Medical Acupuncture
A Journal For Physicians By Physicians

Spring / Summer 1999 - Volume 11 / Number 1
"Aurum Nostrum Non Est Aurum Vulgi"

pediatrics

HAND ACUPUNCTURE EXPERIENCE IN PEDIATRIC PATIENTS
Roberto Jodorkovsky, MD

ABSTRACT
     Korean Hand Therapy is a unique microreflex acupuncture modality. It is particularly suitable for treating children because it is virtually painless. Drawing on clinical experience with more than 100 pediatric patients with either painful or chronic conditions, the author discusses the effectiveness and acceptance of hand acupuncture in a pediatric setting.
KEY WORDS
Korean Hand Therapy, Hand Acupuncture, Chronic Conditions, Acute Pain, Pediatrics

INTRODUCTION
     Acupuncture can be very effective in treating children with muscular skeletal pain.1 Unfortunately, children's natural fear of needles often hinders the full therapeutic potential of acupuncture for complex diseases that may require more elaborate treatment strategies. Acupuncture treatments based on microreflex systems may ameliorate this limitation; these techniques tend to be less painful, more convenient, less invasive, and associated with minimal adverse effects.2 Korean Hand Therapy, a distinct and versatile type of microreflex system acupuncture, was developed by Dr Tae Woo Yoo in 1971.3 Korean Hand Therapy is unique among microreflex acupuncture modalities; the precise mapping of all the Chinese points, micromeridians, and corresponding body and organ parts on the hands permits the application of almost all types of acupuncture paradigms. Hand acupuncture is particularly suitable to treat children since the activation of the hand points is gentle and virtually pain-free. Though many times desirable, needles are not mandatory; magnets, pellets, or low-frequency electromagnetic stimulation can also achieve successful responses. The incidence of adverse effects reported by Yoo is remarkably low.3
     Clinical experience is reported using hand acupuncture in 106 children. This article addresses (a) the effectiveness of hand acupuncture to treat painful conditions in children, (b) the potential usefulness of hand acupuncture to treat other chronic, primarily nonpainful conditions in children, (c) the incidence of adverse effects associated with hand acupuncture in children, and (d) the acceptability of hand acupuncture in a suburban pediatric practice setting. This research is the first stage of a larger effort to study the effectiveness of pediatric hand acupuncture in a randomized, double-blind, controlled fashion.

METHODS
     The research was performed at a general pediatrics practice in Baltimore, Maryland. The cohort included 106 children and adolescents who were well-established patients and randomly consulted for a variety of conditions. Most complaints were acute or chronic pain-related conditions. The patients and their parents were provided information about hand acupuncture, and its potential therapeutic benefit as a complementary option to traditional medicine. All children and their parents enthusiastically consented to the acupuncture treatments. Prior to and following acupuncture, children presenting with painful conditions were asked to assess the degree of pain. A scale ranging from I to 10 was used (1= least pain, 10 = most). Only patients rating pain greater than 5 entered the study. The research also recruited children with nonpainful chronic diseases whose symptoms were not being controlled optimally by traditional treatments. All patients received a full clinical assessment including history-taking, physical examination, and necessary laboratory testing. The clinical diagnosis adhered to the established standards of Western medicine tenets. If necessary, conventional treatments such as analgesics, rest, immobilization, or bronchodilators were prescribed and tailored to each individual. Patients were permitted to alter this treatment as dictated by changes in symptoms, including modifying the dosage of medications.
     The hand acupuncture therapy used was based on the principles developed by Yoo.3 The activation of correspondence points was performed in all cases. All children with chronic diseases, and most consulting for painful symptoms lasting longer than I month, required the activation of additional, more elaborate treatment strategies: Mu and Shu points, extraordinary micromeridians, or the Five-Element paradigm.
     The observation period for each patient was approximately 6 months. Assessment of the clinical response to treatment was based on the patient's self-report; the pain scale, parents' report, and findings of clinical examination were included. This assessment was done during the first treatment, on subsequent office visits, and/or via telephone contacts. The clinical reassessment continued periodically until the symptoms resolved, improved, or were thought refractory to the treatment. The definition of improvement for painful diseases implied either a complete resolution of the pain, or a decrease of its magnitude by at least 50%. The criteria used to define improvement for conditions not deemed painful was: a decrease in the duration of symptoms, number of symptom relapses, or decrease in specific medications by at least 50%. Cases not fulfilling the above definitions were termed a clinical failure.

RESULTS
     The age distribution ranged from 3.5 to 20 years; the majority of cases were clustered in the 10- to 15-year age group (Table 1). The female-to-male ratio was 1.2: 1. Table 2 illustrates the categorization of the symptoms and the total number of treatments required. The painful conditions were mostly due to trauma or muscular overuse syndrome. Six children required radiography studies: 2 had uncomplicated fractures, including a child with a metacarpal fracture, another had a broken toe, a third child had an effusion in the elbow, and the remainder of the findings were reported normal. All patients were instructed to take nonsteroidal, anti-inflammatory agents as needed for pain control. Patients who had fractures were evaluated by an orthopedist. In the children who consulted for headaches, the etiology was thought to be tension in 6; the remaining 2 appeared to have migraine headaches. None were taking prescription medication for headaches. In the 13 children with sore throats, streptococcal cultures were negative; therefore, the etiology was likely viral. The majority of children with otitis and sinusitis were treated with antibiotics. All the patients with allergic rhinitis, asthma, abdominal pain, and 2 with sinusitis exhibited symptoms lasting longer than 3 months. Six patients were deemed to have recurrent functional abdominal pain. Two others had chronic inflammatory bowel disease and were under the care of a gastroenterologist. Patients with asthma used regular bronchodilators; some also took inhaled steroids or mast-cell stabilizers. Most children needed oral steroids for acute asthma attacks in the recent past. All patients with allergic rhinitis, and some with sinusitis, had intermittently tried various antihistamines and nasal steroids.

     Three children with knee pain, and 2 with wrist pain, needed 2 acupuncture treatments. All patients with asthma and allergic rhinitis, and 7 with abdominal pain, received more than 4 treatments. One child with recurrent abdominal pain was treated only twice. The remainder of the patients received a single acupuncture treatment. The total number of acupuncture treatments for all children was 180. Duration of symptoms is shown in Table 3. Thirty-two patients (30%) had symptoms lasting longer than 3 months: 3 children with knee pain, 2 with hand pain, 2 with sinusitis, and all with abdominal pain, asthma, or allergic rhinitis. Nine patients (8.5%) experienced their symptoms between 1 and 3 months: 3 with headaches, 3 with knee pain, 2 with hand pain, and I with foot pain. Sixty-five patients (61 %) had symptoms for fewer than 4 weeks, while 58 patients (55%) had acute symptoms for fewer than 7 days. The types of acupuncture treatment used included pellets in 56 children, needles in 16, single E-beam stimulation in 7, and a combination of these modalities in 27 children.
     Table 4 quantifies the clinical response to treatment: 102 children (96%) experienced improvement in their symptoms. A majority of these (70%) noted improvement within 3 days following treatment.
     Table 5 shows the breakdown of time to symptom improvement by condition: of the 70% of children who reported improvement in fewer than 3 days, most of them had acute symptoms. A small number of children with chronic symptoms reported symptom response in fewer than 3 days. However, symptom improvement in almost all patients with chronic conditions took longer than 3 days, usually I to 2 weeks. The majority of these children had abdominal pain, asthma, or allergic rhinitis. No patients reported adverse effects from the treatments.

DISCUSSION
     This study provides data satisfactorily addressing the basic questions of effectiveness and acceptability of hand acupuncture in a pediatric population. The overall efficacy was 96%. This rate of success included the treatment of a variety of clinical conditions both acute and chronic, painful and not painful. The majority of children, 79% of the sample, were treated for pain, particularly of muscular and/or skeletal origin. Half of these children had experienced acute pain for fewer than 7 days. The remainder of the patients exhibited chronic, nonpainful diseases such as allergic rhinitis, sinusitis, and asthma.
     The limitations inherent to a nonrandomized, uncontrolled study affect the interpretation of the results. However, the data provide evidence that mitigates this study's methodological constraint; the findings persuasively argue in favor of the healing validity of hand acupuncture in children. Table 5 lists the timing of symptom improvement as a function of the presenting conditions. Clinical improvement occurred in most patients; 70% reported an improvement of their symptoms in fewer than 3 days, 52% within 24 hours. The findings are strengthened by the fact that many times after only I treatment, most children with muscular and/or skeletal pain were able to resume their routine activities immediately, avoided taking excessive doses of analgesics, did not require radiological examinations, and had no need for orthopedic or physical therapy consultations. The majority of patients with chronic conditions experienced a significant attenuation of their symptoms within 2 weeks. The children and parents reported the use of fewer medications for these conditions. Children with recurrent abdominal pain appeared to respond to the treatment the quickest of the group with chronic symptoms. This group reported surprise that a seemingly simple manipulation of their hands would significantly decrease or abolish their long-standing, frustrating, annoying symptoms. The children with chronic sinusitis and allergic rhinitis often reported experiencing relief of their resistant nasal obstruction and itching. The children with chronic asthma universally experienced fewer or no exacerbations, and their need for bronchodilators was reduced, even at the time of an exacerbation. None of them needed to use steroids during the study period. Thus, conventional wisdom would argue that this rapid improvement or complete resolution of symptoms, and the positive feelings experienced by the majority of the children, was not likely due to exclusive chance, natural course, or pure placebo effect.
     None of the children reported any adverse effects, local or systemic, from the treatments. All children and their parents readily accepted the treatments. Many of them expressed amazement at the dramatic clinical improvement that was seemingly due to a treatment technique so disparate from conventional medicine. The initial readiness to consent to the treatment should be understood within a larger context: the preexisting trust and rapport between patient and physician, and the patient's reassurance upon learning the physician's view of acupuncture as not being exclusionary of, but unambiguously complementary to, traditional medicine.
     Experience suggests that hand acupuncture can be well accepted in a pediatric practice setting with the characteristics discussed above. Moreover, the patient's acceptability is likely to be further solidified by positive clinical outcomes.
     This article is the first part of a larger research endeavor that will comprise 3 sequential stages. The progress and final conclusion of this project will depend on the stepwise fulfillment of each part's specific research objectives. The second stage of this project will examine the effects of hand acupuncture on a group of children with a nar rower scope of chronic diseases such as asthma, chronic functional abdominal pain, and nocturnal enuresis. Standardized and validated acupuncture research instruments will be used to collect and evaluate data. The final section of this project aspires to study children with the chronic diseases identified in part 2 in a randomized, well-controlled fashion.

CONCLUSION
     This study offers preliminary evidence suggesting that pediatric hand acupuncture is a safe, cost-effective, and well-accepted integrative treatment modality in pediatric practice surroundings.

REFERENCES
1. Jodorkovsky R. Effective abbreviated acupuncture in children. Medical Acupuncture. Fall/Winter 1997-1998;9(2):7-10.

2. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif. Medical Acupuncture Publishers; 1995:132-133.

3. Yoo T-W. Hand Acupuncture. Eckman E-Y, ed. Seoul, Korea: Jin Publishing Co; 1988.

AUTHOR INFORMATION
Dr Roberto Jodorkovsky is in private practice, specializing in General Pediatrics and Medical Acupuncture. He is a Clinical Associate Professor of Pediatrics at the University of Maryland School of Medicine, and an attending Pediatric Nephrologist at the University of Maryland Medical System. Dr Jodorkovsky is the Vice-President and Secretary of the Maryland chapter, Medical Acupuncture Society.

Roberto A. Jodorkovsky, MD
8114 Sandpiper Circle, Suite 200
Baltimore, MD 21236
Phone: 410-931-1100 - Fax: 410-931-0871
E-mail: Roberto_A-Jodorkovsky@mercy-ventures.com

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