Jiang Ti Kong, MD on Acupuncture for Back Pain

have the pleasure of introducing our next
speaker, Dr. Jiang-Ti Kong. Dr. Kong is faculty at the
Stanford Pain Management Center. She is board certified
in anesthesiology, pain management, and
medical acupuncture. She splits are time between
general pain practice, running a busy
acupuncture clinic, teaching, and
carrying out research to integrate acupuncture
into modern pain practice. And I just want to
take this moment to mention that she had just
secured a very important grant from NIH, and we’re all
very pleased for her and proud of her. She was born in China, educated
at MIT, Harvard, and Stanford. She currently sits on the board
of directors for the Society for Acupuncture Research, an
international organization to advance scientific studies
involving acupuncture. Please join me in
welcoming Dr. Kong. JIANG-TI KONG: OK, sounds great. Hi there. So first of all, thank
you for coming here, and welcome to our forum. As you can see here, back
pain is one of those things that affects all
sorts of people, from the young to the
old, man and woman, and people of all ethnicities. So thank you for coming
together for this forum. And before I go further,
I’d like to first tell you our game plan today. We’ll be talking
about acupuncture. Actually before I
start, how many of you have had acupuncture
in the past? Impressive, OK, so then we’ll
breeze through that a bit. I’ll tell you a bit more
of the Chinese theories behind acupuncture
and also contrast and compare that
to Western science, and then we’ll
analyze if acupuncture would work for low back pain. And then more importantly, we’ll
talk to you more about what to expect when you choose to
use acupuncture, and and then finally, we’ll conclude. So by the way, that’s a bamboo
forest, in case you wonder. Love bamboo, they use not
too much water and provide a lot of shades. All right, so what
is acupuncture? So in Greek, acus means needle,
and a puncture means to pierce, and acupuncture is an
ancient therapeutic technique developed in China, about
3,000 years ago or earlier. And so it has garnered much
popularity, not only in Asia, but also in Western countries. As you can see here, on the
other side of the screen, this is from a paper
published in the New England Journal of Medicine, one of the
top journals here in America. This particular
paper here endorses the benefits of acupuncture. And listed a few
interesting points which practitioners typically
use to treat back pain. So the next question,
again for those who haven’t the used
acupuncture, actually for those who have used, do you
think acupuncture hurts? OK, Yep, it doesn’t
hurt too much. So here’s a picture
that contrasts the size of our needle to small things. You can see the match
here is actually huge, and then a tenth of that is a
medical needle, syringe needle. Smaller than that is
a small sewing needle, and acupuncture
is about a quarter of the size of a sewing needle. It punctures through
specific points on the body, and you’re not really
supposed to feel a sharp pain from these needles. And most importantly, at
least in this country, they’re all sterile,
sterily prepared, and one time use only. So there should be no concerns
for infection and such issues. OK, so the next part
is a condensed ideology on Chinese medicine. So how does acupuncture
work, according to the Chinese people? There’s two very important
foundations in the Eastern Chinese medicine. The first concept is
energy flow and meridians. The idea is that there are
invisible channels on top of your body that connects
the external part of the body and internal organs. Externally, refers to
muscles, skin, and bones, and internal refers to
organs, heart, and lungs. So the idea is that you can
achieve optimal health when you have regular energy
flow, or chi flow in Chinese, in these channels smoothly. There are about 12
meridians in your body, and ideally the energy
should flow very well in all these channels. The second concept is more of
a static concept, not dynamic. The second concept
refers to balance. So there’s all kinds of balance. The most famous one is
that yin-yang balance. Right? You probably heard of the
yin-yang twins and whatnot. So in Chinese ideology, yang
refers to the sun, male, energy, and top part
of body, and yin refers to earth, female,
resting, and nutrition. So as you can see
very nicely here, the other part about
interesting yin-yang is that it’s all metaphysical. The yin has yang in it,
and yang has yin in it. So I guess in a way,
if you want to make an example, a beautiful woman,
she is not just all feminine. We value strength and
assertiveness in a woman, and similarly for a man, we
like men who are sensitive, or I guess I do. So any case, so that’s a
very interesting concept from ancient Chinese mythology
and Chinese medicine. So just out of interest,
I love this little picture here from the web. White kitty and black kitty,
and I want to show you quickly my own yin kitty and yang kitty. This beautiful
girl here, her name is Bella, and this very cute
boy here, his name is Thunder. They are great pets. So OK, next. So acupuncture equipments,
what do you typically see in an
acupuncturist’s office? Clearly, the first thing is
needles, all sorts of needles. Just give me a second. [INAUDIBLE] demonstrations. So I guess I’ll pass this
around a little bit later. So these are
acupuncture needles. As you can see,
tiny needles which are used to puncture sites on
the body, the scalp, and also the ears. OK, so another one is,
besides the needles, is electrical stimulator,
which I have one right here. So typically, practitioners
would connect the needles to the electrical
stimulator via wires and a lot of studies,
particularly of recent times, both in China and
the Western world, have shown that electrical
acupuncture seem to have special effects
in reducing pain. Third element, which is used
in almost every acupuncturist’s office is a heat lamp. Typically, these are not
just regular heat lamps. These are far
infrared heat lamps, which has larger wave length
and can penetrate into deeper tissue, such as a muscle. So these are the
principal component of an acupuncture treatment. There are also
adjuncts appendages. For example, moxa which
is sticks of dry mugworts. The provider would
burn the moxa, and they would produce both
heat and a warm incense. And secondly, very
commonly you’ve probably seen in
your acupuncturist office the cupping. So it’s very cool. People would put
hot air in the cups, and then slap the
cup immediately onto a patient’s skin, ideally
along a certain meridian, and then move. So immediately it will suck up
some skin underneath tissues, and you move the
cup up and down. And typically, it’s
very stimulating, and tend to relieve a lot
of pain from the muscles. All right, so the
next thing is, now that we know the eastern
ideology how acupuncture works based on energies and
balance and dynamic flow. How does it really work in
a Western reductive mind? So this is to echo
a lot of points made earlier today from Dr.
[? Mahi ?] and Dr. Darnall. When they mentioned that
pain is a complex pathway which involves both perception
of pain from the periphery and also an influence of
perception via brain and spinal cord. So acupuncture has been
shown, by a lot of studies, to augment this descending
influence of pain perception. Specifically, it produces
this happy chemical called endorphins, which
is a key ingredient in a down regulating pathway. And acupuncture has
been shown to increase endorphins, multiple folds in
both the brain and spinal cord. So that’s one of the best shown
mechanisms of acupuncture, particularly relevant to pain,
including back pain, headaches, and arthritis. So next, how does it work? So when you think a chronic
pain, a lot of people think of pathology and
chronic inflammation. So inflammation does exist,
typically, with chronic pain, both at a tissue level
and at the brain and nerve level and spinal court level. And there are chemicals
involved with inflammation, such as interleukin-1,
interleukin-6, 6 which I did not
detail here, as well as hormones, such as cortisol. Acupuncture has been
shown to modulate these levels of both cortisol
and these inflammatory soup markers. What do you call that? Inflammatory spikes
in your body fluid. So to such an extent
that acupuncture would reduce inflammation both
in the nerves and in the brain and in the periphery, where
the muscle and nerves are. OK, so lastly– again,
I shouldn’t say lastly, because there are many
other known mechanisms. I’m only quoting you here the
most important ones so far, which are relative and
relate to chronic back pain. So the last one is acupuncture
reduces muscle pain profoundly, particularly stiffness and pain,
by working at the neuromuscular junction, which is right here. The junction between nerves
and muscle fiber, acupuncture sometimes elicit
a twitch response. So when your
practitioner needles you, you feel a little twitch. That’s because
the needle is very close to these little
structures here, and they cause stimulation,
which subsequently causes a profound release of
pain and relaxation within these muscles. Basically, the idea is that
muscle tension and weakness causes pain, and acupuncture
reduces the tension significantly. OK, sorry I went
ahead of myself. So does acupuncture
treat back pain? So based on the
mechanisms we talked about, acupuncture
increases happy chemicals, or pain-fighting chemicals,
in the brain and spinal cord. It reduces inflammation
everywhere, and it also reduces
muscle stiffness. It is most likely that it will
help with chronic back pain. Because why? Because regardless of your
cause of back pain, eventually you end up with similar
kind of sufferings involving muscle stiffness,
involving inflammation everywhere, and involving
a general decrease of pain-fighting chemicals. That’s why the stuff
we talked about, psychological therapies,
the physical therapies, may help you boost to
this happy chemicals, and acupuncture gives you
a very profound boost. So in any case, it does
help with chronic back pain. In addition to that, multiple
large scale clinical trials, involving between hundreds
to thousands of patients, both in the West, including
particularly Germany, England, and US and in the east,
particularly China and Japan, showed that acupuncture or
acupuncture-like interventions causes much better
pain relief compared to standard care,
which is defined as the medications, physical
therapy, and physicians visits. So however, I think to
be completely honest and being responsible, as both
a researcher, practitioner, and a medical teacher,
I will tell you that acupuncture, chances are,
will not eliminate all the pain that you have. And particularly, if
you have nerve pain, especially if it’s caused by
disherniation and compression of nerves. And the truth is,
however, that I doubt that there’s any one
single intervention that will eliminate your pain 100%. I think that’ll be a false
message for me to deliver. I think what we’re
trying to do here is to tell you that
chances are magical pills, bolas, needles
don’t really exist. Our goal is to reduce
your pain to enough extent that it will allow you
to function and allow you to also be more independent
and try other techniques. OK again, I can’t help myself. I put these other kitties in. These are the pictures
from two years ago, when I first adopted
them from the shelter. Bella in center there. Yeah, they’re just fabulous. OK. So now that we know
acupuncture probably works for chronic low back
pain by a variety of very helpful mechanisms, you
just have to do acupuncture. Now, what are some
of the expectations? So I’m going to start answering
some questions or FAQs. So first question
is, does everybody respond to acupuncture? Of course, I want the
answered to be 100%, but the reality
is, it’s about 60%. About 60% of the folks
respond to acupuncture, and right now it’s
still largely uncertain what determines a responder. We know that factors such as
your anatomy, your genetics, which you cannot control, and
the way you feel about yourself and your body, which
you can control, together interact and influence
the outcome of acupuncture. However, there has not
been formal studies, until about now, because
I’m leading a study, as Dr. Darnall mentioned. We just got funded from
NIH, starting next year, looking at how acupuncture
will help with their back pain. And most importantly, what
determines a patient’s response to acupuncture. We’ll send out flyers a
little bit later, but just so you know, we
welcome any patients with back pain for
this particular study. OK, the next important
question as a patient would be, what are the side effects. What are the side
effects of acupuncture? So first of all I want to say,
it’s a very safe intervention. As I mentioned, we use tiny
hair-thin needles, which are– you want to see one? AUDIENCE: Will they break? JIANG-TI KONG: Will they break? No, these are made– I hate to say, these are
made in Japan and China. They’re very nice. These are carbonized
stainless steel. So they’re soft. They’re soft and
malleable, hair-thin. You can come and take a look a
little bit later, if you like. And yeah, and they’re one
use only, one time use only. So they’re pretty safe. What’s the chance
that this thing can cause severe damage in you? Extremely minimal. The most common side
effects from acupuncture is just minor pain from the
site of needle insertion, and potentially a small bruise,
which typically will resolve in about two or three days. The chance of major side
effect is extremely rare. I guess the biggest harm
is what you think could be. Right? People think of porcupines,
being stuck, and all that. Actually, it’s not
that bad at all. Most my patients feel a
sense of profound relaxation during the treatment,
and for several days after the treatment as well. So yeah, it’s more
up here sometimes, where the pain and
fear comes from. OK, so what to
expect number two, one should I try acupuncture. So I remembered a lot of you
guys just had a fabulous talk this morning, by our very
own Dr. Heather King, talking about self-care,
which is absolutely great. So I would say you can try
acupuncture if self-care by itself cannot take care of
all your pain and concerns. You can try acupuncture, which
essentially means any time. OK? And the other question is,
can I have acupuncture along with other treatments, such
as wonderful physical therapy [? Corine ?] just talked about
or psychological interventions that Dr. Darnall and
Dr. King mentioned. The answer is not only yes, but
an absolute yes, yes, yes, yes. Because there has been
several clinical study that showed acupuncture augments the
benefits of physical therapy profoundly. And also, psychological
commotions work well with acupuncture. So it’s important, if
you can, combine them. Next one, medications, do
medications affect response to acupuncture. The answer is yes, in different
ways, for example, opiods, such as Vicodin and morphine. They can actually
interfere with the benefits from acupuncture, because
they work together, works with the happy chemicals. When you take
morphine, there’s too much outside happy
chemicals for you to really perceive the
benefits from acupuncture. So I typically tell my patients
to lower their opioid dose, if possible, but not required. And secondly, certain
antidepressants, for example nortriptyline,
a tricyclic antidepressant, it actually can enhance, double
the benefits of acupuncture, because they work through
different mechanisms. Supplements most of them are
fine, except for caffeine. Some of my friends from
Brazil, and also from here, have shown that
caffeine, again, work on the same chemical
as acupuncture in the periphery, which is
a molecule called adenosine. So adenosine helps pain
reduction in the periphery, in the tissues in the muscle. But caffeine can
actually interfere with adenosine
metabolism, the making and breaking down of adenosine. Hence, if you can, moderate
your caffeine intake while receiving acupuncture. It will be very beneficial. OK, now what’s next. What’s a typical
acupuncture session? It is usually about half
an hour to 60 minutes long, costing about
$50 to $200 in the US. It depends on your provider,
how much they charge, and most clinical studies, most
successful clinical studies, involving the use of acupuncture
in treating pain, particularly back pain, they use between 10
to 15 sessions of acupuncture. So we recommend about 10 to
12 sessions, once or twice per week. In China, it’s given a lot more
frequent, could be even daily. We should work too
by their studies, but here, in this
country, what’s more common is once
or twice per week, for a total of about
five to six weeks. That’s considered
a typical course. If you respond, you should
respond by that time. OK again, when do I
expect pain relief by acupuncture, partial
or a little bit or a lot. It really varies. Sometimes, I see
immediate pain relief, by the end of the
treatment session. Sometimes, it may take
a couple of days for you to see the benefits,
and again, I didn’t write down here,
abut a natural segue for this would be, do all
acupuncture is created equal. Right? I think it’s a very
great question, and I think the answer to that
is not exactly straightforward. So yes and no. By yes, I say that again
based on the clinical studies in several large studies. So they don’t see
much of a difference in the training of
their acupuncturist, however these are
standardized acupuncturists. In Germany, they’re usually
physician acupuncturists, and in the US study, there
were licensed acupuncturists with about five years
experience or more. However, if you take
these acupuncturists and compare and
contrast these people, you don’t see much difference. So I think the answer
is not quite there. We’re still trying to figure
it out, but I would say, it’s probably safe to go with
either a licensed acupuncturist with good experience or a
physician acupuncturist, yeah, based on previous studies. OK, very finally insurance,
so who covers acupuncture. This is unfortunate compared to
Germany and England or China. We are way behind in
taking care of our patients using complementary and
alternative medicine. For example, one of the
biggest medical insurance in this country, Medicare, does
not even recognize acupuncture for any conditions. So that doesn’t pay. And second, Medicare
is a hit or miss. It doesn’t always cover. Sometimes it does, and
the problem with Medicare is that it covers in a
very [INAUDIBLE] rate. Which I prefer it not
to do, because they only allow patients to have
treatment of once per month. There’s no study that shows
benefits of acupuncture if you receive only
once per month. Ideally you should be
at least once per week. OK? And then private insurance,
about 50-50 as well. It’s important that you check
your insurance before you start acupuncture treatments. A lot of practitioners
take self-pay. If you do self-pay,
there’s typically a large amount of discount. So figure that out. You want to be financially savvy
and also take care of yourself in the best way possible. All right, so here we go
rapidly to our conclusions. So acupuncture is generally
safe and not painful, and it helps with
chronic back pain through were several mechanisms. By A, increasing pain-fighting
chemicals in the brain and the spinal cord. B, by reducing inflammation
overall in the body tissues and in the spinal cord. And lastly, it reduces
myofascial pain by reducing tense,
stiff muscles. Realize that it may not
take away all of your pain, but it will be
significant, but it works to take away at
least 30% of your pain for a lot of patients,
like in 60% of patients. OK next, back pain patients
should try acupuncture as soon as self-care is
not working by itself. You can try acupuncture
alone or, even better, combine that with physical
therapy and pain psychology. I want to say here with
physical therapy acupuncture, because it relieves
muscle tension, it’ll help you perform
the physical therapy exercises better prescribed
by your therapist. And with psychology, when
you have more relaxation and can better concentrate
and rest better, you will I think be more
receptive to different ideas about self-care managements. OK, so that concludes
my prepared talk. I have to say confess,
on my way here I realized, oh my god,
all these great colleagues have wonderful talks. They make you meditate and
move your backs and everything. I figured I need to
demonstrate something. So what I will show you here
is a bit of a acupressure. So we’re going to show
you two different points. OK, the first point is that
nausea on relaxation point. So when you have pain, sometimes
when it becomes severe, you may feel a bit
nauseous or anxious. So one of the most classic
points in Chinese medicine is this thing called
the inner gates. So come here, find your wrist. There is a crease in your wrist. Right? And you go down the wrist crease
by two finger widths, two thumb widths, one and two, and you
come right into the center. And if you press on
that, typically you will feel a very
nice, deep ache. Now, you can actually do
self-massage on this points. I have some great stories
from a great friend of mine who suffered from
transverse myelitis and he was here at
Stanford hospital. At some point, he was hiccuping
so much, he couldn’t stop. They tried all the medications. So eventually, they got a nurse. They got I think
an emergency nurse. So all she did was this, and
that stopped his hiccuping. And also for nausea,
seasickness, anxiety, this is a great point. You can do both sides. And the way to do
acupressure is, first you have to apply a nice,
steady pressure to the extent that you feel deep ache. Once you feel the
ache, you can do little regular circular
motions, and do that for about two
or three minutes, and try the other side. Now, the second point
I’m going to show you is also a very cool point. So this one, remember, is
called the inner gates. The gate to your inner
self, inner gate. OK, the other point
is right here. It’s called the posterior creek. The idea is for the
posterior side of your hand. If you make a fist,
make a fist, you can see a little protrusion,
right here on the side, just under the big joint
of your small finger. Right? You can feel a little
bit of a protrusion right here, and if you
press that real hard– this is one of the
better classical points in Chinese medicine that
treats back and neck pain. So actually, my mom sent me a
little video, not too long ago, she said, you can just
push your hand on the desk, like this, and rub
it back and forth. So that’s a little way to
release your back and neck pain. So you can try that
in your spare time. So yeah, that’s exactly right. That’s exactly right.

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