The use of acupuncture in first aid of burns—Clinical report

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ScienceDirect journal homepage: www.elsevier.com/locate/burns

The use of acupuncture in first aid of burns—Clinical report A. Loskotova a,b,c, * , J. Loskotova c,d a

Medical Faculty of Masaryk University Brno, Czech Republic, Europe 3rd Medical Faculty Charles University, Department of Preventive Medicine, Prague, Czech republic c SALVE Centrum—Physiotherapy Clinic, Vysoké Mýto, Czech Republic d Faculty of Law—Dept. of Financial Law, Masaryk University, Brno, Czech Republic b

article info

abstract

Article history:

Burns are a very painful skin injury, or injury of soft tissues. The development of post-

Accepted 25 April 2017

traumatic stress disorder can develop, even in those with minor injuries (Ia–IIb degree).

Available online xxx

Development of problems is very rapid and intense since, according to developmental embryology, the skin and central nervous system (CNS) descend from the same germ layer—

Keywords: Burn trauma (BT) Post-traumatic stress (PTS) First aid Acupuncture (ACU) Lung point 7 (LU 7) Large intestine point 11 (LI 11) Large intestine point 4 (LI 4) Wound healing Scar

ectoderm. This clinical report presents the results acquired from the data of 1008 patients suffering from burns treated by the acupuncture (ACU)—from 1983–2015 in the surgery ward of the hospital in Vysoke Myto in the Czech Republic. The data of 1008 patients were processed and evaluated. 1. The report demonstrates a positive effect of ACU treatment signs on the skin were monitored, i.e. reddening, pigmentation, scars. During the treatment the elimination of many of these signs was observed. Improvement of healing process and improvement in the final wound healing were evaluated and shown by the statistical method—the x2 test. For demonstrating the effect of ACU treatment of BT the Pearson's and the Cramer's contingency coefficient were examined. 2. The time of the first application of the ACU treatment after burn was followed and evaluated with a random set. The best results were achieved when the first ACU treatment was applied as soon as possible after BT injury (ideally immediately, optimally within 48h). The positive effect of ACU on burns is medical, economical and biopsychosocial. © 2017 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

Severe burn is defined as a condition which occurs by direct or indirect action of supra-threshold value of thermal energy, electricity, radiation or certain chemicals on the skin, soft tissues or airways due to smoke inhalation [1].

Scalding and burn burns from flame and chemicals, etc. lead to damage or destruction of skin at different depths. The following factors are the most important: area, extent and degree. Other factors also play a role: type of burns, patient’s age, patient’s mental state and condition of their immune system, and comprehensive medical history of the patient.

* Corresponding author at: SALVE Centrum, Department of Physiotherapy, Jiraskova 177/IV, 566 01 Vysoké Mýto, Czech Republic, Europe. Tel.: +420737753321. E-mail address: [email protected] (A. Loskotova). http://dx.doi.org/10.1016/j.burns.2017.04.025 0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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Burns are proportionally less represented than contusions and severe bruising of the skin and soft tissues. But even with a small range of scalding or burns the situation may dramatically deteriorate with rapid development of a burn shock. If it is not treated in time, the patient may even die. This type of trauma is therefore ranked among the most serious injuries. In Europe, burns are ranked 13th in the list of tragic events. The sad fact is that 40% of all burn victims are children [2]. Globally, burns are a serious public health problem. In the last 20 years, the overall number of burn cases has risen due to a higher number of transport accidents, international war conflicts and also terrorist attacks. According to the World Health Organisation, there are over 265,000 deaths each year from fires only, with more deaths from scalds, electrical burns, and other forms of burns for which global data are not available. Burns are also characterized by increased pain intensity and rapid development of post-traumatic stress. Development of circulatory dynamic insufficiency in particular venous and lymphatic systems and development of secondary inflammatory response rapidly arise in many cases. Development of hypertrophic scars is another complication in the context of healing. The important factors that affect prognosis of a burn patient are proper first aid, provision of emergency care and quick transport to a specialised institution [3,4]. The extent and depth of the affected areas are directly proportional to the

length of exposure to heat (boiling liquids, burning or hot objects) [4]. In standard burn care analgesics, sedatives, antibiotics, frequent dressing changes, or also autotransplantation at deep levels of injury (IIb–III) are encountered. Most burn patients are fully conscious and well oriented and try to cooperate. But it is always necessary to insure appropriate first aid [5,6].

1.1.

What is the reason for the use of ACU?

The author’s theory for explanation of the mechanism of action of acupuncture in the acute phase of burn treatment is mostly likely induction, a kind of repetition of previous biological events on the virtual level. This model is represented by a reflection of biological reality in an anti-idiotype network inducing faster healing through interactions with the immune system. This reaction would otherwise occur much later and in more extensive lesions and associated with greater scarring [7,8]. Needling affects the cerebrospinal fluid (CSF) concentrations of naturally occurring opiate substances: dynorphin (acting at spinal level), endorphin (acting within the brain) and encephalin (acting both in the brain and on a spinal level). Endorphins and encephalin are potent blockers that affect pain arising from the musculoskeletal system. Dynorphinis a

Table 1 – Overview of active participation in Congresses in the period 1988–2013. 1988 1996 1998 1998 1999 2000 2001 2005 2005 2006

ICMART ICMART ICMART SA ICMART ICMART ICMART ICMART EXCO ICOM ICMART

Prague, CSSR Nicosia, Cyprus Miyazaki, Japan Recife, Brazil Riga, Latvia Vienna, Austria Berlin, Germany Prague, Czech Republic Daegu, Korea Washington DC, USA

2007

ICMART

Barcelona, Spain

2007 2007

ICOM 20th CA

Taipei, Taiwan PietraNeamt, Romania

2008

ICMART

Budapest, Hungary

2008 2010

ICMART World Congress of Medical Law 18th ISSC SSHL NATO

Thessaloniki, Greece Zagreb, Croatia

2013

9th Asia-Pacific Burn Congress

Hanoi, Vietnam

First aid of acupuncture in burn trauma treatment First aid of acupuncture in burn trauma treatment First aid of acupuncture in burn trauma treatment First aid of acupuncture in burn trauma treatment The use of acupuncture in complex therapy of burn trauma The use of acupuncture in complex therapy of burn trauma The use of acupuncture in complex therapy of burn trauma The use of acupuncture in complex therapy of burn trauma First aid acupuncture in the complex therapy of burn trauma First aid acupuncture in the complex therapy of burn trauma Acupuncture and myofascial manual lymphatic drainage Acupuncture, lymphatic system and dysfunction in traumatology in complex therapy of burn trauma Function changes in traumatology and their therapy—method “LOSANN” The use of acupuncture in complex therapy of burn trauma Acupuncture and myofascial manual lymphatic drainage in complex therapy of burn trauma New methods in traumatology and their application in complex therapy of burn (Award for 3rd place) Functional changes in traumatology and their therapy (BT) Legal, ethical and economic issues of complementary medicine in complex therapy of burn trauma Legal and economic issues of CAM methods (Award for 3rd place in surgery) Physician´s liability and parent´s right in treatment of minors (burn trauma cases) Military Health care Working Group, 1st aid with application of complementary standard in the frame of basic standard therapy Burn trauma and first aid of acupuncture

2013

15th European Burn Association Congress

Vienna, Austria

Burn trauma functional pathology of lymphatic system and soft tissues Burn trauma and first aid of acupuncture

2010 2010 2011

Gdansk, Poland Brno, Czech Republic Praha, Czech Republic

Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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powerful modulator of visceral pain; it has a weaker effect on musculoskeletal pain modulation [9]. The depth of burns is an essential criterion for the selection of surgical intervention or conservative procedures and is a factor in the long-term prognosis of burn patients´ morbidity. The other factors, in particular the elimination of posttraumatic stress, affect the short-term prognosis.

1.2.

History of the acupuncture in burn trauma treatment

The first brief note on the application of acupuncture in sunstroke, with application of needles in the acute care unit, Lung point 7, was mentioned by Lebarbier [10]. In the 1980s, in Czechoslovakia, Karel Prusik, M.D. (general practitioner, acupuncturist) applied acupuncture to a limited number of patients with scalding, and noticed faster and better healing of the skin. However, neither the method nor frequency of application, nor the timing and duration of the action were listed anywhere in the literature.Therefore in 1983 Mrs. Anna Loskotova, M.D. began to carry out an empirical study, when she applied acupuncture to all burn patients in the surgical ward at the hospital in Vysoke Myto (Czech Republic, Europe). Doctor Loskotova also monitored and documented all the dressing changes and results of healing. First, she applied acupuncture twice a day for at least 30min. In some serious cases needles were left for several hours. In more severe degrees of BT, the needles were applied directly in the operating theatre. In some cases the needles were applied directly on the spot of the injury. The patients were then immediately transported to the specialized ward in the hospital. Mrs. Loskotova applied acupuncture to burn patients in the following workplaces:

ongoing years, after getting empirical experiences, acupucture was delivered once a day until complete wound healing.

3.

Methods

According to the evolutionary embryology, the skin, lungs, central nervous system and colon belong to the ectoderm. Therefore, the application of needles into acupuncture active points on these channels is potentially effective in acute treatment of burns and skin healing.

3.1.

2.

Lung Point 7–LU 7 (called Lieque)

Point 7 of the Lung Channel is a point of LUO transition, an output point of the lung meridian with conjunction to the input point of the large intestine meridian. It has LI 4/analgesic and immunostimulating effects. A cardinal point of the meridian REN-MAI, or the Conception Vessel, Intake Channel, is thought to restore the conjunction of lungs with kidneys and affects skin damage. To localise point 7 of the Lung Channel, cross both “Tiger Mouths” (folds between thumb and index fingers) vertically, and the top of the index finger points at it (see Fig. 1). Localisation: between tendons of brachioradialis and abductor pollicis longus, it is in the radial edge of m. pronator quadratus. In the surface layer, there are branches of radial nerve and cephalic vein, and in the deeper layer branches of the radial vein. Innervation is via the cutaneous brachioradialis and superficial radial nerve [11,12] (see Fig. 2). In case of the difficult access to the point LU 7 (severe burn degree, etc.) point LI 11 is used instead.

3.2.  1983–1993 Ward of Surgery, Hospital in Vysoke Myto, Czech Republic.  1993–2014 Clinic of Physiotherapy in Vysoke Myto, Czech Republic.  1990 (02–03) International course on acupuncture under the leadership of Professor Nguyen-Tai Thu in Vietnam— Hanoi, and within this period she gave a workshop on early acupuncture in burn treatment in the Centre for burns Prof. Le The Trung.  2008 (10)–2014 (06) Experiences with burn patients within post-graduate studies at the Clinic of Burns and Reconstructive Surgery, University Hospital in Brno-Bohunice, Czech Republic. The first results of her empirical experiences were presented in various international congresses from the year 1988. Presentation of experiences at Congresses in the period 1988–2013 is given in Table 1.

Large Intestine Channel point—LI 11 (called Quchi)

LI 11 is thought to be an important acupuncture point in treatment of fever, and also LU 7 and BL 40 are used in cases of skin diseases. According to the Traditional Chinese Medicine, it belongs to so called Yang morass. The “Yang morass” affects external pathogenic energy and eliminates it by clearing an excess of yang energy in the form of heat. By applying a needle into this point, we address high temperature in the area of burn. Localisation: flexion of elbow—90 , extensor carpi radialis lonngus, brachialis ligament, in the superficial layer there are

Methodology

Our retrospective study is formed by our 33 years of empirical experience with 1008 patients (since 1983). The injury in each patient was documented by taking pictures at almost every dressing change. All available burned patients were monitored for 2–4 months, according to their clinical state. In the first few years, acupuncture was delivered twice a day. During the

3

Fig. 1 – Demonstration–localization of the Lung Point 7.

Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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Fig. 2 – Man 31 years, burnt by boiler wax, burns IIb dg, 1% TBSA, dominant right hand, acupuncture applied up to 24h, completely healed in 4 weeks without any signs of BT.

branchletsin v. cephalica, in a deeper layer—a. radialisreccurens and n. radialis [11,12] (see Fig. 3).

3.3.

Large intestine point—LI 4 (Hegu)

This is a complementary point to the points LU 7 and LI 11. LI 4 is a homeostatic and immunostimulatory point, which is primarily an analgesic [13–17] and immunostimulatory acupuncture point. See Fig. 4.

3.4. Application of ACU within first aid is suitable at all levels of BT. Significance of an ACU point a) Lung point 7 on the radial side, at the distal third of both forearms. Application of two needles is enough (one on each side). As for locality, it is an easily accessible area and thus very fast and easily applicable first aid. Therefore, in a short period of time it is possible to implement acupuncture with potential effects on burn reaction development. b) Applying needles into the ACU point of LI 11 has rationale in cases when the point of LU7is hard or impossible to access. What is more, the needle in LU7 is applied not so deep and thus there is a danger of its falling out during patient’s transportation. Compared to this, needle application into LI 11 on both sides is very easy, its location is clear and the needle is applied deeper, and thus there is not the danger of its released. Another effect of this point is also elimination of high temperature in the local area of BT. c) In case of deep degree and large extent of burns, over 10% of TBSA, we apply needles not only into LU 7 on both sides, but also LI 11 on both sides. And in case of deep pain, we apply a needle into LI 4 on both hands, for a purpose of analgesia and immunostimulatory effect.

In case of application into LU 7, we use needles of 0.2mm width and of 15mm length. In case of LI 11 (possibly LI 4), we apply needles of 0.2–0.3mm width and of 30–40mm length. In case of field intervention, we apply needles used for intravenous or intramuscular application. What really matters is not the material, width or length of the needle. (From the point of view of the Traditional Chinese Medicine, it is ideal if the needle applied reaches the “qi”, of course.) But what really matters is: as early application as possible, the sooner from the beginning of injury the better, often even before dressing. It is always necessary for the patient to get a follow-up surgical treatment and to be monitored with their clinical state. The acupuncture points we suggest are effectively usable and suitable for all areas and grades of burn injury. Nevertheless, according to our empirical experiences, they work the best and the fastest for the upper part of the body (area of face, neck, chest and upper limbs). Acupuncture within first aid can be also applied to those burn patients to whom subsequent skin grafting is indicated because of the depth and intensity of their burns. 1. Reflective—comes within a few seconds after the application of acupuncture needles. 2. Vegetative—comes within a few minutes. 3. Neurohumoral—comes within a few minutes. Indications for Acupuncture: 1. Severe burn. 2. Functional disorders. 3. Pain (caution: acute abdomen). Contraindications—absolute: 1. Unconsciousness following injury.

Fig. 3 – Man, 34 years, burnt by flame, Ia–IIb degrees, 12% TBSA, burned on the face, neck, both forearms and hands. Acupuncture applied in 18h after the injury, healed in 4 weeks without any sign of scar after 6 weeks. Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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Fig. 4 – Anatomic localization of acupuncture points described above.

Contraindications—relative: 1. Pregnancy 2. Severe forms of diabetes mellitus. 3. Patients significantly affected by analgesics, sedatives, hypnotics. 4. Electric shock (risk of cardiac arrhythmias). 5. Anticoagulation therapy, hemophilia. 6. Patients with serious infections (HIV, hepatitis C, . . . ). 7. Serious psychological distress. 8. After transplantation of inner organs. 9. Serious heart disease and post-operative states.

4.

Set of patients

From 1983 to 2015 a total set of 1008 patients with burns were treated with acupuncture (adults and children). Gender and age is given in Table 2. Burn mechanism (see Graph 1), area, burn depth and extent related to the total number of the patients treated with acupuncture is presented in Table 3.

4 weeks. 98,9% were healed with no signs of BT, and without any use of rehabilitation up to 6 weeks. Summary of results of the acupuncture treatment on BT patients (regarding the time of the 1st ACU application after the BT injury)—see Table 4. The importance of the time interval (between injury and the first acupuncture application) for the final result of treatment of BT is presented it the Graph 2. The development of signs of burns (reddening, pigmentation, scar) on the skin in the dependency on the time interval between injury and the first acupuncture application are following: All patients (921) with acupuncture application within 24h have decreased sign of burns. Patients (54) with acupuncture use within 48h: 5.6% i.e. 3 patients after 4 weeks—the reddening is persisted, but without any signs of the pigmentation or hypertrophic scars. 94.4% i.e. 51 patients are without any sign of the scar.

Table 2 – The structure of patients with BT by gender and age. Adults

Patients

5.

Results

5.1.

Summary of results of acupuncture in burned patients

Patients with minor burns (Ia–IIb) with the extent up to 10% TBSA were healed without hypertrophic scar formation up to

Children

Gender

Men

Women

Boys

Girls

Age (interval) Age (average) Number Percentage

18–72 33 117 11.6

18–81 36 243 24.1

0–17 5.4 351 34.8

0–17 4.5 297 29.5

Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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Graph 1 – Burn manner mechanism (%).

Patients (24) with acupuncture within 72–144h from the injury: 16.7% i.e. 4 patients—the reddening was persistent, 83,3% i.e. 20 patients are without any sign of the scar. Patients (9) with acupuncture within 168–240h: 22.2% i.e. 2 patients—the reddening is persisting after 6 weeks, 11.1% i.e. 1 patient has the pigmentation, 11.1% i.e. 1 patient has the soft hypertrophic scar. 55.6% i.e. 5 patients have no sign of the scar. Final results: 98.9% patients suffered from burns and having been treated by the acupuncture were after 4–8 weeks without any sign of scar. Based on our experience with burn treatment we aimed at the timely treatment, the first acupuncture treatment should have been applied not later than 24h from injury. That is why the number of patients treated by acupuncture after this time limit is low.

5.2.

The comparative study

In order to define effects of acupuncture in acute burns, two sets of patients treated in the period X/2008–VI/2014 were chosen and then compared:

 Group A counted 198 patients to whom acupuncture was applied  Group B counted 63 patients without acupuncture. Both groups counted patients aged 0.5–81, the burn manner mechanism was either scalding, flame or contact, the extent of burn was 0.5–10% TBSA, the depth of burn was IIa– IIb, in all the areas mentioned above, which means face and neck, chest, abdomen, back, upper limbs or lower limbs. According to our empirical experience and monitoring, wound healing of BT with acupuncture application goes through all stages typical of wound healing. The time of healing is given by the time within which acupuncture is applied. Results of the comparison of both sets—see Table 5. For demonstrating the effect of acupuncture treatment (regardless the time of application) the x2 test was used. The final p-value (7.410 43) showed significantly that acupuncture effects are not coincidental. On the contrary, acupuncture use positively affects the treatment outcome (the BT signs on

Table 3 – Burn mechanism, area, burn depth and extent. Burn manner mechanism Flame Scalding Chemical Contact Electricity Explosives

%

Area

%

Burn depth

%

11.4 84.6 1.1 2.7 0.1 0.1

Face +neck Chest Abdomen Back Upper limb Lower limb

8.1 36.9 5.5 3.6 30.6 15.3

I–IIa (surface) IIa–IIb (surface–deep) IIb (deep)

30.6 62.2 7.2

Extent-TBSA (%) 0.5%– 5% 6%–10% 11%–15% 16%–20%

% 62.5 35.6 1.8 0.1

Table 4 – Results—patients treated with acupuncture. Results with ACU

Total number

Within 0,5 h Within 1,0 h Within 2,0 h Within 12 h Within 24 h Within 48 h After 72–144 h After 168–240 h Total

81 180 378 108 174 54 24 9 1008

No signs of prior burns 81 180 378 108 174 51 20 5 997

100.0% 100.0% 100.0% 100.0% 100.0% 94.4% 83.3% 55.6% 98.9%

Reddening (number) 0 0 0 0 0 3 4 2 9

0.0% 0.0% 0.0% 0.0% 0.0% 5.6% 16.7% 22.2% 0.9%

Pigmentation (number) 0 0 0 0 0 0 0 1 1

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 11.1% 0.1%

Hypertrophic scars (number) 0 0 0 0 0 0 0 1 1

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 11.1% 0.1%

Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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Graph 2 – Signs on the skin—in dependence on the first ACU application.

Table 5 – Results—patients treated with ACU (Group A) and without ACU (Group B). Group A: 0,5–10% TBSA (IIa–IIb) Number of patients ACU within 0,5 h ACU within 2,0 h ACU within 12 h ACU within 24 h ACU within 48 h ACU after 168–240 h. ACU total Group B: no ACU

6 63 81 36 9 198 63

No signs of prior burns (number) 6 63 81 36 8 0 194 9

3.0% 31.8% 40.9% 18.2% 4.0% 0.0% 98.0% 14.3%

the skin). The Pearson's contingency coefficient (0.653) and the Cramer's contingency coefficient (0.862), as well, are showing that this dependency is relatively strong. Fig. 5 demonstrate two patients from the comparative study.

5.3.

Our empirical experience

From our empirical experience we noticed: 1. Timely application of the first acupuncture treatment is beneficial—the earlier the application (up to 30–120min) it appears that the results is best acupuncture may trigger the recursion of all initiated pathological processes. 2. With some potential effect of the systemic reaction (burn shock is reduced), also thanks to the effects of acupuncture, infection does seem to occur and immunodeficiency induced by cytokines does not occur [18]. (For non-severe cases: complete healing ad integrum.) 3. We note that with acupuncture use, analgesics and sedatives are used less often. 4. According to our empirical experience with BT gr. IIb: in case the acupuncture was applied early after the injury, the injury did not deepen into gr. III and the process of healing was equal to burn gr. IIa.

Reddening (number) 0 0 0 0 1 1 2 26

0.0% 0.0% 0.0% 0.0% 0.5% 0.5% 1.0% 41.3%

Pigmentation (number) 0 0 0 0 0 1 1 1

0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.5% 1.59%

Hypertrophic scars (number) 0 0 0 0 0 1 1 27

0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.5% 42.9%

5. This method of treatment saves important costs. 6. Lower psychosomatic or psycho-social impacts.

6.

Case

Acupuncture applied in 30min after injury. Demonstration of patient with timely application of acupuncture is given in Fig. 6.

7.

Discussion

The results of our empirical study can be supported by the results of the study by Lee et al. who claim that acupuncture accelerates wound healing using activation of angiogenic growth factors [19]. In our study, the patient in order not to be traumatized even more, histological examination was not carried out, namely because of the fact that almost 2/3 from the whole number of patients were children. Our practical results are also consistent with the results of the study by Lee et al., whose study demonstrates that ACU accelerates the skin regeneration process and participates in effective wound healing [20].

Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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and influence on the skin healing in the affected area. BackSHU points, according to Traditional Chinese Medicine (TCM), are found in the first line of a Bladder Channel, and apart from other indications they are generally used for ACU to regenerate and harmonise the functional state of organs. E.g. Bladder Channel point (BL-13) is a back transmission point for the lungs affecting skin healing. According to evolutionary embryology: lungs and skin are part of the ectoderm. Burns are primarily external along the acupuncture point’s channels of individual organs. Therefore, acupuncture application in the back transmission points, on the first line of the Bladder Channel, is justified. Acupuncture applied on the second line of the Bladder Channel has an important influence on patient’s mental state. Every acupuncture application into active points (until the feeling of Chi) always intervenes in the central nervous system. Acupuncture points choice in burns we indicated according to: Fig. 5 – Man with BT treated with ACU and woman with BT treated without ACU. Description of Fig. 5: BT treated with ACU: Man, 34 years, burnt by flame, face, both hands, forearms, neck gr. IIb, face gr. IIa. 12% TBSA. ACU applied within 18 h. Healed in 4 weeks. No signs of burns after 6 weeks. BT treated without ACU: Woman, 26 years, burnt by flame, left hand and forearm, both arms (front side), chest front upper part gr. IIb-(III). 14% TBSA. Autotransplantation, healed in 4 weeks. 6 weeks after the BT with dark reddening.

Acupuncture proved to be a benefit to burn care also in a study by Ayse Ebru Abali et al. [21]. All the studies mentioned above were carried out on mice and rats. Obviously, the location of ACU points on mice and rats are different from the location of ACU points on a human body. Using ASHI points and Back-SHU points in case of rats makes sense. ASHI points are points with high palpation tenderness and at high percentage; they correspond with active ACU points. ASHI points applications treat acute painful conditions in the field (skin in case of BT). Likewise, needles were applied interdigitally. Extra points BAXI have a strong analgesic effect

a) our empirical experiences, b) the theoretical point of view of the Traditional Chinese Medicine, c) the point of view of embryology (skin, CNS, lungs, large intestine—ectoderm) and (soft tissues, vessels, kidney— mesoderm). Acupuncture suggested by us is the most suitable and usable and the points introduced in this study are very specific for burns. From the TCM point of view LU 7, LI 4 a LI 11 and ST 36 belong together (known as “Ma Danyangxue points”), what is 12 the most important points in acupuncture application. Very easy application of two needles is just a bonus. Nevertheless, we do agree with the conclusions of the third mentioned study on rats, which prove lowering pain and posttraumatic stress, improving microcirculation better wound healing with using acupuncture in complex therapy for burns. There have been so many studies carried out to clarify effects of acupuncture on patients, and due to fast laboratory development and RTG methods many more are coming. From those having been published so far I would like to point out the theory of influence of acupuncture on the central nervous system (Flandin, 1933, Fuye, 1950, Daniaud 1964, Stiefvater,   , 1959 a Mann F., 1970). As a result of acupuncture 1956, CžuLja n application, feedback systems in the central nervous system get

Fig. 6 – Demonstration of patient with timely application of ACU, boy—1.5 years, scalded on the left lower limb with b oiling water, IIa–IIb, 5% TBSA. ACU applied in 30min after trauma. Hospitalized for 5 days, local dressing, without any painkillers and sedatives, healed in 4 weeks with no signs of burns. Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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activated on all levels, from the spinal ones to the brainstem, cerebellar, hypothalamic, thalamic, extrapyramidal and corticalones. Another theory explaining acupuncture effects is the bioplasmatic theory (Sedlak 1967, Injušin 1969). Configuration and frequency and energy spectrum of bioplasma are conditioned by physical and mental state of the organism and even by external environmental factors. They are a reflection of feedback relations with immunological, biochemical and electrical processes in the organism and thus even a source of information on an actual state of the organism. Another very important theory is the endorphin theory (Pomeranz, 1976). It is the latest physiological interpretation of neurohumoral effects of acupuncture, namely in the field of inner analgesic system activation. Pomeranz explains hypalgesic effects of acupuncture. Needle application into an active point irritates deeply embedded sensitive nerve endings. By afferent impulses, there are substances released from diencephalon and pituitary gland which chemically resemble morphine [22,23]. Acupuncture points can be understood as a subsystem, which has the nature of the adaptive system, where they are incorporated memory and feedback. Using acupuncture in a complex therapy for burns has a huge potential. And still, despite all the existing studies, there is still a long way to go for a scientific research acupuncture for burns. We would appreciate our 30 years of mainly empirical studies to inspire and encourage others to further scientific studies on this topic. We are aware of our limited possibilities in the field of laboratory, radiological and other examination at the onset of our study (1983) compared to those which could be performed in recent years. Moreover, we applied acupuncture frequently in terrain (car crashes, fires), etc. Our work should inspire others to perform scientific evidence using the latest technology.

8.

Inspiration for follow-up research studies

Based on our follow-up with a large number of patients, from the medical point of view, application of acupuncture as the first aid treatment for acute burns and its subsequent therapy leads to: 1. 2. 3. 4. 5. 6.

diminished development of post-traumatic stress reduced occurrence and reduction of a burn shock timely-analgesia (diminished pain intensity) [19,20] immunostimulatory effect shorter subsequent healing stream improvement (elimination of dynamic insufficiency of venous and lymphatic system and improves microcirculation) 7. Reduction of hypertrophic scar development 8. bio-medical-psycho-social effect

9.

Conclusion

For demonstrating the effect of acupuncture treatment (regardless the time of application) the x2 test was used. The

9

final p-value (7,410 43) demonstrated positive effect on the outcomes measured by the authors. Using of acupuncture seems to have positive effects on the results of burn. The Pearson's coefficient (0,653) and the Cramer's contingency coefficient (0,862), as well, are showing that this is potentially effective in some, but not all. What we find very important, it is the “time factor” of an early acupuncture application from the beginning of all degrees, localisations and extent of burn. Dealing with I—IIa burns and of lower extent, pain relief comes within 15min from acupuncture application. (It depends on clinical state of the patients, their personal anamnesis and mental state—for children a mental state of their parents or other close relatives is also important). By adding acupuncture to basic therapy, we sought to achieve faster healing and better results. Its application significantly reduces the duration of the treatment and in many cases contributes to overall recovery. With respect to the health system of the country, with a few modifications it can be applied in every country (especially low-income countries) because of the easiness, low-cost and high efficiency of the therapy.

Remark All acupuncture applications, and presentations on Congresses, as well, were financed by the authors. REFERENCES

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Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025

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Please cite this article in press as: A. Loskotova, J. Loskotova, The use of acupuncture in first aid of burns—Clinical report, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.04.025