Physiotherapy & Sports Injury Clinic

Case Study: Acupuncture

Aim: To integrate the theory of acupuncture relative to musculoskeletal conditions

Objective: To determine the effect of acupuncture on the treatment of a patient with lateral elbow pain with respect to pain reduction, improvement in function and grip strength.

Mrs X is a forty year lady who presented for physiotherapy with a three month history of right elbow pain. Mrs. X is a full time housewife. She started back playing badminton 5 months ago having not played for six years. Her reported symptoms were pain on the lateral aspect of her elbow. She also reported a feeling of weakness in the lower arm. Her pain was said to be aggravated by playing badminton, carrying heavy bags and working at her computer. She scored her pain to be 6 on the V.A.S. In the past week she has awoke with the discomfort. She is right handed. She was prescribed anti inflammatories by her GP which provided short term relief. She has no other relevant past medical history. She was taking no other medication.

Objectively she has full range of motion in all directions of her cervical spine. She had no pins and needles or numbness. Examination of the shoulder joint revealed no abnormalities. Pain was reproduced by resisted extension of her wrist and passive wrist flexion. She was found to be tender on palpation along the lateral elbow joint line. Her grip strength was reduced compared to the left.

Following explanation the patient consented to having acupuncture.

Several points around the affected elbow joint were considered as possible treatment points. These included LI 10,LI 11, LI 12,LI 13, LU 5,LI 4, SI 8,P3.

The actual points selected for treatment were LI 10,LI 11,LI 12, LU5, SI 8 and LI 4.

The point selection was based on the TCM principles as follows:

-Points along the affected meridian over the symptomatic area.(LI10,LI 11, LI 12,LI 4)

-Points around and over the symptomatic area. (LI10, LI 11,LI12,LU5 and SI8)

-Drainage points.(LI4)

-He-sea point.LI11

-Additional Effect point. (LI4)

-The sandwich effect was incorporated using points LI 11 and SI8. LI 11 was selected as it is the HE-SEA point of that meridian. The He-Sea point represents an area where the Qi is most abundant. It is one of the principal points when treating proximal meridial dysfunction. LI 4 was selected as it is the source point of the meridian, where the original Qi is stored. In addition it is regarded as the Universal point for pain.

According to the TCM concept pathways called meridians lie along the body. These pathways carry Qi or “life energy” from the various organs of the body to the surface of the body and help to regulate yin and yang, the two opposing forces that are believed to keep the body in harmony (Eshkevari 2005). The yin and the yang can be thought of in |Western medicine terms as the sympathetic and parasympathetic nervous systems in that they are opposing, yet balancing effects on the human body and maintaining health. If this energy cannot pass or becomes interrupted the yin and yang become unbalanced and illness or pathology may occur. The acupuncture points are specific locations where the meridians come to the surface of the skin. The connections between them ensure that there is an even circulation of Qi and a balance between the yin and Yang. Energy constantly flows up and down these pathways. When pathways become obstructed deficient or unbalanced, pathology can occur. There are many factors in the environment as well as within the body that can cause this obstruction (Eshkevari 2005). The environmental factors that include dampness, cold, heat, and wind whereas internal factors include inactivity or over activity, poor diet, excessive alcohol intake, emotional issues, trauma and stress (Eshkevari 2005). All of these causative agents can drain the body of its reserves and predispose the patient to disease.

The condition in question was categorized as a chronic syndrome. The patient was positioned in a comfortable and fully supported position and a full explanation was given. The needles were inserted into selected points by guide tube technique and the needle advanced slowly to the required depth. The technique selected for treatment was the Reinforce/Supply method (RF) using the rotary technique. On insertion of the needles a smallish amplitude (1/4 turn of needles diameter) at a fast speed (3 oscillations per second) was used. This caused the production of the needle sensation i.e. Deqi feeling. This procedure was repeated every 2 – 4 minutes during the course of the treatment duration.

 If this had been a more acute condition the draining or sedate method of the rotary technique would have been used. This involves a larger amplitude turn at a slow speed and is repeated every 10 – 15 minutes. If the syndrome was very acute, recently swollen or hypersensitive the points could have been applied to the opposite arm. Similarly in the very acute situation the point selection may have been LI9, LI10 and LU5. These points are segmental and close to the injury but not directly into the damaged tissue. In addition to, or instead of, a point could be chosen that influences the peripheral nerve that supplies the damaged tissue, in this case the posterior interosseus nerve. Possible point might be TE5.Segmental sympathetic outflow would be stimulated by needling points on the bladder channel between levels T5-9 as these supply the upper limb (Bradnam, 2002).

The patients progress was monitored in between each session.

Following 4 to 6 sessions it is expected that some manner of response would be observed. Following the third session the patient reported a definite improvement in her pain level. She also reported that her arm did not feel as heavy. Objectively her pain on resisted extension and passive wrist flexion was not as sharp. Due to her positive response to treatment we extended the length of treatment from 20 to 30 minutes.

If there was no response after a number of sessions it would be indicated to cease treatment. If there was a poor or moderate response it maybe appropriate to either delay the next visit by 10 – 14 days, extend the umber of visits, concentrate on stimulating the local points or to add supplemental points e.g. He-Sea, Source. Because in this case the patient appeared to be responding well the same points were used.

Whilst the needles were in situ the patient reported various different sensations. During most treatment he reported of heaviness in her arm. On needling the LI4 point she found it to be initially sharp followed by a numbing effect. Often the patient found that area around the needles would seem itchy. Many different types of sensations have been described in response to acupuncture including the following: Soreness, numbness, distension, heaviness, itchiness, radiation, warmth, tenseness/puffiness, creepy crawly sensation, mild electric shock and tickling. She also reported a feeling of relaxation following physiotherapy.

These sensations were the result of DeQi, which happens as a result of stimulation of various sensory neurons predominantly the A delta fibres, followed by the C fibres and the group II fibres. Stimulation of such neurones results in the release of opiods, activation of descending inhibitory control and stimulation of the analgesic system.

The effect that acupuncture has on the body is two fold and includes anaesthesia and analgesia. Several possible theories accounting for the analgesic effect have been put forward and include the following:

The gate theory: This was one of the earliest theories put forward by Melzac and Wall. This theory explains that acupuncture works though the nervous system to alleviate pain. It suggests that the opening and closing of the gate s dependent on the relative activity of the large diameter A Beta and small diameter a Delta and C fibres. Activity in the large diameter fibres is said to close the gate whilst activity in the small diameter fibres tends to open the gate. These nerve fibres come together in the substantia gelatinosa of the spinal chord. The substantia gelatinosa is responsible or sending pain signals to the brain. Acupuncture is said to stimulate the pain inhibitory nerve fibres which lowers the pain input and therefore lowers the pain. Research by Garrison and Foreman 1994 supports this theory as their study shows that the distal horn neurones which can potentially transmit noxious information to supraspinal levels can have their cell activity decreased during TENS application.

Another proposed theory is that endogenous opiates play a roll in the effect. It has been long suspected that acupuncture causes the release of neuoendorphins and other chemical mediaters. Studies have shown that acupuncture stimulation causes release of endogenous analgesics in the brain and this effect can be counteracted by naxolone (an opioid antagonist). Eshkevari et al, 2005. Many studies have also demonstrated that the pain threshold is increased upon acupuncture stimulation leading to the conclusion that acupuncture analgesia is induced through highly specific nervous and chemical mechanisms. Abergalaer S in 1994 demonstrated a significant increase in plasma B endorphin concentrations after both manual and EA stimulation of chronic pain patients and correlated with a reduction in the VAS in the EA patients. Further support for the idea that acupuncture may cause the release of endogenous opiates comes from experiments that have found the transfer of cerebro spinal fluid from one animal under acupuncture analgesia resulted in analgesia of the recipient (Smith F 1992).

Evidence would suggest that the rostral ventral medulla plays a role in acupuncture, liu et al 1987 found that electroacupuncture could stimulate the off cells and inhibit the on cells in this area. The rostral ventral medulla and the periaqueductal grey are functionally linked. Research by He in 1987 found that injecting naxolone into rabbits PAG partially reversed EA analgesia. A study by Wu M T et al 1999 used FMRI and supported the findings of previous studies. They found that stimulation of LI4 and ST 36 resulted in activation of the hypothalamus and nucleus accumbens and deactivation of the rostral part of the anterior cingulated cortex, amygdyla formations and hippocampal complex while control stimulation of did not result in such activations or deasctivations. They concluded that by inhibiting the limbic system structures acupuncture appears to cause the negative connotations of the pain is decreased

Some patients may have a centrally evoked type pain resulting from altered CNS circuitry and processing (Bradnam, 2002). The features of this type of pain include on-going pain after the injury has healed that present as unfamiliar anatomic pain patterns with atypical pain behaviours. The patient sometimes exhibits signs in the related segments including swelling and redness but often there maybe no signs. Slow healing musculoskeletal conditions maybe related to inhibition of the SNS leading to trophic changes in the target tissue. Bradnam suggests acupuncture maybe used in this pain mechanism in particular in the early stages of the chronicity when the level of the dysfunction in the CNS is not known and some inhibitory pathways might be patent. 

There is also some evidence to suggest that there maybe Sympathetic changes associated with acupuncture. Nathan 1980 stated that sympathetic fibers release noradrenaline throughout their course and that peripheral nerves accompanied by sympathetic nerves will be bathed in a solution of noradrenaline whenever there is sympathetic activity. Wall stated that the firing of normal peripheral nerve fibres when tissue is injured is influenced by the temperature, the vasculature, sympathetic efferents the chemical environment and previous stimuli. It has been suggested that it is through stimulation of the sympathetic system that clinicians use to solve complex TCA problems. These points often located in the extremities have a strong sympathetic innervations and so maybe more useful in manipulating sympathetic responses. Needling at the spinal level supplying the target tissue or region can stimulate the sympathetic nervous system or by needling a point in the periphery sharing the segment.

A further supraspinal mechanism activated by acupuncture, given time and intensity parameters are correct is a neuron hormonal effect (Bradnam 2005). Beta-endorphin and adreno-corticotrohic hormone are released in equimolar amounts from the pituitary gland into the bloodstream. The ACTH in turn will influence the adrenal gland increasing the production of anti-inflammatory corticosteroids. Research suggests that these effects can be incorporated into a treatment plan to optimize healing effects in slow healing conditions, treat immune deficient people or those with high intensity demands on their bodies (Bradnam). To influence the organs producing T lymphocytes and NK cells the thymus, spleen and lung needle the segments that supply these organs with strong sympathetic points and possible ear acupuncture to influence vagal parsympathetic activity (Bradnam 2005).

Despite its widespread use and effectiveness in treating a variety of conditions, acupuncture is not without its limitations. It seems that it maybe most effective in the treatment of chronic disorders. Direct needling can be limited in acute syndromes due to discomfort and needling around recent areas of oedema can be restricted. Also progress can be slow among patients who have multi pathology, weak constitution or disturbed personality.

The TCM approach was used in this instance in the treatment of a patient with lateral elbow pain. No other treatments were included for the purpose of the case study. Following 10 sessions of acupuncture the patient reported her pain level on the VAS to be 1. This was provoked if she carried heavy bags. She no longer woke at night due to pain. Her grip strength was almost equal to that of the contralateral side.

There is a growing body of evidence and research in support of the TCM approach to the treatment of chronic pain. Some research exists whish suggests that acupuncture is effective in the short term relief of lateral elbow pain. Five out of six studies examined from the Cochrane database supported this fact. Further research is required to determine the optimal acupuncture treatment for short term pain relief.

References:

Bradnam L (2002) Western Acupuncture Point election: A Scientific Clinical Reasoning Model.AACP p 21-28

Eshkevari L & Heath J(2005) Use of Acupuncture for Chronic pain. Optimising Clinical Practice. Holistic Nursing practice 19(5) 217-221

He L (1987) Involvement of endogenenous opiod peptides in acupuncture analgesia Pain Vol; 31 p 99 – 121

Smith F (1992) Neurophysiologic basis of acupuncture Probl Vet Med. Mar;4(1): p 34-52.