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Preoperative acupuncture:
postoperative analgesia?
Thomas Lundeberg
In the linked study by Coura and col-
laborators, it is reported that acupunc-
ture the day before surgery can reduce
postoperative pain (see article on
page 16).1 Although the study is
small and there are gender differences
between the groups, the findings are
novel, suggesting that acupuncture
may be used the day before surgery
rather than given in the immediate
preoperative period. This sugges-
tion is supported by results showing
that acupuncture given to patients
just before operative removal of
impacted mandibular third molars
resulted in increased pain as com-
pared with a control group receiving
no treatment.2 A relevant question
is whether the results obtained may
be explained from a physiological
perspective—that is, if acupuncture
given the day before surgery may be
used to prevent or reduce the postop-
erative pain.
Nociception is the term for pain
that results from activation of noci-
ceptors (high threshold peripheral
sensory receptors) by noxious stimuli.
Such pain may result from a scalpel
blade cutting through skin. It signals
the existence, location, intensity and
duration of the stimulus and fades
once the scalpel blade is removed.
However, surgery commonly results
in tissue injury, inflammation and
inflammatory pain, a state charac-
terised by heightened pain sensitiv-
ity. This is triggered by the release of
sensitising inflammatory mediators
(eg, prostaglandins, ions, cytokines
and growth factors) that leads to
peripheral sensitisation (a reduction
in the threshold of nociceptors).3 The
peripheral sensitisation then results in
an increase in the excitability of neu-
rons in the central nervous system,
Correspondence to Thomas Lundeberg, Foundation
for Acupuncture and Alternative Biological Treatment
Methods, Sabbatsbergs Hospital, Sweden; thomas.
lundeberg@faab.to
Acupunct Med March 2011 Vol 29 No 1
central sensitisation. These phenom-
ena, although evoked within a matter
of minutes, can outlast the surgical
tissue injury for several hours or days
and drive acute postoperative pain
until the surgical wound has healed.4
Pre-emptive analgesia is a treatment
that prevents establishment of the
altered sensory processing that ampli-
fies postoperative pain. The treatment
should cover the entire duration of
high-intensity noxious stimulation that
can lead to establishment of central
and peripheral sensitisation caused by
incisional and associated inflammatory
injuries. Of these two injuries, the asso-
ciated inflammatory reactions are prob-
ably of greater clinical significance.5
Two approaches have been used to
reveal pre-emptive analgesia. One is
to demonstrate a reduction in pain
intensity and/or analgesic use beyond
the period during which an effective
concentration of a drug is maintained
in the vicinity of its site of action. This
approach is based on a study design
comparing preoperative treatment
and non-treatment groups. The other
approach is to prove that a treatment
applied before surgery is more effective
than the same treatment provided at the
end of surgery. The latter has become
the most common study design for pre-
emptive analgesia.6
The question is then whether it is
possible that acupuncture treatment
1 day before surgery is effective, as
opposed to acupuncture administered
just before surgery. Interestingly, sys-
temic opioids administered before the
start of surgery have a negative effect
on pre-emptive analgesia.7 8 This finding
may be attributable to a phenomenon
that counteracts the effect of pre-
emptive analgesia: the development of
acute tolerance to the analgesic effect
of opioids. Thus, the advantage of the
prevention of surgery-induced sensiti-
sation is lost because of the need to use
larger doses of opioids to overcome
Commentary
acute tolerance. Among the pharma-
cological interventions tested, epidural
analgesia, peripheral local anaesthetic
infiltrations and systemic non-steroidal
anti-inflammatory drugs have been
proved to have an end effect mainly on
a reduction in supplemental analgesics,
whereas systemic N-methyl-D-aspartic
acid receptor antagonists and systemic
opioids have not.9 This would suggest
that acupuncture treatment given the
day before the surgery either reduces
the activity in the nociceptive system
or more likely reduces the inflamma-
tory response following the surgical
intervention. Acupuncture has been
reported to result in the release of the
calcitonin gene-related peptide and
vasoactive intestinal polypeptide—
neuropeptides with anti-inflamma-
tory and antiapoptotic properties.10–14
Also, auricular acupuncture has been
reported to result in the activation of
a vagal cholinergic anti-inflammatory
mechanism.15
The results of clinical studies on
the value of pre-emptive acupuncture
analgesia are far from being unani-
mous. There are a number of poten-
tial problems related to pre-emptive
acupuncture analgesia that could lead
to controversy about its clinical signif-
icance. However, the results of Coura
and coworkers are promising and fur-
ther studies are warranted using the
protocol used.
Competing interests None.
Provenance and peer review Commissioned; not
externally peer reviewed.
Accepted 2 February 2011
Acupunct Med 2011;29:5–6.
doi:10.1136/aim.2011.004002
REFERENCES
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Commentary

postoperative pain and morphine requirement.
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 Downloaded from aim.bmj.com on June 6, 2011 - Published by group.bmj.com

Preoperative acupuncture: postoperative

analgesia?
Thomas Lundeberg

Acupunct Med 2011 29: 5-6

doi: 10.1136/aim.2011.004002

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