Page 324 Guide to Pain Management in Low-Resource Settings

312 Natalia Samoilova and Andreas Kopf

What about the costs of acupuncture? worth using in a simplifi ed and pragmatic way, since the
Due to the increase in popularity of acupuncture, acu- true eff ects of acupuncture may be the result of coun-
terirritation and modulation of central nervous sensitiv-
puncture needles are now widely available. Costs may
vary, but have to be set in relation to the savings from ity and not strictly dependent on the classical concepts
of acupuncture point selection. However, this concept is
using less or shorter-lasting pharmacotherapy. Depend-
ing on the wholesale merchant, a box of hundred nee- not widely recognized, and existing scientifi c literature
has not evaluated this pragmatic approach.
dles may cost around US$5–10.
Since the technique of needle placement is sim-
Is it possible to treat pain with acupuncture ple and acupuncture needles are widely available and
in all patients? relatively inexpensive, it would be a pity if acupuncture
Th eoretically, all patients may benefi t from acupunc- would not be used because of the lack of adequate train-
ture, but studies have only been able to show—so far— ing facilities. Nevertheless, at least some practical and
evidence for selected syndromes. Acupuncture should theoretical training as well as anatomical knowledge are
never be used—after adequate Western medicine di- indispensable to make acupuncture an eff ective and safe
agnosis—as the exclusive method of treatment, since it pain management technique.
might prevent patients, such as cancer patients, from In situations where even the minimum train-
receiving other eff ective treatments. ing is not available, it is advisable to replace the needling
Typical syndromes where acupuncture is eff ec- technique by acupressure with superfi cial point stimula-
tively used are the following: tion, such as by using small wooden sticks. A recent Co-
• Headache (e.g., migraine, tension-type headache chrane review (Furlan et al. [1]) suggests the eff ective-
• Low back pain ness of acupuncture point massage.
• Neck pain
Step one:
Other indications with less proven eff ectiveness
include: Always start with “distant” points to activate the diff er-
• Osteoarthritis ent antinociceptive systems, and choose from the fol-
• Visceral pain syndromes lowing empirical locations for analgesia (ipsi- and con-
• Vascular ischemic pain tralateral sites):
• Post-amputation pain and causalgia • ST 36 (stomach): approx. 4 cm below the patella
• Chronic postsurgical and post-traumatic pain in a depression lateral to the patellar ligament,
syndromes, e.g., post-thoracotomy-syndrome one fi nger width lateral from the anterior border
of the tibia
Does acupuncture also work in acute pain, • B 40 (urinary bladder): midpoint of the transverse
such as postoperative pain? crease of the popliteal fossa, between the tendons

Th ere is strong evidence from studies and meta-analysis of biceps femoris and semitendinosus
that acupuncture has a role in reducing opioid-related • ST 44 (stomach): proximal to the web margin
side-eff ects like nausea, vomiting and sedation. between the 2nd and 3rd metatarsal bones, in a
depression distal and lateral to the 2nd metatarsal
How can I perform acupuncture for pain joint
without knowing complicated acupuncture • LI 4 (large intestine): middle of the 2nd metacar-
point selection using the meridian system?
pal bone on the radial side
Th is question is diffi cult to answer. On one hand side, the • PC 6 (pericardium): approx. 3 cm above the wrist
general view of acupuncture is that it may only be used if crease between the tendons of palmaris longus
it is part of TCM. Th erefore, thorough training would be and fl exor carpi radialis (also good for nausea)
necessary to be able to understand the fundamentally dif- • LI 11 (large intestine): at the lateral end of the
ferent approach to illness and therapy concepts. Th e usu- transverse cubital crease, midway between a line
al approved (basic) training courses for acupuncture in- between the radial side of the biceps brachii ten-
volve more than 200 hours of theory and case seminars. don and the lateral epicondyle of the humerus
On the other hand, recent studies, such as the GERAC • K 6 (kidney): in the depression below the tip of
studies in Germany, suggest that acupuncture might be the medial malleolus