22
7. Conclusion
There is a lack of studies in literature involving acupuncture therapy as
an analgesic method in patients undergoing thoracic surgery, especially in the
West. In this review, acupuncture-associated electrostimulation was shown to
reduce postoperative dosage of opioids.
23
8. Bibliographic References
Barnas GM, Watson RJ, Green MD, Sequeira AJ, Gilbert TB, Kent J, et al. Lung and chest wall mechanical properties before and after cardiac surgery with cardiopulmonary bypass. J Appl Physiol. 1994 Jan;76(1):166-75. Bento, MC. Fisioterapia Pneumofuncional. Rio de Janeiro: Ed. EPUB; 2004. Cassileth BR, Deng GE, Gomez JE, et al. Complementary therapies and integrative oncology in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).Chest 2007; 132(3 Suppl):340S–54S. Coura LE, Manoel CH, Poffo R, Bedin A, Westphal GA. Randomised, controlled study of preoperative electroacupuncture for postoperative pain control after cardiac surgery. Acupunct Med. 2011 Mar;29(1):16-20. Deng G, Rusch V, Vickers A, Malhotra V, Ginex P, Downey R, et al. Randomized controlled trial of a special acupuncture technique for pain after thoracotomy. J Thorac Cardiovasc Surg. 2008 Dec;136(6):1464-9. Dulcetti Jr O. Pequeno Tratado de Acupuntura Tradicional Chinesa. São Paulo: Andrei Editora; 2001. Ellison DL. Physiology of Pain. Crit Care Nurs Clin North Am. 2017 Dec;29(4):397-406. Fu GQ, Zhou J, Tong QY, Zhu YM, Ma W, Zhou H, et al. Observation on the anti-stress effect of acupuncture-assisted anesthesia for pulmonary lobectomy patients]. Zhen Ci Yan Jiu. 2011;36:361–5. Grossi EA, Zakow PK, Ribakove G, Kallenbach K, Ursomanno P, Gradek CE, et al. Comparison of post-operative pain, stress response, and quality of life in port access vs. standard sternotomy coronary bypass patients. Eur J Cardiothorac Surg. 1999 Nov;16(Suppl 2):S39-42. Guizilini S, Bolzan DW, Farezin SM, Alves FA, Gomes WJ. Miniesternotomia na Cirurgia de Revascularização Miocárdica Preserva Função Pulmonar Pós-operatória. Arq Bras Cardiol. 2010;95(5):587-93. Gust R, Pecher S, Gust A, et al: Effect of patient controlled analgesia on pulmonary complications after coronary artery by-pass grafting. Crit Care Med 27:2218-2223, 1999. Han JS, Chen XH, Sun SL, Xu XJ, Yuan Y, Yan SC, et al. Effect of low- and high-frequency TENS on Metenkephalin-Arg-Phe and dynorphin A immunoreactivity in human lumbar CSF. Pain. 1991;47:295–8. Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003;26:17–22.
24
Huang S, Peng W, Tian X, Liang H, Jia Z, Lo T, et al. Effects of transcutaneous electrical acupoint stimulation at different frequencies on perioperative anesthetic dosage, recovery, complications, and prognosis in video-assisted thoracic surgical lobectomy: a randomized, double-blinded, placebo-controlled trial. J Anesth. 2017 Feb;31(1):58-65. International Association for the Study of Pain. Part III. Pain terms, a current list with definition and notes on usage. 2011. Jammes Y, Trousse D, Delpierre S: Identification and properties of parietal pleural afferents in rabbits. J Physiol 567:641-650, 2005. Karavis M. The neurophysiology of acupuncture: a viewpoint. Acupunct Med 1997;15:33–42. Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac Surg Clin Aug;2004 14(3):345–52. Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. Pain 2002;99:509 –14. Liu SS, Wu CL: Effect of postoperative analgesia on major postoperative complications: A systematic update of the evidence. Anesth Analg 104:689-702, 2007. Lome B. Acute pain and critically III trauma patient. Crit Care Nurs Q 2005;28(2): 200–7. Maciocia G. Os Fundamentos Da Medicina Chinesa. São Paulo: Ed. Roca; 1996. Mattox KL, Wall Jr. MJ, Tsai P. Trauma Thoracotomy: Principles and Techniques. 2017. Thoracic Key [internet homepage]. Available in <https://thoracickey.com/trauma-thoracotomy-principles-and-techniques>. Mazzeffi M, Khelemsky Y. Poststernotomy pain: a clinical review. J Cardiothorac Vasc Anesth. 2011 Dec;25(6):1163-78. Meehan DA, McRae ME, Rourke DA, et al. Analgesic administration, pain intensity, and patient satisfaction in cardiac surgical patients. Am J Crit Care 4:435-442, 1995. Moustafa MA, Abdelsamad AA, Zakaria G, Omarah MM. Minimal vs median sternotomy for aortic valve replacement. Asian Cardiovasc Thorac Ann. 2007 Dec;15(6):472-5. OConnor CJ: Pain Relief and pulmonary morbidity after cardiac surgery. Crit Care Med 27:2314-2316, 1999.
25
Pohodenko-Chudakova IO. Acupuncture analgesia and its application in cranio-maxillofacial surgical procedures. J Craniomaxillofac Surg 2005;33:118 –22. Pongratz W, Linke W, Baum M, et al. Electroacupuncture analgesia in 500 heart surgery cases. Anæsthesiol Intensivmed Prax 13:19-33, 1977. PORTUGAL. Ministério da Saúde. Direcção-Geral da Saúde. Circular Normativa nº 9/DGCG de 14/6/2003. Available in: <http://www.dgsaude.pt>. Ragnarsdottir M, Kristjansdottir A, Ingvarsdottir I, Hannesson P, Torfason B, Cahalin L. Short-term changes in pulmonary function and respiratory movements after cardiac surgery via median sternotomy. Scand Cardiovasc J. 2004;38(1):46-52. Ranieri VM, Vitale N, Grasso S, Puntillo F, Mascia L, Paparella D, et al. Time-course of impairment of respiratory mechanics after cardiac surgery and cardiopulmonary bypass. Crit Care Med. 1999 Aug;27(8):1454-60. Rosenquist EWK, Aronson MD, Crowley M. Definition and pathogenesis of chronic pain. Uptodate; 2017. Sasseron AB, Figueiredo LC, Trova K, et al: Does the pain disturb respiratory function after heart surgeries? Rev Bras Cir Cardiovasc 24:490-496, 2009. Silva AAR. Estudo comparativo da analgesia por acupuntura, eletroacupuntura e medicamentos convencionais no pós-operatório de exodontias de terceiros molares inferiores inclusos. São Paulo. [Masters Dissertation] – Universidade de São Paulo; 2004. Sociedade Brasileira para o estudo da Dor. Instituto Central Do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Divisão Clínica Cirúrgica III. Divisão de Anestesia. A dor como 5º sinal vital - Controle da dor aguda no pós-operatório. São Paulo, 2006. Usichenko TI, Dinse M, Hermsen M. Auricular acupuncture for pain relief after total hip arthroplasty—a randomized controlled study. Pain 2005;114:320 –7. Valdix SW, Puntillo KA: Pain, pain relief and accuracy of their recall after cardiac surgery. Prog Cardiovasc Nurs 10:3-11, 1995. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE. Acupuncture Trialists C: acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444–53. Wen, TS. Acupuntura Clássica Chinesa. São Paulo: Ed. Cultrix; 2014.
26
Wong RH, Lee TW, Sihoe AD, Wan IY, Ng CS, Chan SK, et al. Analgesic effect of electroacupuncture in postthoracotomy pain: a prospective randomized trial. Ann Thorac Surg. 2006 Jun;81(6):2031-6. Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, et al. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLoS One. 2016; 11(3):e0150367. Xiong J, Li H, Li X, Wang L, Zhao P, Meng D, et al. Electroacupuncture for postoperative pain management after total knee arthroplasty: Protocol for a systematic review and meta-analysis. Medicine (Baltimore). 2018 Mar;97(9):e0014. Yamamura Y. Acupuntura Tradicional – A Arte de Inserir. São Paulo: Ed. Roca; 2001. York J, Dip G, Wallis M: Patients’ perceptions of pain management after cardiac surgery in an Australian critical care unit. Heart Lung 33:33-41, 2004. Zhao SZ, Chung F, Hanna DB, Raymundo AL, Cheung RY, Chen C. Dose-response relationship between opioid use and adverse effects after ambulatory surgery. J Pain Symptom Manag. 2004;28:35–46.