Acupuncture. Low back pain and migraine prophylaxis ISS 2022 guidelines - Pathos

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Acupuncture. Low back pain and migraine prophylaxis ISS 2022 guidelines

Agopuntura. Linee guida 2022
per la lombalgia e la profillassi dell'emicrania
Short review
Pathos 2022; 29, 4. Online 2022, Dec 22
Marianna Dara
Anestesia Rianimazione e Terapia del Dolore
ASST Sette Laghi, Varese

The popularity and interest in complementary therapies have significantly increased over the last century. Acupuncture is one of the therapies that has received the most attention. It can be considered the most important and certainly the most widespread part of traditional Chinese medicine. Practiced in China and neighboring regions for more than 3000 years as a prevention and treatment of various diseases, it spread to Europe and America from the sixteenth to the nineteenth century.
In Italy, only in 2022 it became part of the guidelines recognized by the Istituto Superiore di Sanità for the treatment of chronic low back pain and migraine prophylaxis. This recognition makes acupuncture extremely topical in clinical practice.
La popolarità e l'interesse per le terapie complementari sono aumentate in modo significativo nell’ultimo secolo. Una delle terapie che ha ricevuto maggiore attenzione è l’agopuntura, che potrebbe essere considerata la parte più importante e sicuramente quella più diffusa della medicina tradizionale cinese. Praticata in Cina e nelle regioni limitrofe da più di tremila anni come prevenzione e trattamento di varie patologie, si è diffusa in Europa e in America dal XVI al XIX secolo.
In Italia, soltanto nel 2022 è entrata a fare parte delle linee guida riconosciute dall’Istituto Superiore di Sanità per il trattamento della lombalgia cronica e la profilassi dell’emicrania. Questo riconoscimento rende l’agopuntura estremamente attuale nella pratica clinica.
Key words
Acupuncture, chronic pain, low back pain, migraine, prophylaxis
Parole chiave
Agopuntura, dolore cronico, dolore lombare, emicrania, profilassi

Acupuncture has been practiced in China for more than 3,000 years: it is a natural therapy that has gained increasing popularity and acceptance among healthcare professionals around the world. The development of acupuncture has progressed steadily throughout the 20th century. Acupuncture research that began in the 1800s peaked in 1987 when the World Federation of Acupuncture and Moxibustion was formally founded; however, it took nearly 100 years for the European physician to accept the clinical application of acupuncture. From these considerations it can be deduced that, although acupuncture has been continuously evolving for 3000 years, it is only in the last half of the century that a rigorous scientific methodology has been applied with the aim of studying its mechanisms and clinical effects.1
Western medicine's approach to TCM (traditional Chinese medicine) has not always been simple, especially in terms of pathological language and vision, as TCM, and specifically acupuncture, has its roots in ancient Taoist thought and has as its primary objective the care of the individual, seen in his physical and psychic totality. The holistic view of TCM considers the human body as a set of interconnected and interdependent functions and refuses to conceive of single organs and systems as separate entities.2 It does not distinguish between physical, mental and emotional components of life and furthermore considers the human being as an integral part of the universe. Thus, a health or disease condition may result from a spiritual, mental, physical and/or environmental balance or imbalance, respectively. An alteration of the normal flow of energy within the channels (meridians) can therefore be the cause of a pathological condition and, in particular, pain can be the expression of an energy blockage and occur locally or along the course of the meridian.3
To deal with the energy imbalance, acupuncture makes use of a set of techniques (acupressure, needle insertion with or without manipulation, electrostimulation, moxibustion or heating of the needles using an infrared lamp) which stimulate precise anatomical points, producing clinically evident.4

Research and evidence
Despite numerous clinical trials on the effectiveness of acupuncture, especially with regard to painful pathology, there are generally no strong recommendations in this regard.5,6 The use of a rigorous scientific method for clinical studies (randomized and controlled) on the effects of acupuncture is of recent introduction and is still marred by various structural difficulties. One critical issue, for example, is the heterogeneity of acupuncturist training, coupled with the variety of style, experience and use of different methods. The choice of a particular treatment protocol with the selection of certain acupuncture points, the ability to evoke the right "de qi" sensation of the needle, the method of needle manipulation employed, and the duration of stimulation are decisive in varying the treatment effect.7
Also, unlike Western medicine clinical trials done with placebos, there is a significant technical barrier in acupuncture studies since the use of needles inserted into the skin does not allow for the possibility of double-blind studies. Over the years, a possible placebo has been sought to compare with acupuncture: an attempt was made with the stimulation of skin areas not associated with acupuncture points (sham acupuncture), but with functional magnetic resonance it emerged that even sham acupuncture in actually induces a physiological response and therefore is not comparable to a placebo.8  Another sham acupuncture technique uses special needles (Park or Streitberger needles) so as not to pierce the skin and still give the specific sensation of piercing to both the patient and the doctor. Unfortunately, the tools have proved too expensive and still induce stimulation of sensitive skin fibers producing physiological responses comparable to acupressure.9,10
The discovery of infrared lasers, invisible to the naked eye, which can be used to stimulate acupuncture points, probably represents the technology that will allow more rigorous double-blind clinical studies to be carried out (both for patient and operator).11

Acupuncture mechanism of action
The numerous studies of neuroanatomy, neurophysiology and neurochemistry conducted since 1970 have shown that the theories of TCM are supported by a precise anatomical-functional substrate.12 Over the years, the complex system of pain pathways, called pain neuromatrix, and its powerful physiological control mechanisms have been progressively discovered, thus allowing us to understand the multiple effects of acupuncture at the central and peripheral nervous system levels.13-15
Thanks to the use of Functional Magnetic Resonance Imaging (RMNf), an advanced visualization method, it has been possible to study the neural response resulting from the stimulation of some known acupuncture points.16
Other studies have also shown that acupuncture does not only evoke an activation of sensitive-motor brain areas and a wide deactivation of the limbic-paralymbic network,17 but it is also able to modulate the connections of various brain regions, including nociceptive, memory, affective and amygdala. These regions process information in circuits that are presumed to involve affective, sensory, cognitive, and inhibitory processing of the experiential component of pain.18
Pomeranz' studies in 1970 also demonstrated the key role of endogenous opioids in the antalgic effect of acupuncture; in fact this effect is antagonized by the administration of naloxone, indicating that the blockage of the endorphinic system interferes with the analgesic benefits of acupuncture.19
PET scan has shown that acupuncture produces a short- and long-term increase in mu-bond potential opioid at the level of the limbic system and a clinical reduction of pain not shown in cases of stimulation of non-specific points not corresponding to real acupuncture points.20 These biochemical and neuroradiological studies demonstrate the fundamental importance of the peripheral and central nervous system in transduction of acupuncture analgesia.
It was thus established that the acupuncture point is a real anatomical entity consisting of a vascular-nerve unit whose stimulation causes the release of endogenous opioids (endorphins, encephalins and dinorphines) and other neuromediators (interleukins, substance P, serotonin, noradrenaline and adenosine) at the central and peripheral levels. This is confirmed by the fact that local anesthesia of a peripheral nerve in the distribution of a given acupuncture point will eliminate the analgesic effects of that point.21

Applications of acupuncture
Acupuncture, associated with the other techniques of TCM (traditional Chinese medicine), represents conventional medicine in the East. For this reason and for its anti-inflammatory, analgesic, antidepressant, rebalancing and muscle relaxant properties, its use has always been quite widespread and extended to various pathological conditions such as:
Pathologies of the locomotor system: osteoarthritis of the spine, cervical and lumbar disc disease and herniated discs, cervicobrachialgia, lumbago, lumbosciatica, lumbocruralgia, spondylolisthesis, collapse of the vertebral bodies due to osteoporosis, osteoarthritis of the temporomandibular joint, epicondylitis, rhizarthrosis of the thumb, osteoarthritis of the small and large joints, carpal tunnel syndrome (early stage), plantar talalgia, local muscle contractures, trigger point deactivation, and fibromyalgia.

  • Nervous system disorders: vascular headache (migraine), tension headache, "cluster" headache, trigeminal neuralgia, "cold" paralysis of the facial nerve, blepharospasm, paresis and paralysis of the limbs following stroke or post-traumatic trauma.
  • Gynecological and obstetric disorders: irregularity of the menstrual cycle and flow (amenorrhea, dysmenorrhea, premenstrual syndrome, climacteric syndrome), infertility, leucorrhoea and recurrent genitourinary infections. Hyperemesis gravidarum, nausea in pregnancy.
  • Andrological disorders: impotence, premature ejaculation, asthenospermia.
  • Urological disorders: urinary incontinence, recurrent cystitis, dysuria, nocturnal enuresis, renal colic.
  • Cardiovascular pathologies: palpitations, arrhythmias, myocardial ischemia, outcomes of IMA, arterial hypertension.
  • Gastrointestinal system disorders: gastritis, gastroduodenal ulcer (chronicity and prevention of recurrence), oesophageal spasm, hiatal hernia, nausea and vomiting, functional epigastric pain, dyspepsia, constipation, alternating evacuation, irritable bowel, tenesmus, haemorrhoidal crises.
  • ENT diseases: sinusitis, vasomotor rhinitis, chronic pharyngitis, hoarseness, deafness, tinnitus, vertigo, anosmia
  • Allergic manifestations: oculorhinitis and asthma of allergic origin, urticaria, skin rashes.
  • Psycho-emotional disorders: anxiety, depression, agitation, panic attacks, insomnia.22-24

Acupuncture and pain
In the West, the best-known indication of acupuncture is certainly represented by painful pathology.25.26 Large, well-designed, well-controlled clinical trials have demonstrated the clinical efficacy of acupuncture and its superiority over routine drug and physical therapy approaches in the treatment of specific pain conditions including neck pain, chronic low back pain, osteoarthritis of the knee and migraine.27-31 Controlled studies such as GERAC and the Cherkin study have demonstrated the long-term efficacy of acupuncture in the treatment of chronic low back pain 8,32 and in 2011, based on literature evidence, acupuncture treatment for chronic low back pain in Great Britain was recognized by the National Health Service.33
A recent three-year study conducted by FISA (Italian Federation of Acupuncture Society - Scientific Medical Society accredited by the Ministry of Health), in collaboration with external consultants including researchers from the Mario Negri Institute in Milan, further demonstrated that acupuncture is equally effective as drugs, but without the latter's side effects, in the treatment of two widespread painful pathologies with a great socio-economic impact: migraine and chronic low back pain. At the conclusion of this study, on 25 July 2022 acupuncture was officially included in the guidelines of the ISS (Istituto Superiore di Sanità), therefore it is the duty of every doctor to consider acupuncture as a possible therapeutic strategy in the treatment of chronic diseases back pain and migraine prophylaxis.34
It is FISA's intention to implement the guidelines for other painful pathologies, but also for the prevention and treatment of the side effects of oncological therapies (chemotherapy and radiotherapy), another area in which acupuncture has demonstrated potential efficacy and sure safety, so much so that it is systematically placed in the integrated oncology departments of major hospitals around the world.35
Acupuncture is generally well tolerated by patients and has few side effects when practiced by experienced and trained physicians. As reported by a large prospective observational study on 229,230 patients who underwent about 10 sessions each, the side effects are represented by local bruising and hematomas (6% of patients), pain during treatment (1.7%), neurovegetative symptoms (0 .7%) and 2 cases of pneumothorax.36 With the systematic introduction of disposable sterile needles, superinfection has become a very rare complication.

Although the path has been long, acupuncture is becoming the cultural heritage of Western medicine and has obtained the right recognition by becoming part of the ISS guidelines regarding the treatment of chronic low back pain and migraine prophylaxis.
Acupuncture is a safe method with an excellent cost-benefit ratio, with few side effects and can be considered a valid choice also in association with pharmacological therapy for the treatment of various acute and chronic pathological conditions.
In 2023, the author hopes, in collaboration with colleagues in the pain therapy unit, to be able to carry out a clinical study to define the role assigned to acupuncture in low back pain Diagnostic Therapeutic Plan (PDTA) of a pain center therapy HUB.

Conflict of interest
The author declares that the article was written without any conflict of interest..
19th December 2022
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