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Acupuncture Relieves Pain in Reflex
Sympathetic Dystrophy: Pitfalls In The
Analysis of Results

Kohler, John P MD, Jin, Ding Lian MD, Mandel, Steven MD
John P. Kohler, MD
Email: jpmk320@gmail.com
Website:
Phone: 610-664-6565
Contact
1. Randomized Controlled Trial HTTP://Wikipedia.org/wiki/ Randomized_controlled_trial Page last
modified on 27 April 2014.
2. Ni, Maoshing. The Yellow Emperors Classic of Medicine: a new translation of the NeijJing Suwen with
commentary: Chapter 5: The Manifestation of Yin and Yang from the Macrocosm to the Microcosm, p.
17: Shambala Publications Inc. Boston Massachusetts, 1995
3. Niemtzow, Richard C. Battlefield acupuncture: Medical Acupuncture. Volume 19,
Number 4, 2007


References
We performed a small retrospective review of patients
with Reflex Sympathetic Dystrophy treated using
multiple methods dictated not by set protocol but by
the best judgment of the treating acupuncture
practitioners. The objective data statistically analyzed
was the extremity visual analogue pain levels. The
question asked is: Does the objective data collected
at the time of acupuncture treatment of a complex
chronic pain condition, which is not amenable to
simple randomized study design, permit conclusions
about the efficacy of treatment?
Objective
At each treatment time the acupuncture
treatment significantly decreased the mean pain
level from the value before the treatment to the
pain level after the acupuncture treatment. First
treatment pre- treatment pain level:7.43+_2.15,
Post treatment 3.86_+ 2.76 (P<0.0019). After
the initial 15 treatments, the pre treatment pain
level did not significantly decline. The pre-
treatment average pain level of 6.5+_1.51 was
not different from the first treatment average
pain level. (P<0.40)
Two patient cases illustrate some of the subtle
parts of the patient course after beginning
acupuncture treatment.
.
Background
All patients were referred for acupuncture treatment.
The diagnosis of reflex sympathetic dystrophy was
confirmed by the referring/consulting neurologist (SM)
and the treating acupuncture providers(JK, JDL). All
patients had been treated with other methods (anti-
inflammatory medication, opioids, neurotrophic
medication, physical therapy, anesthetic nerve block,
operation) before starting acupuncture treatment.
The patients were treated with multiple acupuncture
strategies according to the individual patient as well
treating the pathophysiology of the pain anatomically
and physiologically. If there was insufficient reduction
of pain after an initial treatment the patient was usually
given the opportunity of having adjunctive treatment
with auricular therapy like Battlefield Acupuncture(3) or
directed local treatment. We tried to advance the
strategies to more powerful and more extensive
treatment methods as tolerated.
Methods and Materials
Physicians are urged to practice evidence
based medicine. Outcomes of clinical trials are
used to recommend optimal and unacceptable
treatment. Some published trials have very
significant deficiencies which does not stop the
data from being cited. The vast majority of
patients treated with acupuncture are not
included in clinical trials. Is the experience of
clinicians to be completely disregarded? Some
conditions are too rare or too complex to be
included in a clinical trial. Chronic pain patients
ask their health care provider to improve their
pain. Using the patient as their own control
avoids some of the problems in controlled study
design.
This particular study gives a strong conclusion
but one that is limited to a short time and the
single outcome variable of pain level. Each
acupuncture treatment performed in our office
reduced the extremity pain levels. This is a
good result. Fifteen treatment did not produce
a permanent reduction in pain. There are
many other parameters which indicate the
functional level. We are in the process of
collecting and analyzing the vast amount of
data from our treated patients. The authors do
not consider that this study answers all of the
important questions regarding the treatment of
these complex and suffering patients. .



Discussion
In a small series of patients with reflex
sympathetic dystrophy, acupuncture decreased
the pain level each and every treatment. The
average pre-treatment pain level at the 15
th

treatment was not different than before the first
acupuncture treatment. Paired T test using each
patient as their own control is statistically
appropriate and can be used in clinical studies
severe complicated chronic pain conditions. The
treatment produced more benefit that simple
pain relief.
Conclusions
Despite clinical experience totaling thousands of
years using acupuncture for relief of pain there is
controversy whether acupuncture is as efficacious as
medications and operations. Some publications have
inspired more controversy regarding objective data,
study design, adequate controls and avoiding the
dreaded placebo effect.

Randomized controlled clinical studies are considered
the gold standard for a clinical trial. (1) Many variables
are rigidly controlled in the planning of the study.
Patients are excluded from inclusion if they do not
conform to the study characteristics. In normal clinical
treatment settings patients present to the physician
with the specific chief complaint and all of their
complicating factors. In our practice patients are
typically referred for acupuncture treatment after other
conventional treatments have failed.

The rigid standardization that is entailed in the
randomized controlled study is contrary to the best
tradition of Chinese Medicine. In healing, one must
grasp the root of the disharmony, which is always
subject to the law of yin and yang. Nei Jing: Chapter
5: The Manifestation of Yin and Yang from the
Macrocosm to the Microcosm.(2)
Results
.
Patient 1:Comparison of right hand with RSD to left normal hand.
0
1
2
3
4
5
6
7
8
9
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
A
V
E
R
A
G
E
P
A
I N
L E
V
E
L
TIME (NUMBER OF TREATMENTS)
AVERAGE PAIN LEVEL VS. TIME
Pre Treatment Pain Level Post Treatment Pain Level
Patient 1. 50 yo laborer: Scaffold fell on hand.
Swollen, blue, painful hand
Ineffective: physical therapy, cast placement,
extensive operations, antidepressants, stellate
ganglion block
Acupuncture: sedation, inverse and contrary,
brachial plexus acupuncture, Battlefield
acupuncture, 7 internal dragons, Yang wei mai
triangular equilibration, SAMe, GABA, Fish oil.
With treatment: could workout in gym, (not
right arm), care for son and daughter, Normal
size and color of hand, Back to work as
supervisor (84 treatments over 24 months)
Case 2: 34 yo nurse: hand slammed in door. Right
hand non-functional, cold and swollen, wakes up 5
times a night.
Ineffective: Neurontin, Medrol, Lidoderm, Dilaudid,
sympathetic block, physical therapy, spinal stimulator.
Acupuncture : sedation, inverse and contrary, brachial
plexus, right upper extremity, Battlefield auricular
acupuncture , yang wei mai,
Moves her fingers, Drives, Takes care of kids, Pink
warm hand, sleeps through night
Lost to follow up-experimental RSD ketamine
treatment