This article was downloaded by: [McMaster University] On: 22 December 2014, At: 14:35 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The Journal of Psychology: Interdisciplinary and Applied Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vjrl20
Psychological Factors and Clinical Observations in Acupuncture Analgesia and Pain Abatement Herbert H. Zaretsky Martin Rubin
a b c
, Mathew H. M. Lee
a b c
&
a b c
a
Department of Rehabilitation Medicine , Goldwater Memorial Hospital , USA b
New York University School of Medicine , USA
c
Milbank Special Care Clinic, New York University College of Dentistry , USA Published online: 02 Jul 2010.
To cite this article: Herbert H. Zaretsky , Mathew H. M. Lee & Martin Rubin (1976) Psychological Factors and Clinical Observations in Acupuncture Analgesia and Pain Abatement, The Journal of Psychology: Interdisciplinary and Applied, 93:1, 113-120, DOI: 10.1080/00223980.1976.9921381 To link to this article: http://dx.doi.org/10.1080/00223980.1976.9921381
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the
Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [McMaster University] at 14:35 22 December 2014
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Published as a separate and in The J o u m d of Psychology, 1976, 93, 113-120.
PSYCHOLOGICAL FACTORS AND CLINICAL OBSERVATIONS I N ACUPUNCTURE ANALGESIA AND PAIN ABATEMENT*'
Downloaded by [McMaster University] at 14:35 22 December 2014
Department of Rehabilitation Medicine, Goldwater M e m o d Hospital and New York University School of Medicine; and Milbank Specid Care Clinic, New York University College of Dentistry
The present study attempted to (a) replicate findings on acupuncture reported ip the Chinese literature; (b) investigate the effects of acupuncture in achieving analgesia and pain abatement; and (c) isolate the relevant psychological and/or physiological variables involved. Fifty volunteer men and women between 18 and 30 years of age were administered the acupuncture phase of this study for induction of analgesia and relief of pain in the oral cavity. A comparable group of 30 additional Ss were included in the study for comparison with the acupuncture group on several objective psychological measures. Forty of the acupuncture Ss were classified as totally successful. No significant differences between the acupuncture group and the comparable control group were obtained on the objective psychological measures, including measures of personality, suggestibility, anxiety, and attitudes. The results appear to indicate that psychological factors are minimally involved in obtaining analgesia and pain abatement with acupuncture techniques. Several interesting clinical observations were noted during the acupuncture procedure, including absence of discernable signs of analgesia, consistency of results, contralateral analgesic effect related to the location of acupuncture needles, etc. These results were discussed in terms of the possible role of physiological and psychological factors in acupuncture. Possible areas of future research were also discussed.
For the past several years, professionals from a wide variety of healthrelated disciplines have been interested in the reports of success with the
* Received in the Editorial Ofice on February 28, 1976, and published immediately at Provincetown, Massachusetts. Copyright by The Journal Press. 1 Based on a paper presented at the 51st Annual Session of the American Congress of Rehabilitation Medicine, San Francisco, California, November 22, 1974. The authors are indebted to Dr. Jacob Goldstein and Dr. Bernard Winkelman for their invaluable assistance.
Downloaded by [McMaster University] at 14:35 22 December 2014
114
JOURNAL OF PSYCHOLOGY
modalities delineated as part of the Chinese Medicine. In particular, acupuncture has received special attention because of the widespread positive comments in the media. The ancient Chinese medical art called "acupuncture" uses thin needles inserted into specified parts of the body to apparently treat various diseases, alleviate pain, and effect physiological changes ( 2 ) . Reports from China and France have pointed to the successful use of acupuncture to produce anesthesia ( 3 ) . These reports stress the stability of vital signs during surgery and the positive responses during postoperative recovery. While adequate physiological or neurological explanations of these reported successes are not as yet known, theoretical systems have been presented to attempt to explain the phenomenon ( 10, 13 ) . A frequent explanation of the reports of success with acupuncture has been to attribute these results to hypnosis, suggestion, or psychological factors (5, 6, 8, 9, 10). Without rigorous scientific study to isolate the relevant variables involved in the "successful" use of acupuncture, interpretations and explanations of the mechanisms involved in this procedure can only be classified as hypothetical. In particular, systematic scientific investigation is required to determine whether acupuncture is primarily a physiological or psychological phenomenon. Thus, if the results reported in the literature to date are replicable, then such scientific investigation would be facilitated. The major purposes of the present study were to attempt to replicate findings reported in the Chinese literature and to assess the efficacy of a psychological interpretation of acupuncture. In order to provide the necessary clinical data to achieve analgesia in treating dental problems, a dental treatment model was used which facilitated more effective control of the relevant experimental variables under investigation. This is important to note, since the lack of systematic control of variables in many previous acupuncture studies has detracted from meaningful interpretation of their findings. The present paper, therefore, summarizes the first in a series of studies to investigate acupuncture clinically with a view toward isolating the relevant psychological and/or physiological variables involved.
1. Subjects
Fifty Ss volunteered for participation in the acupuncture phase of the study. All Ss were between 18 and 30 years of age, in good health, and in need of routine dental treatment. The sample consisted of equal numbers of
HERBERT H. ZARETSKY
et al.
115
males and females with about 80% being right-handed. These Ss had a history of previous dental care with local anesthetic. A comparable group of 30 additional Ss was included in the study for comparison with the acupuncture group on several objective psychological measures.
Downloaded by [McMaster University] at 14:35 22 December 2014
2.
Procedure
Prior to undergoing any treatment, all Ss were administered extensive pretesting to determine their pain thresholds for dental procedures, their suggestibility, their attitudes toward dental treatment, relevant personality variables, their knowledge and impressions of acupuncture, and appropriate medical and dental information. To reduce S-E interaction, precautions were taken to minimize contact between the S and those performing the acupuncture and dental procedures. All Ss received a self-administering questionnaire, the Minnesota Multiphasic Personality Inventory, the Corah Dental Anxiety Scale, the Eysenck Personality Inventory, the Taylor Manifest Anxiety Scale, and Semantic Differential Attitude Scales. In addition, the "Weighted Arm" Suggestibility Test and the "Eye-Roll" Test were administered to each S in the acupuncture group. After pretesting, the acupuncture Ss were brought to dental treatment areas where the acupuncture procedure was administered. Analgesia was induced by the introduction of acupuncture needles primarily at the HOKU point (between the thumb and base of index finger) of each hand. Manipulation of the needles was done by manual twirling, the traditional method described in the Chinese literature. Sterilized standard steel 27 gauge needles were used for the acupuncture procedure. Prior to insertion of the needles, the selected areas on the skin were swabbed with alcohol sponges. In order to achieve and maintain any analgesic effect, the needles were continuously manipulated throughout the dental procedure. At brief intervals, testing was conducted to determine whether an acceptable analgesic effect had been achieved. Such testing involved applying pressure with a sharp dental instrument to the gingival tissues of 10 standard selected areas, including the area to be treated. Only when complete analgesia was obtained (i.e., no response to painful stimulus) was any dental treatment initiated. Continuous monitoring of patient reactions was diligently observed throughout the course of the procedure. Blood pressure and pulse measurements were taken before, during and after the acupuncture procedure. Important aspects of the acupuncture procedure were timed, including time to achieve analgesia and, following needle removal at the conclusion of the dental procedure, the time
Downloaded by [McMaster University] at 14:35 22 December 2014
116
JOURNAL OF PSYCHOLOGY
to return of pain sensation. To provide additional subjective information during treatment, each S was encouraged to give verbal reports of his or her reactions, including the occurrence of any sensations or other physiological changes. If acupuncture analgesia was deemed ineffective a t any point during the procedure, then the dental treatment was terminated. Before any further dental work was continued, analgesia was induced by the conventional method of procaine nerve block. In no instance was any premedication given to the Ss. At the completion of the dental procedure, each S was kept under observation for a minimum of one hour, and all Ss were given scheduled appointments for follow-up observation on the day after treatment. At the completion of the dental procedure, Ss were administered posttesting by a psychologist which included a determination of their reactions and attitudes to the acupuncture procedure, as well as their postprocedure tolerance for pain in the oral cavity. A variety of dental procedures was performed, often requiring several sessions and including such problems as cavity preparation and complete removal of caries, tooth extractions, gingival scaling and currettage, and root canal procedures. Of the 50 Ss included in the acupuncture phase of the study, 40 cases or 80% were deemed totally successful by virtue of the fact that a satisfactory analgesic effect was maintained throughout the entire course of each S's dental treatment. For the remaining 10 cases, a degree of acupuncture analgesia was obtained but it could not be adequately maintained to complete the required dental procedure. For the "successful" acupuncture Ss, the average time to induction of the analgesic effect was 7 1/2 minutes (SD = k 3 minutes). The average time to return of pain sensation averaged about 2 minutes (SD = + 1 1/2 minutes). The results of blood pressure and pulse analysis revealed no significant differences when comparisons were made of these variables before, during, and after the acupuncture procedure. No systematic relationship emerged when the tests for sensitivity to pain were compared to subsequent success or failure in inducing acupuncture analgesia. A comprehensive analysis of these "successful" acupuncture Ss revealed that psychological factors apparently were not the major contributors to producing and maintaining the analgesic effect. Supporting this conclusion is the lack of any systematic correlation between the results of the suggestibility tests and subsequent success or failure in obtaining acupuncture analgesia. This finding is a t variance with results reported by Katz ( 7 ) , but is generally supported by Shibutani ( 1 2 ) in a recent article. In addition, no significant
Downloaded by [McMaster University] at 14:35 22 December 2014
HERBERT H. ZARETSKY
et al.
117
difference was obtained between major S groups on the Hysteria Scale of the Minnesota Multiphasic Personality Inventory, a scale that has been reported to be significantly correlated to suggestibility and/or hypnotizability. Furthermore, no, significant differences were obtained between the acupuncture and nonacupuncture groups on the other personality scales of the MMPI, the Corah Dental Anxiety Scale, the Eysenck Extroversion and Neuroticism Scales, and the Taylor Manifest Anxiety Scale. Analysis of the Semantic Differential Attitude Scales supported a positive change in attitude for the acupuncture group on pre- and postcomparisons. However, this change in attitude was not statistically significant, and comparison between acupuncture and nonacupuncture groups on these scales also showed no statistically significant differences. There are several additional findings which also tend to support the notion that the acupuncture analgesia obtained in the present study was not primarily a psychological phenomenon. For example, during the dental treatment procedure and after acupuncture analgesia was obtained, each S was tested for hot and cold sensation in selected areas of the oral cavity. If a hypnotic effect was operable in these cases, then Ss should have reported sensations of hot and cold in reaction to such testing. For the sensations of hot and cold not to be perceived, their absence must be specifically induced as part of a hypnotic effect. However, in every case where a successful analgesic effect was obtained, no positive reaction to hot and cold was reported. This result, suggesting that there was no hypnotic effect operating, is also supported by a recent clinical paper by Nemerof and Rothman ( 11) relating acupuncture and hypnosis, as well as by reports from Veith ( 14), Geiger ( 4 ) , and Dimond (3).
Additionally, the findings related to the induction of acupuncture analgesia were generally consistent from S to S, including such factors as the length of time to achieve analgesia, the length of time for return of pain sensation, and the lack of discernable signs for the S on analgesic effects in the oral ravity until tested with a dental instrument. The replicability and consistency of these findings for 80% of the Ss in the acupuncture group, differing in personality, type of dental problem, attitudes toward acupuncture, knowledge of acupuncture, previous history, etc., is further evidence which is not supportive of psychological factors being considered of primary importance in producing acupuncture analgesia. In addition, the 80% success rate itself for acupuncture dental analgesia also mediates against this phenomenon being explained primarily as due to hyponosis, placebo effect,or other psychological factors. I t should also be noted that the acupuncture Ss reported complete
Downloaded by [McMaster University] at 14:35 22 December 2014
118
JOURNAL OF PSYCHOLOGY
awareness at all times and gave continuous verbal reports of their experiences during the acupuncture procedure. In fact, all Ss in the acupuncture group reported a general willingness to repeat the procedure and compared acupuncture more favorably to other analgesics previously experienced by them. For 70% of the successful acupuncture Ss, one of the most interesting findings was a contralateral analgesic effect as a result of twirling at the HOKU points. As noted earlier, with all the Ss in the acupuncture groups, continuous twirling was generally needed to maintain an adequate analgesic effect. In this regard, manual twirling at the HOKU point in the right hand often resulted in an analgesic effect on the left side of the oral cavity, while twirling at the HOKU point in the left hand resulted in a similar contralateral effect on the right side of the oral cavity. Such a finding appears to suggest a neurophysiological foundation to these results, corresponding to central nervous system functioning. Another important finding that suggested a minimal effect of psychological factors was the result of the inclusion in the procedure of "blind" termination of twirling for 10 of the successful Ss. For each of these Ss, and after analgesia had been obtained with acupuncture, twirling was terminated in one of the hands without the knowledge of the S or the dentist. This lack of knowledge can be confirmed by the responses of the Ss during the procedure and by the reports of the Ss and the dentists during posttesting. The results of this "blind" termination of twirling revealed that generally within 30 to 45 seconds and after stimulation to the gingiva, pain sensation returned to the contralateral side of the oral cavity. Discernible signs of discomfort and pain were observed, and twirling was again initiated, resulting in the restoration of the analgesic effect, generally within 1 to 1 1/2 minutes. Additional phenomena related to acupuncture analgesia were also noted. In 90% of the cases, insertion of the acupuncture needles was reported to be less painful than insertion of a syringe needle. Of those who were righthanded, 65% reported feeling more pain in their left hand due to the acupuncture needle. When their gums were probed for sensation after analgesia was achieved, 75% of the Ss reported a "dull pressure." I t was also observed that the analgesia was more effective and more rapidly obtained with faster manual twirling. With regard to the effects at the site of the acupuncture needle, erythema was present in 80% of the cases and lasted up to 20 minutes. In those cases of marked erythema, the analgesic effect seemed to be more pronounced. I t should also be reported that in 90% of the cases, Ss reported up to a 15 minute residual numbness in the hand after the needles were removed. Each of the successful cases also reported a relaxed or "seda-
Downloaded by [McMaster University] at 14:35 22 December 2014
HERBERT H. ZARETSKY
et al.
119
tive" effect for up to 24 hours after the procedure, which facilitated the relief of postoperative discomfort (i.e., for extractions). In fact, with each of the extractions, Ss reported that no postprocedure medication was taken or required. These findings concerning the "sedative" effect, the absence of postoperative pain, and the relatively high rate of success in obtaining acupuncture analgesia in dentistry were supported in a recent study by Brandwein and Corcos ( 1) . In summary, therefore, the results of the present study appear to indicate that acupuncture analgesia is not primarily a psychological phenomenon. However, while these findings tend to minimize the influence of psychological factors in acupuncture analgesia, further systematic investigation is necessary to define clearly the limiting effects of psychological variables. Much additional research is needed to investigate the role of such factors as placebo effects and such physiological variables as blood pressure, blood chemistry, EEG, skin resistance, EMG, etc. Additionally, further research is necessary to assess the role of brain function, particularly as regards the reported "contralateral" phenomenon; to investigate more comprehensively the role of psychological factors; to conduct comparable animal studies; to compare systematically acupuncture analgesia to other conventional analgesics; to compare systematically different acupuncture procedures for inducing analgesia, including manual needling, mechanical needling, electrical stimulation, acupressure, and stable needle insertion (absence of needling). I t is also necessary to investigate systematically the reported "unsuccessful cases" where acupuncture was used. Finally, as these investigations provide a scientific foundation and framework for understanding acupuncture, research is also needed to assess the efficacy of this technique for abatement and relief of chronic pain, a problem as important to dentistry as it is to other clinical specialities. While it is too early to tell, our research in this latter area on a limited number of cases has yielded encouraging and positive results (e. g., facial pain, migraine, etc.). The present study represents an effort to clinically replicate reported results in the Chinese literature regarding acupuncture analgesia and, by so doing, determine the possible role of psychological factors in these findings. By attempting to coordinate scientific methodology with practical, clinical procedures, this investigation suggests that acupuncture may not be, as some have said, "primarily a psychological phenomenon with physiological overtones." From the present results, it would appear that acupuncture analgesia is primarily a neurophysiological phenomenon, with psychological variables playing a secondary role.
120
JOURNAL OF PSYCHOLOGY
Downloaded by [McMaster University] at 14:35 22 December 2014
However, the authors are cautious in noting that much research in acupuncture needs to be conducted, and while we are currently in a position of having a limited number of answers, we do have sufficient clinical and research data available to begin to define the appropriate scientific questions to study. T o expand further our body of knowledge on the effects of acupuncture, it is important for each practitioner and researcher to observe and investigate this phenomenon systematically and, where possible, to be sensitive to physiological and psychological factors as they may relate to the emerging advantages and limitations of acupuncture. Only by so doing, can we adequately assess whether acupuncture is a valuable and effective addition to the techniques currently available in dentistry, medicine, and psychology.
BRANDWEIN, A., & CORCOS, J. Acupuncture analgesia in dentistry. Amer. J. Acupuncture, 1975, 3, 241-247. CHEN, J. Y. P. Acupuncture, medicine and public health in the People's Republic of China. U. S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, Bethesda, Maryland, 1972. Pp. 65-89. DIMOND,E. G. Acupuncture anesthesia. J. Amer. M e d . Assoc., 1971, 218, 1558-1563. GEIGER,H. J. HOWacupuncture anesthetizes: The Chinese explanation. M e d . World News, July 13, 1973, 14, 51. GOWSTEIN,D. N. Cult of acupuncture. W i s . M e d . J. 1972, 71, 14-15.. HYATT,C. L. Acupuncture. J . Ark. M e d . Soc., 1972, 69, 128. KATZ,R. L. Acupuncture studies in progress. In Jenerick, H. P., et al., Proceedings o f the National Institutes of Health Acupuncture Research Conference ( N I H 74165). Bethesda, Md.: National Institutes of Health, 1974. Pp. 73-75. KROCER,W. S. Hypnotism and acupuncture. J. Amer. M e d . Assoc., 1972, 220, 10121013.
. Acupunctural analgesia: Its explanation by conditioning theory, autogenic training, and hypnosis. Amer. J. Psychiat., 1973, 130, 855-860. MELWCK,R., 8 WALL,P. D. Pain mechanisms: A new theory. Science, 1965, 150, 971-979.
NEMEROF,H., & ROTHMAN,I. Acupuncture and hypnotism: Preliminary experiments--And a warning. Amer. J. CZin. Hypnosis, 1974, 16, 3 . SHIBUTANI,K. Injecting science into the acupuncture picture. M e d . World News, March 23, 1973, 14, 25. TIEN, H. C. Acupuncture anesthesia: Neurogenic interference theory. World J. Psychosynthesis, 1972, 4, 36-41. VEITE, I. Acupuncture in traditional Chinese medicine. Calif. M e d . , 1973, 118, 70-79.
Department of Rehabilitation Medicine Coldwater Memorial Hospital New York University Medical Center Franklin D . Roosevelt Island New York, New York 10017
The Journal of Psychology: Interdisciplinary and Applied Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vjrl20
Psychological Factors and Clinical Observations in Acupuncture Analgesia and Pain Abatement Herbert H. Zaretsky Martin Rubin
a b c
, Mathew H. M. Lee
a b c
&
a b c
a
Department of Rehabilitation Medicine , Goldwater Memorial Hospital , USA b
New York University School of Medicine , USA
c
Milbank Special Care Clinic, New York University College of Dentistry , USA Published online: 02 Jul 2010.
To cite this article: Herbert H. Zaretsky , Mathew H. M. Lee & Martin Rubin (1976) Psychological Factors and Clinical Observations in Acupuncture Analgesia and Pain Abatement, The Journal of Psychology: Interdisciplinary and Applied, 93:1, 113-120, DOI: 10.1080/00223980.1976.9921381 To link to this article: http://dx.doi.org/10.1080/00223980.1976.9921381
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the
Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [McMaster University] at 14:35 22 December 2014
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Published as a separate and in The J o u m d of Psychology, 1976, 93, 113-120.
PSYCHOLOGICAL FACTORS AND CLINICAL OBSERVATIONS I N ACUPUNCTURE ANALGESIA AND PAIN ABATEMENT*'
Downloaded by [McMaster University] at 14:35 22 December 2014
Department of Rehabilitation Medicine, Goldwater M e m o d Hospital and New York University School of Medicine; and Milbank Specid Care Clinic, New York University College of Dentistry
The present study attempted to (a) replicate findings on acupuncture reported ip the Chinese literature; (b) investigate the effects of acupuncture in achieving analgesia and pain abatement; and (c) isolate the relevant psychological and/or physiological variables involved. Fifty volunteer men and women between 18 and 30 years of age were administered the acupuncture phase of this study for induction of analgesia and relief of pain in the oral cavity. A comparable group of 30 additional Ss were included in the study for comparison with the acupuncture group on several objective psychological measures. Forty of the acupuncture Ss were classified as totally successful. No significant differences between the acupuncture group and the comparable control group were obtained on the objective psychological measures, including measures of personality, suggestibility, anxiety, and attitudes. The results appear to indicate that psychological factors are minimally involved in obtaining analgesia and pain abatement with acupuncture techniques. Several interesting clinical observations were noted during the acupuncture procedure, including absence of discernable signs of analgesia, consistency of results, contralateral analgesic effect related to the location of acupuncture needles, etc. These results were discussed in terms of the possible role of physiological and psychological factors in acupuncture. Possible areas of future research were also discussed.
For the past several years, professionals from a wide variety of healthrelated disciplines have been interested in the reports of success with the
* Received in the Editorial Ofice on February 28, 1976, and published immediately at Provincetown, Massachusetts. Copyright by The Journal Press. 1 Based on a paper presented at the 51st Annual Session of the American Congress of Rehabilitation Medicine, San Francisco, California, November 22, 1974. The authors are indebted to Dr. Jacob Goldstein and Dr. Bernard Winkelman for their invaluable assistance.
Downloaded by [McMaster University] at 14:35 22 December 2014
114
JOURNAL OF PSYCHOLOGY
modalities delineated as part of the Chinese Medicine. In particular, acupuncture has received special attention because of the widespread positive comments in the media. The ancient Chinese medical art called "acupuncture" uses thin needles inserted into specified parts of the body to apparently treat various diseases, alleviate pain, and effect physiological changes ( 2 ) . Reports from China and France have pointed to the successful use of acupuncture to produce anesthesia ( 3 ) . These reports stress the stability of vital signs during surgery and the positive responses during postoperative recovery. While adequate physiological or neurological explanations of these reported successes are not as yet known, theoretical systems have been presented to attempt to explain the phenomenon ( 10, 13 ) . A frequent explanation of the reports of success with acupuncture has been to attribute these results to hypnosis, suggestion, or psychological factors (5, 6, 8, 9, 10). Without rigorous scientific study to isolate the relevant variables involved in the "successful" use of acupuncture, interpretations and explanations of the mechanisms involved in this procedure can only be classified as hypothetical. In particular, systematic scientific investigation is required to determine whether acupuncture is primarily a physiological or psychological phenomenon. Thus, if the results reported in the literature to date are replicable, then such scientific investigation would be facilitated. The major purposes of the present study were to attempt to replicate findings reported in the Chinese literature and to assess the efficacy of a psychological interpretation of acupuncture. In order to provide the necessary clinical data to achieve analgesia in treating dental problems, a dental treatment model was used which facilitated more effective control of the relevant experimental variables under investigation. This is important to note, since the lack of systematic control of variables in many previous acupuncture studies has detracted from meaningful interpretation of their findings. The present paper, therefore, summarizes the first in a series of studies to investigate acupuncture clinically with a view toward isolating the relevant psychological and/or physiological variables involved.
1. Subjects
Fifty Ss volunteered for participation in the acupuncture phase of the study. All Ss were between 18 and 30 years of age, in good health, and in need of routine dental treatment. The sample consisted of equal numbers of
HERBERT H. ZARETSKY
et al.
115
males and females with about 80% being right-handed. These Ss had a history of previous dental care with local anesthetic. A comparable group of 30 additional Ss was included in the study for comparison with the acupuncture group on several objective psychological measures.
Downloaded by [McMaster University] at 14:35 22 December 2014
2.
Procedure
Prior to undergoing any treatment, all Ss were administered extensive pretesting to determine their pain thresholds for dental procedures, their suggestibility, their attitudes toward dental treatment, relevant personality variables, their knowledge and impressions of acupuncture, and appropriate medical and dental information. To reduce S-E interaction, precautions were taken to minimize contact between the S and those performing the acupuncture and dental procedures. All Ss received a self-administering questionnaire, the Minnesota Multiphasic Personality Inventory, the Corah Dental Anxiety Scale, the Eysenck Personality Inventory, the Taylor Manifest Anxiety Scale, and Semantic Differential Attitude Scales. In addition, the "Weighted Arm" Suggestibility Test and the "Eye-Roll" Test were administered to each S in the acupuncture group. After pretesting, the acupuncture Ss were brought to dental treatment areas where the acupuncture procedure was administered. Analgesia was induced by the introduction of acupuncture needles primarily at the HOKU point (between the thumb and base of index finger) of each hand. Manipulation of the needles was done by manual twirling, the traditional method described in the Chinese literature. Sterilized standard steel 27 gauge needles were used for the acupuncture procedure. Prior to insertion of the needles, the selected areas on the skin were swabbed with alcohol sponges. In order to achieve and maintain any analgesic effect, the needles were continuously manipulated throughout the dental procedure. At brief intervals, testing was conducted to determine whether an acceptable analgesic effect had been achieved. Such testing involved applying pressure with a sharp dental instrument to the gingival tissues of 10 standard selected areas, including the area to be treated. Only when complete analgesia was obtained (i.e., no response to painful stimulus) was any dental treatment initiated. Continuous monitoring of patient reactions was diligently observed throughout the course of the procedure. Blood pressure and pulse measurements were taken before, during and after the acupuncture procedure. Important aspects of the acupuncture procedure were timed, including time to achieve analgesia and, following needle removal at the conclusion of the dental procedure, the time
Downloaded by [McMaster University] at 14:35 22 December 2014
116
JOURNAL OF PSYCHOLOGY
to return of pain sensation. To provide additional subjective information during treatment, each S was encouraged to give verbal reports of his or her reactions, including the occurrence of any sensations or other physiological changes. If acupuncture analgesia was deemed ineffective a t any point during the procedure, then the dental treatment was terminated. Before any further dental work was continued, analgesia was induced by the conventional method of procaine nerve block. In no instance was any premedication given to the Ss. At the completion of the dental procedure, each S was kept under observation for a minimum of one hour, and all Ss were given scheduled appointments for follow-up observation on the day after treatment. At the completion of the dental procedure, Ss were administered posttesting by a psychologist which included a determination of their reactions and attitudes to the acupuncture procedure, as well as their postprocedure tolerance for pain in the oral cavity. A variety of dental procedures was performed, often requiring several sessions and including such problems as cavity preparation and complete removal of caries, tooth extractions, gingival scaling and currettage, and root canal procedures. Of the 50 Ss included in the acupuncture phase of the study, 40 cases or 80% were deemed totally successful by virtue of the fact that a satisfactory analgesic effect was maintained throughout the entire course of each S's dental treatment. For the remaining 10 cases, a degree of acupuncture analgesia was obtained but it could not be adequately maintained to complete the required dental procedure. For the "successful" acupuncture Ss, the average time to induction of the analgesic effect was 7 1/2 minutes (SD = k 3 minutes). The average time to return of pain sensation averaged about 2 minutes (SD = + 1 1/2 minutes). The results of blood pressure and pulse analysis revealed no significant differences when comparisons were made of these variables before, during, and after the acupuncture procedure. No systematic relationship emerged when the tests for sensitivity to pain were compared to subsequent success or failure in inducing acupuncture analgesia. A comprehensive analysis of these "successful" acupuncture Ss revealed that psychological factors apparently were not the major contributors to producing and maintaining the analgesic effect. Supporting this conclusion is the lack of any systematic correlation between the results of the suggestibility tests and subsequent success or failure in obtaining acupuncture analgesia. This finding is a t variance with results reported by Katz ( 7 ) , but is generally supported by Shibutani ( 1 2 ) in a recent article. In addition, no significant
Downloaded by [McMaster University] at 14:35 22 December 2014
HERBERT H. ZARETSKY
et al.
117
difference was obtained between major S groups on the Hysteria Scale of the Minnesota Multiphasic Personality Inventory, a scale that has been reported to be significantly correlated to suggestibility and/or hypnotizability. Furthermore, no, significant differences were obtained between the acupuncture and nonacupuncture groups on the other personality scales of the MMPI, the Corah Dental Anxiety Scale, the Eysenck Extroversion and Neuroticism Scales, and the Taylor Manifest Anxiety Scale. Analysis of the Semantic Differential Attitude Scales supported a positive change in attitude for the acupuncture group on pre- and postcomparisons. However, this change in attitude was not statistically significant, and comparison between acupuncture and nonacupuncture groups on these scales also showed no statistically significant differences. There are several additional findings which also tend to support the notion that the acupuncture analgesia obtained in the present study was not primarily a psychological phenomenon. For example, during the dental treatment procedure and after acupuncture analgesia was obtained, each S was tested for hot and cold sensation in selected areas of the oral cavity. If a hypnotic effect was operable in these cases, then Ss should have reported sensations of hot and cold in reaction to such testing. For the sensations of hot and cold not to be perceived, their absence must be specifically induced as part of a hypnotic effect. However, in every case where a successful analgesic effect was obtained, no positive reaction to hot and cold was reported. This result, suggesting that there was no hypnotic effect operating, is also supported by a recent clinical paper by Nemerof and Rothman ( 11) relating acupuncture and hypnosis, as well as by reports from Veith ( 14), Geiger ( 4 ) , and Dimond (3).
Additionally, the findings related to the induction of acupuncture analgesia were generally consistent from S to S, including such factors as the length of time to achieve analgesia, the length of time for return of pain sensation, and the lack of discernable signs for the S on analgesic effects in the oral ravity until tested with a dental instrument. The replicability and consistency of these findings for 80% of the Ss in the acupuncture group, differing in personality, type of dental problem, attitudes toward acupuncture, knowledge of acupuncture, previous history, etc., is further evidence which is not supportive of psychological factors being considered of primary importance in producing acupuncture analgesia. In addition, the 80% success rate itself for acupuncture dental analgesia also mediates against this phenomenon being explained primarily as due to hyponosis, placebo effect,or other psychological factors. I t should also be noted that the acupuncture Ss reported complete
Downloaded by [McMaster University] at 14:35 22 December 2014
118
JOURNAL OF PSYCHOLOGY
awareness at all times and gave continuous verbal reports of their experiences during the acupuncture procedure. In fact, all Ss in the acupuncture group reported a general willingness to repeat the procedure and compared acupuncture more favorably to other analgesics previously experienced by them. For 70% of the successful acupuncture Ss, one of the most interesting findings was a contralateral analgesic effect as a result of twirling at the HOKU points. As noted earlier, with all the Ss in the acupuncture groups, continuous twirling was generally needed to maintain an adequate analgesic effect. In this regard, manual twirling at the HOKU point in the right hand often resulted in an analgesic effect on the left side of the oral cavity, while twirling at the HOKU point in the left hand resulted in a similar contralateral effect on the right side of the oral cavity. Such a finding appears to suggest a neurophysiological foundation to these results, corresponding to central nervous system functioning. Another important finding that suggested a minimal effect of psychological factors was the result of the inclusion in the procedure of "blind" termination of twirling for 10 of the successful Ss. For each of these Ss, and after analgesia had been obtained with acupuncture, twirling was terminated in one of the hands without the knowledge of the S or the dentist. This lack of knowledge can be confirmed by the responses of the Ss during the procedure and by the reports of the Ss and the dentists during posttesting. The results of this "blind" termination of twirling revealed that generally within 30 to 45 seconds and after stimulation to the gingiva, pain sensation returned to the contralateral side of the oral cavity. Discernible signs of discomfort and pain were observed, and twirling was again initiated, resulting in the restoration of the analgesic effect, generally within 1 to 1 1/2 minutes. Additional phenomena related to acupuncture analgesia were also noted. In 90% of the cases, insertion of the acupuncture needles was reported to be less painful than insertion of a syringe needle. Of those who were righthanded, 65% reported feeling more pain in their left hand due to the acupuncture needle. When their gums were probed for sensation after analgesia was achieved, 75% of the Ss reported a "dull pressure." I t was also observed that the analgesia was more effective and more rapidly obtained with faster manual twirling. With regard to the effects at the site of the acupuncture needle, erythema was present in 80% of the cases and lasted up to 20 minutes. In those cases of marked erythema, the analgesic effect seemed to be more pronounced. I t should also be reported that in 90% of the cases, Ss reported up to a 15 minute residual numbness in the hand after the needles were removed. Each of the successful cases also reported a relaxed or "seda-
Downloaded by [McMaster University] at 14:35 22 December 2014
HERBERT H. ZARETSKY
et al.
119
tive" effect for up to 24 hours after the procedure, which facilitated the relief of postoperative discomfort (i.e., for extractions). In fact, with each of the extractions, Ss reported that no postprocedure medication was taken or required. These findings concerning the "sedative" effect, the absence of postoperative pain, and the relatively high rate of success in obtaining acupuncture analgesia in dentistry were supported in a recent study by Brandwein and Corcos ( 1) . In summary, therefore, the results of the present study appear to indicate that acupuncture analgesia is not primarily a psychological phenomenon. However, while these findings tend to minimize the influence of psychological factors in acupuncture analgesia, further systematic investigation is necessary to define clearly the limiting effects of psychological variables. Much additional research is needed to investigate the role of such factors as placebo effects and such physiological variables as blood pressure, blood chemistry, EEG, skin resistance, EMG, etc. Additionally, further research is necessary to assess the role of brain function, particularly as regards the reported "contralateral" phenomenon; to investigate more comprehensively the role of psychological factors; to conduct comparable animal studies; to compare systematically acupuncture analgesia to other conventional analgesics; to compare systematically different acupuncture procedures for inducing analgesia, including manual needling, mechanical needling, electrical stimulation, acupressure, and stable needle insertion (absence of needling). I t is also necessary to investigate systematically the reported "unsuccessful cases" where acupuncture was used. Finally, as these investigations provide a scientific foundation and framework for understanding acupuncture, research is also needed to assess the efficacy of this technique for abatement and relief of chronic pain, a problem as important to dentistry as it is to other clinical specialities. While it is too early to tell, our research in this latter area on a limited number of cases has yielded encouraging and positive results (e. g., facial pain, migraine, etc.). The present study represents an effort to clinically replicate reported results in the Chinese literature regarding acupuncture analgesia and, by so doing, determine the possible role of psychological factors in these findings. By attempting to coordinate scientific methodology with practical, clinical procedures, this investigation suggests that acupuncture may not be, as some have said, "primarily a psychological phenomenon with physiological overtones." From the present results, it would appear that acupuncture analgesia is primarily a neurophysiological phenomenon, with psychological variables playing a secondary role.
120
JOURNAL OF PSYCHOLOGY
Downloaded by [McMaster University] at 14:35 22 December 2014
However, the authors are cautious in noting that much research in acupuncture needs to be conducted, and while we are currently in a position of having a limited number of answers, we do have sufficient clinical and research data available to begin to define the appropriate scientific questions to study. T o expand further our body of knowledge on the effects of acupuncture, it is important for each practitioner and researcher to observe and investigate this phenomenon systematically and, where possible, to be sensitive to physiological and psychological factors as they may relate to the emerging advantages and limitations of acupuncture. Only by so doing, can we adequately assess whether acupuncture is a valuable and effective addition to the techniques currently available in dentistry, medicine, and psychology.
BRANDWEIN, A., & CORCOS, J. Acupuncture analgesia in dentistry. Amer. J. Acupuncture, 1975, 3, 241-247. CHEN, J. Y. P. Acupuncture, medicine and public health in the People's Republic of China. U. S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, Bethesda, Maryland, 1972. Pp. 65-89. DIMOND,E. G. Acupuncture anesthesia. J. Amer. M e d . Assoc., 1971, 218, 1558-1563. GEIGER,H. J. HOWacupuncture anesthetizes: The Chinese explanation. M e d . World News, July 13, 1973, 14, 51. GOWSTEIN,D. N. Cult of acupuncture. W i s . M e d . J. 1972, 71, 14-15.. HYATT,C. L. Acupuncture. J . Ark. M e d . Soc., 1972, 69, 128. KATZ,R. L. Acupuncture studies in progress. In Jenerick, H. P., et al., Proceedings o f the National Institutes of Health Acupuncture Research Conference ( N I H 74165). Bethesda, Md.: National Institutes of Health, 1974. Pp. 73-75. KROCER,W. S. Hypnotism and acupuncture. J. Amer. M e d . Assoc., 1972, 220, 10121013.
. Acupunctural analgesia: Its explanation by conditioning theory, autogenic training, and hypnosis. Amer. J. Psychiat., 1973, 130, 855-860. MELWCK,R., 8 WALL,P. D. Pain mechanisms: A new theory. Science, 1965, 150, 971-979.
NEMEROF,H., & ROTHMAN,I. Acupuncture and hypnotism: Preliminary experiments--And a warning. Amer. J. CZin. Hypnosis, 1974, 16, 3 . SHIBUTANI,K. Injecting science into the acupuncture picture. M e d . World News, March 23, 1973, 14, 25. TIEN, H. C. Acupuncture anesthesia: Neurogenic interference theory. World J. Psychosynthesis, 1972, 4, 36-41. VEITE, I. Acupuncture in traditional Chinese medicine. Calif. M e d . , 1973, 118, 70-79.
Department of Rehabilitation Medicine Coldwater Memorial Hospital New York University Medical Center Franklin D . Roosevelt Island New York, New York 10017
