Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:
1. Distinguish the significance of undertreated pain worldwide.
2. Describe the history of Chinese medicine and the use of acupuncture in pain therapy and review aspects of traditional Thai medicine.
3. Identify precautions that should be taken in using traditional medicine.
Inadequate treatment of pain is a significant problem worldwide, not only for patients who are suffering, but also for health care professionals caught in a dilemma between over- and underprescribing opioids. Inadequate pain relief for both acute and chronic pain has become a usual way of life in many parts of the world. Many people, especially in low-income countries, have limited access to pain relief medicines. On the other hand, recently, there has been an increasing number of overdose deaths from synthetic opioids in the United States.1,2 Thus, traditional medicine as another treatment option for pain management has become of wide interest among various agencies such as the World Health Organization (WHO) and The Joint Commission.3,4
Traditional medicine combines the knowledge, skills, and practices based on the theories, beliefs, and experiences native to different cultures. Many countries have long used traditional medicine as part of a national health system, such as those found in China, Korea, Japan, Thailand, and the Arab countries.
Chinese traditional medicine is one of the most important and popular alternative medicines. Traditional Chinese medicine (TCM) evolved more than 2500 years ago and adapted much medical information from Arab countries, Japan, and India.5 Chinese medicine is traditional health care, including holistic treatment, which considers the different and specific nature of pain in dimensions of health and medical science. The WHO has accepted TCM as a method for treating and relieving pain.
Likewise, there is evidence that the Thai people used herbal medicine to treat various symptoms and diseases and health promotion before AD 1238. Thailand has its own system of traditional medicine, called "Thai traditional medicine" (TTM).5 TTM and Thai herbal medicine, traditional Thai massage, and other TTM modalities have been a part of the Thai health service system. The Ministry of Public Health of Thailand has designated October 29 of each year as "National Thai Traditional Medicine Wisdom Day."6 Although TTM is not considered a primary traditional medicine in the world, there are an increasing number of randomized clinical trials comparing TTM and Western medicine. In this article, we present various pain management models of TCM and TTM that not only are practiced throughout Thailand but also are required teaching in medical schools and other health care agencies.
Pain is one of the most frequent health problems and often a warning signal that there is something wrong or dangerous in the body. Approximately 1 in 5 adults suffers from pain, and 1 in 10 adults is diagnosed with chronic pain each year. A person can experience acute, chronic, and intermittent pain or a combination of those 3.7 Undertreatment of pain is a significant problem for all of us.8 Pain treatment can be by both pharmacologic and nonpharmacologic approaches. Nonpharmacologic pain treatment has become popular recently because it broadens a safe and effective range of treatment options. The patient can use less medication and even can be medication-free in many cases.
Nondrug pain treatment includes holistic health care that uses a variety of alternative sciences such as reflexology, therapeutic massage, acupuncture, guided imagery meditation, music therapy, hypnosis, and meditation.
Acupuncture
Alternative medicine for pain treatment includes acupuncture, which can be traced back for at least 2500 years to the rule of Emperor Huang Ti (2695-2597 BC).5 Huang Ti is said to be the author of the Nei Ching Su Wen, translated into English by Ilza Veith and published in 1949 as "The Yellow Emperor's Classic of Internal Medicine" by the University of California Press.
The first part of this work, the Nei Ching, consists of long discussions between the emperor and his chief physician, Ch'I Po, on the indications for the use of acupuncture and the conditions that respond best to it. A slightly later work, The Yellow Emperor's Book of Acupuncture, translated from Chinese by Henry Lu and published by the Academy of Oriental Heritage in 1973, describes in depth more of the history, meridians, and uses of acupuncture, but depends mostly on the writings from the Yellow Emperor.
Acupuncture is based on the assumption that there are patterns of energy flow (Qi) through the body that are vital for health. The principle of Chinese medicine is to find the cause of pain due to blockages and imbalances of the flow of Qi or from insufficient blood supply. Acupuncturists use fine needles, traditionally gold or silver but now more likely to be made of stainless steel, to stimulate specific anatomic acupuncture points to achieve the recovery of health. Acupuncture works by deflecting the meridians and adjusting the circulation of the blood; when the flow of Qi and blood improves, the pain is abated.
The Academy of Traditional Chinese Medicine and the Research Institute of Acupuncture and Moxibustion were simultaneously established in 1955. Teachers were trained and textbooks written for medical schools. Although Chairman Mao Tse-Tung had spoken of the necessity of cooperation between doctors of traditional and Western medicine, few advances had been made. In England, Sir William Osler, MDCM, in his book, Principles and Practice of Medicine (Appleton and Co, New York, 1892), referred on 2 occasions to acupuncture for sciatica (p 820). But there is no evidence that Sir William actually practiced acupuncture, but rather that he acquired his knowledge from Dr Sydney Ringer, FRS, who did practice the art some 19 years earlier.
Acupuncture was not well recognized in the United States until the visit of President Richard M. Nixon to China in 1972, when it was announced that one of his staff, Scotty Reston, received acupuncture for pain relief after an appendectomy.
The treatment works by using mainly fine needles to penetrate defined acupuncture points through the skin by a variety of techniques to improve the body's energy flow (Qi), resulting in body balance and maintaining overall vitality.9 Its use for pain relief has become of interest in the Western world, especially amid the opioid epidemic, when large numbers of people died from opioid overdose.10,11
The WHO recommends acupuncture for several painful disease conditions, since acupuncture has been proved through controlled trials to be an effective treatment. Examples of those conditions are primary dysmenorrhea, neck pain, knee pain, low back pain, and postoperative pain.12 However, the treatment results in each patient will be different, due to different acupuncture responses in individuals. The effect may depend on the duration of the disease. If the pain is chronic, the results will not be as good as for those who have suffered for a shorter period. If the patient's condition is fragile or poor, acupuncture may not be beneficial. Therefore, the doctor should carefully evaluate the patient's condition and give a patient complete information before deciding to go on with the treatment (Figure 1).
Precautions in Pain Management With Acupuncture
As mentioned earlier, although acupuncture is an acceptable alternative to pain management, it may have a long-term effect in requiring taking time off work or completing some daily activities. Furthermore, acupuncture may not be suitable for some patients, such as pregnant women, especially during childbirth, and patients who are unable to tolerate lying or sitting for a long time.
Patients with blood clotting disorders such as hemophilia and untreated cancer are not good candidates for acupuncture.
Acupuncture with electrical needle stimulation is not for patients with heart disease who have a cardiac pacemaker.
If a patient cannot have acupuncture, the doctor may consider cupping. In Chinese medicine, the blockage of blood flow causes muscle pain. In fire cupping therapy, the cup is placed upside down on the skin once the fire goes out. The cool air inside the cup creates a vacuum, which causes the skin to rise and expand blood vessels in the affected area. The cup is usually left in place for about 3 minutes (Figure 2). A large bubble is formed which lasts for weeks but generally is not painful. This treatment is commonly used in physical therapy centers in the United States.
Moxibustion
Moxibustion is the burning of dried herbs (Chinese mugwort, Artemisia vulgaris) on acupuncture points with or without acupuncture needles (Figure 3). The word is derived from 2 Japanese words, moe kusa (burning herb). The moxa's heat is conducted down the needle to the surrounding tissues. The combined action of temperature, radiation, and pharmacologic effects of burning mugwort causes physiologic changes. It has been increasingly used in rheumatic conditions.13 A meta-analysis suggested that moxibustion plus drug treatment reduced the rate of symptoms, compared with conventional drug treatment alone.14
However, excessive inhalation of moxibustion smoke increases the incidence of chronic laryngitis among acupuncturists, which represents the main concern of moxibustion safety.15 There is also the possibility of burns of the skin due to displacement.
Thai Traditional Medicine
TTM is one of the most valuable legacies of Thai ancestors. Thai people began to use herbal medicine to treat various symptoms and diseases and health promotion before AD 1238.5,16 Later, King Rama III of the Chakri dynasty had compiled TTM knowledge and disseminated it widely, as evidenced by the inscribed marble tablets at Wat Phra Chetuphon Vimolmangklaram Rajwaramahaviharn, also called Wat Pho, a Buddhist temple complex in Bangkok. King Rama also had statues built of Thai traditional stretching exercises ("Ruesi Dudton") at Wat Pho. TTM has become prosperous and has made a significant contribution to the health of the Thai people as a result of the teachings and works of this king. Therefore, the Ministry of Public Health of Thailand has the title of "the Father of Thai Traditional Medicine" to King Rama III.
The practice of TTM has 4 main areas:
1. Thai herbal medicine
2. Thai traditional medicine, which makes the diagnosis and treatment of diseases based on TTM theory
3. Traditional Thai massage
4. Psychological treatment
Based on TTM theory, there are 4 elements in the human body (ie, earth, water, wind, and fire) in equilibrium. An imbalance of these elements causes either excess or depletion and a person becomes ill. The way to treat an illness is to focus on adjusting the 4 elements to equilibrium by using herbal medicines, massage, and health promotion.6
Since ancient times, the Thai people have used traditional herbal medicine for their families as part of daily life (Figure 4). Even now, there is always at least one type of herbal medicine in each household, for example, herbal balm. It is considered one of the major household remedies. Thai people use herbal balm for headaches, muscle sprain, joint pain, and insect bites by rubbing the affected area. The balms have many herbal ingredients, such as camphor, racemic menthol, peppermint oil, Zingiber montanum, and black galingale. The elements can vary depending on the local area.
Kratom
Perhaps, the most recent well-known Thai herbal is "kratom" or Mitragyna speciosa. Kratom is usually grown in Southeast Asia, especially in southern Thailand and northern Malaysia. According to the Amended Narcotics Act, in Thailand, kratom is no longer a narcotic since 2021. Thus, it can be legally cultivated and sold commercially in Thailand with impunity.
Kratom leaves and their extracts have long been used to manage pain, as antipyretics, and as stimulants to sustain energy during hard day labor.17 As a secondary use, it is promoted as a means to alleviate the signs and symptom of opioid withdrawal. Proponents claim this drug to be the most effective treatment for pain alleviation in chronic diseases such as fibromyalgia, lupus, rheumatoid arthritis, multiple sclerosis, and many others.
However, an increasing number of patients are coming to the emergency department with symptoms of kratom overdose due to ingestion of food with high-dose kratom recipes. Thus, there is an urgent need to promote public awareness of how to use this herb safely. Although there was a move to ban kratom in the United States in 2016, it has been met with resistance, with awareness and funds raised by the American Kratom Association (founded in 2014). Currently, kratom is legal for use in the United States, except for a few cities and states where kratom is either banned or can be used in only natural form with some restrictions.
Herbal Compress
Thai herbal compress or "Luk Prakob" is another way of using Thai herbal medicine. Herbal compresses have been used in Thailand for hundreds of years, either as a stand-alone therapy or as a combination with traditional Thai massage (Figure 5).
Herbal compresses must be steamed for 10 to 15 minutes before use to enable heat conduction and to release active substances and volatile oils from herbal ingredients. The combined effects of herbal compress come from heat conduction to increase regional blood flow, the anti-inflammatory effects of herbs, and the relaxation action of aromatic volatile oil.18 The herbs in the compress can be varied, depending on the availability of herbs in different local areas. The ingredients can be dried or fresh and some of them crushed into a powder form. The examples of combined herbs are Siamese yellow ginger, lemongrass, turmeric, neem leaves, kaffir lime peels and leaves, camphor, and menthol. Hot herbal compression has been approved by the Thai Ministry of Public Health, the department for development of Thai traditional and alternative medicine, as an anti-inflammatory, local analgesic, and muscle relaxant. Furthermore, it improves the range of motion and local circulation.6
Thai Traditional Massage
King Rama III of the Chakri dynasty had ordered TTM knowledge, medicine formulas, a diagram of Thai massage (called Nuad Thai), and nuad pressure points compiled and inscribed on marble tablets and placed on the cloister walls of Wat Pho. UNESCO registered the epigraphic of Wat Pho as a "Memory of the World" in 2011. Therefore, Wat Pho was regarded as the first open university in Thailand and is still one of the most outstanding massage schools in Thailand.6 According to the theory of Thai traditional massage, there are 27,000 sen lines ("sen" in the Thai language means "line") throughout the human body. Among these are 10 main sen lines, which are wind paths. When dysfunction obstructs the wind paths, such as through illness or injury, some wind-related disorders will occur. The treatment can be the massage alone or in conjunction with hot herbal compress and herbal medicines. The health benefit of Thai traditional massage is improved blood and lymphatic circulation and nervous system function. Recently, there has been increasing scientific evidence explaining the beneficial effects of Thai traditional massage in pain relief, for example, activating the parasympathetic nervous system, increased delta activity in the electroencephalogram (EEG), and a reduction in salivary substance P.19
Conclusion
The current medical system treatment focuses on integrating modern medicine and alternative medicine such as TCM and TTM for a comprehensive treatment. Modern medicine from the Western world may lead to a decline in traditional medicine, but modern medicine alone cannot cover all populations in various geographical environments. Also, many far-flung communities do not have access or the financial means to acquire Western medicines. Most of the medical services therefore use alternative medicine as another way of treatment that will connect to the culture and way of life of patients in a given region. Such treatment is known and familiar to generations in these cultures and communities.
Pain management in traditional medicine, both in TCM and TTM, emphasizes a holistic approach, which considers an individual patient as a whole, including body, mind, spirit, and emotions, to achieve optimal pain management.
In recent decades, TCM and TTM have been revived and integrated into the National Health Service systems of some countries. Furthermore, recent clinical trials of traditional medicine compared with Western medicine have encouraged the application of ancient knowledge into conventional treatment and improved the service quality of both traditional and modern medicine.
References