Richard C. Niemtzow, MD, PhD, MPH
from
Integration of Complementary Disciplines Into the Oncology Clinic
Guest Editor
Peter A.S. Johnstone, MD, MA
to be published in Alternative and Complementary Therapies in Oncology
INTRODUCTION
The American public appears to have become increasingly frustrated with the high-tech,
low-touch approach to care often encountered in the U.S. healthcare delivery system.(1)
Patients are addressing this dissatisfaction by turning to alternative medicine: according
to a recent survey, four of 10 Americans used alternative therapies in 1997.(1) Moreover,
total visits to alternative care physicians and clinics now exceed the visits to all U.S.
primary care physicians.(1) This represents millions of dollars spent by these consumers.
Alternative medicine is the next generation of high technology medicine. In particular,
the field of acupuncture is becoming more widely rooted in mainstream medicine in the
United States, with an Americanized version of acupuncture beginning to emerge in its own
right.(2) Even now, a broad new discipline has emerged, designated by the term
"Medical Acupuncture."(2) Medical acupuncture differs from classical Chinese
acupuncture in that the Western physician has integrated the best acupuncture has to
offer, diagnostic and therapeutic, into allopathic medicine.(2) This mélange of two
technologies promises to benefit the patient. Perhaps in the future, needles may be
replaced by electronic contacts over the classical Chinese acupuncture points, computers
may assist in treatment configurations, and data from the meridians may be analyzed in a
manner similar to the electrocardiogram (EKG).(3) The best acupuncture treatment
applications will be prescribed in combination with Western drug therapy.(2)
This chapter highlights important concepts of the most researched of the alternative
medicines: acupuncture. A brief historical overview is included, and some of the more
modern research authenticating acupuncture points and meridians are presented. Techniques
of integrating acupuncture into clinical medicine are reviewed. Finally, our experience
incorporating acupuncture into the oncology clinics at the Naval Medical Center San Diego
are presented based on patient cases.
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ACUPUNCTURE
About 70% of the world practices some alternative type of medicine. These
practices may be self-care based on folk principles or performed in an organized
healthcare system. A large number of disciplines is potentially included within
alternative medicine; many of these alternatives are difficult to research because of
variations in different parts of the world and interpretation of usage. Further, diagnoses
of various diseases in different folk medicine schemas are not standardized.
Nevertheless, acupuncture is probably the most thoroughly researched and documented of
the alternative medicines. Acupuncture complements our understanding of Western
neuro-anatomy and pain physiology.(2) A series of controlled studies has shown compelling
efficacy of acupuncture in the treatment of a variety of conditions, including
osteoarthritis, chemotherapy-induced nausea, asthma, back pain, dysmenorrhea, and migraine
headaches.(2) The National Institute of Health Consensus Conference on Acupuncture
endorsed its use for adult postoperative and chemotherapy nausea and vomiting and
postoperative dental pain.(4) Helms states that acupuncture further may be useful in
addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia,
myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.(2)
Studies of acupuncture have shown variable results in chronic pain management.(2)
Ultimately, rigorous clinical trials must be performed to substantiate its diagnostic and
therapeutic merits.
Traditionally, acupuncture consists of inserting very thin-gauged needles into specific
locations in the skin (acupuncture points) to achieve a desired beneficial medicinal
effect. These points are located over 12 basic meridians and over a number of specialized
meridians.(2) The clinical outcome is thought to be a result of modulating or unblocking
energy (Qi) flowing through the meridians. These meridians, in turn, are associated with a
major visceral organ and a functional body system.(2) The balancing of this energy was
directly related to the Chinese philosophy of Yin and Yang.(2) The origin of this practice
dates back over 2000 years.
Acupuncture points may be stimulated electrically through a tiny probe, a laser, or by
heat. The use of magnets, metallic/non-metallic pellets, and herbs may also be employed.
The adaptability of classical and hybrid acupuncture approaches in Western medical
environments is the key to their success and popular appeal.(2)
Acupuncture practice in the United States is varied, and "standards of care"
are debatable (and in many instances not well defined or non-existent). Nevertheless, the
Western physician must meet acceptable practices. For example, the author would not treat
a bacterial pharyngitis with acupuncture, but rather would employ the appropriate
antibiotic. If a painful sore throat could not be controlled with analgesic medication,
then the use of acupuncture as adjunctive therapy is justified and acceptable. The
majority of patients treated by the author have not responded satisfactorily to
traditional Western medicine. In other instances, acupuncture may complement Western
medicine (e.g., a patient with a migraine headache may respond to beta blockade and
acupuncture, but to neither alone.)
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HISTORICAL CONSIDERATIONS
Ancient Chinese Theories
The ancient Chinese believed that disease was caused by the imbalance in the body of
two principles called Yin and Yang. They believed that man was either in harmony or
disharmony with the universe, and that diseases were caused by responses to external
extremes of wind, heat, dryness, cold, anger, excitement, worry, fear, and sadness.
Correcting this imbalance was achieved by needling selected acupuncture points.(2)
The classical anatomy of acupuncture consists of energy channels traversing the body.
The principal energy pathways are named for organs whose realms of influence are expended
from their conventional biomedical physiology to include functional, energetic, and
metaphorical qualities (e.g., the kidney supervises bones, marrow, joints, hearing, head,
hair, will, and motivation).(2)
The most superficial of these pathways are the tendon-muscular meridians, which serve
as an interface between the organism and its external environment, providing the first
defense for the body’s response to climatic conditions and external trauma.(2) The
principal meridians travel through the muscles and provide nourishment and vitality to all
the tissues for animation and physical activity.(2) The ancient Chinese postulated that
the Qi-vital energy flowed in the Twelve Paired Channels in a precise cyclic sequence.(2)
The distinct meridians go directly from the surface of the body deep to the organs, and
allow the nourishment and energy produced by the organs to circulate throughout the
body.(2) Finally, a system of pathways called the curious meridians create connections
among the principal acupuncture channels, and serve as energy reservoirs for extreme
conditions of emptiness or fullness.(2) The network of energy circulation is organized
into three bilateral symmetrical plates that divide the body into six sagittal territories
of influence.(2) Each plate manifests the energy derived from four organs as it circulates
in their anatomical territory of influence .(2)
The classical physiology of acupuncture involves a dozen internal organs that interact
to produce basic energy and blood from ingested solid and liquid nourishment, then mix in
the energy from inspired air and propel the transformed energy and blood through all the
body’s organs and tissues.(2) Pathology in acupuncture involves an early
manifestation of disharmony associated with the subtle influence of an organ, a disruption
of the Qi flow in one of the subdivisions of the circulation network associated with an
organ, or a frank disturbance in an organ’s metabolic or transport function.(2)
Diagnosis in acupuncture involves recognizing the level of manifestation of a
disturbance.(2) Obstruction of energy flow or blood through the principal meridians
manifests as a musculoskeletal pain in the territory of the channel.(2) Organ pathology is
identified either in conventional biomedical terms or as a disturbance in the organ’s
physiological activities according to acupuncture terms (e.g., nephrolithiasis is a
disturbance in both kidney and bladder organs and spheres of influence).(2) Treatment in
acupuncture involves the insertion of needles along channels of the involved organs to
stimulate energy circulation that can influence the problem at its level of manifestation,
and thus restore energetic balance and organ function in the organism.(2)
Western Perspectives
The most significant influence on Western acupuncture was a result of the translations
and teachings of George Soulie de Morant, a scholar and diplomat in China from 1901- 1917.
His translations and teaching of Chinese acupuncture texts introduced the concepts and
terminology of meridian and energy that are still used today.(5,6)
Electrophysiological Mechanisms of Acupuncture Points and Channels
1940s-1950s: The French physician Niboyet demonstrated through the use of a very
sensitive galvanometer, that points of lowered electrical resistance on the human body are
usually found in the acupuncture zones illustrated in the classical Chinese meridian
charts.(7)
1962: Grall verified Niboyet’s research comparing acupuncture point electrical
resistance (ranging between 5 and 50 kilo-ohms) to that of neutral non-acupuncture points
(ranging from 0.5 to 3 mega-ohms).(8) When low resistance points were plotted on [a[er
overlying the body, the classical acupuncture channels were delineated.(9)
1970s: Terral, a medical student at the Faculte de Medecine de Montpellier, France,
produced analgesia in a rabbit’s paw using acupuncture and injected its serum into
another rabbit causing analgesia in the same corresponding paw. This simple but elegant
experiment depicted that acupuncture points when stimulated produced complex biochemical
and electrophysiological reactions.(10)
1975: Bossy (11,12) and Rabischong (13) separately reproduced Niboyet’s research.
Bossy,(11,12) working on fresh cadavers, concluded that the transmission of acupuncture
electrical activity is not entirely dependent on an intact nervous system.
Acupuncture Channels and Points: Modern Evidence of Their Existence
Darras (14,15) injected technetium 99 into classical acupuncture points as well as loci
that were not acupuncture points. Tracer distribution was followed with a scintillation
camera. The trajectories of the radioisotope diffusion from the acupuncture point
topographically corresponded to classical described acupuncture channels. Technetium 99
injected in non-acupuncture loci did not diffuse into any linear pattern and only produced
a centrifugal diffusion. Stimulation of the injected acupuncture points with a needle,
electricity or helium neon laser increased the migration rate along the channel. The fact
that these rates did not appear to correspond to vascular or lymphatic circulation rates
led the authors to conclude that the observed isotopic migration demonstrated the
perimuscular pathways of acupuncture channels.(16)
Senelar described an acupuncture point as located in a vertical column of loose
connective tissue surrounded by the thick, dense connective tissue of the skin, itself not
a good electrical conductor. The structural elements of the acupuncture points are
associated with capillaries, myelinated and unmyelinated nerve fibers, capillaries, a
vein, an arteriole, and a lymphatic vessel.(17)
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NEEDLING ACUPUNCTURE POINTS AND EFFECTS
An acupuncture needle usually consists of a shaft composed of metal and a handle which
may abe metal or plastic. Once inserted, the needle has thermoelectrical properties as
well as the ability to disturb electrons in the penetrated tissues. A directed electron
flow in a meridian may also be achieved by placement of needles in conjunction with
electrical stimulators connected to form an electrical circuit. Why this small electron
flow should have a beneficial physiological effect is not well understood. Taking into
account that all cells have transmembrane electrical potentials that are in dynamic
electrical and thermodynamic equilibrium, it is possible that minute induced external
electrical currents on the cellular membrane may serve as homeostatic regulators in the
pathological state.(18)
Six different effects result from needling: analgesic, sedatory, homeostatic or
regulatory, immune-enhancing, anti-inflammatory, and motor recoverability.(19) Pain relief
may be explained by the Gate Control Theory proposed by Melzack and Wall in 1965.(20)
Chemical or humoral mechanisms are also involved in acupuncture. The research of several
authors suggests that the naturally occurring endorphins play a prominent part.(8,21)
These authors theorize that by binding on the opiate receptors in the brain cells, the
endorphins released by acupuncture could produce analgesic effect.(22) Over 100
neurotransmitters possibly may be involved in the pain mechanism released during
acupuncture and may be dependent on the frequency of the electrical stimulation.(23) Two
model systems of acupuncture analgesia have been proposed: 1) an endorphin-dependent
system involving low-frequency, high intensity electrical stimulation of acupuncture
needles (2-4 Hz) that is slow in onset, generalized through the body, and cumulative on
subsequent stimulation; and 2) a monoamine-dependent system involving high-frequency
electrical stimulation of the acupuncture needles (70 Hz or greater) that is rapid in
onset, segmental, and not cumulative.(2)
By combining the neurohumeral models with other observations and speculations, a model
is created of an acupuncture needle simultaneously activating multiple systems in the
body’s physiology. Becker demonstrated that meridians had electrical characteristics
of transmission lines, while non-meridian skin did not,(24) and proposed that acupuncture
points served as booster amplifiers along the meridians. Electrical measurements
demonstrated that as current propagated along the meridian became attenuated over a
distance increased, the signal was processed in the acupuncture point and amplified to
continue its transmission through the meridian circuit.(24)
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INTEGRATION OF ACUPUNCTURE IN THE ONCOLOGY CLINIC
Acupuncture has proven to be very useful and well accepted at our institution for
adjunctive and palliative purposes in the medical, surgical, and radiation oncology
clinics. It is not used to compete with allopathic medicine, nor is it a substitute to
deviate from the quality or the standard of care. Acupuncture may be considered a
"new technology" to most Western-trained physicians, but we have found that in
many instances, it may "salvage" oncology patients who have failed traditional
therapies in the treatment of nausea, vomiting, acute and chronic pain, decreased
appetite, xerostomia, hot flashes, lymphedema, and peripheral neuropathy. Acupuncture
assists the physician in understanding symptoms that do not follow allopathic disease
patterns. Employing the acupuncture paradigm may lead to resolution or attenuation of the
side effects from cancer therapies or of the malignancy itself. Furthermore, it addresses
the entire patient: spirit and body.
The skepticism among Western physicians appears primarily directed against the paucity
of clinical trails and inadequate data. For the most part, the acupuncture literature is
confusing and inconsistent. It is the author’s view that healthy skepticism is
certainly acceptable, but should not exclude acupuncture from consideration as a
complementary discipline. In the United States, many physicians have integrated
acupuncture into their allopathic practices. It has become a new specialty, bringing with
it a technology characterized by favorable clinical outcomes for patients who otherwise
would suffer.
Case 1:
This 55-year-old white male had a history of node-positive tonsil cancer, treated with
radiotherapy and surgery. He developed xerostomia secondary to radiation which was not
relieved by pilocarpine therapy. At the time of acupuncture, his complaint was dry oral
cavity mucosa and inability to expectorate. The physical examination confirmed the absence
of saliva. The patient was treated with acupuncture, and after 15-20 minutes of therapy,
heavy secretion of saliva in the mouth was observed. During follow-up visits, the patient
reported no lack of saliva. This was clinically confirmed on several visits.
Twelve cancer patients with pilocarpine-refractory xerostoma secondary to head and neck
radiotherapy were treated with acupuncture, and similar results were noted. Different
degrees of quality and quantity of saliva were secreted among the patients. Only one
patient (an alcohol and tobacco abuser) subjectively failed to respond. Several patients
reported maintaining saliva up to one month with only a single acupuncture treatment. No
relapses have been observed in this limited observation.
Case 2:
This 50-year-old woman was treated with the combined modalities of surgery, radiotherapy,
chemotherapy, and hormone therapy for breast cancer. She complained of episodes of
perspiration and intense hot flushes on an hourly basis. Sleep at night was very
disturbed. None of the medications prescribed were effective in attenuating the symptoms.
After five treatments with acupuncture, the patient reported 2-3 mild warm-ups during the
day, with no perspiration or undisturbed sleep at night. Maintenance therapy with
acupuncture was initiated on a 3- 4 week schedule.
Six breast cancer patients having similar complaints of hot flashes were treated with
acupuncture and obtained excellent results. In all cases, heavy perspiration ceased, and
the frequency of episodes decreased, if not disappeared, after 4-5 treatments. Follow-up
visits with maintenance acupuncture were tailored to the individual patient.
Case 3:
This 79-year-old woman had a remote history of breast cancer and chronic right chest wall
pain following a modified radical mastectomy and post-operative cobalt radiation. Pain
control was not satisfactory with oral medications. Clinical evaluation revealed extensive
radiation fibrosis in the painful arearecurrent disease had been ruled out clinically and
radiographically Acupuncture consisted only of treating ear points
(electro-auriculotherapy). The patient became pain free after one treatment and was able
to achieve almost full range of motion with both arms without any pain.
Acupuncture has been helpful with three other patients who experienced pain and reduced
range of motion of the upper extremities due either to malignant disease or post
therapeutic complications. In each case, the patient benefited from receiving acupuncture
with reduction of pain and increase in range of motion of the upper extremities.
Case 4:
This 34-year-old male diagnosed with sarcoma arising in the right iliac wing was
receiving preoperative radiotherapy. The patient requested acupuncture over conventional
pain medication, as it achieved better pain-free periods. Pre-operative radiotherapy loss
of appetite was also controlled with acupuncture, whereas conventional medications had
failed.
We have found acupuncture to be very helpful in reducing pain from local and metastatic
disease when narcotics are insufficient to achieve pain control. In some cases, the
acupuncture was proven to be a superior therapy or helpful as an adjunct especially to
control nausea and vomiting.
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CONCLUSION
Acupuncture is successfully employed in our oncology clinics, and we are convinced that
it can contribute to an increased quality of life for our cancer patients. Whether
prescribed alone or used adjunctively, we have found it to be extremely helpful and
without side effects noted to date. Our patients are eager to undergo this therapy. At our
center, observations continue to confirm that the use of acupuncture to assist our cancer
patients is desirable, economical, and safe. It is now part of our palliative therapy
options. Outcome analyses continue.
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