CAM Approaches for Pediatric Pain 21 Acupuncture

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In adults, acupuncture is among the most frequently used CAM treatments for chronic medical conditions (15-17), and its effectiveness has been supported for several specific pain problems, such as headaches (18) and chronic back pain (19). Reports of serious adverse effects are rare (20,21). Although the exact mechanisms by which acupuncture exerts analgesic effects have not been specified, numerous investigations have demonstrated that the nervous system, neurotransmitters, endogenous substances, and Jingluo (meridians) may respond to needling stimulation and electroacupuncture (EA) (22), in which an acupuncture needle is attached to a low-voltage electricity source.

As reviewed by Ma (22), early studies demonstrated that the analgesic effects of EA are mediated by opioid peptides in the periaqueductal gray; more recent evidence showed that nitric oxide plays an important role in mediating cardiovascular responses to EA stimulation through the gracile nucleus-thalamic pathway. Several substances, including serotonin, catecholamines, inorganic chemicals, and amino acids, such as glutamate and a-aminobutyric acid, are proposed to mediate certain cardiovascular and analgesic effects of acupuncture, although at present their role is poorly understood (22).

There are few published reports on acupuncture for treatment of pain in children. One of the principal reasons for this scarcity of research is the conventional view that children react to needles with fear and distaste (23). Pediatricians will often fail to suggest acupuncture if they suspect such an aversion to needles (23); researchers may believe that inadequate patient enrollment and retention would prevent them from carrying out an adequate trial of acupuncture in children.

Kemper and colleagues (23), however, found that 67% of children referred to an acupuncturist for chronic pain problems (most commonly migraine headaches, endometriosis, and reflex sympathetic dystrophy) and 60% of their parents thought that acupuncture was a positive experience; 70% of the children and 59% of the parents reported definite pain relief from the intervention. These findings support the feasibility and acceptability of acupuncture for pain relief in children. However, most of the patients in this study were adolescents (median age, 16 years), and only those patients who were referred and actually visited the acupuncturist were interviewed. No information was available regarding the percentage of referred patients who refused acupuncture or the reasons for their doing so. Thus, this study may have overestimated the acceptability of treatment. These researchers recommended further prospective investigations, particularly in younger samples.

2.1.1. Chronic Pain

We evaluated the efficacy and acceptability of a combined acupuncture and hypnotherapy intervention package in 33 children 6-18 years old (mean, 13 years) who were referred to a chronic pain clinic; the most common diagnoses in this group were myofascial pain and migraine headaches (46%), abdominal pain (21%), fibromyalgia (11%), and complex regional pain syndrome type 1 of an extremity (11%) (24). The children were offered six weekly sessions of acupuncture, with a 20-minute hypnotherapy session that was conducted while the needles were in place. Only 2 patients refused treatment, and more than 90% completed the 6-week course. No adverse effects were reported, and both parents and children reported significant improvements in children's pain and functioning. This study supports the high acceptability of a combined acupuncture/ hypnotherapy intervention and provides preliminary evidence of its effectiveness for chronic pediatric pain. However, the acceptability and efficacy of acupuncture alone, without the addition of hypnotherapy, remain unclear. Moreover, the study was limited by the absence of a control group.

2.1.2. Pediatric Migraine

Only one randomized, controlled study of acupuncture in children with chronic pain was located in the literature. Pintov and colleagues administered either true acupuncture or a placebo intervention (superficial needling) to 22 patients, aged

7-15 years, complaining of migraine headaches (25). Of the children, 12 were treated with 10 weekly sessions of true acupuncture, with needles inserted subdermally, according to the principles of traditional Chinese medicine. The 10 children in the placebo group had needles of the same size inserted in the stratum corneum once a week for 10 weeks. Children, parents, and nurse raters who administered the pain measures were all blinded to study group assignment. No children received prophylactic medications.

Blood samples were taken from all children to examine treatment effects on plasma panopioid activity and levels of P-endorphin because dysregulation of the endogenous opioid antinociceptive system has been hypothesized as a possible factor in migraine (26,27). The true acupuncture group reported reductions in migraine frequency and severity, and panopioid activity in plasma, and P-endorphin levels also rose significantly. No such changes were observed in the placebo group. These findings, in a rigorously designed study, provide good evidence to support the efficacy of acupuncture in the treatment of pediatric migraine. However, there are several caveats. First, the sample sizes were relatively small. Second, although many pediatric migraine patients receive regular, prophylactic, or as-needed medications, all such patients were excluded from this study. Thus, the study sample may not be representative of pediatric migraine patients. Third, these investigators reported no information on refusal rates, so it is not possible to determine the acceptability of the treatment. Finally, no follow-up data were presented, and it is not known whether or how long after the study the treatment gains persisted.

In summary, acupuncture may be designated as possibly efficacious for pediatric migraine specifically based on evidence from the Pintov et al. study (25) and as a promising therapy for chronic pediatric pain in general from existing evidence according to the 1995 Task Force criteria. No published studies to date have examined the use of acupuncture for acute pain in children. More research is required to establish the efficacy and acceptability of acupuncture for a range of pain problems in children.

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