Hypnosis and acupuncture--no general anesthesia--for major knee surgery.

The Center for Complementary and Integrative Medicine (CIM) at Henry Ford Health System (HFHS) officially opened in June of 2002. The CIM Center is one of the first of its kind, offering complementary modalities in a Center that is integrated with a major healthcare delivery system, HFHS. Of the many therapies offered at this Center, hypnosis is a featured mind-body therapy. One of the advantages of the integration of complementary and conventional services within HFHS is having the ability to test novel alternative approaches to commonly used conventional procedures.

Dr. Michael Seidman, the CIM Center's medical director, was to undergo anterior cruciate ligament (ACL) reconstruction surgery using an autologus, patellar tendon graft (i.e., a graft was taken from his kneecap on the knee with the damaged ACL). In lay terms, the procedure involves isolating the middle third of the patellar tendon along with a plug of bone on each end of the tendon. The bone part of the graft must be harvested by cutting and chiseling. The harvested graft is then positioned in place of the damaged ACL, once the remnants of the ACL are removed. The thigh and shin bones must be drilled so that the bone plugs from the graft can be anchored with titanium screws. This procedure is considered quite painful due to its invasiveness and extensive perturbation of bone.

Rather than receiving general or spinal anesthesia, Dr. Seidman elected to receive hypnosis and acupuncture as the primary means of anesthesia. The orthopaedic team headed by Dr. Dave Collon, with Dr. Kyle Anderson as the lead surgeon, agreed with this plan provided that general anesthesia would be used as backup in the event that the patient experienced any undue discomfort or the operation was hindered in any way. Dr. Robert Levine, the research director of the CIM Center, provided hypnosis for anesthesia. He trained under Dr. Anne Spencer at Infinity Institute, finishing his IMDHA certification in 2002. Dr. Ramon Nunez, one of the CIM Center's acupuncturists and master of traditional Chinese medicine, provided electro-acupuncture for anesthesia. While it is likely that either modality would have been sufficient to provide anesthesia for the patient, both were employed to maximize the opportunity to complete the surgery without delivering chemical general anesthesia. The focus of this article is on the hypnotherapy training provided to the patient.

Dr. Seidman met with Dr. Levine 3 days prior to surgery for a single 1.5 hour training session. Dr. Levine then recorded a custom compact disc (approximately 15 min) for Dr. Seidman to use to reinforce his mastery of self-hypnosis for anesthesia. Dr. Seidman listened to the CD twice each day for 2 days, once in the morning and once in the evening, and the last time the morning of surgery (total of five listening experiences). Total hypnosis training time was less than 3 hours.

Prior to inducing hypnosis at the initial hypnotherapy session, the objectives for the session were discussed with the patient as follows: 1) induce hypnosis and establish somnambulism (physical relaxation followed by mental relaxation to achieve amnesia); 2) patient experiences being relaxed, peaceful, confident, and comfortable, regardless of circumstances; patient also releases feelings of being concerned, fearful, anxious, etc.; 3) patient creates a "patient-operated" mental anesthesia on-off switch that when switched on allows sensation intensity to be quantified on a 0-10 comfort scale (0 most comfortable), but patient does not experience pain; 4) patient experiences no voluntary muscle reaction to a potentially painful stimulus (aggressive skin pinch) when mental anesthesia switch is on; 5) suggestions are made for the subconscious mind to support the restriction of blood flow to blood vessels perturbed by the surgery and allow normal blood flow to intact vessels; 6) the steps in the successful surgery are described; 7) suggestions are made for creating partnership between patient, surgical, and anesthesia teams; 8) suggestions are made to listen to the preoperative custom CD twice daily, and following surgery, the postoperative custom CD twice daily; 9) patient emerges from hypnosis.

In the initial treatment, the amnesia associated with somnambulism was established by: 1) progressive physical relaxation and deepening and 2) mental relaxation through counting aloud descending whole numbers from 100 until the numbers have disappeared from the mind. Patient was instructed to count one number at a time, and in between each number say the words "deeper ... relaxed" and take a deep relaxing breath. Under hypnosis, the anesthesia switch was tested in the off and on position. In the on position, the patient had no voluntary muscle reaction to an aggressive skin pinch of the inner thigh. Patient was asked to report the level of sensation intensity on a comfort scale from 0 to 10 with 10 being the least comfortable (typical scores with the switch on were 4-6). When the switch was turned off, patient instantly reacted with voluntary muscle contraction and felt a significant pain stimulus to a less aggressive skin pinch in another inner thigh location (comfort scale scores were 9-10). The switch was tested several times in the off and on position. The patient was clear that he had the capacity to remain still with no voluntary muscle reaction to any stimuli during the surgery. This ability was a key to the success of the surgery. After accomplishing all the objectives listed above, the patient emerged.

On the day of and just before surgery, Dr. Levine had the patient self-induce hypnosis and reinforce the states of being relaxed, peaceful, confident, and comfortable. During this time, Dr. Nunez inserted the acupuncture needles and stimulating electrodes. A tourniquet was placed around the upper thigh of the leg, but was not inflated. The tourniquet is normally inflated to prevent excessive blood flow from blood vessels perturbed during surgery. However, it was felt that an inflated tourniquet might interfere with the acupuncture, which is why the hypnotic suggestion was made to restrict blood flow to perturbed blood vessels (see #5 above). During surgery, the patient received local anesthetic at the incision site and periodically received a light sedative administered by the anesthesiologist, Dr. Judith Rapp. The patient was awake throughout the surgery, which proceeded uneventfully. The patient communicated periodically the level of sensations to the surgical team on the scale of 0-10. The sensation intensity remained between 0-3 for the majority of the surgery. There were five occasions during the 2 hour procedure where the intensity level reached between 7 and 9 for about 15 seconds on each occasion. At each instance, the patient was coached to lower the intensity level, which was accomplished each time. Most importantly, there was no voluntary muscle reaction during these instances. There was also minimal bleeding even though the tourniquet was not used. Further, no general or spinal anesthesia was needed during the surgery. Following surgery, the patient was moved to the recovery area. The patient listened to the recovery CD twice each day and was back to work in 8 days, which is considered quite rapid for this surgery. Recovery has been uneventful and rapid.

This case report demonstrates that hypnosis combined with acupuncture is sufficient for managing a patient through ACL reconstruction surgery without general or spinal chemical anesthesia. Both hypnosis and acupuncture alone are effective in producing anesthesia during surgery, and in this case, both were used to optimize for a successful outcome. Benefits of using this procedure are that the patient is not exposed to the potential complications of anesthesia. There was also no need for using a tourniquet to control bleeding. It is appropriate to conduct further tests of this promising procedure, which has a higher degree of safety for patients than surgery employing chemical general anesthesia.

Robert A. Levine, Ph.D., IMDHA member, is Director of Complementary and Integrative Medicine Research at Henry Ford Health System. He will present on this subject at the IMDHA Annual Conferencein October, 2003. email: [e-mail]