Teishin Treatment in Inpatient Setting

Full title: “Teishin Treatment in Inpatient Setting – Gentle Touch of Contact Needle”

Abstract

During the first year of inpatient acupuncture program at University of California, Irvine, Medical Center, a number of patients have been successfully treated with teishin, contact needle or non-insertive needle. Some patients respond better and prefer teishin to filiform needle or insertive needle. Patients who have history of trauma or anxiety for needles seem to respond well to gentle touch of teishin. Teishin has delivered desirable effects to a number of patients without puncturing patients’ skin or causing painful needling sensation. More brain activity is observed when filiform needles are inserted, compared to stimulation of non-insertion needle, however, some patients may have altered brain activity due to trauma. It is possible patients with trauma history perceive filiform needling sensation as a threat, which makes it difficult for patients to relax and receive full benefit of filiform needle acupuncture. Teishin is a great acupuncture tool for these patients.

1 | INTRODUCTION

Susan Samueli Integrative Health Institute started an inpatient acupuncture program at University of California, Irvine, Medical Center (UCIMC) in March 2019. Within a year of its inception, the Integrative Health (IH) Service has given over 3,000 acupuncture treatments. After a physician or a nurse practitioner puts in a consult order for IH acupuncture, acupuncturists assess and treat patients accordingly. The acupuncturists typically follow patients 3 to 5 days/week, Monday through Friday, depending on the patient’s availability and willingness. Consult requests typically are for pain, which ranks as the most popular request, then headache, anorexia, anxiety, neuropathy, nausea, fatigue, and insomnia follow respectively.

When our service first began treatments, only filiform acupuncture needles were used. Later, teishin, or contact needle, was added as an alternative to filiform needle (FN) to treat those who are afraid of needles or who are not within UCIMC IH acupuncture guidelines. These guidelines were established through a collaboration with the infectious disease department. The purpose of the guidelines is to avoid any possible infection. According to the guidelines, the contraindications for FN acupuncture treatment are: (1) temperature of or above 38.5°C within the last 24 hours, (2) 24 hours before and 14 days after hardware implant, (3) platelet counts less than 25,000/microliter, (4) neutropenia, (5) bone marrow transplant, (6) solid organ transplant during transplant admission, and (7) admission to psychiatry unit. Per infectious disease department, patients are more vulnerable to infection around the time of hardware implant mentioned above.

Teishin is a Japanese pronunciation of Chinese characters, 鍉针 (di zhen). It is one of the nine acupuncture needles described in one of the ancient texts of Chinese medicine.¹ Teishin and a few other acupuncture needles of the nine are designed to manipulate qi without penetrating patients’ skin.² Teishin stays in practitioner’s hands during treatment. The objective of teishin is to manipulate qi, and not to add pressure, unlike acupressure or massage.³

A few months into teishin, it was noted that some patients responded better to teishin treatments than others. Once they qualified for FN acupuncture treatment, for example, as the 14 days had passed since the hardware implant, if patients stayed in the hospital long enough, FN was introduced to patients. Some could not wait to get “real” acupuncture, or FN acupuncture treatment. Some preferred to continue with teishin, however.

Most patients IH sees at UCIMC have never experienced acupuncture treatment prior to hospitalization. Those who prefer to get FN acupuncture have usually received regular acupuncture treatments either in the past or currently. The common trends seen among patients who respond better to teishin treatments are sensitivity to needles, needle phobia, and trauma.

Patients who are sensitive to needles say it is difficult to relax while FN are in the body, and often acknowledge that it is the mental component. Anxiety responds wonderfully to FN acupuncture, however, patients seem to prefer teishin when they are both anxious and sensitive to needles. Some prefer teishin because the last thing they want is to be “poked” after having been “poked” all over the body during the hospital stay through various procedures. They would fall into a category of needle-sensitive patients with anxiety.

Hardware implant is usually done during orthopedic surgery or neurosurgery. Orthopedic surgery is frequently a result of physical trauma such as motor vehicle accident, fall, or other traumatic incidents. Neurosurgery does not necessarily mean physical trauma, however, many veterans come to UCIMC for neurosurgery, then get transferred back to VA Long Beach Healthcare System in Long Beach, CA. Post-traumatic stress disorder (PTSD) is a common disorder in military population.⁴

At the time of this writing, there has been no consult order for bone marrow transplant patients, only 1 consult order for organ transplant patient, and 3 consult orders for patients in the psychiatry unit.

2 | CASE REVIEW

Here are a few of the patients who responded well to teishin treatments.

2.1 | Case 1: 4-year-old male

2.1.1 | History

On April 19, 2019, patient sustained second and third degree burn on 80-90% of total body surface area. Patient was intubated at another hospital and airlifted to UCIMC for comprehensive burn care at burn intensive care unit (ICU). Burn ICU first consulted IH on June 25, 2019 for anxiety and pain. Due to very limited access to skin, the decision was made not to treat the patient at the time.

2.1.2 | Teishin treatment:

On 8/12/19, IH received another consult order for anxiety. Patient was wheeled out of playroom and told that he was receiving acupuncture treatment. He was crying and screaming for the fear of needles. Due to the limited skin availability, only left ear shenmen and DU 20 were touched with teishin. Patient cried during treatment, except for a brief moment when ear shenmen was being touched. As patient got used to teishin treatment over the next few days, and upon realizing teishin was not painful, he willingly received treatment.

On August 16, 2019, a physical therapist (PT) and an occupational therapist (OT) were in the room working with patient. Patient was out of his wheelchair, which made him anxious. With teishin treatment, there were a few brief moments when patient became quiet and calm. On August 19, 2019, upon PT and OT’s request, teishin treatment was combined with PT/OT session. Patient screamed during the session, however, PT, OT, and mom noted he was less nervous, cried less, and stood on his feet longer compared to the usual PT/OT sessions. On August 21, 2019, Mom requested wound care team and IH coordinate so that patient can get teishin treatment during wound care. Patient screamed during the wound care, but seemed calmer when teishin was touching acupuncture points. Nurses also commented that the patient was calmer compared to previous sessions.

Since then, there were one more combined session with wound care and 2 more with PT/OT. As the skin healed, more body points were used to treat skin itchiness and anxiety. Patient became fond of ear points and started leaning on teishin needle whenever ear points were touched. Patient had a total of 19 teishin treatments during his stay at UCIMC.

2.2 | Case 2: 61-year-old male

2.2.1 | History:

On November 19, 2019, patient sustained a mechanical fall from estimated 25-foot high roof, which resulted in C2 and C3 fracture and acute disk herniation with incomplete spinal cord injury. Anterior cervical discectomy and fusion of C5 and C6 were performed on November 22, 2019, and C3 through C6 laminoplasty on November 29, 2019. There were T2 and T3 compression fracture deformities and left vertebral artery occlusion, but a decision was made not to operate. Patient was transferred to inpatient acute rehab unit (ARU) on December 6, 2019. At the time of admission to ARU, patient rated neck pain to be 3-4/10. The worst would be 6-7/10 when medications wean. Patient reported poor sleep, no bowel movement for 3 days, and no urinary issues.

2.2.2 | Teishin treatment:

ARU consulted IH on December 9, 2019. Because of the surgical hardware implant, he was not a good candidate for FN acupuncture according to the guidelines. Patient always fell asleep during treatment so it was difficult to measure how much treatment helped with pain, however, patient started taking less oxycodone when teishin treatments started while other pain medications remained the same. Over the second weekend in ARU, when he did not get a treatment, usage of oxycodone increased. Patient had 10 acupuncture treatments during his stay at ARU, 2 of which on December 19, 2019 and December 20, 2019 were with FN’s when more than 14 days had passed since the surgical hardware implant. Patient was not sure if FN’s were more effective for pain control and asked for teishin treatment as it was more relaxing for him. There was no difference in medication usage after teishin and FN treatment. Before patient was discharged on December 23, 2019, he requested physician’s referral for outpatient acupuncture.

TABLE: TIMES OF ACUPUNCTURE AND OXYCODONE ADMINISTERED

2.3 | Case 3: 23-year-old female

2.3.1 | History

On December 30, 2019, patient was brought to emergency room (ER) by her boyfriend due to concern for seizure. Patient’s whole body was shaking, and eyes were rolling back. Patient was recently diagnosed with gastric cancer and had multiple hospitalizations for paracentesis. Patient had not started cancer treatment due to insurance issues. Patient had lost 13.5 kg in the last 3 months. At the time of admission, patient had poor appetite and diarrhea for a few days. Patient’s height was 1.626 m. Weight was 30.8 kg.

2.3.2 | Teishin treatment:

Palliative team consulted IH on February 21, 2020 for pain. Patient complained of back pain. Due to emaciation and extreme deficiency, only 5 auricular points were needled with FN’s, and teishin was applied to the rest of the body. Patient was able to sleep during and after the first treatment. Since then, patient was treated for jaw pain, anxiety, insomnia, and generalized body pain. Patient would fall asleep or feel relaxed. . Pain level would go from 4/10 to 0/10 or from 8/10 to 5/10. Patient always looked forward to teishin and FN acupuncture treatment.

As patient became more deficient over the course of 9 treatments, less auricular points were needled. By March 4, 2020, only teishin was used. During the last treatment on March 13, 2020, only auricular points were touched with teishin. Patient deceased on March 16, 2020. By then, she only weighed 29.3 kg.

2.4 | Case 4: 23-year-old male

2.4.1 | History

On May 14, 2020, patient had a single gunshot wound to left knee and was brought into ER by friends. On May 16, 2020, patient had a procedure involving left femur open reduction internal fixation and application of external fixator. Patient was discharged on May 21, 2019, but he returned to ER for worsening pain in left leg on May 24, 2019. IH received a consult order on May 27, 2019.

2.4.2 | Teishin treatment:

Patient was hesitant about acupuncture treatment for the fear of needles, however, he was open to teishin treatment. Because less than 14 days had passed since the hardware implant, patient would not have been a good candidate for FN acupuncture. Patient seemed nervous and agitated, having a hard time to be still or relax. During the first half of the treatment, he was calmer but still moved a lot. When treatment reached the second half, however, patient became still, quiet, and soon fell asleep. By the time treatment was over, he was sleeping soundly. On the next day, patient reported less pain and relaxed feelings after teishin treatment. Patient fell sound asleep immediately during the second teishin treatment. He was discharged on the same day. There was no significant difference in medication intake.

2.5 | Case summary

Cases 1, 2, and 4 all experienced trauma and anxiety. Case 2 was one of those who asked for teishin over FN. Case 4 did not stay in the hospital long enough to try FN, however, he responded so positively that it would have been unnecessary to introduce FN especially with needle phobia. Case 1 would not have been a good candidate for FN acupuncture, considering his age and his first reaction when he heard about acupuncture. Case 3 was a little different. According to UCIMC guidelines, she qualified for FN acupuncture, and she was willing. Because of deficiency, however, patient had benefited more from teishin rather than FN.

3 | LITERATURE REVIEW

More brain activity is observed in healthy people through functional magnetic resonance imaging (fMRI) when filiform acupuncture needles were inserted, compared with stimulation from blunt non-inserting needle.⁵ However, fMRI of those with PTSD has altered brain activity at a resting state.⁶ When processing trauma-related stimuli, those with PTSD demonstrates disrupted “innate alarm circuit.”⁷

Although patients with PTSD have higher threshold for chronic pain, they are hypersensitive to painful stimuli if it is perceived as a threat.⁸ This explains why some patients with PTSD are sensitive to FN. If patients had never had acupuncture treatment prior to experiencing trauma or developing PTSD, FN could be perceived as a threat, though they are very thin and much less painful than hypodermic needles. Because teishin does not produce painful stimuli, patients may feel less threatened and more likely to relax.

Gentle touch on the skin especially soft stroke activates low-threshold unmyelinated mechanoreceptors (C-tactile) afferents, which is perceived as pleasant and can be similar to mother-infant interaction.⁹ Prior to and during teishin treatments, I palpate patient’s abdomen and pulse on bilateral wrists in order to determine treatment protocols and to assess patient’s response to the treatment. I apply gentle touch with teishin throughout the treatment and occasionally stroke patients’ skin using teishin and my hands. Some patients particularly love the stroking technique. Almost all patients feel relaxed after teishin treatments. Is it possible that teishin, through gentle touch, activates C-tactile afferents? It may be possible during palpation and stroking, but may not be the case with some of the treatment. C-tactile afferents are most common in forearms and scarce in distal parts of the extremities.¹⁰ Distal parts of the extremities are where most of the five-transporting-acupuncture-points are located and most often used during treatment.

Not all PTSD patients appreciate gentle touch, however. Patients with interpersonal trauma-related PTSD perceive touch, especially personal touch from another person, as unpleasant because it reminds them of trauma.¹¹ One out of three women and one out of six men have experienced childhood sexual abuse, and one out of five men and women have experienced childhood physical abuse.¹² Although medical charts do not always reveal interpersonal trauma history, it is perhaps reasonable to assume some of the patients have experienced such trauma. In fact, some patients disclose interpersonal trauma experience to acupuncturists. Yet, there has not been a patient who describes teishin acupuncture as unpleasant or decline treatments for that reason. A handful of patients have declined FN acupuncture, however, because of painful sensation FN produces upon insertion.

Why then are patients with interpersonal trauma history still able to enjoy teishin treatment? When touch was applied with a soft object, which still activated C-tactile afferents, there was no subjective or objective difference between the two groups of PTSD and healthy.¹¹ During patient care, acupuncturists’ touch patient through gloved hands or teishin tool in gloved hands. Because there are objects between my skin and patient’s skin, touch may be perceived as impersonal and therefore tolerable to those with interpersonal trauma history.

4 | DISCUSSION

The application of teishin is gentler than that of FN, therefore, patients may not perceive it as a threat compared to needles and are able to enjoy the treatment. Without the “threat” of the FN, those who are sensitive to needles or have history of trauma are able to relax more and respond well to the treatment. Even the patients with interpersonal trauma history, who are averse to personal touch, seem to obtain benefits of teishin possibly because touch is not directly from another person’s skin. It may be possible that teishin treatment activates C-tactile afferents, but further studies are required.

5 | CONCLUSION

Teishin is a wonderful acupuncture tool. Unfortunately it is not used often enough. Even with the guidelines at UCIMC, IH has been able to continue seeing patients because of this non-insertion acupuncture needle, which has been well received by patients and other practitioners. Some patients do prefer and respond better to FN acupuncture, however, it has made a significant difference to have an alternative.

References

1. Tian, D, Liu, G. Jiu zhen lun. In: Ling shu jing. Beijing, China: Renmin Weisheng Press; 2005: 157-160.
2. Kishida, Y. Teishin tte donna hari? In: Sasanai hari teishin nyumon – Morimoto shiki teishin wo tsukatta chiryou. Tokyo, Japan: Human World; 2009: 7-14.
3. Kishida, Y. Teishin wo tsukaumaeni. In: Sasanai hari teishin nyumon – Morimoto shiki teishin wo tsukatta chiryou. Tokyo, Japan: Human World; 2009: 15-112.
4. Jain, S, Mcmahon, GF, Hasen, P, et al. Healing Touch with Guided Imagery for PTSD in returning active duty military: a randomized controlled trial. Milit Med. 2012:177(9):1015–1021. doi:10.7205/MILMED-D-11-00290.
5. Chae, Y, Lee, H, Kim, H, Sohn, H, Park, JH, Park, HJ. The neural substrates of verum acupuncture compared to non-penetrating placebo needle: An fMRI study. Neurosci Lett. 2009;450(2):80–84. doi:10.1016/j.neulet.2008.11.048.
6. Yin, Y, Li, L, Jin, C, et al. Abnormal baseline brain activity in posttraumatic stress disorder: A resting-state functional magnetic resonance imaging study. Neurosci Lett. 2011;498(3):185–189. doi:10.1016/j.neulet.2011.02.069.
7. Rabellino, D, Densmore, M, Frewen, P, Théberge, J, Mckinnon, M, Lanius, R. Aberrant Functional Connectivity of the Amygdala Complexes in PTSD during Conscious and Subconscious Processing of Trauma-Related Stimuli. PLoS One. 2016:11(9):e0163097. doi:10.1371/journal.pone.0163097.
8. Defrin, R, Ginzburg, K, Solomon, Z, et al. Quantitative testing of pain perception in subjects with PTSD – Implications for the mechanism of the coexistence between PTSD and chronic pain. Pain. 2008;138(2):450–459. doi:10.1016/j.pain.2008.05.006.
9. Löken, LS, Wessberg, J, Morrison, I, Mcglone, F, Olausson, H. Coding of pleasant touch by unmyelinated afferents in humans. Nat Neurosci. 2009;12(5):547–548. doi:10.1038/nn.2312.
10. Vallbo, Å, Olausson, H, Wessberg, J. Unmyelinated afferents constitute a second system coding tactile stimuli of the human hairy skin. J of Neurophysiol. 1999:81(6):2753–2763. doi:10.1152/jn.1999.81.6.2753
11. Strauss, T, Rottstädt, F, Sailer, U. Touch aversion in patients with interpersonal traumatization. Depression and Anxiety. 2019;36(7):635–646. doi:10.1002/da.22914.
12. Briere, J, & Elliott, DM. Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Negl. 2003;27(10):1205–1222. doi:10.1016/j.chiabu.2003.09.008.