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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.61 no.1 Campinas Jan./Feb. 2011
Alysson Bruno Oliveira SantosI; Judymara Lauzi Gozzani, TSAII
IAnesthesiologist Specialist in Pain at SBA; Acupuncture Specialist at CMBA
IIPhD in Medicine from Unifesp, Co-responsible for the CET/SBA of SCSP; Coordinator of the Pain Department of SCSP
BACKGROUND AND OBJECTIVES: Cerebrovascular diseases are responsible for a large proportion of deaths in the world. Among survivors, the majority of limiting sequelae observed is motor in origin; but when sensorial pathways or centers are affected patients can evolve with sensorial changes in the body region represented by the area of the brain affected. When the affected area is related to the thalamus the patient might develop thalamic syndrome. The objective of this report was to demonstrate the use of electroacupuncture as adjuvant in the treatment of central pain, diagnosed as thalamic syndrome difficult to control with pharmacologic therapy.
CASE REPORT: This is a 46 year-old female with history of ischemic stroke in the left temporoparietal region in April 2003 that evolved to right hemiparesis and hemitaxia. One year later, the patient developed continuous, insidious pain on the right side of the body with allodynia and hyperalgia, diagnosed as thalamic syndrome. In January 2006, she was admitted to the department of pain therapy and palliative care of Santa Casa de Misericórdia de São Paulo where pharmacologic treatment was instituted with poor response; she was scheduled for neurofunctional surgery. In July 2009, electroacupuncture, in an attempt to obtain better pain control, was proposed to the patient. Electroacupuncture was done on points in the scalp. After the 11th session, her pain was controlled, with no use of opioids or topical amitriptyline, her well-being had increased, her motor coordination improved, she presented global pain reduction, complete in hand and face.
CONCLUSIONS: The efficacy of electroacupuncture in pain control and well-being are in agreement with modern studies which demonstrated activation of antinociceptive pathways in the brain. Controlled prospective studies are required to reaffirm and consolidate electroacupuncture as an important technique in controlling central pain.
Keywords: Acupuncture Analgesia; Electroacupuncture; Pain; Stroke.
Cerebrovascular diseases are responsible for the majority of deaths in the world. The annual incidence estimated in most populational studies is between 300 and 500 per 100 thousand people. In Brazil, this reality is not different. In 2005, it showed a mortality of 87,344 patients, surpassing coronariopathies. Up to 90% of survivors have some type of deficiency, which can lead to personal and social limitations and economic downfall, since many patients are below 65 years of age 1,2,3. Most limiting sequelae observed are motor in origin; but when sensorial pathways and centers are affected, patients can evolve with sensorial changes in the area of the body corresponding to the affected area of the brain. When that area is related with the thalamus, thalamic syndrome might follow. This is characterized by rapidly progressive hemiparesis; persistent superficial hemianesthesia or hemi-hyperesthesia; marked deep sensorial changes; subtle hemiataxia and asterognosia; severe, persistent, paroxysmal pain usually unbearable and that does not respond to traditional analgesic treatment; and ipsilateral coreoatetosis 4. The treatment used most often is based on rehabilitation with physiotherapy, use of pharmacologic arsenal, psychotherapy, sympathetic or peripheral nerve blocks, peripheral or central electric stimulation, laser, and acupuncture 5.
The objective of this report was to demonstrate the use of electroacupuncture as adjuvant in the treatment of central pain, diagnosed as thalamic syndrome difficult to control with pharmacologic treatment.
This is a 46 years old female, weighing 53 kg, smoker, with history of ischemic stroke in the left temporoparietal region in April 2003 (Figures 1 and 2) who evolved with right hemiparesis and hemitaxia. One year later she developed insidious, continuous diffuse pain affecting the right side of her body, along with allodynia and hyperalgia that evolved to severe, difficult to control pain which was later diagnosed as thalamic syndrome. The patient had intermittent frequently worsening of the pain spontaneous or secondary to emotions (fear, happiness, sadness, worry). During this period, the patient developed depression and panic attacks, which hindered even more her functionality and socialization. In January 2006, the patient was admitted to the pain therapy and palliative medicine of Santa Casa de Misericórdia de São Paulo where she was treated uninterruptedly by psychiatry and neurosurgery. In 2009, she was receiving Gabapentin 400 mg every 8 hours, Fluoxetine 60 mg in the morning, Clonazepam 1 mg at bedtime, Talniflumate, Pentoxifylline, rescue Codeine (3 times a day), and 2% amitriptyline ointment to be applied in areas of increased allodynia. Even with this medication she complained that her pain was not under control, which caused great limitations in daily activities, sleep, and social life. She had constant episodes triggered by emotions. A magnetic resonance imaging (MRI) showed focal lesions in angular and supramarginal gyri, long insular gyri, and non-specific hypersignal foci in periventricular white matter and semioval centers (Figure 3). In another attempt to control her pain, the functional neurosurgery department scheduled the patient to undergo implantation of a neurostimulator, but they were still waiting for a bed.
In July 2009 the use of electroacupuncture was proposed to the patient in an attempt to improve pain control while she waited for the implant. The patient agreed and weekly sessions were scheduled. Each session was composed of two steps. The first, electroacupuncture, with frequency of 8 Hz in YNSA points and motor, sensorial, and vasodilation lines of classical scalp electroacupuncture (scalp step). In the second step, the patient underwent classical systemic acupuncture with some of those points stimulated by mixed frequency of 2 and 100 Hz (points IG4 - TA 5, and BP6 - E40) for 20 minutes (systemic step). In the first five sessions, to avoid increasing her pain, acupuncture needles were applied only to the left side of the patient (healthy side). In the remainder sessions, the needles were successfully applied to both sides of her body. From the eighth session on, the first step was maintained, changing the points stimulated by electroacupuncture along with the frequency of the second step (systemic step) that was changed to continuous strengthening wave of 2 Hz in points IG4 - IG10, P3 - TA5, E36 - BP10, and VB34 - B59 on the right side for 20 minutes. In all sessions, data like pain severity, evaluated by the visual analogue scale, use of rescue medication, evolution during the week, and verbal scale quantifying well-being, were collected. The patient underwent 11 sessions of acupuncture, without interruptions, and she was scheduled for maintenance treatment to increase pain control.
The patient referred improvement of her pain, increase well-being and sleeping almost discontinuing the rescue opioid (codeine) and use of topical amitriptyline since the first session, which was continuous and progressive. After the third session, she showed a significant reduction of allodynia and hyperalgia in the palm of her hand, which stimulated her to start several routine manual activities and improved her social life, and she did not require rescue medication or topical amitriptyline. After the fifth session, she referred improved control of movements of her right hand and foot, elevated well-being, better control of emotion-triggered crisis, and higher motivation. She had started to exercise more, increased the variety of daily activities, and became more independent. After the 11th session her pain was controlled without opioids and topical amitriptyline (since the second week of treatment), her well-being had increased, she showed reduction of paresia, and improved motor coordination. She said she would like to continue the treatment and was thinking about postponing the neurosurgical procedure.
The first descriptions of central pain as a consequence of strokes date back to the mid XIX Century. In 1983, Greiff made the first complete description of central pain in which he evaluated a patient with constant pain secondary to a brain lesion that included the thalamus. In 1906, Dejerine and Roussy described the clinical characteristics of thalamic syndrome, which was named after both authors 4. Luckily, complete thalamic syndrome is rare. Treatment is based on rehabilitation with physiotherapy, drugs, psychotherapy, sympathetic or peripheral nerve blocks, peripheral or central electrical stimulation, laser, and acupuncture. Among the drugs used are anticonvulsants (carbamazepine, oxcarbazepine, gabapentin, clonazepam), antidepressants (amitriptyline, nortriptyline, imipramine, fluoxetin, sertraline, venlafaxine), neuroleptics (chlorpromazine, periciazine), muscle relaxants (baclofen, cyclobenzaprine), and opioids (codeine, tramadol, methadone) 5.
Electroacupuncture was first used in China in the decade of 1930. It was investigated more seriously from the decade of 1950 on, along with the development of acupuncture for anesthesia, and became popular in the decade of 1970. Today, it is widely used to treat pain and physical disorders, as well as inducing analgesia in surgical procedures 6. Several studies of different medical areas widened the use of this technique in several specialties. Electroacupuncture consists of electrical stimulation of a specific frequency through needles inserted in classical acupuncture points or microsystems (scalp acupuncture, auriculoacupuncture, or Yamamoto new scalp acupuncture). Chinese scalp acupuncture was developed at the end of the decade of 1960 and unlike classic acupuncture it does not use acupuncture points or meridians; the needles are inserted in the scalp looking for correspondence for cortical functional areas 6-8. Yamamoto New Scalp Acupuncture (YNSA) was developed in 1970 and published in 1973, in the 25th meeting of the Japanese Society of Ryodoraku, in Osaka, Japan. Yamamoto new scalp acupuncture is a somatotopic acupuncture. According to this technique, it is believed that the body has representation in small predetermine areas of the scalp, which are punctured to achieve results in the represented areas 8.
The efficacy of the treatment in controlling pain and increasing well-being in the case reported here is in agreement with current studies using functional magnetic resonance imaging that demonstrated that electroacupuncture stimuli in specific points (IG4, E36, VB34) activate structures of the antinociceptive pathways (hypothalamus, accumbens nucleus, primary somatic sensory-motor cortex, anterior insula, middle cingulate cortex, pontine raphe), inactivate multiple limbic areas involved in pain connections (rostral anterior cingulate cortex, amygdala, and hippocampal complex), suggesting the importance of the adjunct treatment of central pain with electroacupuncture.9-13 The release of several neurotransmitters induced by electroacupuncture, such as endorphins, enkephalins, dinorphins, serotonin, and norepinephrine has been associated to its analgesia effect 13. A controlled study with YNSA points showed a significant difference in controlling induced pain in the calcaneus when compared to placebo, showing the analgesic efficacy of the technique 8,14. However, controlled prospective studies are necessary to consolidate electroacupuncture as an important tool in the control of central pain.
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Correspondence to: Submitted on June 28, 2010. Received from the Department of Pain and Palliative Care of Santa Casa de Misericórdia de São Paulo, Brazil.
Dr. Alysson Bruno Oliveira Santos
Av. Chibarás, 44/1.301, Planalto Paulista
040976-000 - São Paulo, SP, Brazil
Approved on July 27, 2010.
Submitted on June 28, 2010.
Received from the Department of Pain and Palliative Care of Santa Casa de Misericórdia de São Paulo, Brazil.