jussara regiane de barros ladeia effects of acupuncture … - eff… · including postoperative...

JUSSARA REGIANE DE BARROS LADEIA

EFFECTS OF ACUPUNCTURE THERAPY IN PAIN

MANAGEMENT IN PATIENTS UNDERGOING THORACIC

SURGERY

São Paulo

2018

Monograph presented to Erich Fromm University –

Florida, United States – to obtain the title of

specialist in acupuncture.

Teacher advisor: Dr. Alfredo Alexander Raspa

i

Abstract

LADEIA, Jussara R. Barros. Effects of acupuncture therapy in pain

management in patients undergoing thoracic surgery. Monograph, Erich

Fromm University – Florida, United States – São Paulo, 2018.

Objective: The aim of this study was to review recent literature about the

effects of acupuncture therapy in pain management in patients undergoing

thoracic surgery.

Methods: This is an integrated review, performed from the online Pubmed

and Scielo databases. The terms "acupuncture therapy", "pain" and "thoracic

surgery" were used.

Results: Were found 18 articles in the Pubmed database. Four clinical

studies were selected for analysis after applying the inclusion and exclusion

criteria. These were randomized and controlled trials.

Conclusion: There is a lack of studies in literature involving acupuncture

therapy as an analgesic method in patients undergoing thoracic surgery,

especially in the West. In this review, acupuncture-associated

electrostimulation was shown to reduce postoperative dosage of opioids.

Key-words: acupuncture therapy; pain; thoracic surgery.

ii

Summary

ABSTRACT .............................................................................................................................. I

1. INTRODUCTION .............................................................................................................. 3

2. OBJECTIVE......................................................................................................................... 4

3. LITERATURE REVIEW ................................................................................................... 5

3.1 THE ORIGIN OF DISEASES BY TCM.......................................................................................... 5

3.1.1 Internal Causes .................................................................................................................... 5

3.1.2 External Causes ................................................................................................................... 5

3.1.3 Other Causes ......................................................................................................................... 5

3.2 ACUPUNCTURE ........................................................................................................................... 5

3.2.1 Effects of Acupuncture ..................................................................................................... 6

3.2.2 Pain and Acupuncture ..................................................................................................... 6

3.3 THORACIC SURGERIES .............................................................................................................11

3.3.1 Postoperative pain ...........................................................................................................11

3.3.2 Pain assessment ................................................................................................................14

4. METHODS ....................................................................................................................... 16

4.1 PUBMED SEARCH STRATEGY ...................................................................................................17

4.2 SCIELO SEARCH STRATEGY ......................................................................................................17

4.3 INCLUSION CRITERIA ...............................................................................................................17

4.4 EXCLUSION CRITERIA ...............................................................................................................17

5. RESULTS ......................................................................................................................... 17

6. DISCUSSION ................................................................................................................... 20

7. CONCLUSION ................................................................................................................. 22

8. BIBLIOGRAPHIC REFERENCES ................................................................................ 23

3

1. Introduction

Acupuncture belongs to Traditional Chinese Medicine (TCM) and is

used for prevention and also treatment of several diseases and disorders.

Through insertion of needles, the technique acts on the energy channels,

known as acupuncture points, or acupoints, reaching homeostasis,

reestablishing the free circulation of vital energy and promoting health

(Dulcetti Jr, 2001).

Acupuncture has been widely used in Asian countries for the treatment

of pain. The National Institutes of Health suggest that acupuncture can be

used as a complementary or alternative treatment for many diseases,

including postoperative pain. Clinical studies have shown that acupuncture

can help relieve postoperative pain, reduce the dosage of opioid analgesics

and other related side effects and is a low-cost, easily applied and accepted

method (Wu et al., 2016; Xiong et al., 2018).

Thoracotomy is associated with elevated pain levels in the immediate

postoperative period. Some patients experience continuous pain lasting over

60 days, and this pain may persist for years. Karmakar & Ho (2004),

demonstrated that about 30% of patients still feel pain up to four to five years

after surgery. Post-thoracotomy pain causes distress, impaired lung function

and mobility, leading to increased morbidity. Treating post-thoracotomy

chronic pain is more difficult (Karmakar & Ho, 2004; Deng et al., 2008).

Therefore, due to the deleterious effects of postoperative pain of

thoracic surgeries and the potential analgesic effect of acupuncture, it is

important to review the evidences presented in literature supporting the use of

this technique in such scenario.

4

2. Objective

The aim of this study was to review recent literature about the effects of

acupuncture therapy in pain management in patients undergoing thoracic

surgery.

5

3. Literature Review

3.1 The Origin of Diseases by TCM

Identifying the cause of patient disharmony is one of the most

important parts of Chinese medical practice.

3.1.1 Internal Causes

The view of TCM is different from Western medicine. In TCM, the mind-

body is not a pyramid, but a circle of interaction between internal systems and

their emotional aspects (Maciocia, 1996).

Emotions only become pathological causes when they are particularly

intense and prolonged and if not expressed or recognized. Physical

symptoms are caused by their emotions: fury, joy, sadness, worry and

abstraction, fear, shock (Maciocia, 1996).

3.1.2 External Causes

They are due to climatic factors: wind, cold, summer heat, humidity,

dryness, fire (Maciocia, 1996).

3.1.3 Other Causes

Other causes can be: debilitated complexion (depends on the health of

the parents); excessive physical exercise; excessive sexual activity; irregular

diet; trauma - physical trauma causes local stagnation of Qi or blood (Xue),

causing pain, edema and hematoma; parasites and poisons; inadequate

treatment (Maciocia, 1996).

3.2 Acupuncture

Acupuncture has been widely practiced in China for over four thousand

years. According to TCM theories, the human body has an energy system in

6

which a vital energy (Qi) circulates and is responsible for the functioning of all

organs. The structures of the organism are balanced by the energies of Yin

and Yang. That way, if the energies of Yin and Yang are in perfect harmony,

surely the body will be healthy. Needles are inserted at specific spots in the

body in order to rebalance the flow of energy along the meridians, transmitting

specific health benefits (Silva, 2004; Wong et al., 2006; Wen, 2014).

3.2.1 Effects of Acupuncture

The effects of acupuncture are related to the origin of our energy body

and our physical form. We have the junction of two essences through the

mental and physical body, the Lin Tai and the Yin Chao, which generate the

Essential Ancestral Qi and which will successively form the energies: Zang

Fu, Xue Qi (Blood), Jing Luo (Energy Channels and Collaterals), Mental

energy and physical form (Yamamura, 2001).

Acupuncture changes the blood circulation. Through the stimulation of

certain points, the dynamics of regional circulation from micro-dilatations can

be changed. And other points promote muscle relaxation, healing spasms,

reducing inflammation and pain (Wen, 2014).

3.2.2 Pain and Acupuncture

3.2.2.1 Physiology of pain

According to the International Association for the Study of Pain (IASP),

pain is defined as "an unpleasant sensory and emotional experience

associated with or related to actual or potential tissue injury. Each individual

learns to use this term through their previous experiences" (International

Association for the Study of Pain, 2011).

Nociception is the term used to describe how pain becomes a

conscious experience. Nociceptors are a highly specialized subset of primary

sensory neurons that respond only to pain stimuli, converting these stimuli

into nerve impulses, which the brain interprets to produce pain sensation

7

(Rosenquist et al., 2017). They are categorized as either myelinated or non-

myelinated, indicating the type of stimulation they respond to: chemical,

mechanical and thermal (Ellison, Rosenquist et al., 2017).

A-delta fibers are large, myelinated, and fast-conducting. They are

responsible for immediate acute pain. The activation of these fibers causes

the medullar reflex of withdrawal, before the pain sensation is perceived

(Ellison; Rosenquist et al., 2017).

Type C fibers are non-myelinated, smaller, and constitute the majority

of peripheral nociceptors. They are located in the tendons of muscles, in

organs and on the skin. They transmit uncomfortable, painful or burning

sensations that are poorly located and often present as constant pain. They

can respond to thermal, mechanical and chemical stimuli. In relation to the A

delta fibers, the C fibers are slow conducting and recover from fatigue more

slowly, in addition to producing a longer lasting pain. (Ellison; Rosenquist et

al., 2017).

There are four stages in pain nociception: (1) transduction, (2)

transmission, (3) perception and (4) modulation (Figure 1).

Transduction is the first process of nociception. It refers to the

conversion of a noxious stimulus, which may be thermal, mechanical or

chemical, into electrical activity at the peripheral terminals of sensory fibers of

the nociceptor (Ellison; Rosenquist et al., 2017).

When nociceptors are stimulated, they release chemical mediators

that activate more nociceptors (histamine, bradykinin, acetylcholine, serotonin

and substance P). These chemical mediators may increase pain sensitivity,

reduce or inhibit pain perception. For example, prostaglandins are believed to

increase the sensitivity of pain receptors, enhancing the bradykinin-triggering

effect. Substance P, found in C fibers, amplifies the pain signal. However,

endorphins and enkephalins, which are natural opioids, inhibit the

transmission or perception of pain (Ellison, 2017).

Endorphins produce effects by linking the receptors to opioids, which

can be stimulated by afferent nerve activity. The release system of this

substance covers the hypothalamus and a neural network that protrudes into

the nuclei of the midbrain and brainstem. Through this pathway it has the

property of influencing pain sensitivity. Increased production of endorphins

8

promotes pain relief and can also provide a sense of satisfaction. Enkephalins

are substances considered as neurotransmitters. They have analgesic action

and are capable of reversibly binding to opioid receptors (Silva, 2004).

Transmission is the second process of nociception. Transmission

refers to the passage of peripheral terminal action potentials along the axons

to the central nociceptor terminal in the central nervous system (CNS). It is

during this process that pain control can occur. Opioids block the release of

neurotransmitters, particularly substance P, which disrupts pain at the marrow

level. The impulses then synapse with the projection neurons (tertiary

neurons), cross the midline of the spinal cord and ascend to the brain through

two different spinothalamic tracts. The neospinothalamic tract transmits rapid

impulses of strong and acute pain. The paleoespinothalamic tract transmits

slow impulses of low and chronic pain. The rapid and acute pain is first

noticed, followed by a throbbing and low pain. These tracts connect to the

reticular formation, hypothalamus, thalamus, and limbic system. The impulses

are then projected to the somatosensory cortex for interpretation and for other

areas of the brain for an integrated response to pain stimuli (Ellison;

Rosenquist et al., 2017).

Perception is the third process of nociception. Perception refers to the

"decoding" or interpretation of the afferent input into the brain that gives rise to

the individual's specific sensory experience. It is the conscious perception of

pain. The transmission of stimuli ends in the reticular and limbic systems and

in the cerebral cortex, which is where perception occurs. Pain interpretation

can be influenced by many factors, including genetics, cultural preferences,

gender roles, life experience, past pain experiences, health condition, etc.

(Ellison, Rosenquist et al., 2017).

Modulation is the last process of nociception. Modulation refers to the

change (e.g.: increase or suppression) of the sensory input. The modulation

of the pain stimulus prior to the perception of pain is made either by inhibition

or augmentation through supraspinal influences emerging from the bridge,

marrow and midbrain (Lome, 2005; Elisson, 2017). Supra-spinal inhibition

leads to the release of endogenous opioids that limit the release of

neurotransmitters from the primary neuron and hyperpolarize the secondary

neuron, so that greater pain stimuli are required for action potential to be

attained. Norepinephrine and serotonin can be released from the dorsal horn

of the marrow, both inhibitory substances. Supra

the release of additional neurotransmitters to increase the progression of

stimuli from the primary neurons to the secondary ones (Lome, 2005; Elisson,

2017).

3.2.2.2 Analgesia Mechanism of

Scientific studies show that the action of acupuncture is clearly related

to the nervous system (Yamamura, 2001).

the release of hormones, such as cortisol and endorphins, promoting

analgesia. There is internal regulatio

Acupuncture exacerbates these mechanisms to restore balance and health in

less time. Research shows that the stimulation of the hypothalamus, pituitary

gland and other glands acts to hasten recovery of metabolism, whic

important in the healing process (Wen, 2014).

Figure 1Physiology of Pain. Dec;29(4):397


of the marrow, both inhibitory substances. Supra-spinal stimulation occurs by


primary neurons to the secondary ones (Lome, 2005; Elisson,

Mechanism of Acupuncture


to the nervous system (Yamamura, 2001). Stimulating certain points promotes


analgesia. There is internal regulation to offer resistance to the disease.



gland and other glands acts to hasten recovery of metabolism, whic

important in the healing process (Wen, 2014).

1. Four stages in nociception. (From: Ellison DL. Physiology of Pain. Crit Care Nurs Clin North Am. 2017 Dec;29(4):397-406).

9


spinal stimulation occurs by


primary neurons to the secondary ones (Lome, 2005; Elisson,


Stimulating certain points promotes


n to offer resistance to the disease.



gland and other glands acts to hasten recovery of metabolism, which is

Ellison DL. Crit Care Nurs Clin North Am. 2017

10

The analgesic action of acupuncture requires integrity of the superficial

and deep primary afferent peripheral discriminatory pathways and is blocked

by the action of local anesthetics on the peripheral nervous system. It occurs

by stimulation of the physiological systems of pain suppression, specifically

the segmental block at medullar level, the descending suppressor system and

also through the opioid system of the brain from the introduction of needles at

specific points (Silva, 2004).

The electrical potential of acupuncture needles acts on the free nerve

terminations at these points, altering the cell membrane potential, triggering

action potential and conducting nerve stimulation (Yamamura, 2001).

A-delta and C-fibers are the main types of fibers related to conduction

of the acupuncture needle stimulation. Studies mention that A-delta fibers are

dominant, followed by C fibers (Yamamura, 2001). Activation of A-delta fibers

by acupuncture or electroacupuncture blocks the afferent impulses from C

fibers at the medullar level through the release of enkephalin (Silva, 2004).

The effect of the needle depends on the depth of its insertion, since the

types of nerve receptors are distributed differently. The superficial ones will

reach the nerve receptors associated to the A-delta fibers (acute pains and

thermoception). The insertion of needles determines three local effects:

electric, neurochemical (by mechanical action, the needle damages the

tissues and releases substances) and mixed (Yamamura, 2001).

During the last decades, there has been a growing appreciation of

acupuncture in the West. One of the main potential benefits of acupuncture

was its application in regional anesthesia for the treatment of several forms of

pain. Studies have shown promising results of the use of acupuncture in the

management of early postoperative pain in several types of surgery

(Pohodenko-Chudakova, 2005; Usichenko et al., 2005; Lin et al., 2002).

Electroacupuncture (EA) began to be used as a complement to pain

management as early as the 1970s (Pongratz et al., 1977) and it is possible to

reduce the amount of medication administered in patients after general

surgery (Wong et al. , 2006). EA is performed by inserting small needles into

the skin at specific acupuncture points and stimulating them with electric

current (Karavis, 1997; Han, 2003).

Clinical studies from the 1980s have revealed that acupuncture may be

11

an effective and safe alternative method of anesthesia for lung resection.

Later, the combined application of acupuncture and general anesthesia was

shown to be beneficial in pneumonectomy (Fu et al., 2011). A meta-analysis

of 2012 provided clear evidence that acupuncture is favorable in the treatment

of chronic pain (Vickers et al., 2012). In addition, the method was

recommended by the American College of Chest Physicians as

complementary therapy in lung cancer patients suffering from post-

chemotherapy nausea and post-thoracotomy pain (Cassileth et al., 2007).

3.3 Thoracic Surgeries

Thoracic surgeries may be performed through large cuts (thoracotomy)

or by video (video-assisted). Some conditions treated by thoracic surgery are:

pleural diseases, tumors, congenital lung defects, lung/heart transplants,

cardiac surgeries, lung diseases (abscess, bronchiectasis), etc.

Surgeries can be approached by different incisions (Figure 2), for

example: longitudinal sternotomy, anterior intercostal thoracotomy, side

intercostal thoracotomy, posterolateral intercostal thoracotomy, posterior

intercostal thoracotomy, and ministernotomy (Bento, 2004).

3.3.1 Postoperative pain

Postoperative pain is somewhat unavoidable due to intense surgical

trauma (Coura et al., 2011). Postoperative analgesia must be adequate for

different types of operations, and it is more difficult to treat pain after surgery

in the thoracic and upper abdominal regions than on the face and extremities

(SBED, 2006).

Multiple nociceptive stimuli occur in thoracotomy procedures such as

surgical incision, insertion of thoracic and mediastinal tubes and stimulation of

the parietal pleura, making the prescription of analgesia quite complex and

requiring a combination of techniques and medication (Coura et al., 2011). A

series of studies suggest that patients after cardiac surgery have significant

postoperative pain in the intensive care unit (ICU) and after transfer to the

12

ward (Meehan et al .; Valdix & Puntillo, 1995). An Australian study of 102 ICU

patients after cardiac surgery showed that patients who had worse pain were

women, patients with internal mammary artery grafts and younger individuals

(York et al., 2004).

Figure 2 . Types of incision for approach in thoracic surgeries. (Adapted from: Mattox KL, Wall Jr. MJ, Tsai P. Trauma Thoracotomy: Principles and Techniques. 2017. Thoracic Key [internet homepage]. Available in: <https://thoracickey.com/trauma-thoracotomy-principles-and-techniques>).

Most cardiac surgeries are performed through median sternotomy and

many patients experience significantly greater pain than expected after this

type of incision. Typically, acute pain is most intense on the first postoperative

day at the surgical incision spot and the worst pain is experienced when

moving or coughing. Often, pain continues increasing up to one week after

surgery, and the location may change during this time away from the incision

site and towards the shoulders (Mazzeffi & Khelemsky, 2011). In

cardiothoracic surgery, posterolateral thoracotomy is the gold standard of

MEDIAN STERNOTOMY ANTEROLATERAL THORACOTOMY

TRANSESTERNAL ANTEROLATERAL THORACOTOMY

PARTIAL ANTERIOR THORACOTOMY

13

surgical access to the chest for anatomical resection of the lung.

Unfortunately, standard thoracotomy is also arguably the most painful incision

of all surgeries (Wong et al., 2006).

Some studies comparing median sternotomy with thoracotomy have

shown that sternotomy is a relatively better procedure than thoracotomy due

to lower thoracic cavity trauma (Barnas et al., 1994; Ranieri et al., 1999).

Following the same reasoning, Guizilini et al. (2010) showed that patients

submitted to ministernotomy (eight centimeter incision) had better

preservation of lung function when compared to standard median sternotomy

(20 centimeters). In addition, previous studies have shown that patients

submitted to ministernotomy had less painful sensation than those submitted

to conventional median sternotomy (Grossi et al., 1999; Moustafa et al.,

2007).

Median sternotomy impairs thoracic stability, worsens its expandability,

reduces forced vital capacity and forced expiratory volume in the first second

for days or even weeks (Ragnarsdottir et al., 2004). Good pain management

relieves post-surgical stress response and may improve clinical outcomes

(Mazzeffi & Khelemsky, 2011). Several studies have shown that poorly

controlled postoperative pain is associated with impaired pulmonary function,

causing a decrease in vital capacity and spirometric values by up to 33%,

leading to a restrictive deficit especially in the first three postoperative days.

There is also an increase in intrapulmonary shunt and alveolar-arterial oxygen

pressure gradient, and reduction of partial oxygen blood pressure (Sasseron

et al., 2009; Gust et al .; OConnor et al., 1999). Better control of pain may also

shorten hospital stay, reducing costs (Mazzeffi & Khelemsky, 2011).

Pain mechanisms in the postoperative period are complex. There is

damage to the skin, subcutaneous tissues, bones and cartilage. In addition to

the nociceptive inputs caused by direct tissue trauma, the inflammatory

response generated leads to sensitization of peripheral and central pathways

that result in the experience of pain. A number of inflammatory mediators

(prostaglandins, histamines, substance P, bradykinins, serotonin, adenosine

triphosphate, nitric oxide, leukotrienes) and ions (e.g.: sodium, potassium and

calcium) spread on the spot (Coura et al., Mazzeffi & Khelemsky, 2011).

Some of these molecules directly activate the nociceptors, while others work

14

through indirect mechanisms. These inflammatory molecules also play an

important role in sensitizing both central neurons. The presence of chest and

mediastinal drains, which irritate the parietal pleura and pericardium, are also

a significant source of pain for patients. The intercostal nerves that emerge

from the roots of the thoracic nerve innervate the sternum, the ribs, and the

surrounding subcutaneous tissue. The parietal pleura is also richly innervated

with nociceptive fibers that can be activated by mechanical or chemical

stimuli. The pericardium is innervated with pain fibers from the vagus nerve,

phrenic nerve and sympathetic trunks (Jammes et al., 2005; Mazzeffi &

Khelemsky, 2011).

In most cases, pain control is achieved through administration of

opioids, a substance that may cause several undesirable side effects such as

nausea, vomiting, constipation, decreased consciousness, and respiratory

depression (Wong et al., 2006; et al., 2011). Some personalized strategies

may be used to minimize side effects due to reduced opioid dose such as

patient controlled analgesia (PCA). However, even so, the incidence of

adverse effects is still high (Coura et al., 2011).

Poor pain control is associated with the activation of the nervous

system and the increase of the hormonal response to stress. This response

may contribute to multiple post-operative adverse effects, including increased

blood pressure with consequent increase in left ventricular post-load and

myocardial oxygen consumption, myocardial ischemia, cardiac arrhythmias,

hypercoagulability, atelectasis and other pulmonary complications, increased

rates of delirium, higher risk of infection, especially of sternum, venous

thrombosis and hyperglycemia (Coura et al., Mazzeffi & Khelemsky, 2011).

Studies have shown that better pain control is associated with lower rates of

cardiovascular complications, pneumonia and hypercoagulability in the

postoperative period (Liu & Wu, 2007).

3.3.2 Pain assessment

The assessment and recording of pain intensity by health professionals

15

has to be performed in a continuous and regular way, in the same way as vital

signs, in order to optimize therapy, provide safety to the health care team and

improve the quality of life of the individual. The intensity of the pain is always

that referred by the patient. The scale used must always be the same. For a

correct assessment of pain intensity it is necessary to use a common

language between the health professional and the assessed individual, which

is translated by a standardization of the scale to be used and by the teaching

prior to its use. It is essential that the patient correctly understands the

meaning and use of the scale used.

Pain assessment must include: a detailed history, physical

examination, laboratory and imaging exams and, if possible, a differential

diagnosis must be remembered. Regional, anatomical, etiological,

pathological and functional diagnosis must be obtained. Postoperative pain

may be measured by the patient's report, using the scales (Figure 3), the

amount of analgesic the patient requests and the need for analgesic

supplementation (SBED, 2006).

The verbal scale commonly uses words to describe pain intensity.

Usually the following words are used: absent, mild, moderate and intense,

which are scored as: absent = 0; mild = 1; moderate = 2 and intense = 3. The

visual analogue scale (VAS) is an extremely simple, sensitive and

reproducible instrument to assess pain, since it allows its continuous analysis.

The verbal numerical scale is an alternative for the verbal and visual analogue

Visual Analogue Scale (VAS)

No pain Most intense pain

Facial Expression Scale

Figure 3. Pain scales. (Adapted from de PORTUGAL. Ministério da Saúde. Direcção-Geral da Saúde. Circular Normativa nº 9/DGCG de 14/6/2003. Available in: <http://www.dgsaude.pt>)

16

scales. The patient suggests a number to represent his pain intensity, where

zero means no pain and ten the most intense pain possible. The facial

expression scale is mainly used for children, but may also be used to assess

the pain of illiterate or mentally ill patients (SBED, 2006).

4. Methods

This is an integrated review, performed from the online Pubmed and

Scielo databases.

17

4.1 Pubmed search strategy

The terms "acupuncture therapy", "pain" and "thoracic surgery"

(acupuncture therapy[MeSH Terms]) AND Pain[MeSH Terms]) AND Thoracic

Surgery[MeSH Terms]) were used.

4.2 Scielo search strategy

The terms in Portuguese and their equivalent in English have been

used: “acupuncture therapy/ terapia por acupuntura”, “pain/ dor” and “thoracic

surgery/ cirurgia torácica” in the "all indexes" field.

4.3 Inclusion criteria

Clinical studies were chosen in which the method involved the use of

acupuncture analgesia for acute pain of patients undergoing thoracic surgery.

The search was limited to English, Portuguese and Spanish languages.

4.4 Exclusion criteria

Articles not available online have been deleted.

5. Results

Pubmed: From the terms and combinations used 18 articles were

found. Nine studies were deleted because they were from different languages

(two in French; four in Chinese; two in Italian; one

were outside the proposed topic; one study was not a clinica

was not available online.

(Figure 4).

Figure

Scielo: no articles were found fro

Chart 1 presents the

as well as the types of intervention and results obtained in each one

different languages (n=9)

outside proposed topic

not available on

Sistematic Review

Total =


two in French; four in Chinese; two in Italian; one in Russian);

were outside the proposed topic; one study was not a clinical trial and one

was not available online. Four clinical studies were selected for analysis

Figure 4. Flowchart for searching the analyzed articles

Scielo: no articles were found from any combination of terms

Chart 1 presents the characteristics of the selected studies' population,


Pubmed(n=18)

Analyzed(n=4)

different languages (n=9)

outside proposed topic (n= 3)

not available on-line (n=1)

Sistematic Review (n=1)

Total = 14

Scielo (n=0)

18


); three studies

l trial and one

Four clinical studies were selected for analysis

the analyzed articles.

m any combination of terms.

characteristics of the selected studies' population,


19

Author , year Population Intervention Results

Wong et al., 2006

Patients with lung cancer undergoing video-assisted thoracic surgery.

Controlled Randomized Double-Blind Study Intervention Group: EA 30 min/day for 7 days (IG4, VB36, TA8, VB34 - on the same side of the thoracotomy) Control Group: the same protocol simulating therapy

EA decreased dosage of analgesics.

Deng et al., 2008

Patients with lung cancer undergoing unilateral thoracotomy.

Blind Randomized Controlled Study Intervention Group: 2 days prior to surgery, intradermal needles were inserted at points of the spine (B12 to B19), E36 and at the auricular Shenmen and replaced 1 week later. The needles remained at points E36 and Shenmen for 1 week and in the spine for 3 weeks after the replacement. Control Group: not performed on acupoints, or with real needles.

There was no reduction of either pain or dosage of analgesic after thoracotomy.

Coura et al., 2011

Patients undergoing elective cardiac surgery.

Randomized Controlled Study Treatment group: EA (IG4, IG11, F3, E36, CS6, TA5) - 30 min (12-18 hours prior to surgery) + PCA in PO Control Group: electrostimulation with electrodes at the same spots - 30min (12-18 hours prior to surgery) + PCA at PO

Treatment group had a reduction in the postoperative opioid dosage.

Huang et al., 2015

Patients submitted to video-assisted lobectomy.

Controlled Randomized Double-Blind Study Points: CS6, IG4, P7, IG11 Transcutaneous stimulation on the acupoints (TEAS) for 30 min; before anesthetic induction/during surgery/24 hours and 48 hours after surgery. Group "2/100": stimulation with frequency alternating between 2 to 100Hz every 3 seconds. Group "2": stimulation with frequency 2Hz Group "100": stimulation with frequency 100Hz Control Group: no stimulation, only electrodes positioned

TEAS groups had a decrease in intraoperative opioid dosage; decrease in anesthetic recovery time and time for extubation; improved PaO2 during unilateral ventilation; decrease in pain score.

Chart 1. Characteristics and results of the analyzed studies.

EA: Electroacupuncture; PCA: patient controlled analgesia; PO: posteoperative period; TEAS: transcutaneous electrical acupoint stimulation); PaO2: partial pressure of oxygen.

20

6. Discussion

In the present study, the results show the scarcity of studies on the use

of acupuncture in pain control in patients undergoing thoracic surgery. Most of

them used the electrostimulation associated with acupuncture and obtained

good results in relation to the reduction in the dosage of analgesics in the

postoperative period. We also observed that some articles were not included

in the analysis because they were not available in English or Spanish. The

technique is mostly used in the East and research in Western countries is still

growing.

Out of the analyzed articles, all were randomized controlled clinical

trials, two of them double-blind. However, the methodologies were very

different from each other. This may be a reflection of the difficulty in

establishing a good control group model, making it challenging to isolate the

placebo effect from the actual effect of acupuncture.

There is no standardization of the acupoints used in the therapies.

Good results were observed in studies with IG4 point stimulation. There is

also recurrence of the use of points IG11 and CS6. IG4 (Hegu - Junction

Valley) is located on the radial side, in the middle of the second metacarpal

and its actions include analgesia, tonification and harmonization of Qi

increase and decrease (Wen, 2014). IG11 (Quchi - Crooked Pond) is located

at the lateral end of the elbow fold and its actions include analgesia, cooling

the blood (internal heat), removing heat in the canal (Wen, 2014). CS6

(Neiguan - Inner Gate) is located 2 cun above the wrist, in the center of the

anterior side of the forearm, between the tendons and its actions include

moving Qi and Xue in the thorax. Also ideal for pain control, distension in the

thorax and abdomen, nausea, vomiting and anxiety (Wen, 2014).

Regarding electrostimulation, the frequency used was not similar

among the studies. Authors have already demonstrated that low frequency

and high frequency EA induced the release of different opioid peptides. For

example, 2Hz induces the release of endorphins and enkephalins and 100Hz

induces the release of dynorphins. Therefore, using alternating frequencies in

the same therapy may have a more efficient analgesic effect (Han et al.,

21

1991; Zhao et al., 2004; Huang et al., 2015).

The study that obtained better results in the control of pain after

thoracic surgery was that of Huang et al., 2015, who performed

electrostimulation with electrodes in the acupoints at different moments (pre,

intra and postoperative). This corroborates with the recommendation of the

Brazilian Society for the Study of Pain. It is recommended that postoperative

pain control be started before the start of the operation, with pre-emptive or

preventive analgesia consisting of administering drugs and/or using analgesic

techniques before the incision. Preemptive analgesia aims to reduce pain

intensity and avoid central sensitization, consisting of the use of analgesic

therapy before injury until resolution of the acute inflammatory phase.

Preemptive analgesia may be performed on any part of the painful pathway,

such as the periphery, the conduction pathway, the marrow and upper centers

(SBED, 2006). That is, acupuncture has the potential to be used in all phases

of surgery.

Due to the analgesic effect provided by acupuncture, the results

obtained in the studies show that it is possible to reduce the dosage of opioids

and, consequently, the adverse reactions caused by the use of such

substances, such as nausea and vomiting, in addition to promoting early

extubation, minimizing postoperative pulmonary complications.

22

7. Conclusion

There is a lack of studies in literature involving acupuncture therapy as

an analgesic method in patients undergoing thoracic surgery, especially in the

West. In this review, acupuncture-associated electrostimulation was shown to

reduce postoperative dosage of opioids.

23

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