Acupuncture

Overview

In recent years, there has been an increased interest in alternative medicines, such as acupuncture. This holistic approach may be used to treat many symptoms associated with concussions. While research on acupuncture as a treatment for concussion is still relatively new, there is some evidence that points in the direction of this alternative treatment option being a successful treatment. This evidence includes support from the United States Department of Defense and Veterans Affairs, support from Dr. Nathan Zasler (a renowned authority on post-traumatic headache and concussion), and some preliminary scientific research on acupuncture’s effectiveness. Acupuncture has the potential to provide relief of concussion symptoms without the potential side effects of pharmaceutical treatments.

Acupuncture for concussion

Following a concussion, some patients experience a wide range of symptoms. Certified acupuncturists can treat many of the common concussion symptoms by using a variety of acupuncture techniques. Many patients experience chronic headaches following concussion, and acupuncture can be a way to get rid of this long-term pain. Acupuncturists can help treat:

  • Headache

  • Neck and shoulder pain

  • Dizziness

  • Fatigue

  • Vertigo

  • Nausea

  • Emotional issues (depression, anxiety)

Symptom management is an integral part of concussion recovery, and being able to manage symptoms in a non-invasive, holistic way can be very beneficial for patients. There are many benefits of holistic practices, which we discuss below.  

What is acupuncture?

Acupuncture is a form of East Asian Medicine (EAM) that has gained popularity in Western countries as a means of chronic pain treatment. In modern EAM, acupuncture comes in many different forms and can be used for treating a variety of conditions, but it has shown promise in treating pain, such as in post-concussive syndrome. In a meta-analysis published in the journal Evidence-Based Complementary Alternative Medicine, numerous studies of Chinese and English origin have found analgesic effects when using acupuncture to treat pain in acute and chronic conditions. 

How does acupuncture work?

Acupuncture is based on fixing the body’s flow of energy, traditionally called “chi,” through the twelve meridians. These meridians are analogous to the major organs in Western medicine. One of the overarching theories in EAM describes that when a person is ill, there is an imbalance or disruption to the flow of “chi,” which is the body’s energy. Thus, the insertion of acupuncture needles increases the fluidity of this flow so that sufficient energy can reach all lengths of the body. Generally, acupuncture techniques consist of using fine needles (varying from 13 to 130 millimeters wide) that penetrate areas of abnormalities. These needles are so thin that they cannot be felt when penetrating the skin most of the time.

Picture of the 12 meridians

The techniques of acupuncture emphasize penetration through the deep fascia, which is the layer of fibrous, protective tissue above muscle tissue that provides a protective barrier between muscles and skin tissue (see image below). The fascia is impenetrable to most biological substances such as blood, water but is known to be able to conduct electricity within itself. In fact, in EAM, the fascia is known as the conductor of “chi,” the energy in our body.

Acupuncture as a treatment for pain

As theories of fascia conductivity arose in EAM, further research began to explore conductivity in treating illness. For instance, modern acupuncture has paired stimulation technology with traditional acupuncture to observe the neurobiological changes in the brain that may be causing disease. Research from Peking University has found that patients who received acupuncture paired with electrical stimulation had an increased release of endorphin and endogenous opioids (opioids made by our bodies), which was in line with their physical pain relief.

Acupuncture needle penetration through skin to fascial layer- image from Dynamic ROTO Therapy Laboratory.

Endogenous opioids such as endorphins are typically released in the body to relieve pain; thus, these endogenous substances play a significant role in determining the degree of pain felt by the individual.

Additionally, an increased endorphin release prevents the release of a neuropeptide known as substance P. Substance P is a crucial neuropeptide that sends pain information to the central nervous system (CNS) to perceive pain and is released when pain is present in the body. In theory, inhibiting substance P will prevent pain from being perceived by the CNS; however, acupuncture's exact role in the pain pathway is still under study. 

In addition, acupuncture is also commonly paired with other treatments such as massage therapies, medications, physical therapy, and more.

Evidence in support of the use of acupuncture for concussion

The following examples from Veterans Affairs and the Department of Defense, as well as some scientific journal articles, show support for acupuncture being used to treat concussion.

Veterans Affairs and the Department of Defense are using acupuncture for concussions

Veterans and active-duty soldiers have a high risk of an injury that can result in a concussion or TBI. Since 2000, the US Army has reported more than 350,000 brain injuries (TBI in Iraq and Afghanistan Veterans). With that being said, the Department of Defense and Veterans Affairs has been looking for a way to help their soldiers deal with the side effects of these brain injuries, which has led them to acupuncture. See more on our Veterans page. 

The United States government has implemented acupuncture in recent years to help veterans recovering from varying levels of TBI. There are various examples of acupuncture being used by both the Department of Defense (DOD) and Veterans Affairs (VA). An article posted on the VA website discusses the basics of acupuncture, its effectiveness, and the ways in which it is being utilized to help veterans. A policy recently put into place includes acupuncture in a veteran’s medical benefits package if the veteran’s care team determines that acupuncture would be beneficial in the given situation. As of February 2018, a policy has been put in place that allows for certified acupuncturists to be hired by VA medical centers, which makes acupuncture even more accessible to the veterans who need it.

The Department of Defense has also been using acupuncture to help active-duty soldiers who have suffered concussions. An article posted by McClatchy Newspapers talked about how the DOD has sent certified acupuncturists to Afghanistan in order to treat soldiers who have become concussed in the line of duty. Having access to an acupuncturist in the time directly after the injury has been very beneficial in helping soldiers recover and return to duty. The use of acupuncture by the VA and DOD is an important step in acupuncture becoming more recognized by western medicine.

Treating concussion symptoms with acupuncture: Current research

While evidence supporting acupuncture to treat concussion is mostly anecdotal, there are some examples of scientific studies that examine the effectiveness of treating concussion with acupuncture. The first study below is an example of acupuncture being used to treat veterans, which shows how important the use of acupuncture by the VA and DoD is in creating support for acupuncture in the scientific community. 

An article in the Journal of Clinical Psychiatry by Wei Huang et Al. examines the use of acupuncture to treat veterans suffering from sleep disturbances as a result of a mild traumatic brain injury; sleep disturbances are a common symptom after a concussion. Some of the patients in the study also suffered from PTSD, which is not uncommon amongst veterans or TBI patients. The study found that acupuncture significantly reduced sleep disturbances in TBI patients with and without PTSD. With this study finding that acupuncture as an alternative medicine can be effective in helping patients in a clinical setting, it provides hope that more research will be done in the coming years to spread the knowledge of acupuncture as a beneficial treatment for a variety of ailments.

Danielle M. Gergen’s 2015 article in the Journal of Chiropractic Medicine examines a combination of chiropractic and acupuncture treatments in a 31-year-old woman who was experiencing symptoms of a concussion following a fall. After pharmaceutical treatments were unsuccessful, the patient turned to acupuncture and chiropractic to help deal with her persistent symptoms. These included acute neck pain, headache, dizziness, nausea, tinnitus, difficulty concentrating, and fatigue. Over two and a half weeks, the patient received six acupuncture treatments, which included a focus on the cranial and cervical locations. She also received chiropractic treatment at these sessions. By the end of the 2.5 week period, the patient noted that almost all symptoms had completely resolved. This case study is a great example of how pharmaceutical treatments are not the best option for every patient, and how alternative methods can be a less invasive option.

Attitudes towards holistic medicine

Despite the increased acceptance of acupuncture in Western societies, attitudes toward holistic medicinal methods have been met with skepticism in Western medicine. According to many Western scholars, acupuncture lacks scientific evidence and reasoning. As one physician we interviewed stated, "The proposed theories and mechanisms behind acupuncture are not visible when we open the human body. However, although I wouldn't suggest it to a patient directly, I am not opposed to someone seeking acupuncture if it is helpful for them." This viewpoint is common among many Western medicine practitioners and continues to be emphasized.

Other skeptics also cite that treating pain with acupuncture may be a placebo effect. When needles are penetrated into the skin, the expectation of being healed from acupuncture may cause pain relief. However, EAM has conducted studies using controls for acupuncture efficacy research to disprove this critique. For instance, sham acupuncture, which consists of needle penetration at non-acupuncture points, is commonly used to mimic a placebo effect. A meta-analysis study on chronic pain and acupuncture efficacy showed that sham acupuncture was less effective than acupuncture performed at actual acupuncture points. 

Another factor that may continue these attitudes of skepticism is the lack of consistency in treatment approaches. EAM focuses on holistic approaches to a patient's health and promotes the body's self-healing capabilities; the body is seen as a whole and is treated with herbal medicines, massage therapy, acupuncture, etc. On the other hand, Western medicine focuses on healing symptoms using interventions such as surgery and medications.

With differing perspectives in Eastern and Western medicine, understanding of illnesses presents differently and poses difficulties when met with complex diagnoses. For instance, if chronic pain is considered, treatment in both perspectives of medicine can be challenging to assess due to the subjectivity and varying onset of pain. Despite holistic medicine's increasing popularity in Western societies, many factors continue attitudes of skepticism towards holistic medicine, such as acupuncture.

Accessing care

In order to practice acupuncture, one needs to obtain a certification through a master’s or doctoral program. These programs exist on both the east and west coast of the United States, as well as internationally. Becoming a certified acupuncturist is a great career option for those interested in the medical field and patient care, without the drawn-out residency programs required for an MD. 

Many certified acupuncturists will accept insurance, but not all insurance providers will cover acupuncture. Those companies that do cover acupuncture will usually cover anywhere from $60-120 per visit, and some will cover the entire cost of the visit. This topic was discussed further in our interview with certified acupuncturist Iris Cutler. If your insurance does not cover acupuncture, you may be interested in a community acupuncture clinic which is a lower-cost option, which you can read more about here. 

To find a medical acupuncturist near you, use the search engine linked below. The search engine provides you with a list of American Academy Medical Acupuncture-associated providers.

Dry needling

An increasingly popular technique similar to acupuncture is dry needling. Pioneered by Dr. Janet Travell in the 1940s, dry needling was developed to primarily treat myofascial pain but expanded to other pain management realms such as chronic back pain, muscle spasms, and post-concussion headaches, and much more. The technique consists of thin, stainless steel needles placed at trigger points that are thought to loosen up tension in muscles causing pain and discomfort. To identify trigger points of pain, the clinician will perform palpitations to find areas of discomfort. When the patient is comfortable, needles will be inserted deeply in the area of pain, penetrating the fascia, and are pushed in and out constantly until muscle twitches or cramps are observed– known as a pistoning technique. Once a physical response in the muscles is observed, the clinician continues the pistoning technique until muscle response subsides. Continuing the pistoning technique until the muscle’s twitches are gone is important to maximize the benefits of dry needling. Many sessions are usually needed to loosen up areas of muscular pain completely. This dry needling is often done in a series of days until the patient feels complete relief. 

To scholars in EAM, dry needling can release the “knots” formed by everyday tensions that we place on our bodies. It is analogous to a massage to relieve pain but on a minute scale. Additionally, dry needling has potential neurochemical benefits as well. In a 2013 study by Abbaszadeh-Amirdehi et. al., dry needle stimulations were found to decrease acetylcholine release in muscles. Acetylcholine is a neurotransmitter involved in contraction and dilation of muscles and when out of balance in the body can cause myofascial referred pain.

Dry needling is performed by a variety of clinicians: physical therapists, medical doctors, acupuncturists, chiropractors, dentists, and occupational therapists. Across the U.S., some laws limit physical therapists specifically from practice dry needling; however, other types of providers can practice dry needling. Supporters of this limitation cite that physical therapists' education is insufficient and unfitting to perform dry needling on patients. When seeking clinicians who practice dry needling, it is essential to understand the legislation in your state. Here is a resource map for dry needling laws regarding physical therapists in different states.

Here is an example of a clinician practicing dry needling.

Provider input: Interview with Dr. Iris Cutler, DAHM, EAMP

In an interview with a Seattle-based acupuncturist who treats post-concussive syndrome-derived pain, Dr. Cutler highlighted the importance of making the patient comfortable with bodywork and being touched. Since acupuncture can seem daunting at first, it is essential to give the patient all the resources they need in order to understand and be comfortable with acupuncture. 

Interview with Dr. Iris Cutler: 

What are the most common concussion symptoms that you treat at your clinic:

The most common concussions symptoms that I see are migraines and cervical head, neck, and shoulder pain. Other concussion symptoms I’ve seen are patients with more activated sympathetic nervous systems. What this would look like is having increased anxiety and mood instability likely due to head injuries. Additionally, many concussion patients report low energy and mood, so acupuncture can assist with those symptoms too. Concussion symptoms less common in my practice are nausea and vertigo. The reason for this is that typically I see patients a few years after their incident, and nausea/vertigo generally is a symptom that is a few months following a concussion. 

How did you get involved in treating concussions with acupuncture?

At the Sound View Acupuncture clinic, patients typically come to me. I advertise my acupuncture work as a pain treatment. Additionally, a high population of my patients is veterans because Sound View accepts local veteran insurance (Triwest). I also get involved with treating people who are open to the idea of bodywork and reach out on their own. These individuals consist of women, athletes (history of starting bodywork early in life), those with good coverage insurance, VMA/bike accident victims (if the pain is untreatable). 

How does insurance work with acupuncture?

For me, I just started taking insurance last year, so currently, most patients pay via insurance. Only a handful pay out of pocket. The rule of thumb with insurance is $60-120 dollar reimbursement to acupuncture clinics through the insurance. Any insurance that reimburses below that acupuncturists typically don’t accept. 

If someone is on the fence about acupuncture, what would a typical visit look like? 

The first thing I do when I meet a patient is to fill out their medical history chart. This includes family history, social history, or any other relevant history. The first visit will typically consist of making the patient feel comfortable with acupuncture. I will have them lay on the table if they are comfortable and palpate and feel major joints, abdomen for areas of pain or abnormality. Some people are nervous around needles, so I will typically show them what the needle looks like, describe to them what it feels like when inserted, and how they might feel afterward. 

What specific types of acupuncture?

At the clinic I work at, I perform “engaging vitality” and “applied channel technique.” This requires palpitations in the body meridian channel and checking in with the patient as to where they have pain

Are there problems with accessibility that you’ve noticed?

There is a popular perception of what acupuncture is good for and what it isn’t suitable for, and a lot of scholars in Western medicine still deny its efficacy, but it has been shown in studies to be good for acute and chronic pain. 

Why do you think Western Medicine still has attitudes of skepticism towards acupuncture?

The first phenomenon is that we are typically not given proper education to navigate Eastern medicine outside of mainstream medicine. Additionally, more research needs to be done, and more cross-cultural research needs to be looked into. There is a lack of connection between different Western and Eastern medicine practices, and this continues the lack of understanding between the two practices.