Can acupuncture help ease debilitating and persistent chronic pain

Chronic pain can upend a person's life. Depending on the type and location, persistent pain can disrupt sleep, make it impossible to work and negatively affect personal relationships.

As many as 10% of all women experience chronic pain in the vulva or genital area, a condition known as vulvodynia. Occurring sometimes on its own, or with activity or intercourse, the condition is poorly understood, said Judith Schlaeger, a professor in the College of Nursing at the University of Illinois Chicago.

"It's woefully understudied, and women suffer. It can destroy psyches, relationships and lead to thoughts of suicide," she said.

As a certified nurse midwife, Schlaeger long used acupuncture, the traditional Chinese medicine practice of inserting thin needles into skin for therapeutic relief, to treat patients with vulvodynia. Now, she's just completed and published the results of one of the most rigorous clinical studies of acupuncture and vulvodynia. She is also studying the effect of acupuncture on chronic pain for sickle cell disease.

"There's never been a trial like this," Schlaeger said.

"It was long considered impossible for acupuncture research to do a double-blind trial," she said, referring to the common clinical trial design where neither participants nor researchers know who is getting treatment or a placebo. "This trial was so rigorous, and it's the first evidence that acupuncture produces a significantly longer-lasting reduction in vulvodynia pain compared to a placebo."

The study results, published in the Journal of Pain, are from one of several trials at UIC testing acupuncture's ability to alleviate pain in a variety of conditions. Also underway is Schlaeger's trial to treat stable angina - ischemic chest pain stemming from stress or exertion, and chronic pain from sickle cell disease, in which deformed blood cells get stuck in blood vessels and cut off the flow of oxygen causing pain.

From patient to practitioner

Schlaeger was introduced to acupuncture as a patient herself, looking for relief for serious allergy symptoms.

"I was on antihistamines and still having bad allergies," she said. "When you don't get relief, and you're still having symptoms, you're willing to try something new."

Acupuncture was fruitful. "I started not only getting relief with my allergies, but I started sleeping better. My vision was better. I felt healthier. This is the salutogenic effect of acupuncture," Schlaeger said, referring to the theory of and approach to health that emphasizes measures to support well-being, contrasted with a pathogenic paradigm that emphasizes fighting disease.

"This is very different than in Western medicine, where if you take a pill, the effect of the pill stops when the pill wears off. With acupuncture, if you get a series of acupuncture treatments, there can be a change in the body towards healing," Schlaeger said.

Though acupuncture has been practiced for centuries, only recently have researchers started investigating how, and in what scenarios, it might provide relief, according to Schlaeger.

"Acupuncture research is in its infancy in the United States and even in China," Schlaeger said. "We're just starting to learn about how it works, biomechanically."

After over a decade as a nurse midwife, Schlaeger became a licensed acupuncturist. She specialized in treating patients with vulvar pain, many of whom came to her after getting no relief from Western medical treatments. Little is known about what causes vulvodynia, and treatment plans can be scattershot, consisting of oral medications, injections and topical creams, as well as physical and talk therapies.

"That was my passion, to do acupuncture for vulvodynia," Schlaeger said.

These experiences spurred her to pursue a PhD in acupuncture science at China's Guangzhou University of Chinese Medicine. There, she developed the study protocol that served as the foundation for her recent trials of acupuncture's effect on vulvodynia.

A first-of-its-kind trial

Building off her earlier work in China, Schlaeger received a $2 million, five-year grant in 2017 from the National Institute of Health's National Institute of Child Health and Human Development. The grant funded the study of acupuncture to treat vulvodynia by Schlaeger, her UIC colleagues - including College of Medicine professor Dr. William Kobak- and key outside collaborators, including Nobuari Takakura from Japan's Tokyo Ariake University of Medical and Health Sciences and Ted Kaptchuk, director of Harvard Medical School's Program in Placebo Studies.

One of the first questions they needed to address was how to do a double-blind study of acupuncture. After all, a patient would know if a needle was inserted into her skin. How could the researchers create a placebo for their study?

Placebos are essential in rigorous clinical trials of Western medicine. When testing a new blood pressure drug, for example, a participant receives either a real pill containing the medication or a sugar pill that looks identical but contains no medicine.

"The person who gives the pill to the patient doesn't know, because they both look alike, and the patient doesn't know either," Schlaeger said. The study is "double-blind."

Takakura provided a breakthrough for the acupuncture study: double-blind acupuncture needles that enabled the researchers to treat participants with a placebo. Previously, this was thought to be near-impossible in acupuncture studies, Schlaeger said.

The double-blind needles developed by Takakura are housed in a tube that adheres to the skin via a small pedestal base. Neither acupuncturist nor patient knows what kind of needle is inside the tube: either a sharp-tipped needle that penetrates the skin and provides actual acupuncture or a blunt-tipped placebo that touches the skin, providing a sensation to the patient, without actually piercing it. This way, both the acupuncturist and the study participant don't know which treatment is applied to which patient.

Using these needles, the researchers tested treatment on 89 women with vulvodynia. Both the placebo and the penetrating needle groups experienced a reduction in pain, the team found. But the duration of effect was longer for the penetrating acupuncture; patients experienced relief up to three months after they received the treatment.

There are reasons why even the placebo may have provided strong pain relief, Schlaeger said. One involves a powerful phenomenon called the expectancy effect, which has been shown to influence how patients are affected by acupuncture for other types of pain, including pain from cancer.

"A patient can think, 'I've got so much riding on this'," Schlaeger said. They're so hopeful or expectant that the treatment will work - oftentimes because it represents a last-ditch effort in alleviating their discomfort - that they experience real relief even though they received a placebo, she said.

Investigating other chronic conditions

Schlaeger now is testing acupuncture's effect on other types of chronic pain. This fall she'll finish recruiting for a trial testing acupuncture for stable angina pain, a collaboration with co-investigators Holli DeVon, professor emerita in the College of Nursing, and Dr. Joan Briller, cardiologist and professor of clinical medicine in the College of Medicine. In some cases of stable angina, which is chest pain experienced during exertion or stress, therapies designed to reduce cholesterol buildup in arteries around the heart don't work.

With Ardith Doorenbos, the Harriet H. Werley Endowed Chair for Nursing Research in the College of Nursing, and Dr. Robert Molokie, associate professor of hematology and oncology in the College of Medicine, Schlaeger recently wrapped up a five-site trial of acupuncture and guided relaxation for chronic sickle cell pain management. This study was funded by the NIH's HEAL Initiative, which is dedicated to developing pain-management strategies in the face of America's ongoing opioid crisis. Sickle cell patients experiencing chronic pain are often treated with opioids but can encounter stigma when they go to emergency departments seeking help.

"There's shame and blame of patients when they come in in incapacitating pain," Schlaeger said. "They can be labeled as drug seekers, and then there's untoward suffering if physicians don't know how to prescribe narcotics or are afraid to prescribe narcotics like opioids to the level that is needed."

Studies like Schlaeger's aim to develop approaches that reduce opioid use and serve as supplemental or alternative treatments.

"There are so few alternatives for the management of chronic pain," she said. "Therefore, the NIH and other agencies are devoting more funding to studies of complementary and integrative health approaches to be used in conjunction with Western medicine."

This, Schlaeger said, is where acupuncture can really shine: as a complement to conventional avenues of treatment.

"Can we reduce the amount of opioids that people take if they get acupuncture, let's say, twice a week? Can we prevent a sickle cell crisis if a patient gets preventative acupuncture? These are questions we're hoping to get at," she said.

Other UIC co-authors on the vulvodynia study published in the Journal of Pain include Alana Steffen, Marie Suarez, Monya Meinel, Larisa Burke, Heather Pauls, Katelyn Sullivan and Jennifer Glayzer from the College of Nursing.