The definition of pain by the International Association for the Study of Pain (IASP), as revised in 2020, states that it is "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage," suggesting that pain or similar unpleasant sensory experiences may arise even if the cause of such sensations cannot be clearly identified. Pain, on the other hand, has been classified chronologically as acute, subacute or chronic pain such as those directly caused by cancer and non-cancer diseases and by the mechanisms involved. These are divided into nociceptive, neuropathic, and nociplastic pain, the last one of which is a recent addition to the classification. WHO created an independent category dedicated to chronic pain in its latest version of the International Classification of Diseases (ICD-11) defining it as pain that continues or reiterates over a period of three months or longer. As prolonged pain causes both physical and mental damage resulting in degradation of quality of life, it has been stressed that such pain must be approached from both the physical and mental perspectives. For this reason, multi-faceted evaluation is useful in treating chronic pain. In Japan, there are a number of guidelines for the treatment of chronic pain that have been published by different scientific societies as well as by a study group of the MHLW's Chronic Pain Policy Project. These serve as guides for providing evidence-based treatments to affected patients. Chronic pain remains a major challenge since they not only lower the quality of life of affected patients but also cause considerable damage to Japanese society as a whole.

In 2021, the Clinical Practice Guidelines (CPG) for the Management of Chronic Pain was published, and included a section on acupuncture treatment for integrated medicine and chronic headaches. The purpose of this symposium was to discuss the current understanding of the evidence for acupuncture treatment for chronic pain and the expansion of guidelines. As a working group member of the CPG, Dr. Namba Toshimune introduced the process of including acupuncture in the CPG and discussed not only each field of specialty but also the outlook for developing unique CPG for acupuncture. Dr. Kubo presented the status of basic research on acupuncture treatment for pain in recent years, introduced about the effects of acupuncture stimulation on adenosine, orexin, and oxytocin in mice and rats, as well as the specific reactions of acupuncture points to acupuncture stimulation, and emphasized the importance of basic research to establish the effectiveness of acupuncture for chronic pain. Dr. Udo Yukihiro provided a detailed review of clinical research on acupuncture treatment for chronic pain, reporting on the current status of acupuncture treatment methods, stimulation sites, and stimulation methods. Minakawa described the current situation where systematic education for acupuncturists has not been sufficiently implemented and discussed their own acupuncture treatments for patients with chronic pain. We hope that the contents of this symposium will be helpful in clinical practice, research, and education.

Recently, non-specific low back pain without clear diagnosis has been changed of the diagnosis and treatment. I showed the data of Yamaguchi Low Back Pain study in the article. It has been shown that we can select appropriate treatment based on the clear diagnosis. I described the current status and issues of low back pain treatment and outlined the classification and differentiation of non-specific low back pain.

Low back pain is ranked number one burden of disease and a symptom that afflicts people worldwide. Although many cases of low back pain are considered non-specific, there is no unified agreement on the classification method. Furthermore, the biopsychosocial model is used as an interpretation model for understanding low back pain. Therefore, the effectiveness of acupuncture treatment for low back pain must be verified while clearly identifying the perspective from which low back pain is viewed and considering psychological factors. In this symposium, lectures were given by Akasaka, Inoue, Kikuchi, and Kondo. Akasaka explained specific and non-specific low back pain from the perspective of a physical therapist. Specifically, he presented the classification of low back pain based on structural anatomy of the musculoskeletal system such as facet joint, myofascial, and intervertebral discogenic pain as non-specific low back pain, and explained about the effectiveness of physical therapy. Inoue presented the results of randomized controlled trials of acupuncture treatment in patients with low back and lower limb pain that he had conducted. He also discussed the importance of needling at specific points such as the erector spinae group of muscles after carefully palpating these points. Furthermore, Inoue outlined the effects of needling along nerve pathways in patients with lower limb symptoms. Kikuchi reported the results of a retrospective observational study on the effectiveness of acupuncture in treatment of low back pain by classifying patients according to their movement reproducibility. He well stated that patients with movement reproducibility showed more improvement in low back pain-related quality of life. Kondo elaborated on how psychosocial factors in patients with low back pain could affect the effectiveness of acupuncture treatment. He also reported that the less catastrophic thinking about pain was, the greater effectiveness of acupuncture treatment was. In addition, Kondo also indicated that the lower risk on the Subgrouping for Targeted Treatment Back Screening Tool was, the more easily reduced pain was.We hope that the content of this symposium would serve as a valuable resource for clinical, research, and educational activities starting tomorrow.

Tongue diagnosis in Kampo medicine is considered to be a diagnostic method that can provide information about a patient's constitution and medical condition. We have identified the following problems in tongue diagnosis: the influence of external environmental factors such as light source, room temperature, and dryness, as well as subjective factors that depend on the knowledge and experience of medical doctors. To overcome these problems and to support Kampo diagnosis, we developed the Tongue Image Analyzing System (TIAS). Regarding color, objective numerical values L*a*b* were measured and standardization and objectification were promoted. We introduce some of the progress that has been made over the past 15 years since the development of TIAS.

[Introduction] This study compared the effects of joint immobilization and concurrent electroacupuncture stimulation on fracture line appearance, which is indicative of differences in cortical bone structure, in the femurs of young adult rats. [Materials and Methods] Forty-two 7-week-old Wistar rats were divided into three groups: a hindlimb immobilized group (IM), a hindlimb immobilized group with concurrent electroacupuncture stimulation (IMEA), and an untreated control group (CO). IM and IMEA were immobilized for two weeks with a jacket-type immobilization device that immobilized the hip joint in extension and restricted hip joint adduction and abduction. Acupuncture needles were inserted into the femoral region during the immobilization period in the IMEA group, and continuous alternating current was used for stimulation. A low-frequency stimulator was used to generate electrical current (250 μsec, 50 Hz, 0.24 mA, 500 Ω load resistance), and stimulation was performed daily for two weeks at 10 min/day. The extracted femur was fractured from the anterior part of the diaphysis or metaphyseal end by three-point-bending under constant conditions with 10 mm between the fulcrum and a crosshead speed of 10 mm/min. [Results] IM showed significantly lower Stiffness, Deformation, and Strength values than CO. Bone morphometry parameters also showed lower values for IM. A cement line was observed between lamellar and non-lamellar bone in CO and IMEA, but was indistinct in IM. In CO and IMEA, minute bone fragments were formed in the deep diaphysis region sandwiched between the inner and outer circumferential lamellae, but no such fragments were found in IM. IMEA had less resorption than IM, and lamellar bone with a structure similar to CO was maintained. Moreover, cracks observed in CO and IMEA ran longitudinally in the vicinity of the cement line and rest line, but no such cracks were found in IM. [Discussion and Conclusion] These findings suggest that electroacupuncture mitigates bone weakening in immobilized rat femurs, and this affects the appearance of the fracture line.

[Objective] Instructional videos on five of the 17 acupuncture techniques (hereinafter referred to as "techniques") were created, and a questionnaire was distributed among acupuncture and moxibustion college teachers to evaluate the utility of the educational materials.[Methods] The sparrow pecking technique (straight and oblique stabbing), gyration, rotation and twisting techniques, as well as vibration stimulation, were performed and the hand was simultaneously imaged with a diagnostic ultrasound device and filmed with a video camera. The questionnaire and a QR code for viewing the videos were sent to training schools by mail. The questionnaire included open-ended and multiple-choice questions regarding the teaching status of the techniques, changes in perception of the techniques after viewing the video, and the value of using the video as a teaching tool.[Results] Responses were received from nine schools (14 teachers). Each technique was taught only once at five of the schools. For all the techniques featured in the videos, not all the respondents answered that the subcutaneous and muscular tissue movements were consistent with their perceptions. Meanwhile, only 35.7% of the respondents had perceptions that were congruent with the video on vibratory stimulation. According to 78.6% of the respondents, instructional videos on these techniques were deemed to be necessary.[Discussion and Conclusion] The minimal repetition on the education of acupuncture and moxibustion techniques implies a lack of emphasis regarding these skills. The dissonance between the subcutaneous and muscular tissue movements that were familiar to the instructors and those discussed in the video highlighted the significant differences in skills training among the various training institutions. Based on this feedback, instructional videos can be considered essential in accurately teaching acupuncture and moxibustion techniques by providing visual aids.

[Introduction] We report a case of patient with migraine that improved after acupuncture and additional treatment for comorbidities of dry eye.[Case presentation] Subject was a 59-year-old female patient who was 156 cm tall and 49 kg in weight (BMI: 20.1). Her blood pressure was 122/69 mmHg, and her pulse was 70 beats per minute. She had suffered from headaches for about ten years and had been previously diagnosed with migraine. Due to the worsening of the headaches, she began acupuncture treatments. Since the onset of the headaches, she was also diagnosed with dry eye.[Treatment] At the initial visit, the subject's Headache Impact Test (HIT-6) score was 65. Manual acupuncture in her back and neck area and C2 peripheral nerve field stimulation with electroacupuncture were performed for migraine. At week four of treatment, the HIT-6 score was 60 and the headaches appeared 14 times a month, which improved to 48 and 7, respectively, at week 12. However, her headaches worsened after treatment interruption. At week 40, the HIT-6 score and headache frequency worsened and increased to 60 and 13, respectively. Acupuncture treatment for migraine was resumed, and treatment for comorbidities of dry eye, that included manual acupuncture around the orbits and self-care, was also performed. Subsequently, her headaches ameliorated significantly. At week 56, the HIT-6 score was 48 and the headaches appeared only five times a month. Migraine relief persisted and the symptoms of dry eye also improved.[Discussion and Conclusion] The additional dry eye treatment had a positive effect in improving the symptoms of migraine. It has been speculated that the pathogenesis of both diseases is related to central sensitization of the optical and trigeminal nervous systems. If so, the improvement of dry eye symptoms may have had an effect on migraine relief as well.

This paper gives an overview of acupuncture and moxibustion usage in British Columbia (BC), Canada. In Canada, acupuncture and moxibustion are handled and regulated differently in each province; in BC, it is managed and supervised through the Health Regulatory Colleges under the Health Profession Act. In the field of oriental medicine and acupuncture, the College of Traditional Chinese Medicine Practitioners and Acupuncturists of BC (CTCMA) has been established to manage and supervise doctors of Traditional Chinese Medicine and oriental medicine practitioners, with specific duties that include public protection and the registration, examination, and evaluation of the quality of services of practitioners. The CTCMA is characterized by a centralization of operations that in Japan are carried out by several government agencies.Next, I will describe my impressions of acupuncture and moxibustion from those who I met in Vancouver, where I live, at the school I attended, at the clinic that I practice, etc. Although there are many Chinese immigrants, I did not feel that acupuncture and moxibustion are particularly widespread, but I got the impression that they are well recognized as a common treatment. Finally, I will briefly touch on the examinations and visa requirements for acupuncture and moxibustion practitioners who are considering immigration to Canada. Five years of education is required to take the examination, and although there are cases in which the content of education received in Japan can be transferred, it is better to receive acupuncture and moxibustion education in Canada. As health professionals, acupuncture and moxibustion practitioners can also earn points toward permanent residency. Canada's regulatory system for medical care is new in its institutional design and appears to be consistent throughout the health care system, as it comprehensively regulates all health professionals. The impression I gained is that acupuncture and moxibustion are recognized as effective treatments. Canada, a country of immigrants, has a national character that likes "new things" and accepts change flexibly, and there is much potential for acupuncture and moxibustion treatments to increase in the field of health care in the future.