AIP 29-1 Text - AACP

Acupuncture in PhysiotherapyTM

Journal of the Acupuncture Associationof Chartered Physiotherapists

Summer 2017 Volume 29, Number 1

ISSN 2058-3281

Acupuncture in Physiotherapy

TMVolum

e 29, Num

ber 1, Sum

mer 2017

The JCM Clinical Mastery Series

Orthopaedics and Traumatology Treatment by Chinese Medicine with Karl ZippeliusOctober 28/29 2017 Brighton, England

Orthopaedics and traumatology is a multi-disciplinary speciality in Chinese medicine, combining acupuncture, external herbs and tuina to treat what are the most common disorders encountered in the clinic. This practical two day course is aimed at a wide range of health practitioners, including acupuncturists, physiotherapists, medical and sports massage therapists and medical doctors - indeed anyone who has to deal with patients suffering from disease of the locomotor system.

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Early bird price (until September 1st 2017) £180

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© 2017 Acupuncture Association of Chartered Physiotherapists 1


www.aacp.org.ukAcupuncture in Physiotherapy is printed twice a year for the membership of AACP. It aims to provide information for members that is correct at the time of going to press. Articles for inclusion should be submitted to the clinical editor at the address below or by e-mail. All articles are reviewed by the clinical editor, and while every effort is made to ensure validity, views given by contributors are not necessarily those of the Association, which thus accepts no responsibility.

Editorial addressDr Val Hopwood18 Woodlands CloseDibden PurlieuSouthampton SO45 4JGUK

E-mail: [email protected]

The AssociationThe British association for the practice of Western research-based acupuncture in physiotherapy, AACP is a professional network affiliated with the Chartered Society of Physiotherapy. It is a member-led organization, and with around 6500 subscribers, the largest professional body for acupuncture in the UK. We represent our members with lawmakers, the public, the National Health Service and private health insurers. The organization facilitates and evaluates postgraduate education. The development of professional awareness and clinical skills in acupuncture are founded on research-based evidence and the audit of clinical outcomes.

AACP LtdSefton House, Adam Court, Newark Road, Peterborough PE1 5PP, UK

Tel: 01733 390007

Printed in the UK by Henry Ling Ltd at the Dorset Press, Dorchester DT1 1HD

ContentsSummer 2017

Editorial .........................................................................3Chairman’s report ........................................................5Chief Executive Officer’s report ..............................7

ParadigmsCountering the sceptics and respecting patient preferences: making the case for acupuncture by K. Coleman- Rooney .....................................................9

Original researchScientific Evaluation and Review of Claims in Health Care (SEaRCH): a streamlined, systematic, phased approach for determining “what works” in healthcare by W. B. Jonas, C. Crawford, P. Elfenbaum & L. Hilton ..........................................17

Meridian masterclassThe Spleen meridian: the foot Tai Yin channel by R. Lillie ....................................................................29

Case reportsAcupuncture for the treatment of whiplash- associated disorder by S. Cronin .............................39Acupuncture for the management of pain in a woman with muscular sclerosis by K. Biss .............49Acupuncture treatment for a 50- year- old female with fibromyalgia suffering from a whiplash injury following a road traffic accident by C. Hamer ......................................................................59Electroacupuncture in the treatment of patellar tendinopathy in a 52- year- old male by B. Bradford ...............................................................67Use of acupuncture to treat an academy football player with ankle impingement by G. Parry ..................................................................75Acupuncture as an adjunct to standard physiotherapy in the management of adhesive capsulitis by L. Bennett ..............................................83Myofascial pain masquerading as neuropathic pain by C. Waldock ....................................................91

Good practice statementAcupuncture for pregnancy- related low back pain and pelvic girdle pain .....................................95

ReviewsBook reviews .............................................................99News, views and interviews .................................. 103

Guidelines for authors ........................................... 109

Ask your

Physiotherapist

about acupuncture

and see how it

could help you

Acupuncture can be combined with

other physiotherapy treatments

such as exercise, manual therapy

and relaxation techniques, to treat

a wide range of common health

problems and to reduce pain.

Acupuncture Association of

Chartered Physiotherapists

For more information

about acupuncture,

visit www.aacp.co.uk

AcC



www.aacp.org.uk

Journal Committee

Clinical EditorDr Val Hopwood FCSP

Corporate EditorAndrew J. Wilson(e-mail: [email protected])

Book Review EditorWendy Rarity(e-mail: [email protected])

News EditorRosemary Lillie(e-mail: [email protected])

Public Relations and Marketing OfficerJennifer Clarkson(e-mail: [email protected])

AACP Office ManagerLisa Stephenson(e-mail: [email protected])

AACP Ltd Board Members

Chairman: Jon HobbsLesley PattendenPaul BattersbyDiana LacraruGeorge ChiaChristopher HallWendy RarityCaspar van Dongen Chief Executive Officer: Caspar van DongenAuditor: Rawlinsons, PeterboroughCompany Secretary: Michael Tolond

Editorial

Welcome to the latest edition of Acupuncture in Physiotherapy. As ever, we have a wide- ranging selection of original research, opinion, case reports, news and reviews.

Kaye Coleman- Rooney (pp. 9–15) provides some good general information about acupunc-ture that you can offer to your friendly local general practitioners, who may well become more inclined to refer their patients to you. The serious science in this issue is covered by Wayne Jonas et al. (pp. 17–27), who take a close look at how we evaluate our service and “what works” in healthcare.

The latest in our series of meridian master-classes is provided by Rosemary Lillie, who discusses the Spleen meridian (pp. 29–38). This continuing feature has provided members with a great deal of additional information, and the whole collection will soon be brought together in an exclusive AACP publication. Watch this space!

Our case studies are very interesting: pain in multiple sclerosis from Kay Biss (pp. 49–57); adhesive capsulitis from Louisa Bennett (pp. 83–89); and electroacupuncture in the treatment of patellar tendinopathy from Ben Bradford (pp. 95–98).

We also have two variations on whiplash injury from Suzanne Cronin (pp. 39–47) and Charlotte Hamer (pp. 59–66). It’s always inter-esting to compare and contrast treatments, bearing in mind that we all know that every patient is different anyway.

Then we have an academy football player with an ankle impingement from Gemma Parry, and finally, an intriguing view of myofascial pain from Colin Waldock (pp. 91–93).

We also have an interesting selection of book reviews (pp. 98–101) and acupuncture news (pp. 103–108), including some information from Beverley de Valois about her recent, highly commended work with moxa and oncology research (pp. 103–105).

Val HopwoodClinical Editor


Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 5–6

Chairman’s report

Welcome to the Summer 2017 edition of Acupuncture in Physiotherapy. As ever, there has been a lot of activity since the last edition of the journal.

This year saw the trial of a 1- day Annual Conference, which was held on Saturday 13 May 2017 in Coventry. In an effort to reach out to members across the UK, the AACP has organ-ized three, 1- day events this year: the others will take place in Bristol and Edinburgh.

The 1- day Annual Conference format, which featured talks covering a range of special inter-est areas within acupuncture and physiotherapy, was well received. Among the guest speakers were: Dr Kien Trinh, who flew in from Canada to discuss an evaluation of the National Institute for Health and Care Excellence guidelines for low back pain (LBP) (NICE 2016); and Sinead McCarthy, who reviewed the evidence for the safety and effectiveness of acupuncture for pregnancy- related LBP and pelvic girdle pain.

Sinead will also attend AACP’s Bristol Conference on 23 September 2017, where she will talk about the use of acupuncture in men’s health. This event will also feature: Dr Val Hopwood, who will deliver an enlightening overview of acupuncture in the UK from both a political and historical perspective; Professor Tianjun Wang, who will discuss an innovative approach to scalp acupuncture; Dr Elisa Rossi, who will cover acupuncture in paediatrics; and Tom van Callister, who will outline the role and importance of acupuncture in musculoskeletal problems, and perform a practical demonstra-tion of his approach to the treatment of neck pain.

The previous success of the AACP Ireland and Scotland conferences sees this year’s event brought to Edinburgh on 21 October 2017, where a variety of topics will again be covered. Amos Ziv from Israel will present his meridian wave acupuncture theory, and include a practical demonstration. John R. Cross will discuss the use of acupressure for neurological conditions.

Johnny Wilson, who is head of sports medicine at Notts County Football Club, will discuss the use of acupuncture within the realm of professional football. He can be seen treating Notts County striker Jon Stead in a video on our website (Austin 2017). Also look out for a forthcoming longer video from AACP featuring Johnny and players from Notts County pro-moting the use of acupuncture in professional football.

On the subject of promotion, the Association’s media and public relations officer, Jennifer Clarkson, née Hodges (e- mail: [email protected]), has been working tire-lessly along with the rest of the team at Sefton House to develop a variety of media projects. To date, we have now promoted the benefits of receiving acupuncture from a AACP- registered chartered physiotherapist in several print media titles, including but not exclusively, Ask the Doctor, Balance, Calibre, Athletics Weekly, The Guardian and The Mail on Sunday, reaching a total readership of more than 5 million. Jennifer also continues to produce guidance on how to promote ourselves effectively via social media, and has created a selection of ready- made tweets, Facebook posts and electronic images to help members get started. As always, may I encourage members to engage with the AACP administration team in order to take full advantage of this facility, and see how we can support members in the promotion of their own services to the general public. The team also includes AACP clinical adviser Christopher Ireland (e- mail: [email protected]), who is on hand to support members with queries about subjects ranging from indi-vidual treatments to policy, management and commissioning issues related to the integration of acupuncture within physiotherapy.

The new website format has also given the Association’s public interface a facelift. This is not only designed to be more user- friendly, but now offers more features than ever, including online booking for conferences, journal article

Chairman’s report

© 2017 Acupuncture Association of Chartered Physiotherapists6

and conference presentation archives, news articles, and an online shop.

The new online shop offers members exclu-sive deals on a wide variety of products, and makes a guaranteed price- match promise. As a not- for- profit organization, AACP can offer a huge discount on needles and other clinical supplies to members, providing another valu-able membership benefit. The benefits of the online shop, combined with significant savings in sharps and contaminated waste management from B Hygienic, and clinical supplies from Economed offer real cash value to all members in addition to the professional standing associ-ated with being a member.

The website also lists forthcoming training events and courses, and these can be booked online. However, if you do not see a course listed that you would like to have run in your area, please feel free to contact AACP training and education coordinator Claire Buckingham, née Brough (e- mail: [email protected]), who will be happy to discuss the option of you hosting courses of your choice in your region. The Association can support you in marketing and advertising, and there are also two free

places available on each course or the monetary equivalent for the host. Check out the new website for events soon to take place in your area.

There are always a variety of projects in the pipeline that the AACP team are work-ing on, but if you think that there are other things that we need to look at or you have any ideas on how you would like to see the Association develop, then please feel free to get in touch with the Office or me directly (e- mail: [email protected]). As ever, I look forward to catching up with you at an AACP event some-where soon.

Jonathan HobbsChairman

ReferenceAustin S. (2017) Inside the Treatment Room: Watch Jon Stead’s

Acupuncture Session. [WWW document.] URL https://www.aacp.org.uk/news/16/inside- the- treatment- room- watch- jon- steads- acupuncture- session

National Institute for Health and Care Excellence (NICE) (2016) Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE Clinical Guideline 59. National Institute for Health and Care Excellence, London.



Chief Executive Officer’s report

AACP: your professional organizationA professional organization is generally defined as “an organization of and for professional people” (TFD 2017).

Since its inception in 1984, AACP has cer-tainly been an organization for professionals, i.e. chartered physiotherapists who practise acupuncture. The Association has also always been run by professionals, which has resulted in it becoming by far the largest acupuncture organization in the UK.

In recent years, AACP has increasingly become a fully- fledged professional organization in the sense defined above. The services pro-vided by the AACP Office, which is profession-ally administered by our office manager, cover a varied and wide- ranging number of activities and services that will support you in your day- to- day acupuncture physiotherapy work.

The AACP membership department is available to answer any questions that you may have about your subscription. A member management system contains all the informa-tion needed to help us deal efficiently with your queries. Failing that, the vast experience of the staff at the department will certainly be able to help you further.

Booking continuing professional development (CPD) courses or Acupuncture Foundation Courses (for new members) is an easy online process, and all our courses effectively managed by our education and training coordinator.

Many of you have put questions to our clinical advisor, who also participates in the development of our clinical and medical leaflets and documents. He and several AACP directors represent you by getting involved in the various issues concerning Western medical acupuncture addressed by the National Institute for Health and Care Excellence and regulatory bodies.

Our public relations and marketing officer has made great inroads in realizing very

cost- effective insertions in many patient- oriented publications. These have reached mil-lions and encouraged them to search for their acupuncture physiotherapist via our website (www.aacp.org.uk/search). Together with our office manager, she is also involved in the organization of three well- attended AACP con-ferences across the country each year.

The Association runs a legal service for you that is accessible through the website. Free advice can be obtained on human resources, health and safety, employment, and tax issues, among other things.

Lastly, our new AACP online shop, exclusively for members, is now up and running. This is a one- stop shop for your all acupuncture and physiotherapy needs, offered at the best prices possible.

An organization of and for professional people; that’s your AACP.

Conferences and Annual General MeetingAnother very successful AACP Conference was held at the Hilton Hotel Coventry in May. Like our other conferences, it was a gathering with a real buzz, and afterwards, we received a lot of compliments about the organization and the quality of the event from delegates, speakers and trade representatives alike. Our conferences are ideal opportunities to: hear the latest about acupuncture in physiotherapy from both speak-ers and trade representatives; add some useful CPD hours; and network with colleagues. You can find more details of our upcoming confer-ences in Bristol and Edinburgh on our website (www.aacp.org.uk/events/conferences).

During our Conference in May, the AACP Annual General Meeting accepted all the pro-posals put before it with substantial majorities. The Board’s overall strategy remains focus-ing on improving communication with our

Chief Executive Officer’s report


membership, the public and the authorities, and enhancing the quality and number of benefits for our members.

The 2016 AACP financial year was summa-rized as one in which earlier years’ membership growth started to materialize into increased rev-enue, and the first steps were taken to reach out to the media in a more professional and targeted way. The new public relations and marketing function within the organization has managed to spread the AACP message to an audience of millions in the UK for the first time, while its in- house design function has reduced the cost of developing promotional and support materials.

The 2016 financial result was achieved through maintaining a carefully managed bal-ance between income and costs during the year. The aim was to achieve a close- to- break- even situation in which as much as possible of the

Association’s income was redeployed for the benefit of its members, an objective that was achieved. After a small deficit in 2015, we ended 2016 with a small surplus. The two main sources of income remain membership subscriptions and course provision. At the end of the year, the total membership of AACP stood at over 6000.

As always, we are your Association, and if you have suggestions for positive changes, or adding any services or benefits, please don’t hesitate to contact me directly at the AACP Office (e- mail: [email protected]).

Caspar van DongenChief Executive Officer

ReferenceTheFreeDictionary (TFD) (2017) Professional Organization.

[WWW document.] URL http://www.thefreedictionary. com/professional+organization


Correspondence: Kaye Coleman- Rooney, The Acu-puncture Academy, 54 High Street, Leamington Spa CV31 1LW, UK (e- mail: [email protected]).


PARADIGMS

Countering the sceptics and respecting patient preferences: making the case for acupuncture

K. Coleman- RooneyThe Acupuncture Academy, Leamington Spa, UK

AbstractThe argument that acupuncture is a placebo performed by the irresponsible on the gullible is one that is familiar to most practitioners. Sceptics describe acupuncture as prescientific, challenge its fundamental theories, specifically the existence of Qi and the meridians, and dismiss research as of no clinical relevance. However, biomedical research in fields as diverse as stem cell and genomic theory, embryology, and neurophysiology now offers a more con-structive framework for interdisciplinary discussion around the different physiological and neurological models involved in an understanding of acupuncture. Quantitative and qualita-tive research into acupuncture treatment and the setting in which it is offered is effectively reframing the placebo and “real versus sham” debate, as well as demonstrating the efficacy of acupuncture as a treatment and management tool across a wide range of conditions. Healthcare policy researchers increasingly argue for the development of best- practice models that, in line with the UK National Health Service Constitution, prioritize patient prefer-ences for alternative, safe and low- technology treatment options as ethical and economic imperatives.

Keywords: acupuncture, healthcare policy, patient preference, placebo effect, real versus sham needling.

IntroductionWhen readers search for the term “acupunc-ture” on The Guardian website (www.theguardian. com), an article dating from 2013 still tops the list. “Why acupuncture is giving sceptics the needle” (Derbyshire 2013) was prompted by a vehement opinion piece by David Colquhoun and Steven Novella in the journal Anesthesia and Analgesia (Colquhoun & Novella 2013). Their editorial attacks the principles underlying tradi-tional Chinese medicine (TCM) as “bizarre” and “prescientific”, contending that “acupuncture

is little or no more than a theatrical placebo” (Colquhoun & Novella 2013, p. 1360).

These and similar accusations regularly circu-late online, and express doubts familiar to every practitioner of acupuncture from discussions with healthcare providers and professional col-leagues trained in other disciplines. While many patients are enthusiastic about the benefits that they have experienced as a result of acupunc-ture, the sceptics’ arguments would appear to reflect the reservations of many potential patients. Therefore, it is worthwhile reviewing the evidence base for acupuncture in the light of the sceptics’ specific claims and objections.

Those dubious about complementary tradi-tions and approaches characterize patients who

Making the case for acupuncture


seek out alternatives to the biomedical and pharmacological approaches as gullible and desperate (Colquhoun & Novella 2013). Since respect for patient preferences is now enshrined in principle in the National Health Service (NHS) Constitution for England (DH 2015), the present paper also discusses the ethical and economic arguments for facilitating informed patient choice.

Journalist David Derbyshire’s (2013) article for The Guardian explores three aspects of the argument in some detail:(1) Qi, which is fundamental to TCM and

acupuncture theory, is “meaningless in the context of medical science”.

(2) Research does not meet the required standards for randomized controlled tri-als (RCTs), while recent meta- analyses show “barely clinically significant” results, according to David Colquhoun, who is quoted in the article.

(3) “Real” acupuncture offers no significant benefits over sham acupuncture, and there-fore, is little better than a placebo.

Sceptics who, like Colquhoun & Novella (2013, p. 1361), claim that the flow of Qi through meridians in the body is “purely imaginary” are ignoring significant advances in current bio-medical research. The work of leading research-ers in fields as diverse as stem cell and genomic theory, embryology, and neurophysiology is providing robust support for acupuncture’s theoretical principles (Keown 2014). Qualitative research also increasingly provides evidence of acupuncture’s relevance to, and efficacy in, clinical settings where individualized treatments by trained practitioners make valuable contribu-tions to improved health (Paterson & Britten 1999; Hopton et al. 2013: MacPherson et al. 2014).

Considering the evidence

Medical science can explain QiIn the mid- 1970s, as acupuncture first started to become more widely known in the West, biomedicine made use of then- current endor-phin release and gate control theories of pain

modulation in its first attempts to understand how acupuncture might work simply as analge-sia (Birch & Felt 1999; Stux & Hammerschlag 2001).

However, the clinical applications of acu-puncture and its benefits to patients extend sig-nificantly beyond pain control, with the primary physiological focus being on regulating and bal-ancing the homeostatic processes of the body (Kaptchuk 2000; Maciocia 2015). Therefore, research that is limited to analgesic enquiry is clearly inadequate for any real understanding of acupuncture, the concept of Qi or the creation of a meaningful evidence base for its efficacy (Birch & Felt 1999; Stux & Hammerschlag 2001; Keown 2014). It is little wonder that Colquhoun & Novella (2013) found explanations based on this area of research unconvincing: it is only part of the story. In the 4 decades since the endorphin and gate control theories were pinned to acupuncture, new biomedical disciplines have emerged that not only extend the frontiers of conventional medicine, but provide new conceptual frameworks of intelligent, dynamic physiological organization and communication.

In the West, we typically translate “Qi” as “energy”, and view it as something that we should be able to quantify. A medical doctor and trained acupuncture practitioner, Daniel Keown argues that it is more helpful to think of Qi as shorthand for, or a metaphor expressing the idea of, an “intelligent and organised metabo-lism” (Keown 2014, p. 26). The discovery in the 1990s of a number of neuropeptides linking the immune, endocrine and nervous systems (Pert 1999) allowed neurophysicists for the first time to conceive and map the signalling, receptor and regulatory mechanisms of the body in terms of information theory. They characterized peptides and their individual receptors as facilitators of homeostasis, and described the body as a series of “internal conversations” (Pert 1999, p. 263). This new understanding provided a significantly different biomedical model of somatic and psychological interdependence. It corresponds more closely with and contributes to a more- appropriate framework for understanding the different physiological and neurological models that TCM encapsulates as Qi, and the meridians

K. Coleman- Rooney


through which it flows (Pert 1999; Keown 2014).

The work of American academic, Dr Charles Shang (2001, 2009, 2011) updated a considerable body of research, synthesizing neurophysiology, stem cell theory, genetics and embryology (Birch & Felt 1999; Keown 2014). Shang’s growth control theory describes and evidences an integrated theory of acupuncture, defining Qi in biomedical terms as “morphogens and electrical currents running in connective tissue planes” (Keown 2014, p. 85). Acupuncture points are mapped to the organizing centres fundamental to embryol-ogy, and acupuncture meridians to planes of the fascia (Keown 2014). Meridians derive from growth control folds in the embryo in utero, where associated gap junctions form discrete communication departments that continue to develop after birth, creating an interconnected network of bioelectric currents – correspond-ing to Qi – navigating the borders of the fascia and connective tissue.

The conduct and conclusions of researchIn addition to basic research focused on con-ventional biomedicine, and despite the difficul-ties of securing funding for research into inter-ventions outside conventional pharmacological and surgical approaches (Birch & Felt 1999), there is now a considerable body of research centred on the meaningful evaluation of acu-puncture. Colquhoun & Novella (2013) claimed that generally inconclusive results typically force researchers to conclude that “more research is needed” (Derbyshire 2013).

Their view sidelines robust programmes of evaluation and integration at some of the world’s leading healthcare and health policy institutions – including the World Health Organization (WHO 2013) – producing and evaluating research on acupuncture’s efficacy and value in clinical applications as diverse as the management of cancer- related symptoms (Javdan & Cassileth 2015) and chronic pain (MacPherson et al. 2014).

However, acupuncture is a complex interven-tion, presenting researchers and reviewers with considerable challenges when adjusting for

multiple variables, and controversial approaches to controls, allocation and blinding. As Derbyshire’s (2013) article concedes, the use of sham needling techniques used to provide a third control group between acupuncture and no acupuncture/usual care controls “con-tinues to muddy the waters of research into acupuncture”.

Problematic enough in single- focus RCTs, it is unsurprising that these issues are ampli-fied in the meta- analysis of RCTs. Derbyshire (2013) highlighted the controversy around the Vickers et al. (2012) meta- analysis, stemming from Colquhoun & Novella’s (2013) charge that the apparently positive conclusions are unwar-ranted, and that the improvements noted lack clinical significance. The present author will now discuss these claims before examining the charge that “real” acupuncture offers no signifi-cant benefits over sham needling.

Using data from 29 high- quality RCTs involv-ing 17 922 patients, Andrew J. Vickers and his fellow researchers found that acupuncture is “superior to both no- acupuncture control and sham acupuncture for the treatment of chronic pain”, and concluded that “acupuncture is a reasonable referral option” (Vickers et al. 2012, p. 1450). Colquhoun & Novella (2013) disputed Vickers et al.’s (2012) endorsement of acupunc-ture’s efficacy, comparing its methodology unfa-vourably with a study that had a similar intent (Madsen et al. 2009), but smaller scope (13 trials with 3025 patients). The Madsen et al. (2009) study came to a conclusion more in line with Colquhoun & Novella’s (2013) own opinion, i.e. that any slight analgesic effect of acupuncture had no clinical relevance and was vulnerable to bias.

However, contrary to Colquhoun & Novella’s (2013) claim, Vickers et al.’s (2012) meta- analysis supports its important conclusions with a robust and thorough methodology. The research team went to considerable lengths to exclude and adjust as appropriate for, inter alia:

• clinical and methodological heterogeneity;

• statistical variance at baseline and follow- up;

• the type and delivery of genuine treatment; and

• varieties of sham treatment.



In addition, RCTs with a high likelihood of bias from unblinding were excluded. Crucially, Vickers et al. (2012) also prioritized individual patient data meta- analysis, obtaining raw data from the studies under review to ensure greater precision and reliability.

By contrast, the Madsen et al. (2009) study demonstrates considerable shortcomings in its methodology. In stark contrast to the Vickers et al. (2012) review, Madsen et al. (2009) under-took no raw data analysis. Instead, data were pooled, aggregated and standardized to mean outcomes. This was done despite Madsen et al.’s (2009) admission of considerable heterogene-ity between the studies under review, with the researchers noting more variation than could be expected by chance.

Assessing sham versus “real” acupuncture and the placebo effectColquhoun & Novella (2013) substantiated their dismissal of acupuncture as an elaborate placebo by reference to the apparent scant dif-ference in benefit between sham acupuncture and “real” needling techniques.

Research results (MacPherson 2014) do show that patients receiving sham acupuncture typi-cally report improvements over patients receiv-ing no or usual treatment. Leading practitioner and researcher Hugh MacPherson (2014), for example, cites Vickers et al.’s (2012) estimate that 60% of reported benefits could be ascribed to sham needling techniques and other factors, such as the patient–practitioner relationship. The remaining 40% improvement is the addi-tional effect of “true” acupuncture. As the debate rages around sham and “real” needling, it is easy to lose sight of patients’ perceptions of worthwhile benefit (Paterson & Britten 1999; Paterson et al. 2011; Hopton et al. 2013), and that sham or “real” is, anyway, an artificial difference (MacPherson 2014): no general prac-titioner (GP) will offer patients sham treatment.

Relevance to the individual patient in the clinical setting is key to understanding many of the limitations of the biomedical research model when assessing treatments predicated on a rationale that is fundamentally different from

that of conventional medicine. In contrast to Western normative traditions, where treatment protocols are specific to the disease, acupuncture tailors treatment specifically to the individual (Kaptchuk 2000). Therefore, the acupuncture treatment offered to individual patients follow-ing standardized research protocols is generally suboptimal for the majority of patients (Birch & Felt 1999; Birch 2004; MacPherson 2014).

However, although a research methodology evaluating the impact of individual, more- optimal treatment is challenging to design (Paterson et al. 2011), recent qualitative and quantitative research in the general practice set-ting has robustly demonstrated that the addition of 12 sessions of Five Element acupuncture to normal GP care brought sustained improve-ments in health and well- being to patients over a 12- month period (Paterson et al. 2011).

It is clear that there are significant shortcom-ings associated with using sham acupuncture as an apparent placebo control (Birch & Felt 1999; Birch 2004). While a sugar pill is clearly an inac-tive placebo, needling or intense pressure at any point on the body causes a measurable physi-ological response (Birch & Felt 1999; Keown 2014). The validity of a sham control is further compromised because many points selected as inert by researchers are, in fact, recognized by qualified practitioners as more or less powerful points on the acupuncture meridians (Birch & Felt 1999; Birch 2004; MacPherson 2014).

Therefore, the measurement of real against sham is not the comparison of optimal, con-sidered treatment with a demonstrably inert placebo. In effect, in studies where sham acupuncture is involved, researchers are actu-ally noting the difference between two active, albeit suboptimal, treatments and their impact on the patient (Birch & Felt 1999; Birch 2004; MacPherson 2014).

The patient’s perspectiveIn its current National Institute for Health and Care Excellence (NICE) best practice guidelines on improving the experience of care in adult NHS services (NICE 2012, 2013), the NHS advises practitioners to take into account not

K. Coleman- Rooney


only the needs of patients, but also the require-ment to offer services that reflect patients’ preferences and values. This extends to providing alternative options for the treatment and man-agement of their health and emotional well- being, and includes support to optimize quality of life.

Furthermore, while the majority of patients may still be unaware of its existence, the NHS Constitution for England (DH 2015) explicitly prioritizes patient preferences in the design of NHS services. Its statement of principles is clear and unambiguous: “NHS services must reflect, and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers” (DH 2015).

A growing body of qualitative research (Paterson & Britten 1999, 2003; Luff & Thomas 2000; Hopton et al. 2012; Mulley et al. 2012; Hopton et al. 2013) supports the NICE advice, and underpins this fundamental principle of NHS service design. Findings suggest that con-ventional treatment options increasingly fail to reflect the diversity of values that patients bring with them to the surgery. There is also evidence that sufferers of many chronic conditions are frustrated by, and disappointed in, conventional treatment (Paterson & Britten 1999; Mulley et al. 2012), particularly when they perceive or experi-ence adverse effects from prescribed medication or surgical intervention (Mulley et al. 2012).

In their 1999 report, “‘Doctors can’t help much’: the search for an alternative”, Paterson & Britten (1999) observed that many patients are wary of the risks of pharmaceutical and surgical interventions to the extent that they welcome, and prefer, alternative options, including acu-puncture. These authors commented that:

“[H]ealth professionals make value judge-ments on what constitutes acceptable risks from side- effects of drugs. This study reminds us that many patients make their own judgements about risk.” (Paterson & Britten 1999, p. 629)

Their conclusion – that patients find much of modern high- technology medicine irrelevant and/or inappropriate to their needs – is sup-ported by their own, more- recent studies

(Paterson & Britten 2003; Paterson et al. 2011), and those of other researchers (Luff & Thomas 2000; Hopton et al. 2012; Mulley et al. 2012).

A recent and wide- ranging attitudinal survey, from influential healthcare think- tank The King’s Fund, goes further, arguing the ethical case for patient preference. In Patients Preferences Matter: Stop the Silent Misdiagnosis (Mulley et al. 2012), authors Al Mulley, Chris Trimble and Glyn Elwyn argue that doctors are, in a signifi-cant number of cases, offering pharmacologi-cal and surgical approaches that patients find inappropriate and/or irrelevant. Contending that “there are breathtaking gaps between what patients want and what doctors think they want” (Mulley et al. 2012, p. 5), they make a case for the development of best- practice models that prioritize patient preferences for alternative treatment options as an ethical imperative.

Cost and service efficiency benefitsSensitivity to preferences can also deliver ben-efits to the NHS budget. Making reference to a wide range of diseases, including the chronic and long- term conditions GPs and primary care providers find particularly intractable, and for which many patients welcome alternative interventions such as acupuncture (Hopton et al. 2012, 2013), Mulley et al. (2012) pointed to the potential for considerable cost savings. In particular, they cited research by Wennberg et al. (2010) demonstrating that options that help patients manage their own conditions satis-factorily can deliver, for example, reductions in hospital admissions, and attendance at accident and emergency departments.

In another example, MacPherson & Thomas’ (2007) RCT of acupuncture for low back pain in a primary care setting went further than reporting continued health improvements at 12 and 24 months. They also rated the treatment as a “highly cost- effective” option when measured against quality- adjusted life- year criteria.

Similarly, in an evaluation of the Beating Back Pain Service (Cheshire et al. 2013), research into patient outcomes, and experiences of an acu-puncture and self- care service for persistent low back pain in an NHS primary care setting in



central London, found that more than one- third of patients experienced a clinically significant improvement in their pain at the 3- month time point. The researchers also found statisti-cally and clinically significant improvements in a wider range of health and quality of life indicators, including improved physical activity, reductions in the use of prescription painkillers, psychological well- being and self- efficacy. They concluded that the provision of acupuncture contributed to an “effective and valuable” (Cheshire et al. 2013, pp. 1 & 11) service for patients managing long- term chronic back pain.

SafetyContrary to the sceptics’ charge of irresponsi-bility, the safety of acupuncture procedures is of primary concern (BAcC 2016), and when carried out by fully trained practitioners, is well evidenced. In 2001, a prospective survey (MacPherson et al. 2001) of 34 407 treatments by fully trained practitioner members of the British Acupuncture Council (BAcC) that was published in the BMJ, Hugh MacPherson and his team found no (zero) serious adverse events (defined as problems requiring hospital admission, or leading to permanent disability or death).

This equates to an underlying serious adverse event rate of between 0 and 1.1 per 10 000 treatments by BAcC members, and resulted in a BMJ editorial recommending acupuncture as “safe in the hands of competent practitioners” (Vincent 2001, p. 467).

ConclusionAcupuncture is a beneficial, valued, safe and cost- effective treatment option. Notwithstanding its considerable limitations as a paradigm for the understanding of acupuncture, quantitative biomedical research increasingly offers an evi-dence base that facilitates a science- led discus-sion of the fundamental concepts of Qi and the meridians, and demonstrates the efficacy of acupuncture across a range of conditions.

Qualitative research shows that the provi-sion of acupuncture in the primary care setting makes a significant contribution to the sustained

well- being of patients, particularly those with chronic, hard- to- manage conditions. Offering acupuncture also conforms to NHS principles and NICE guidelines on reflecting patients’ preferences and values. Last, but not least, it has been shown that acupuncture should be considered as a cost- effective option that can potentially contribute to overall cost savings.

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Hopton A. K., Curnoe S., Kanaan M. & MacPherson H. (2012) Acupuncture in practice: mapping the provid-ers, the patients and the settings in a national cross- sectional survey. BMJ Open 2: e000456. DOI: 10.1136/bmjopen- 2011- 000456.

Hopton A., Thomas K. & MacPherson H. (2013) The acceptability of acupuncture for low back pain: a quali-tative study of patient’s experiences nested within a randomised controlled trial. PLOS ONE 8 (2): e56806. DOI: 10.1371/journal.pone.0056806.

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Luff D. & Thomas K. J. (2000) Sustaining complemen-tary therapy provision in primary care: lessons from existing services. Complementary Therapies in Medicine 8 (3), 173–179.

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MacPherson H., Vertosick E., Lewith G., et al. (2014) Influence of control group on effect size in trials of acupuncture for chronic pain: a secondary analysis of an individual patient data meta- analysis. PLOS One 9 (4): e93739. DOI: 10.1371/journal.pone.0093739.

MacPherson H. & Thomas K. (2007) Traditional acu-puncture for low back pain: developing high quality evidence while maintaining the integrity of the inter-vention. The European Journal of Oriental Medicine 5 (4), 26–30.

Madsen M. V., Gøtzsche P. C. & Hróbjartsson A. (2009) Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 338: a3115. DOI: 10.1136/bmj.a3115.

Mulley A., Trimble C. & Elwyn G. (2012) Patients’ Preferences Matter: Stop the Silent Misdiagnosis. The King’s Fund, London.

National Institute for Health and Care Excellence (NICE) (2012) Patient Experience in Adult NHS Services: Improving the Experience of Care for People Using Adult NHS Services. NICE Clinical Guideline 138. National Institute for Health and Clinical Excellence, London.

National Institute for Health and Care Excellence (NICE) (2013) Into Practice Guide. NICE Process and Methods 30. National Institute for Health and Clinical Excellence, London.

Paterson C., Taylor R. S., Griffiths P., et al. (2011) Acupuncture for “frequent attenders” with medically unexplained symptoms: a randomised controlled trial (CACTUS study). British Journal of General Practice 61 (587), e295–e305.

Paterson C. & Britten N. (1999) “Doctors can’t help much”: the search for an alternative. British Journal of General Practice 49 (445), 626–629.

Paterson C. & Britten N. (2003) Acupuncture for people with chronic illness: combining qualitative and quanti-tative outcome assessment. The Journal of Alternative and Complementary Medicine 9 (5), 671–681.

Pert C. B. (1999) Molecules of Emotion: Why You Feel the Way You Feel. Pocket Books, London.

Shang C. (2001) Electrophysiology of growth control and acupuncture. Life Sciences 68 (12), 1333–1342.

Shang C. (2009) Prospective tests on biological models of acupuncture. Evidence- Based Complementary and Alternative Medicine 6 (1), 31–39.

Shang C. (2011) The Mechanism of Acupuncture – Beyond Neurohumoral Theory. [WWW document.] URL https://medicalacupuncture.wordpress.com

Stux G. & Hammerschlag R. (eds) (2001) Clinical Acupuncture: Scientific Basis. Springer- Verlag, Berlin.

Vickers A. J., Cronin A. M., Maschino A. C., et al. (2012) Acupuncture for chronic pain: individual patient data meta- analysis. Archives of Internal Medicine 172 (19), 1444–1453.

Vincent C. (2001) The safety of acupuncture. [Editorial.] BMJ 323 (7311), 467–468.

Wennberg D. E., Marr A., Lang L., O’Malley S. & Bennett G. (2010) A randomized trial of a telephone care- management strategy. The New England Journal of Medicine 363 (13), 1245–1255.

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Kaye Coleman- Rooney is a student practitioner at The Acupuncture Academy in Leamington Spa. She is also a student member of the British Acupuncture Council.

© 2017 Wayne B. Jonas, et al. 17

*Correspondence and present affiliation: Wayne B. Jonas MD, H&S Ventures, 1800 Diagonal Road, Suite 617, Alexandria, VA 22314, USA (e- mail: [email protected]).


ORIGINAL RESEARCH

Scientific Evaluation and Review of Claims in Health Care (SEaRCH): a streamlined, systematic, phased approach for determining “what works” in healthcare

W. B. Jonas,* C. Crawford & P. ElfenbaumSamueli Institute, Alexandria, VA, USA

L. HiltonSamueli Institute, Alexandria, VA, and RAND Corporation, Santa Monica, CA, USA

AbstractAnswering the question of “what works” in healthcare can be complex, and requires the careful design and sequential application of systematic methodologies. Over the past decade, the Samueli Institute has, along with multiple partners, developed a streamlined, system-atic, phased approach to this process called the Scientific Evaluation and Review of Claims in Health Care (SEaRCH™). The SEaRCH process provides an approach for rigorously, efficiently and transparently making evidence- based decisions about healthcare claims in research and practice with minimal bias. SEaRCH uses three methods combined in a coordi-nated fashion to help determine what works in healthcare. The first, the Claims Assessment Profile (CAP), seeks to clarify the healthcare claim and question, and its ability to be evalu-ated in the context of its delivery. The second method, the Rapid Evidence Assessment of the Literature (REAL©), is a streamlined, systematic review process conducted to determine the quantity, quality and strength of evidence, and risk/benefit for the treatment. The third method involves the structured use of expert panels (EPs). There are several types of EPs, depending on the purpose and need. Together, these three methods – CAP, REAL and EP – can be integrated into a strategic approach to help answer the question “What works in healthcare?” and what it means in a comprehensive way. SEaRCH is a systematic, rigorous approach for evaluating healthcare claims of therapies, practices, programmes or products in an efficient and stepwise fashion. It provides an iterative, protocol- driven process that is customized to the intervention, consumer and context. Multiple communities, including those involved in health service and policy, can benefit from this organized framework, assuring that evidence- based principles determine which healthcare practices with the great-est promise are used for improving the public’s health and wellness.

Keywords: decision- making, evidence- based medicine, expert panel, patient- centred care, policy, systematic review.

IntroductionConsumers, practitioners, insurance companies and governments spend billions of dollars annually on therapies that have limited or no solid medical evidence, and which may interact

Scientific Evaluation and Review of Claims in Health Care

© 2017 Wayne B. Jonas, et al.18

adversely with existing treatments or produce direct adverse effects of their own, and even exacerbate existing medical conditions (Berwick 2013). Ideally, any type of treatment should only be offered to the public when it has known mechanisms of action, and clinically relevant safety and efficacy data from definitive Phase III, controlled, randomized clinical trials (RCTs). While such an ideal is not possible, more streamlined and systematic steps can at least be provided that are organized in a way to allow the most appropriate interventions to be based on best current evidence at the time.

In addition to the extensive use of conven-tional practices that are not evidence- based, the public uses many practices from outside the conventional healthcare system, usually without supervision or knowledge of their effectiveness. These are often called complementary and alter-native medicine (CAM). When the two systems (conventional and CAM) are integrated into the mainstream health system, the term comple-mentary and integrative medicine (CIM) or just integrative medicine (IM) is often used (Coulter et al. 2013). The 2007 National Health Interview Survey of more than 30 000 US adults found that 38% of American adults had used some form of CAM within the past year, spending nearly $36 billion on these practices and prod-ucts, mostly out of their own pocket (Nahin et al. 2009). In addition, it was recently shown that 44% of military members use CAM therapies (Goertz et al. 2013). Despite widespread use and dramatic claims of benefit for serious disease, relatively little has been definitively established regarding the efficacy, effectiveness and safety of the majority of IM practices (Coulter et al. 2010).

In order to select the most appropriate interventions from any practice, whether con-ventional, CAM or IM, the first question is often “What works?” when deciding what to do, pay for or avoid. As simple as this ques-tion is to ask, attempts to answer it for any particular treatment are often complex. This is true whether the question is applied to a product, practice, programme or policy, and for any particular outcome, be it cure, enhanced well- being, satisfaction or cost. Because of this

complexity, answering this question requires a careful design and the sequenced application of a set of methodologies.

This article describes a streamlined, system-atic, phased process for determining “what works” for any treatment – be it a programme, practice or product – by breaking down the process into a subset of corollary questions designed to piece together the overall picture of the treatment and its outcomes (Crawford et al. 2015; Coulter et al. 2016; Hilton & Jonas 2017). The approach is called the Scientific Evaluation and Review of Claims in Health Care (SEaRCH™), and uses three methods combined in a coordinated fashion to help determine what works in healthcare. The first method is the Claims Assessment Profile (CAP) (Hilton & Jonas 2017), which seeks to clarify the healthcare claim and question. The second method is the Rapid Evidence Assessment of the Literature (REAL©), which uses streamlined systematic review methods to determine the current state of the evidence (Crawford et al. 2015). The third method involves the structured use of expert panels (EPs) (Coulter et al. 2016) in order to deliver evidence- informed decisions to the end user in a transparent fashion.

SEaRCH has been developed over a number of years with input from scientists, practitioners, healthcare administrators and policy- makers, and it has been “field tested” on multiple treatments and claims (Buckenmaier et al. 2014; Costello et al. 2014; Attipoe et al. 2015; Crawford et al. 2015, 2016a, 2017; Boyd et al. 2016a, b; Coulter et al. 2016). This validation testing has been done on existing practices in areas of behav-ioural medicine, self- care, nutrition, lifestyle programmes and CIM. However, the principles of this framework are drawn from general scientific evaluation methods, and are applicable to any healthcare claim, whether about a pro-gramme, practice or product already in use. Its value is demonstrated not so much in examining new theories, but in analysing existing practices that have not been fully evaluated or validated. This article describes the evolution of SEaRCH as an organized framework, the sequences of corollary questions and methodologies that make it up, and the approaches developed to

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answer these questions and synthesize their information for determining “what works” in healthcare. Through collaboration and partner-ships, it is hoped that this organized framework can be improved and implemented more widely to deliver evidence- informed knowledge of what works in healthcare.

Evolution and development of SEaRCHTypically, the scientific process begins in the laboratory or with a new technology, and then moves forward through Phase I, Phase II, and finally, Phase III clinical trials. This process can take many years and cost hundreds of millions of dollars. Thus, many promising practices (even perhaps the best practices) never make it through this process. In recognition of this fact, researchers and funding agencies have taken the pragmatic approach of occasionally mov-ing into Phase II and III trials before perfect information regarding mechanisms of action is available. These trials can still often take 5 years or more to complete, and cost tens of millions of dollars. Many of the most promising CIM practices (perhaps even the best practices) are not commercially profitable, and so will never be supported at such levels or delivered to the public. In addition, a number of such trials have been performed, and the results have been nega-tive (Jonas et al. 2013). It is, therefore, impera-tive that the best choices possible are made regarding specific treatment protocols, including dosing, duration and frequency of treatment. In the past, funding agencies such as the US National Institutes of Health (NIH) and the Department of Defense have relied upon infor-mation derived from evidence- based reviews, as well as public health significance and best case series, to develop Phase III clinical trial initia-tives (NCCAM 2011). The latter, however, are risky and expensive without adequate pilot data and systematic review evidence. Clinical trials of a more modest size help to develop preliminary tools and information on appropriate outcomes measures, feasibility of data collection, patient burden and effect size. Prospective studies with appropriate control groups collect preliminary

data, and assist in the development of both mechanistic/preclinical studies and larger- scale RCTs.

SEaRCH was developed over a number of years with the support of the NIH, the Centers for Disease Control and Prevention (CDC), and the US military. These methods included field investigations and the Prospective Outcomes Evaluation Monitoring System (POEMS) system used by the National Cancer Institute. What was needed was an organized way to move the CIM field forward through rigorous evaluation of actual clinical practice. SEaRCH development has grown through public–private partnerships over the past decade. The original concept was conceived in 1996, through a governmental mandate to the NIH, to docu-ment and evaluate alternative therapies and practices. Through collaboration with the CDC, the Office of Alternative Medicine (OAM) at the NIH developed the Field Investigation and Practice Assessment (FIPA) programme in 1997, and conducted evaluations of dozens of CAM practices around the world.

The concept of conducting CAM research within the practice setting is not unique. From 1995 to 1999, the NIH OAM sponsored the FIPA programme, under which OAM con-ducted 33 site visits of CAM practices. The major goals of this programme were to: (1) contact CAM and/or CIM and conventional practices that offered promising therapies for specific diseases; (2) assess the feasibility of conducting a practice outcomes assessment/monitoring programme or an RCT; and (3) screen unusual cases to see if sufficient data existed to engage in retrospective and/or pro-spective outcomes studies. The OAM followed up on initial site visits by contracting with the CDC to conduct formal field study investiga-tions of promising CAM clinical practices. An example of this work is a field investigation on naturopathy in the treatment of menopause symptoms by Cramer et al. (2003). In addition, OAM, in conjunction with the National Cancer Institute, established the Cancer Advisory Panel for Complementary and Alternative Medicine to advise them on conducting a Best Case Series programme (IMCUCAMAP 2005).



This programme led to the development of large- scale RCTs to study therapies that offered promise for cancer outcomes, and evolved into using the Best Case Series design to screen other therapies making claims of benefit for cancer patients. While case series have been conducted by investigators in a number of countries on local treatments for serious dis-ease, the research methodology used in these studies is often inadequate for supporting objective conclusions. SEaRCH addresses this inadequacy by pulling from and organizing the best of these methods, and gathering the research expertise necessary at the local and international levels to collect sound data on these practices.

A variation of the NIH FIPA programme was extended in 2003 under the congression-ally mandated CAM Research for Military Operations and Health Care programme run by the Samueli Institute. It was further developed under the name Epidemiological Documentation Service (EDS) through a subcontract to the National Foundation of Alternative Medicine. The EDS was later taken over by the Samueli Institute, where it was further developed, redesigned and renamed SEaRCH. The goal of this latter redesign was to enable more rapid and complete throughput and assessment of not only CAM practices, but any practice, conventional or unconventional, already in use and claiming a particular benefit. Part of the improvement in SEaRCH was done in collaboration with the RAND Corporation, which houses a Samueli/RAND programme on policy research in integrative health. This collaboration enhanced the descriptive and qualitative section of SEaRCH (Hilton et al. 2016). In addition, the Institute has begun to incorporate EP methodology, adapted from RAND’s “appropriateness” process to complete the SEaRCH design described here (Shekelle et al. 1991; Coulter et al. 2016).

Prospective outcomes studiesOne method not incorporated into SEaRCH in its current version is the prospective clinical trial. Walach (2001) has developed a cogent

argument for the value of prospective out-comes studies. He cautions against rushing to placebo- controlled RCTs without sufficient information on critical issues such as healing rates, diseases that might respond best to the therapy, time to initial improvement, dose and so on. To address this, an approach was pro-posed called the prospective outcomes docu-mentation system (PODS) for getting informa-tion on practice delivery and effectiveness in real- world settings. Unlike most prospective studies, PODS (and the similar method developed by NCI called POEMS) captures prospective data without interfering or altering the clinical practice as a whole. Examples can be found in prospective outcomes studies in the chiropractic literature. Hayden et al. (2003) conducted a prospective cohort study of chi-ropractic treatment for paediatric patients with low back pain (LBP) and concluded they had a favourable response to chiropractic manage-ment. Nyiendo and colleagues reported a series of positive findings from their practice- based study of chiropractic for medical patients with LBP (Nyiendo et al. 2001; Haas et al. 2002; Stano et al. 2002).

Perhaps the best examples of prospective outcomes evaluations have occurred in the area of CAM treatments for cancer. Richardson et al. (2000, 2001) collected prospective out-comes data from several oncology clinics that take a CAM approach to cancer therapy. They reported on both the feasibility and challenges of conducting outcomes research of CAM therapies in cancer clinics. Pfeifer & Jonas (2003) used a PODS approach to investigate immunoaugmentative therapy (IAT), a CAM therapy used by thousands of cancer patients that had not been previously evaluated in a systematic fashion for either safety or effi-cacy. This PODS demonstrated no significant improvement in cancer survival following IAT over expected outcomes when all patients were followed up. A previous best case series had reported positive outcomes for IAT (Shekelle et al. 2003). Often a PODS or RCT is recom-mended by a research panel after a claim is assessed by SEaRCH. That will be demon-strated later in this article.

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SEaRCH process and frameworksThe SEaRCH process is drawn from two primary scientific methods for evaluation of therapeutic claims in medicine and healthcare. The first, called the Evidence House (Jonas 2001; Jonas & Guerrera 2015), is a modi-fication of the standard evidence hierarchy used by multiple groups, including clinical trialists, systematic reviewers, clinical guide-line developers and federal agencies dealing with product regulation (e.g. the Food and Drug Administration), comparative effective-ness research (e.g. the Agency for Healthcare Research and Quality) or patient- centred research (e.g. the Patient- Centered Outcomes Research Institute) (Fig. 1).

In the Evidence House framework, knowl-edge elements are matched to particular meth-ods, and then these methods are matched to the goals of stakeholders and decision- makers, such as patients, practitioners, researchers or regula-tors. These are placed in a semi- hierarchical arrangement, with laboratory and qualitative research as the foundational methods seeking to collect new information, with the goals of moving them toward determining their “reality” and “relevance”, respectively. Evidence is then added vertically through four other, more com-plex approaches needed to build on these two types of knowledge. Since SEaRCH is focused on existing practices or products, it draws from qualitative, observational, controlled trial and systematic review approaches to construct a “mixed- method” sequence specifically designed for the central question of interest: “What works in healthcare?”

The second framework that was used in the design of SEaRCH is the Methodology Mandala© illustrated in Fig. 2. Created primarily to facilitate better management of compara-tive effectiveness research, the Methodology Mandala uses a circle of questions (inner ring) with a matching set of methods (outer ring), each integrated into a set of coordinated approaches to the questions asked in each knowledge domain. Specifically, the current SEaRCH design draws from and streamlines

the evaluation of methods beginning at the top of the mandala through practice descriptions in order to answer “What is it and how is it being applied?” through a method called the CAP, and then uses systematic review methods to answer “What is the current state of the evidence?” through a streamlined process called the REAL. Then it selects application and implementa-tion methodologies to answer the question “How can the practice be translated to other settings?” using structured, evidence- informed EPs. Together, these methods, which are all aimed to answer specific questions about what works, are arranged into a simplified, phased methodological process (Table 1). In other

Figure 1. The Evidence House.

Figure 2. Research Methodology Mandala©.



words, each method is designed to answer the particular sub- questions needed to complete the knowledge necessary to achieve the “What works in healthcare?” goal. The outcome of this process can be applied to decisions about the appropriateness of a practice, policies for pay-ment and implementation, and/or in building a logical research agenda. The use of SEaRCH methodology may point to the use of other methods listed around the mandala, such as the PODS or randomized trials, and ultimately, the translation of the evidence into public value.

SEaRCH methodsThe current version of SEaRCH consists of three primary methods: the CAP, REAL and EP processes. The CAP methodology seeks to describe the practice and clarify the health-care claim/question. It does this by accurately describing the practice, precisely defining what it claims to do, and determining readiness, capacity and the resources involved in further research or evaluation (Hilton & Jonas 2017). The second method is the REAL, which is a streamlined, efficient systematic review process conducted to determine the quantity, quality and strength of evidence, and risk/benefit for the treatment, as reflected in current research. The REAL provides the evidence base of a healthcare claim, so that groups can identify the gaps and next steps needed in a field (Crawford et al. 2015). The final method involves the struc-tured management of EPs for making value judgements about the use of current evidence (Coulter et al. 2016). There are several types of EPs, depending on the purpose and need. A clinical EP focuses expert opinion on the appropriateness of a given clinical practice or product for clinical use. A research EP focuses

expert opinion on research directions for a practice or product. A policy EP focuses on making the evidence- based policy judgements needed to direct implementation of a practice claim. Patients can be incorporated into the panel process for making more patient- centred decisions, which is called a patient EP.

Method for addressing the sub- questions

Describing the interventionEach of the above methods is designed to pro-vide the types of information needed to answer “What works in healthcare?” These are posed as a series of sub- questions that must be addressed in order to have a full evidence base for the answer. The first sub- question involves defining and describing what the intervention is for any claim. If the intervention is a single chemical agent, this becomes relatively simple, includ-ing standardization and quality control of the product, and isolation of its effects in random-ized, placebo- controlled trials. If the product is a combination of chemicals, such as a herb or supplement, quality control and the issues of synergy of product components multiply the complexity logarithmically. If the intervention is a practice, then variation in the practice adds increased complexity to the description. For example, a surgical procedure may be described in uniform terms, but delivered in a variety of ways. A procedure such as acupuncture, where different philosophies and individualization of treatment occur, also adds complexity. If an intervention involves a combination of practices customized to the particular patient involving, for example, a product for delivery, a method of education and a behavioural change (such as a

Table 1. Scientific Evaluation and Review of Claims in Health Care (SEaRCH) framework

Query SEaRCH method Outcome

What is it? How is it applied? Claims Assessment Profiles and stakeholder engagement

Detailed description of practice, process and reported outcomes

What is the current evidence? Systematic reviews Summary of the evidence supporting practice or product

How can the practice be utilized? Expert panels Detailed outline for next steps in research or clinical application

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lifestyle change), this further increases variations in delivery. If the intervention requires the com-pliance of the patient or participant, behavioural changes, or changes in attitude and expectation, the key components of the “it” (the interven-tion or treatment) may be difficult to measure, and so may be missed in an evaluation. Multiply this complexity again if there are multiples of interventions in a policy guideline attempting to optimize and coordinate various approaches. These types of interventions – product, prac-tice, programme and policy – layer on each other, and rapidly increase the complexity and variability of delivery, measurement and analysis. The first methodological segment in SEaRCH – the CAP – is designed to address this complexity. The CAP provides an approach to determine what the “it” is for answering the question of “What works?” A full description and examples of the CAP method can be found in detail elsewhere (Hilton & Jonas 2017). The outcome of a CAP is a full description of the intervention, and its hypothesized outcome and impact on the claim.

Describing the outcomesIn addition to answering the question of what the “it” of the intervention is, the question of what impact “it” has becomes another sub- question the CAP addresses. This is the question of “It works for what?” or “What is (are) the claimed or hypothesized outcome(s) from the treatment?” An outcome might be a defined change in a biochemical parameter, such as cholesterol, or it might be the elimi-nation of pathology, such as a tumour, or it might be the alleviation or elimination of an illness, as defined by a complex experience of symptoms or a functional ability. If the outcome falls into a more elusive or subjec-tive category, such as wellness or prevention, it becomes more complex and difficult to measure. For example, consider how wellness is defined: “Who wants it, in what context and over what time period?” Depending on the stakeholder, the outcome may have nothing to do with individual health at all. Common outcome questions include “What is the cost?”,

“How many people are getting the service?” or “How does it compare with some other intervention?” Some of these outcomes may or may not be of particular interest to a patient or their family. The involvement of key stake-holders throughout each segment of SEaRCH, not only the CAP, but also the REAL and EP, frames the outcomes to ensure relevance for the end user (Crawford et al. 2015; Coulter et al. 2016; Hilton & Jonas 2017).

Describing the populationAnother corollary question is “What works for whom?” Is the outcome something that will be used by or for a specific group? For example, cancer survival and a longer life might be the main goal of the medical profession for cancer patients. However, in an elderly population or those undergoing a serious intervention with many side effects, this may not be the outcome of most interest to a patient. Patients may be more interested in quality of life, or achieving specific lifeline goals.

Describing the comparisonsFinally, the most complex corollary question of all may be “How does it work when compared to what?” To determine if an intervention is producing a value relative to other inter-ventions requires that they be compared on outcome, adverse effects, feasibility, preference and cost, both human and economic. That is, what is the overall cost- value of two different interventions? A rational approach to such a comparison can only be conducted when the primary intervention is fully described in the CAP (Hilton & Jonas 2017). For example, if the intervention is a chemical, it means comparing it to the same treatment without the chemical. If the intervention is a practice or a programme, it means comparing it to a patient receiving a different practice or programme, or receiving no practice or programme. The first of these comparisons is called “efficacy,” and the second of these comparisons is called “comparative effectiveness”. These are very different types of evidence, and working with key stakeholders to decide what is the most meaningful and useful



evidence needed is essential in framing research questions and agendas.

Design of SEaRCHGiven the complexity of answering the primary question of “What works?”, and the sub- questions of “What is it, for what, for whom and compared to what?” that are essential for ensuring useful evidence, it is little wonder that so few existing interventions (conventional or complementary) are adequately evaluated. Often, some of the sub- questions are answered, but without the full picture of evidence needed to answer the primary question of “What works?” The CAP helps to define clearly with the stakeholders involved the answers to those essential questions. The REAL comes into play for determining “What is the current evidence?” to support the “it”, and clarifying the “What, for whom and compared to what?” issues. This clarification is called Population, Intervention, Control/Comparator and Outcomes (i.e. the PICO framework for systematic review) (Richardson et al. 1995), where the evidence of interest is clearly defined with the key stakehold-ers upfront, and a streamlined process applied to determine the evidence base for the claim rigor-ously and objectively. Finally, the EP process allows decision- makers in healthcare – policy- makers, researchers, clinicians and patients – to weigh in on making complex decisions, but with good evidence as a basis.

Aligning the components of SEaRCHThere is currently no systematic, streamlined and inexpensive way of going from one sub- question to another in an organized manner in healthcare decisions. SEaRCH is designed to do that. SEaRCH creates a linear, phased set of methods to answer each sub- question. To preserve rigour, each method is applied using current standards of evidence quality.

Streamlining judgement, managing bias and enhancing rigourIn order to achieve a streamlined process for incorporating judgements about relevance,

SEaRCH uses two important systems. First, it uses a structured EP process for the judge-ment process. That process can focus on which research approaches are needed (research EP), what is appropriate for clinical practice based on existing evidence (clinical EP) or which implementation guidelines are needed (policy EP), or determine patient needs, preferences and perspectives (patient EP). Whatever its composition, the EP uses a semi- quantitative Delphi method. The method involves extracting judgement from the stakeholders (e.g. clini-cians, researchers, policy- makers and patients) in a way that allows for independent, blinded opinions from diverse perspectives about the relevance and use of the evidence presented. This reduces the bias that is often introduced when EPs are employed, and at the same time, accesses the best expert judgement grounded in evidence. Secondly, SEaRCH uses an informa-tion technology platform throughout its design that increases efficiency and reliability, and ensures complete transparency. Through the use of an online technology platform designed specifically for this process, SEaRCH is able to deliver results faster with improved accuracy and reliability, and provides a complete audit trail of all changes made during each step of the process. Samueli has applied this system to integrate across the SEaRCH steps so that all data can be captured remotely in the system, and the reports shared across the three steps. The technology alone can reduce the cost and time by threefold. Figure 3 graphically illustrates the design of SEaRCH, and how the sub- questions are answered in each step.

Each of these methods (the CAP, REAL and EP) have been described in detail in previous publications (Crawford et al. 2015; Coulter et al. 2016; Hilton & Jonas 2017). The approach is designed for practices that are already being used and delivered, such as those in primary care, traditional (indigenous) practices, market- derived products and procedures, military medi-cine, and CAM/CIM. It is especially useful in controversial areas where independent analysis, bias reduction, transparency and balanced input from diverse stakeholders are needed. In addi-tion, SEaRCH is useful for the evaluation of

W. B. Jonas et al.


self- care practices such as weight loss, dietary supplements, and stress and pain management programmes that people adopt and use for self- care (Buckenmaier et al. 2014; Costello et al. 2014; Attipoe et al. 2015; Boyd et al. 2016a, b; Crawford et al. 2016a, b). The approach has been presented at national and international conferences, in research methodology forums, and through workshops and online training. The goal is to be able to use this method in any area of healthcare when confronted with the chal-lenging question of “what works” in healthcare.

ConclusionsThis article describes the overall SEaRCH process and its components. These include the CAP, the REAL and the EP. The CAP process provides a detailed description of the treat-ment and claim. The REAL process provides a rigorous assessment of the current literature to support making evidence- based decisions. The EPs are the final method used for gaining struc-tured insight into what experts believe about the implications of the evidence for a given treatment or approach. Together, these methods can be used to address the question of “what works” in healthcare in a rigorous yet efficient and stepwise manner. In summary, SEaRCH is a series of methodologies for evaluating claims about the prevention or treatment of disease, and/or for improving health. Through its sys-tematic, streamlined, protocol- driven process,

it can critically evaluate claims for healthcare. Consumers, medical and healthcare communi-ties, and researchers can benefit from SEaRCH by using it to evaluate healthcare claims to determine those with the greatest promise for treating disease and improving health.

AcknowledgmentsThe authors would like to acknowledge Mr Avi Walter for his assistance with the overall SEaRCH process developed at the Samueli Institute, and Ms Viviane Enslein for her assis-tance with manuscript preparation. In addition, the authors would like to acknowledge all partners who were involved in the evolution and development of the SEaRCH framework. This project was partially supported by award number W81XWH- 08- 1- 0615- P00001 (United States Army Medical Research Acquisition Activity). The views expressed in this article are those of the authors and do not neces-sarily represent the official policy or position of the US Army Medical Command or the Department of Defense, or those of the National Institutes of Health, Public Health Service, or the Department of Health and Human Services.

Author disclosure statementNo competing financial interests exist.

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Figure 3. Scientific Evaluation and Review of Claims in Health Care (SEaRCH™) overview.



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Wayne B. Jonas MD, Cindy Crawford BA, Lara Hilton MPH and Pamela Elfenbaum PhD all worked for the Samueli Institute in Alexandria, VA, USA. Wayne is now affiliated with H&S Ventures, which is also based in Alexandria. Pamela also works for the RAND Corporation in Santa Monica, CA, USA.

This is an open- access article distributed under the terms of the Creative Commons Attribution- Noncommercial Licence (http://creativecommons.org/licenses/by- nc/4.0/), which permits noncommercial use, distribution and reproduction in any medium, provided the original author(s) and source are credited.

This article is reprinted from The Journal of Alternative and Complementary Medicine, pub-lished by Mary Ann Liebert, Inc. Original publication: The Journal of Alternative and Complementary Medicine, Vol. 23, No. 1, pp. 18–25 (January 2017).


Correspondence: Rosemary Lillie, West Wimbledon Physiotherapy Clinic, 532 Kingston Road, Raynes Park, London SW20 8DT, UK (e- mail: [email protected]).


MERIDIAN MASTERCLASS

The Spleen meridian: the foot Tai Yin channel

R. LilliePrivate Practitioner, London, UK

AbstractThis article presents an overview of the Spleen meridian, and its potential clinical uses for the physiotherapist. The channel theory is introduced, and an outline of the functions of the Spleen according to principles of traditional Chinese medicine (TCM) is given. The course of the Spleen meridian is explained, and key points are examined in depth. The principles of TCM are examined in conjunction with Western concepts in order to demonstrate the clinical reasoning behind the selection of points along the course of the channel.

Keywords: acupuncture, Spleen meridian, traditional Chinese medicine.

IntroductionAccording to traditional Chinese medicine (TCM), vital energy (Qi) flows through a sys-tem of 12 channels or meridians, regulating bodily functions. Each meridian is associated with an organ or function. The 12 organs are divided into six pairs, one being yin (Zang) and the other yang (Fu). The Spleen (Pi) is a Zang organ and is paired with the Stomach (Fu). In Five Element Theory, these organs belong to Earth. Each organ is kept in check by another one: the Spleen is controlled by the Liver, and in turn, it controls the Kidneys. The Stomach and Spleen are the root of Post- Heaven Qi, which derives from the nourishment that food and fluids take into the body, and also the origin of Qi and Blood. Therefore, the Stomach and Spleen nourish and indirectly tonify all the other organs.

In TCM, the functions of the Spleen are held to be transformation and transportation.

This organ controls the digestion of food, and is responsible for the intake of fluid. It takes the output from the Stomach, transforms this into Blood (by providing the Heart with energy), fluids and Qi, and moves these around the body. The Spleen assimilates the Qi from nutrition, and nourishes and moves the Blood. If it fails to control Blood, excessive bleeding can occur. It also controls the ascension of Qi. If Qi cannot ascend, things are not held in place, giving rise to varicose veins, prolapse or poor muscle tone. The Spleen also governs the connective tissue, and holds the organs in place. It controls Blood, muscles and limbs, providing vigour and bulk to the muscles. It also houses the intellect, i.e. how we process information and think things through. The Spleen produces Blood, which the heart depends upon, and with the Stomach, is the main support for the Heart. It opens to the mouth, controls the sense of taste and is manifested in the lips. It controls saliva. In cases of Spleen Qi stagnation, typi-cal signs are chewing or picking the lips. The external climatic influence is Dampness, and the internal emotional influence is depression.

The Spleen meridian


In cases of perverse energy invasion, typical symptoms include abdominal distension with flatus, vomiting after meals and stiffness at the root of the tongue, and internal causes result in diarrhoea, pain in the cardiac area, a generalized feeling of stiffness and pain at the root of the tongue.

Abdominal symptoms of excess in the Spleen channel result in shooting pains in the abdomen, and deficiency results in distension of the belly.

Factors that affect the Spleen include over-thinking, poor diet (e.g. consuming too many dairy products or fried foods), external Damp and problems with the Liver, especially Liver Qi stagnation. Remember, the Liver controls the Spleen.

Pathological conditions associated with this organ include full/excess (e.g. Damp Heat or Damp Cold invasion), or empty/deficiency (e.g. Spleen Qi deficiency or descent, Spleen blood deficiency, Spleen yang deficiency, Spleen yin deficiency, Spleen and heart defi-ciency, or Spleen and lung deficiency with lung phlegm).

Problems with the Spleen (Zang) are gener-ally treated using the coupled Stomach (Fu) meridian. This follows the general rule of basic yin–yang theory. Yin is the solid material basis for the yang function of moving Qi. Again, in general, yin is better for tonifying, and yang for draining. Therefore, it is most appropriate to treat Spleen excess, Heat and stasis by using the Stomach meridian. Conversely, for deficient- type digestive disorders that may also involve Cold in the Stomach channel, the Spleen merid-ian is most effective channel to use in treatment (Wang & Robertson 2008).

The sources for the acupuncture points and their functions included in this masterclass have been taken from the books and websites listed in the reference section (Deadman et al. 1998; Ellis 1999; Maciocia 2005, 2007; Betts 2006; Wang & Robertson 2008; Woodley 2009; Dorfman 2017; Oriental Medicine 2017). Because of the present author’s special interest in women’s health, she has highlighted those taken from Betts (2006), since these are specific to the use of acupuncture during pregnancy and childbirth.

The course of the Spleen meridianThe primary channel of the Spleen meridian begins on the medial side of the tip of the big toe, runs along the medial border of the foot and ascends behind the medial malleolus (Fig. 1). It then travels up the medial aspect of the leg into the lower abdomen, where it ascends again, terminating in the seventh intercostal space. A branch travels across the diaphragm, along the oesophagus and ends in the middle of the tongue. Another branch goes through the diaphragm and links with the heart (Fig. 2).

Clinical application of the meridian and acupuncture pointsThe connections of the primary channel of the Spleen meridian are as follows:

• It connects with the following Zang Fu organs – the Spleen, the Stomach and the Heart.

• At Spleen (SP) 4 (Gong Sun), the connecting channel links with the Stomach meridian.

• It meets the Lung meridian at Lung 1 (Zhong Fu).

• It connects with the Conception Vessel (Ren Mai) meridian at Conception Vessel (CV) 3 (Zhong Ji), CV4 (Guan Yuan) and CV10 (Xia Wan).

• It passes through the lateral costal region.

• It connects with the Heart Zang.

• The Spleen meridian sinew channel con-verges at the external genitalia, and binds at the umbilicus.

Spleen 1: Yin Bai, “Hidden White”Location: The point is located 0.1 cun proximal to the corner of the nail of the big toe.

Innervation: On the anastomosis of the dorsal digital nerve derived from the superficial pero-neal nerve, and the proper digital branch of the medial plantar nerve. The significance of this is that this point has rich innervation from the nervous system, and consequently, responds well to stimulation.

R. Lillie


Dermatome segment: L5.

Notes: Spleen 1 is the Jing- Well point of the Spleen meridian. Jing- Well points are the most distal Shu or transporting points of a channel, and are where Qi emanates from, like water in a well. This is one of the major points for strengthening the Spleen’s function of holding Blood in its proper place. Therefore, it is very useful for controlling bleeding, especially in the Lower Jiao. Examples of this include any uterine bleeding, or blood in the urine or stools.

Spleen 1 is also useful for treating such prob-lems in the Upper Jiao, such as nosebleeds or vomiting blood. The technique of “pricking to bleed” is often used to control bleeding caused by Spleen deficiency.

The Spleen also controls dampness, and in turn, swelling. Abdominal distension and swelling in the limbs can occur in Spleen deficiency. Because the Jing- Well point is the most dynamic point in the channel, stimulating it can be particularly effective when treating oedema, including oedema that is secondary

Figure 1. Course of the Spleen (SP) meridian, the foot Tai Yin channel: lower limb (AACP 2015).

The Spleen meridian


to steroid use, and also that caused by system failures.

As a Jing- Well point and because of the Spleen meridian’s links with the Heart, SP1 can also be used to treat heart agitation, manic depression and insomnia. It can also be used for loss of con - sciousness, like Governor Vessel 26 (Shui Gou).

Good combinations include: SP1 with Bladder (BL) 40 (Wei Zhong) for severe nosebleeds; SP1 with Stomach (ST) 45 (Li Dui) for nightmares; and SP1 with Liver (LR) 1 (Da Dun) for loss of consciousness.

In the present author’s experience, Jing- Well points are not used very often because of where these are located and the intense reac-tions produced by needling. Therefore, the beneficial effects of stimulating these points are not utilized sufficiently.

Spleen 2: Da Du, “Great Metropolis”Location: Spleen 2 is found on the medial side of the great toe, anterior and inferior to the first metatarsophalangeal joint.

Figure 2. Course of the Spleen (SP) meridian, the foot Tai Yin channel: trunk (AACP 2015).

R. Lillie


Innervation: On the proper plantar digital nerve arising from the medial plantar nerve.


Notes: This is the Ying- Spring and Fire point of the Spleen meridian. These points are the principal ones for clearing Heat in the channel. Hence, SP2 is used in cases of Damp or in chronic conditions. Its primary use is to reduce excess patterns.

This is a particularly useful point for treating swelling and a feeling of heaviness, and also abdominal distension and insomnia. It is also a useful distal point in the treatment of lumbar pain.

Spleen 2 is used in combination with SP3 (Tai Bai) in local treatment for arthritis of the first metatarsophalangeal joint, which is a com-mon condition seen in most physiotherapy clinics.

Spleen 3: Tai Bai, “Supreme White”Location: The point is located posterior and inferior to the head of the first metatarsal bone.

Innervation: At the branches of the saphenous and superficial peroneal nerves. Purely sensory in function, the saphenous nerve is the largest cutaneous branch of the femoral nerve.


Notes: Spleen 3 is the Shu- Stream, Yuan- Source and Earth point of the meridian, and it connects with ST40 (Feng long). The Shu- Stream is the point in the channel where flow is stronger and deeper, and the movement of Qi can transport things; for example, external pathogens can be carried into the interior. However, to counteract this, defensive (Wei) Qi gathers here. The Shu- Stream point in yin organs is also referred to as the Yuan- Source point. This is where the source Qi of the Spleen is stored in the merid-ian. Consequently, stimulation of this point can

build strength and energy in its related meridian or organ system.

Spleen 3 has a very powerful action on regulating the Qi of the Spleen and Stomach, particularly when there is a deficiency. It har-monizes the flow of Qi in the Middle Jiao, and regulates both the Lower and Middle Jiao.

General conditions that SP3 can be used for include abdominal pain and distension, diar-rhoea, vomiting, vertigo, chronic fatigue, and pain and tension in the thorax and epigastric region. It can also help in cases of constipation in which Qi is insufficient to move and activate the bowels. If Dampness or Damp Heat invade the body, which is common when there is under-lying Spleen deficiency, SP3 is indicated in the treatment of heaviness of the body with pain in the knees or lumbar pain. Avoid using Yuan- Source points in pregnancy, because original Qi should be directed to the foetus (Betts 2006).

Useful combinations include: SP3 and ST36 (Zu San Li) for tonifying the Spleen and Qi; and SP3 and ST40 for eliminating Dampness and phlegm.

Spleen 3 is a very useful distal channel point, and the present author finds that it can be effec-tive when treating back pain, especially if L4 is the source of the pathology since it lies within the L4 dermatome. Take care when needling because this is another sensitive point. The pre-sent author usually employs a smaller and finer needle to avoid causing too much discomfort for the patient (15 × 0.18 mm).

Spleen 4: Gong Sun, “Grandfather Grandson”Location: The point is found on the medial border of the foot, in a depression immediately distal to the base of the first metatarsal bone.

Innervation: At the saphenous nerve and the branch of the superficial peroneal nerve.


Notes: This is the Luo- Connecting point of the Spleen meridian, linking with ST42

The Spleen meridian


(Chong Yang), and the confluence point of the Penetrating Vessel. The Penetrating Vessel (Chong Mai) originates in the lower abdo-men (the uterus in women). It ascends along the spine, by way of the Kidney channel, up the throat and around the lips to the eye; it descends along the medial side of the lower leg, and also to the big toe. The Penetrating Vessel links the Stomach and Kidney merid-ians, and is known as the Sea of Blood. It acts as a reservoir for excess Qi and Blood, and also circulates the defensive (Wei) Qi and protects against external pathogens. It has no acupuncture points, but shares coalescent points on the meridians. Hence, Spleen 4 is an important regulator of the Penetrating Vessel, and helps to calm the spirit and regulate Qi in the Middle Jiao.

This point can be effective following abdominal surgery. It is also used to treat loss of appetite, indigestion with thin bowel move-ments, dysmenorrhea, abdominal distension and vomiting, and to relieve lower abdominal pain.

Spleen 4 regulates the Spleen, Stomach and Penetrating Vessel, and therefore, it is used to treat nausea in pregnancy (Betts 2006).

Good combinations include:

• SP4, Pericardium (PC) 6 (Nei Guan) and CV12 (Zhong Wan) for abdominal problems, nausea and vomiting;

• SP4, ST36 and SP10 (Xue Hai) for Blood stagnation; and

• SP4, CV6 (Qi Hai) and CV3 for stagnation of Qi and Blood, dysmenorrhea, and dif-ficult menstruation.

The significance of this point is the link with the Penetrating Vessel. This is important in the field of gynaecology. Spleen 4 is particularly useful in cases of blood pathology. With Blood stasis, the result is dysmenorrhea, i.e. painful periods. With Blood Heat, the result is menorrhagia, i.e. heavy periods. With blood deficiency, the result is amenorrhea, i.e. a lack of or scanty periods. All these conditions can be effectively treated by stimulation of the opening and coupled points SP4 and PC6, together with Kidney 14 (Si Man) and SP10.

Spleen 5: Shang Qiu, “Shang Mound”Location: Spleen 5 is found in the hollow anterior and inferior to the medial malleolus.

Innervation: In the medial crural cutaneous nerve, a branch of the saphenous nerve, and the branch of the superficial peroneal nerve.

Dermatome segment: L4

Notes: This is the Jing- River and Metal point of the Spleen meridian. The Jing- Well is a place through which Qi flows, and SP5 can be used to treat coughs and asthma caused by pathogenic Cold and Heat. The Metal point on a meridian is also known as the sedation point, and it is used in cases of excess energy within the meridian, i.e. hot, acute conditions. Needling SP5 particularly benefits the sinews and bones. It is a good local point for treating ankle joint problems.

Spleen 6: San Yin Jiao, “Three Yin Meeting”Location: This point is found 3 cun above the medial malleolus, just posterior to the tibial border.

Innervation: Superficially, this is the medial crural cutaneous nerve; deeper, in the posterior aspect, this is the tibial nerve.


Notes: Spleen 6 is reputedly the third most com-monly used point in acupuncture treatments. It is the royal point for gynaecological problems. It is also the meeting point of the three yin channels of the leg, i.e. the Spleen, Liver and Kidney meridians, which are all influenced by it. Spleen 6 traditionally balances the yin and yang energy of the Kidney. It supports the abdomi-nal viscera, and therefore, is a master point for urogenital disorders including enuresis, and

R. Lillie


difficulty with urination. Stress incontinence is often the result of uterine collapse, and can be treated by reinforcing Qi at SP6.

This point is used to treat menstrual prob-lems, including irregular menstruation, uterine bleeding, menorrhagia, amenorrhoea, dysmen-orrhoea and leucorrhoea. Spleen 6 is a general tonification point for the body, and it can be stimulated to speed up uterine contractions during labour and relieve pain. It can be used for gastrointestinal problems (e.g. diarrhoea and abdominal distension), urogenital problems (e.g. impotence, frigidity and dysmenorrhea), allergic and immunological diseases, and skin disorders. Spleen 6 is a valuable point for insomnia because it helps to calm the mind (Shen). It can resolve Dampness, particularly in the Lower Jiao, includ-ing oedema and heaviness of the body.

Spleen 6 should be avoided in pregnancy, especially in combination with Large Intestine (LI) 4 (Hegu), LR3 (Tai Chong) and BL60 (Kun Lun) (Betts 2006).

Good combinations are:

• SP6 and SP9 (Yin Lin Quan) to eliminate dampness; and

• SP6 and CV12 to support the digestive system.

Any physiotherapist working in women’s health will find that SP6 is an invaluable point. It is very useful for treating any problems associated with menstruation, and is a good point to use in combination with LI4 for the promotion of labour. This is usually done by using chopsticks to apply acupressure at these points (Betts 2006). It is also very useful when treating incontinence, and a major point for oedema.

Spleen 8: Di Ji, “Earth Pivot”Location: Spleen 8 is found on the medial side of the leg, 3 cun below SP9 (Yin Ling Quan), at the posterior border of the tibia.

Innervation: This is the saphenous nerve, a branch of the femoral nerve (L2–4).


Notes: Spleen 8 is the Xi- Cleft point of the meridian, and the Spleen Qi accumulates most deeply in this area. For this reason, Xi- Cleft points are very effective in the treatment of diseases affecting their own meridian systems in which pain or bleeding is involved. Spleen 8 is effective in acute Spleen problems.

It is indicated for lumbago, menorrhagia, dys-menorrhoea and abdominal distension. Spleen 8 is not a point that the present author uses very often, but her research suggests that it is of value and perhaps she should make more use of it.

A good combination for acute dysmenorrhea is SP8 and LI4 with the addition of electroacu-puncture (Deadman 1998).

Spleen 9: Yin Ling Quan, “Yin Mound Spring”Location: This point is found in a depression just below the medial condyle of the tibia on a level with the tuberosity of the tibia.

Innervation: Superficially, different sources indi-cate either the medial crural cutaneous nerve or the saphenous nerve, a branch of the femoral nerve (L2–4); deeper, this is the tibial nerve.


Notes: This is the He- Sea and Water point of the Spleen meridian. He- Sea points represent places where rivers merge and enter the sea, and therefore, the flow of Qi is deeper and stronger here.

Spleen 9 is the main point for treating Dampness accumulating in the body because of a Spleen dysfunction. It is a good point for treating oedema, particularly swelling in the legs. Spleen 9 can also be used for abdominal pain and distension. If there is Damp Heat in the intestines leading to fresh blood in the stools, or if there are haemorrhoids, SP9 can help to resolve this. As a He- Sea point, it is indicated for perverse Qi flow, i.e. Qi flowing in the wrong direction (e.g. diarrhoea).

The Spleen meridian


Spleen 9 also opens the Water passages, moves Water and aids urination. Therefore, it is very useful for treating urinary problems, including enuresis (i.e. bed- wetting), urinary retention and painful urination. In cases of Spleen and Kidney yang deficiency presenting as nephritis, both SP9 and SP6 can help to eliminate Dampness and oedema. Spleen 9 clears Heat and resolves Dampness from the Lower Jiao, and therefore, it can be effective in the treatment of urinary tract infections.

This point can also treat vaginal discharge and itching, which are signs of Dampness in the genitals (Betts 2006).

As a local point to the knee, SP9 can be used in cases of Bi syndrome. In acupuncture terminology, Bi means obstruction; it may be wandering, painful, fixed or febrile. Most musculoskeletal disorders are grouped into one of the several Bi syndromes as a guide to the selection of acupuncture points. Spleen 9 can also be used to treat swelling in the knee.

It also can be used as a remote point when other points on the Spleen meridian are being treated.

The fact that SP9 is the Water point on this channel makes it particularly useful for treating Water problems, and it can be an invaluable body point for physiotherapists who treat con-tinence issues.

Spleen 10: Xue Hai, “Sea of Blood”Location: This point is found 2 cun proximal to the upper border of the patella at the highest point of vastus medialis muscle.

Innervation: This is the anterior femoral cutane-ous nerve, and the muscular branch of the femoral nerve.


Notes: The translation of the Chinese name indicates one of the major uses of SP10, which is in the treatment of Blood disorders. It can nourish, hold, cool and invigorate Blood. It also helps to stop bleeding and regulate menstruation.

Spleen 10 is good for painful periods because it invigorates Blood in the uterus.

This point is very useful for treating urticaria and skin rashes because it cools Blood in the skin. It is used for skin disorders that are hot and irritating.

Spleen 12: Chong Men, “Surging Gate”Location: Spleen 12 is located on the inguinal groove, in the depression of the saphenous hiatus, just lateral to the femoral artery. The point is slightly more than one hand’s width lateral to the anterior midline. Furthermore, it is about one finger’s width lateral to the palpable femoral artery and approximately 1 cun lateral to LR12.

Innervation: Superficially, this involves the femoral branches of the genitofemoral nerve from L1.


Notes: Spleen 12 is the place where the Spleen and Liver meridians meet, and the point of the yin linking vessel (Yin Wei Mai). It is con-nected to the Penetrating Vessel, and hence, it invigorates Blood and moves Qi. It also helps to subdue Chong Mai rebellious Qi, and can be used to treat foetus Qi rushing upwards to har-ass the Heart. Spleen 12 resolves Dampness in the bladder, and is particularly useful for treat-ing urination problems including retention, and painful and difficult urination. It is a good local point for treating the hip joint, and traditionally, can be used to treat inguinal hernias.

Spleen 15: Da Heng, “Great Horizontal”Location: This point is found 4 cun lateral to the umbilicus and level with ST25 (Tian Shu).

Innervation: Superficially, this is the lateral cuta-neous thoracic nerve from T11.

Dermatome Segment: T11.

Notes: Spleen 15 is an important point for treat-ing abdominal complaints. Because it regulates

R. Lillie


the Qi in the abdomen, it is useful for alleviating abdominal pain. It is also employed for chronic constipation caused by Spleen Qi deficiency. However, paradoxically, because SP15 can resolve dampness in the intestines, it can also be used to treat chronic diarrhoea with mucus in the stools.

Because this point strengthens the Spleen, it can be used to treat tiredness and sadness. By strengthening the Spleen, SP15 transports food essence to the limbs, and therefore, it can be used to treat cold and weak limbs.

Spleen 21: Da Bao, “Great Wrapping”Location: Spleen 21 is found on the mid- axillary line in the seventh intercostal space.

Innervation: This is the lateral cutaneous thoracic nerve from T6 or T7.

Dermatome segment: T6–7.

Notes: Spleen 21 is the great Luo- Connecting channel of the Spleen meridian. This is the point where a meridian splits off and links with its interiorly or exteriorly related meridian or organ system.

It helps to regulate the Qi in the chest, and therefore, is useful in treating breathlessness, chest and rib pain, and coughs.

It acts to invigorate the Blood in the Blood- Connecting channels via the Penetrating Vessel. Therefore, SP21 is useful in the treatment of pain across the whole body.

Finally, it benefits the sinews, and can be used to treat weak or flaccid limbs, or weak joints.

This is the final point on the Spleen meridian.

Points excludedThe following points have been excluded from the main body of the present article because these have more- limited uses, and hence, are not employed as frequently in clinical practice. The present author might use the points listed below occasionally, but these are more useful in TCM practice. Physiotherapists who are involved with

chest therapy would probably find SP18, SP19 and SP20 to be of value.

Spleen 7: Luo Gu, “Dripping Valley”This point is not commonly used in clinical practice, but it can resolve Dampness and pro-mote urination.

Spleen 11: Ji Men, “Winnowing Gate”Spleen 11 can be used for urinary problems including retention and enuresis.

Spleen 13: Fu She, “Abode of the Fu”This point can be used for abdominal pain, and pain in the thigh.

Spleen 14: Fu Jie, “Abdomen Knot”Spleen 14 can be used for stagnant or rebellious Qi in the abdomen.

Spleen 16: Fu Ai, “Abdomen Sorrow”This point is used to regulate the intestines.

Spleen 17: Shi Dou, “Food cavity”Spleen 17 is mainly used for local pain, and for treating food stagnation.

Spleen 18: Tian Xi, “Heavenly Stream”This point is used to treat problems of the breast, shortness of breath and hiccups.

Spleen 19: Xiong Xiang, “Chest Village”Spleen 19 is used for coughing and shortness of breath.

Spleen 20: Zhou Rong, “Encircling Glory”This point is used for chest problems including coughing, phlegm and shortness of breath.

DiscussionIt is unusual to find research papers that only examine a single acupuncture point, although there are exceptions such as PC6 and LI4.

However, there is a good overview of SP9 by Li Shi Zhen (1991) that goes into great depth about the conditions that can be treated by using this point.

The Spleen meridian


There are two articles that look at SP6: Kashefi et al. (2011) describe the use of this point to improve women’s general health; and Wong et al. (2010) examine its use in treating dysmenorrhoea.

The majority of research articles discuss Spleen meridian points in combination with others since this would be normal clinical prac-tice. Therefore, the most expedient method of researching the use of different acupuncture points would be to select a specific condition or pathology, and direct a search in this manner.

ConclusionThe Spleen meridian is extremely useful for any physiotherapist working in women’s health because of the influence of the Spleen on both Blood and Water. This makes it invaluable in treating menstrual problems, incontinence and swelling. It also has one of the key points used in treating hot and itchy skin conditions, and can be very effective for insomnia. The Spleen meridian is useful for treating musculoskeletal conditions in the legs and lower back, and this links well with the direct nervous innervation and dermatome distribution demonstrated above.

ReferencesAcupuncture Association of Chartered Physiotherapists

(2015) Acupuncture Foundation Course Manual, Version 2.4. Acupuncture Association of Chartered Physiotherapists, Peterborough.

Betts D. (2006) The Essential Guide to Acupuncture in Pregnancy and Childbirth. The Journal of Chinese Medicine Publications, Hove.

Deadman P., Al- Khafaji M. & Baker K. (1998) A Manual of Acupuncture. The Journal of Chinese Medicine Publications, Hove.

Dorfman B. (2017) Seattle Acupuncture – the Spleen Meridian. [WWW document.] URL ht tp ://sea t t l eacupunctureandcoach ing.com/seattle- acupuncture- the- spleen- meridian/

Ellis N. (1999) Acupuncture in Clinical Practice: A Guide for Health Professionals, 2nd edn. Nelson Thornes, Cheltenham.

Kashefi F., Khajehei M., Ashraf A. R. & Jafari P. (2011) The efficacy of acupressure at the Sanyinjiao point

in the improvement of women’s general health. The Journal of Alternative and Complementary Medicine 17 (12), 1141–7.

Maciocia G. (2005) The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists, 2nd edn. Churchill Livingstone, Edinburgh.

Maciocia G. (2007) The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs, 2nd edn. Churchill Livingstone, Edinburgh.

Oriental Medicine (2017) Point Theory. [WWW document.] URL http://www.orientalmedicine.com/point- theory

Wang J.- Y. & Robertson J. D. (2008) Applied Channel Theory in Chinese Medicine: Wang Ju- Yi’s Lectures on Channel Therapeutics. Eastland Press, Seattle, WA.

Wong C. L., Lai K.- Y. & Tse H.- M. (2010) Effects of SP6 acupressure on pain and menstrual distress in young women with dysmenorrhea. Complementary Therapies in Clinical Practice 16 (2), 64–69.

Woodley S. (2009) Points Database. [WWW document.] URL http://www.steve- woodley.co.uk/?content=pointsearch

Zhen L. S. (1991) Yinlingquan: SP- 9. The Journal of Chinese Medicine 36 (May), 5–9.

Rosemary Lillie BSc(Hons) MCSP is an advanced member of AACP who combines acupuncture with tra-ditional physiotherapy at her private clinic in London. She is also currently training in the practice of Chinese herbal medicine, which she believes will augment her approach to treatment.

Rosemary is a member of the Pelvic, Obstetric and Gynaecological Physiotherapy professional network, and has a special interest in pelvic pain in both men and women. She treats infertility and supports her patients throughout all aspects of pregnancy. Rosemary also treats incontinence, and finds that acupuncture is an important treatment modality for this group of patients. The Spleen meridian is particularly useful for women’s health issues.

She is a sponsor of Sutton United Football Club, and also has a particular interest in sports medicine and football injuries. Again, acupuncture plays an important part in her treatment.

Rosemary is the news editor of Acupuncture in Physiotherapy, and is always interested in hearing about any interesting information that members may come across.


Correspondence: Ms Suzanne Cronin, Rehabilitation Centre, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough TS4 3BW, UK (e- mail: suzannec [email protected]).


CASE REPORT

Acupuncture for the treatment of whiplash- associated disorder

S. CroninRehabilitation Centre, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK

AbstractThis case report describes the acupuncture treatment of a 37- year- old female suffering from whiplash- associated disorder. The rationale for using acupuncture alongside other physio-therapy modalities is discussed with reference to recent evidence and guidelines. Acupuncture was chosen to alleviate pain, and to facilitate the use of other physiotherapy techniques in order to improve movement and function. The outcome measures implemented included a visual analogue scale (VAS) for pain, the Oxford Scale, the Neck Disability Index (NDI) and range of motion. The subject completed six sessions of acupuncture on a weekly basis in a private physiotherapy setting. Her reported pain score fell from 7/10 to 0/10 on the VAS between the first and final assessments. There was also an improvement in the NDI score from 8/50 to 2/50. The proposed reasoning for this marked reduction in pain is discussed.

Keywords: acupuncture, pain, whiplash- associated disorder.

IntroductionWhiplash- associated disorder (WAD) is a debili-tating condition that accounted for approxi-mately 300 000 insurance claims in 2003 (Burton 2003, cited in Mercer et al. 2007), a figure that has no doubt risen since then.

This disorder results in soft- tissue and/or bony injuries following a rapid acceleration- deceleration movement of the head and neck, and can affect other areas of the spine (Moore et al. 2005). It can be complicated and worsened by psychosocial factors. Chronic WAD is asso-ciated with pain lasting for more than 6 months, and research has indicated that around 14–42% of sufferers go on to develop chronic pain (Barnsley et al. 1994).

A definition of the condition is contained in the guidelines produced by the Quebec Task Force on Whiplash- Associated Disorders (Spitzer et al. 1995, p. 22S):

“Whiplash is an acceleration- deceleration mechanism of energy transfer to the neck. It may result from a rear- end or side- impact motor vehicle collisions, but can also occur during diving or other mishaps. The impact may result in bony or soft- tissue injuries (whiplash injury), which in turn may lead to a variety of clinical manifestations called Whiplash- Associated Disorders.”

Hartling et al. (2001) graded the categories of WAD as follows:(0) no complaint about the neck and no physi-

cal sign(s);(1) neck complaint of pain and no physical

sign(s);(2a) neck complaint and musculoskeletal

sign(s);

Treatment of whiplash- associated disorder


(2b) neck complaint, musculoskeletal sign(s) and neurological sign(s); and

(3) neck complaint, and fracture or dislocation.

Although acupuncture is commonly used in physiotherapy, there is a limited amount of strong evidence for the most effective physio-therapy management of WAD, with guidelines recommending self- management strategies and highlighting any psychosocial factors (Verhagen et al. 2007; Williamson et al. 2009; NICE 2015a). In a systematic review, Verhagen et al. (2007) concluded that the then- current evidence did not provide confirmation of the most effective treatment for WAD, and suggested that active treatments are “probably” more beneficial than a more “passive” approach.

The Chartered Society of Physiotherapy (CSP) developed guidelines that recommend that individuals who are suffering from WAD should be provided with education on posture, the use of heat, and exercises to activate the deep neck flexor muscles and improve range of motion (ROM) (Moore et al. 2005). The authors of the guidelines reported that there was weak evidence for the use of acupuncture to treat this condition, and therefore, that they could not support or oppose its use. Additionally, an earlier review by White & Ernst (1999) found no evidence for the efficacy of acupuncture in the treatment of neck pain.

The National Institute for Health and Care Excellence (NICE) guidelines for the manage-ment of WAD concluded that there is weak evidence for the long- term effectiveness of physiotherapy treatments such as exercise and mobilization (NICE 2015a). Although the authors of this clinical knowledge summary were not confident that physiotherapy is of benefit for patients with WAD, this was in direct contradiction to other recommendations issued by the same organization, which suggested that acupuncture treatment is of short- term benefit for subacute and chronic neck pain. This evi-dence is detailed in the NICE guidelines for the treatment of non- specific neck pain (NICE 2015b) and low back pain (LBP) (NICE 2009).

There is growing support of the use of acupuncture in the reduction of neck pain (He

et al. 2004; White et al. 2004; Vas et al. 2006; Trinh et al. 2006; Willich et al. 2006; Witt et al. 2006; Fu et al. 2009). It has been proposed that needling activates the body’s own pain- relieving responses both locally and segmentally, and by having a central effect on the nervous system (White et al. 2008).

It has been suggested that acupuncture can modulate inflammatory conditions through an inflammatory effect (White et al. 2008). Needling has been shown to induce a phenotypic switch of muscle macrophages. This causes a reduction in pre- inflammatory cells and an increase in anti- inflammatory cells, and thus, facilitates a healing response (da Silva et al. 2015). Therefore, it has been hypothesized that promoting an inflam-matory cascade with acupuncture will induce a healing response and improve patient reha-bilitation. Omoigui (2007, p. 1169) stated that: “The origin of all pain is inflammation and the inflammatory response.” In chronic conditions like chronic whiplash, inflammatory mediators such as bradykinin can add to the sensitization of tissues, which will lead to a smaller stimulus triggering a pain response (Chopade & Mulla 2010). It is important that physiotherapists recognize the necessity of choosing the most effective treatments for WAD at the earliest stage possible in order to prevent the condition becoming chronic.

The evidence for the pain- relieving effect of acupuncture on these systems will be con-sidered in the rationale for the acupuncture point selection described later in the present paper. Acupuncture treatment was justified in this case in order to attempt to alleviate pain and maximize the potential for the subject’s rehabilitation.

Case reportBackgroundThe present subject was a 37- year- old female who was the mother of two teenage children. She worked full time as a desk- based admin-istrator, and attended Pilates classes and went swimming twice a week.

Three weeks before presentation, the subject had been involved a road traffic accident, during

S. Cronin


which her stationary vehicle was hit from behind by a car travelling at around 64 km h−1. She was wearing her seatbelt at the time, but her head was thrown backwards and forwards by the impact. The subject had felt no pain at first, but its onset began later that night and headaches followed. While working at her computer 4 days before presenting, she moved her head suddenly and felt a “twinge” in her neck, after which the pain had grown worse and her neck felt “stiff ”. Since then, the pain had increased (particularly at the end of the day), with the subject report-ing the intermittent sharp pain to be 7/10 on a visual analogue scale (VAS), and 5/10 during the assessment.

Her general practitioner had diagnosed whip-lash, and her insurance company had approved six sessions of physiotherapy.

Besides pain, the subject reported a reduction in movement and function, and difficulty per-forming work and activities of daily living. She described occasional anxiety when her workload was heavy. The subject had a previous medical history of hypothyroidism, for which she took levothyroxine daily. She also took paracetamol for pain relief.

Clinical impressionThe subject’s head was in a forward position, and she exhibited increased lower cervical flex-ion and upper extension with protracted girdles. She had rounded shoulders. The subject pre-sented with reduced deep neck flexor activation, reduced cervical flexion (60%), reduced right and left cervical rotation (80%), and reduced cervical side flexion (75%) bilaterally. She rated her pain on all resisted cervical movements as 7/10 on the VAS.

No neurological findings were detected upon assessment with upper limb tension tests, and myotomal, dermatomal and reflex testing. There were no red flags.

TreatmentThe subject had not received any previous treat-ment for her neck pain. Because all her symp-toms appeared consistent with WAD (Ferrari et al. 2005), a diagnosis of Quebec grading 2a

was made: “Neck pain with point tenderness and reduced range of motion” (Hartling et al. 2001).

Acupuncture treatment was discussed with the subject, and was chosen to treat her pain and facilitate other physiotherapy modalities. No contraindications were noted. Following advice about possible adverse effects, the sub-ject agreed, read the patient information leaflet and signed an informed consent form.

Treatment planInformed consent was obtained from the subject prior to each treatment session, which involved the following approaches:• acupuncture for pain management;

• education about posture, anatomy, pain, pacing and diagnosis (including advice about her posture throughout the day and while sat at her desk – a workstation assessment was discussed);

• exercises intended to improve ROM, stability and control; and

• manual techniques and massage.

The acupuncture point selections and treatment outcomes, and the clinical reasoning for the points selected are described in Tables 1 and 2, respectively.

The outcome measures implemented included a VAS for pain, the Oxford Scale, the Neck Disability Index (NDI) and ROM.

Rationale for acupuncture point selectionOnly three acupuncture points were chosen during the first session because the client had not had acupuncture before. This was increased to seven points during the second session. White et al. (2008) recommend using six points bilater-ally in order to achieve the desired response.

It has been proposed that acupuncture acti-vates the body’s own pain- relieving responses. The insertion of the needles leads to local effects in the skin, and segmental and extra-segmental effects in the body. It is because of these effects that acupuncture is used to treat pain in the shorter and longer terms (Carlsson 2002).



Table 1. Acupuncture point selection and treatment outcome: (ROM) range of motion; (LI) Large Intestine; (GB) Gall Bladder; (BL) Bladder; (GV) Governor Vessel; (SI) Small Intestine; (VAS) visual analogue scale; and (NDI) Neck Disability Index

Objective of treatment*Acupuncture points† Needling technique Dose (min) Acupuncture response

Session 1Reduce pain from 7/10 LI4

GB20GB21

30 mm perpendicular, 1 cm depth25 mm oblique/inferior, 1 cm depth25 mm posterior oblique, 1 cm depth

10‡ No adverse effectsPain: VAS = 4/10No change in ROMNDI = 8

Session 2Reduce pain from 7/10Improve ROM

LI4GB20GB21BL10GV14SI15BL60

30 mm perpendicular, 1 cm depth25 mm oblique/inferior, 1 cm depth25 mm posterior oblique, 1 cm depth30 mm oblique, 0.5 cm depth30 mm perpendicular, 1 cm depth30 mm oblique, 1.5 cm depth30 mm perpendicular, 1 cm depth

20 No adverse effects Pain: VAS = 4/10Improvement in cervical flexion to 75%



All as above 20 No pain after treatmentSubject reported that she has had no further headachesImprovement in cervical rotation to 90% bilaterally



All as above 20 Pain: VAS = 2/10 after treatment Cervical flexion full



All as above 20 Pain: VAS = 2/10 after treatment

Session 6 Reduce pain from 2/10

LI4 GB20 GB21 BL10 GV14 SI15 BL60

All as above

20

No pain after treatment NDI = 2 Subject reported that she still gets a slight pain if she reads for more than 1 h Cervical rotation now 100% bilaterally Cervical side flexion now 95% bilaterally

*Visual analogue scale scores.†All points needled bilaterally.‡Because first treatment.

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Small Intestine (SI), Bladder (BL) and Gall Bladder (GB) points were selected to allow for a segmental and local approach to the subject’s pain (White et al. 2008). Additionally, Governor Vessel (GV) 14 was added during the second session since this point can help to ease postural neck pain (White et al. 2004).

Gall Bladder 20 was used bilaterally because it is believed to ease occipital headache, and relieve pain and stiffness in the neck (White et al. 2008). White et al. (2004) stated that GB20 and GB21 should be considered for the treat-ment of neck pain in a clinical setting.

The local effects of acupuncture lead to a release of calcitonin gene- related peptide (CGRP), a vasodilator that causes the release of inflammatory mediators that can promote healing and local pain relief (White et al. 2008).

For example, needling activates Aδ and C- fibres in the skin and muscles, causing the sensations of heaviness, tingling and soreness that contribute to the sensation of De Qi (White et al. 2008).

Supporting evidenceSystematic reviews have concluded that the evidence to support acupuncture treatment for

WAD is limited and further research is required (Moon et al. 2014). In a randomized single- blind placebo-controlled trail involving 80 participants with chronic WAD, Sterling et al. (2015) found that dry needling and exercise demonstrated some efficacy, but reported that the results were not “clinically worthwhile”.

Acupuncture may result in pain relief and increased ROM (Witt et al. 2006), and be cost- effective in the management of chronic neck pain (Willich et al. 2006). Furthermore, in a large long- term study, Ross et al. (1999) found that patients in primary care respond well to acupuncture.

In a study by He et al. (2004), 24 participants with muscular neck pain were randomized into acupuncture and sham control groups. The acupuncture group received electroacupuncture (EA) over 16 body points. However, the partici-pants also self- administered auricular acupunc-ture over six points, clearly undermining the statistical power of the study. The control group received sham EA, which was applied without any current. The intensity and frequency of pain was significantly lower in the acupuncture group, improvements that were retained 3 years later in comparison to the control subjects.

Table 2. Clinical reasoning for acupuncture point selection: (LI) Large Intestine; (GB) Gall Bladder; (BL) Bladder; (GV) Governor Vessel; and (SI) Small Intestine

Points selected* Justification for the points selected and supporting evidence

LI4 LI4 covers the C6–7 dermatomes, and is considered to be a “master point for pain”It creates a calming response, and was also chosen to induce an extrasegmental effect (White et al. 2008)When needled bilaterally, LI4 is a distal point that has a strong descending inhibitory effect on supraspinal pain (White et al. 2008)Additionally, Wu et al. (1999) found that LI4 promotes activity in the limbic area that is related to pain responses, and activates the descending anti- nociceptive pathwaysHaker et al. (2000) found that needling LI4 bilaterally and an ear point led to a sympathetic response in the related segment, resulting in pain relief

GB20 GB20 is another “master point for pain” that activates the sympathetic nervous system (Hecker et al. 2007)

GB21 GB21 was chosen bilaterally to achieve local, segmental and extrasegmental effects, and subsequently, to target the subject’s head and neck pain, and stiffness (He et al. 2004; White et al. 2008)

BL10 BL10 is effective in the treatment of neck pain (Vas et al. 2006)BL10 is indicated for cervical pain (Hecker et al. 2007)

BL60 BL60 is a distal point that amplifies the strength of the Bladder meridian (White et al. 2004)

GV14 GV14 was employed during the second treatment session because it can relieve postural neck pain (White et al. 2004)

SI15 SI15 is effective in the treatment of neck pain (He et al. 2004)

*All points needled bilaterally.



In a randomized controlled trail by Vas et al. (2006), the following points were used and stand-ardized: GB20, GB21, Liver 3, Large Intestine 4, GB34, BL10, GV14, SI3, BL62 and GB39. However, as in the study by White et al. (2004), the sham transcutaneous electrical nerve stimula-tion (TENS) was not turned on, and statistically significant improvements were demonstrated in the acupuncture group when compared to the participants receiving sham TENS.

Additionally, França et al. (2008) found that acupuncture was more effective when combined with physiotherapy for facilitating pain relief in tension neck syndrome. With regard to the present subject’s headache, the NICE guidelines support the use of acupuncture for chronic headaches (NICE 2012). Furthermore, a sys-tematic review of acupuncture for tension type headache suggested that needling is more effec-tive than sham acupuncture (Linde et al. 2009).

In a study with a large sample size, White et al. (2004) demonstrated that acupuncture treatment for mechanical neck pain has a significant effect in comparison to sham TENS over the same acupoints.

In a large- scale German study (n = 3766), Witt et al. (2006) found that the use of acupunc-ture was associated with improvements in neck pain and disability when compared to routine care alone. In a Cochrane Review with a smaller number of participants (n = 661), Trinh et al. (2006) found moderate evidence that acupunc-ture was more effective at relieving patients’ neck pain than some sham treatments.

With regard to WAD, the CSP guidelines con-clude that there is not enough clinical evidence to support or refute the use of acupuncture (Moore et al. 2005). However, it is still widely employed in conjunction with other physio-therapy modalities. In a systematic review of 14 studies of the effectiveness of acupuncture for neck pain, Fu et al. (2009) agreed that longer- term follow- up was required in this area, but reported that it provided short- term benefit.

The NICE clinical guidelines have previously recommended acupuncture for the treatment of LBP (NICE 2009). Additionally, a systematic review conducted by Furlan et al. (2005) sug-gested that this modality may be a useful adjunct

in the treatment of chronic LBP, but stated that more high- quality research is required. A review of the literature by the present author suggests that acupuncture has a place in the treatment of pain conditions.

The evidence for the effectiveness of acu-puncture within physiotherapy is uncertain, and researchers have reported a preponderance of low- quality evidence and small sample sizes. The biggest problem with the majority of studies is that the placebos used (i.e. the “sham” tech-nique employed) are not genuine controls. Sham acupuncture also produces a treatment effect, and it has been demonstrated that a blunt needle can have profound effects on the limbic system (Pariente et al. 2005). Sham acupuncture involves needling non- acupuncture points, or using a device that presses a guide tube against the skin (Lund et al. 2009). In the latter case, the needle either penetrates the skin very slightly (i.e. it only pierces the superficial tissue), or not at all.

Following a review of the literature, the evi-dence suggests that acupuncture is effective in the alleviation of neck pain as part of a physio-therapy treatment plan.

DiscussionThe present subject reported no pain following the sixth and final treatment session. Her NDI score, which was 8 at the initial assessment, was reduced to 2 by the final session. The NDI is an outcome measure that is considered to be a valid and reliable tool for measuring neck pain (Vernon & Mior 1991; Stratford et al. 1999).

Improvements in ROM were observed follow-ing the third session. Full rotation was achieved by the final session, but because the subject still had some muscular tightness in side flexion, she was advised to continue with the stretch-ing exercises. As recommended by Moore et al. (2005), education was provided on posture, the use of heat, manual techniques, and exercises to improve muscular control and ROM. The favourable results that the subject experienced may have been a result of a combination of the pain- relieving mechanisms of the acupuncture treatment and the other physiotherapy modali-ties that were used.

S. Cronin


Upon reflection, EA could have been used as an alternative treatment in this case. In a random-ized, double- blind study, Sator- Katzenschlager et al. (2004) found that weekly auricular EA reduced pain, and therefore, proved more effec-tive than manual acupuncture in the treatment of chronic LBP.

Dry needling trigger point acupuncture could have been another possible approach to treatment. Trigger point acupuncture over SI15 can be used to manage myofascial trigger points, which are common in this area, and to ease muscle spasms in the upper trapezius muscle (White et al. 2008). This approach was supported by Itoh et al. (2007), who found that trigger point acupuncture treatment was more effective than manual acupuncture, and reduced the intensity of neck pain.

It has been proposed that mechanical dis-ruption of connective tissues in the body can have an effect on local and global anatomical tissues, and lead to disturbances in the electri-cal response of tissues and cellular activity (Langevin & Yandow 2002). In addition to the documented pain- relieving effects of acupunc-ture, a structural response has been observed following needle manipulation. Langevin et al. (2006) demonstrated that collagen gathered around a needle inserted into the subcutaneous tissue of a mouse, and found alterations in the cellular activity of fibroblasts several centimetres away from the site of acupuncture. This mecha-nism could explain and may have contributed to the improvement in the present subject’s ROM.

The reduction in pain may have been caused by the segmental effects of acupuncture. These stimulate Aδ and C- fibres in the skin, and type II and type III fibres in the muscles, triggering the release of enkephalin (White et al. 2008). Clement- Jones et al. (1980) showed that an increased level of β- endorphin was detected after treatment in patients who received acu-puncture compared to controls. The segmental activation leads to an analgesic effect that can last not only for the duration of the session but for days after the initial treatment (White et al. 2008). This may explain how repeated acupunc-ture treatments can have a cumulative effect on pain.

Individuals with WAD have been shown to be hypersensitive to mechanical pressure, which can lead to changes in the central processing of pain (Scott et al. 2005). The brain’s cerebral cortex detects this sensation of needling, and activates the periaqueductal grey (PAG) matter, which is the primary control centre for descend-ing pain. The PAG has a high concentration of the cells that produce enkephalin (White et al. 2008), and when these are activated via the mechanism of acupuncture, this can lead to the release of the noradrenaline and serotonin, lead-ing to pain relief as a result of the activation of descending pain inhibition (White et al. 2008). Furthermore, functional magnetic resonance imaging studies have demonstrated the effect of acupuncture on the pain pathways of the brain (Napadow et al. 2009).

The pro- inflammatory effect of acupuncture may also have been responsible for the reduction in the present subject’s pain. When treating rats with acupoint GB30, Wang et al. (2014) showed that acupuncture regulates the opioid- containing macrophages and anti- nociceptive mediators associated with in inflammatory pain. However, studies using animal models have limitations when generalizing the results to human beings.

The present subject had not undergone acu-puncture before, and in addition to its effect on physical pain, needling influences the psycho-logical aspects of pain. Some researchers have suggested that a positive expectation of pain relief may amplify the results of the treatment (Kong et al. 2009; Shi et al. 2012).

Additionally, the headache that the present subject had experienced since suffering from the injury seemed to have benefited from treat-ment. However, this may have been a result of improvements in ROM and function that were achieved after the other physiotherapy modali-ties were employed. However, other researchers have advocated acupuncture for tension- type (Linde et al. 2009) and neurovascular headaches (Zhao et al. 2011).

Another problem with the studies described above is the small sample sizes used, which lead to the risk of a type II error being made. Furthermore, the limitations of many of these reports means that the authors did not



investigate acute or subacute neck pain, which is commonly what a patient will present with when attending physiotherapy.

ConclusionsIt appears that the segmental, extrasegmental and central effects that are associated with acu-puncture treatment had a good pain- relieving effect on the present subject. Because of its subjective nature, pain is difficult to study. There is only a limited amount of strong evidence for the effectiveness of acupuncture for the treat-ment of WAD, leading to contradictions in the guidelines, and frustrations for acupuncturists who see the benefit that this modality can have on a daily basis.

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Linde K., Allais G., Brinkhaus B., et al. (2009) Acupuncture for tension- type headache. The Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD007587. DOI: 10.1002/14651858.CD007587.

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Napadow V., Dhond R. P., Kim J., et al. (2009) Brain encoding of acupuncture sensation – coupling online rating with fMRI. NeuroImage 47 (3), 1055–1065.

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Reviews, Issue 3. Art. No.: CD004870. DOI: 10.1002/14651858.CD004870.pub3.

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Wang Y., Gehringer R., Mousa S. A., et al. (2014) CXCL10 controls inflammatory pain via opioid peptide- containing macrophages in electroacupuncture. PLOS ONE 9 (4): e94696. DOI: 10.1371/journal.pone.0094696.

White A., Cummings M. & Filshie J. (eds) (2008) An Introduction to Western Medical Acupuncture. Churchill Livingstone, Edinburgh.

White A. R. & Ernst E. (1999) A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatology 38 (2), 143–147.

White P., Lewith G., Prescott P. & Conway J. (2004) Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Annals of Internal Medicine 141 (12), 911–919.

Williamson E., Williams M., Hanson Z., Joseph S. & Lamb S. E. (2009) Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: the Managing Injuries of the Neck Trial (MINT) Intervention. Physiotherapy 95 (1), 15–23.

Willich S. N., Reinhold T., Selim D., et al. (2006) Cost- effectiveness of acupuncture treatment in patients with chronic neck pain. Pain 125 (1–2), 107–113.

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Suzanne Cronin qualified in 2012, and is now a senior physiotherapist within the pulmonary rehabilitation

service at South Tees Hospitals NHS Foundation Trust. She is passionate about promoting patient inde-pendence, and helping individuals to self-manage their

lung conditions. Suzanne also has a keen interest in chronic pain and musculoskeletal conditions, and works in a private physiotherapy setting.


Correspondence: Mrs Kay Biss, Physiotherapy Outpatients, Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham, West Midlands B18 7QH, UK (e- mail: [email protected]).


CASE REPORT

Acupuncture for the management of pain in a woman with multiple sclerosis

K. BissPhysiotherapy Outpatients, Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK

AbstractMultiple sclerosis (MS) is a neurological condition affecting the central nervous system that damages the myelin sheath of nerve fibres. Pain is one of the symptoms associated with this disorder. Since it is a long- term, progressive condition, MS pain must be managed in order to allow patients to have a decent quality of life, and to continue with their normal activities and hobbies. Acupuncture was used to treat a 36- year- old woman with MS since previous traditional physiotherapy treatments had been unsuccessful. This case report highlights the lack of previous research into the effects of acupuncture on MS pain, and indicates that there may be a place for its use. More research is needed to increase the evidence base for the treatment of MS pain with acupuncture.

Keywords: acupuncture, multiple sclerosis, neurology, pain.

IntroductionMultiple sclerosis (MS) is a neurological condi-tion affecting the central nervous system that damages the myelin sheath of nerve fibres. It affects more than 100 000 people in the UK, and almost three times as many women are affected than men; symptoms start between 20 and 40 years of age (MacLean 2011). There are four main types of MS: relapsing- remitting, second-ary progressive, primary progressive and benign. The exact aetiology of MS is unknown, but it is thought to be caused by a T- cell- mediated auto-immune response against the central nervous system (CNS) that is triggered by environmental exposure in an individual who is genetically sus-ceptible (Goodin 2009; Goverman 2009).

The symptoms of MS vary, and each indi-vidual’s experience will be different. Some common symptoms include: balance problems; bladder and bowel disturbances; cognition changes; weakness; spasticity; depression; pain; fatigue; tremor; difficulty with speech and swallowing; visual disturbances; and dizziness (Webster & Whittam 2013). At present, there is no cure, but research is ongoing. There have been recent developments in the use of immu-noablation followed by immune- cell- depleted autologous haemopoietic stem cell transplanta-tion, which has been shown to stop all detect-able inflammatory activity in the CNS and result in a “substantial recovery of neurological function” (Atkins et al. 2016, p. 576). However, while research is still in progress, the symptoms of MS must be managed as effectively as pos-sible, and this can be done in a wide variety of ways, such as disease- modifying treatments, complementary medicines, exercise and lifestyle changes (MacLean 2011).

Management of pain in a woman with multiple sclerosis


The symptom of pain in MS could be man-aged with acupuncture. This modality has been found to relieve pain in several different ways. Locally, acupuncture increases blood flow to the area being needled, and triggers an inflamma-tory response (Sandberg et al. 2003). In turn, this leads to the secretion of endorphins and increased synthesis of endorphin receptors (Stein et al. 2001; Carlsson 2002). Acupuncture also works segmentally by stimulating the Aδ fibres in the skin and muscle that help to block nociceptive messages from the C- fibres, and thus, closes the pain gate (White et al. 2008). More globally, in the spinal cord and brain, acupuncture has been shown to relieve pain by causing the release of opioid peptides and sero-tonin (Han & Terenius 1982). Segmental acu-puncture may be able to influence the neurons in the lateral spinal cord, which contain the cell bodies of the autonomic nervous system (ANS) efferent fibres (Bradnam 2003, 2007). The ANS is also under central control, via the vasomotor centre in the medulla and the hypothalamus. It is believed that low- intensity input may reduce sympathetic outflow from that segment (Sato et al. 1997), and high- intensity, low- frequency may be most beneficial for supraspinal effects.

At present, there are no Cochrane Reviews of the use of acupuncture for MS; although one was proposed in 2010 (Cui et al. 2010), no results have been published to date. There is no specific reference to the use of acupuncture in the treatment of MS in the National Institute for Health and Care Excellence guidelines (NICE 2014), although these do state that musculoskeletal pain should be assessed and treatment offered. Despite the lack of overarch-ing protocols, there is some evidence to suggest that the use of acupuncture in the management of MS may be beneficial. A survey by Wang et al. (1999) found that approximately two- thirds of respondents experienced short- term relief from many symptoms, including pain, spastic-ity, bladder and bowel problems, problems with coordination, and sleep disorders. Bowling & Stewart (2002) reported that 20% of respond-ents had used acupuncture for pain and anxiety management, and about half of these described improvements in fatigue, depression, spasticity

and insomnia. A review of the evidence of the effects of acupuncture on MS by Karpatkin et al. (2014) found that, although there is much to recommend the extensive use of acupuncture in the treatment of MS, there is only a small amount of literature describing its efficacy, and much of this is methodologically flawed. The above authors go on to state that “practition-ers should not assume that acupuncture is not effective in this population but rather that the literature is insufficient to make claims either for or against its use” (Karpatkin et al. 2014, p. 8).

Case report

BackgroundThe present subject was a 36- year- old female who was referred with chronic bilateral mid- back pain around her scapulae that radiated upwards to her neck. She also had low back pain, but although she had previously received physiotherapy for this, she reported no improve-ment. Her current pain was sharp and intermit-tent, and more pronounced on her right than her left. Aggravating factors included thoracic rotation and standing, and rest eased her dis-comfort. The subject’s pain was worse towards the end of the day and after sustained activity. Her other problems included fatigue. There was no record of previous X- rays or other investi-gations. The subject’s main problems were pain and fatigue, and the main aim of the treatment was to reduce her pain levels and increase her level of function.

The subject lived with her husband and three children, who were aged 4, 5 and 11 years. She was a housewife who had last worked 6 years ago. Her husband assists with all heavy lifting activities, but she is otherwise independent.

Her drug history included dimethyl fumarate, gabapentin, amoxicillin and aspirin.

Clinical impressionThe subject had a slumped posture with pseudo- winging of her scapulae bilaterally. She had: full cervical range of motion (ROM); full thoracic ROM with pain at end- of- range exten-sion, left rotation and left side flexion; and full

K. Biss


shoulder ROM with discomfort at end- of- range abduction.

No neurological findings were detected upon assessment with upper- limb tension tests, and myotomal, dermatomal and reflex testing. There were no red flags.

TreatmentThe subject was given information about her symptoms and their management. She was also provided with education regarding chronic pain management, and a paced increase in general exercises, such as walking and swimming, to manage fatigue. She was given literature produced by the MS Society relating to MS and fatigue, muscle spasms and pain. A home exercise plan of paced functional exercises and specific strengthening exercises for scapular control was devised. She was also given postural re- education.

Before treatment began, the subject was pro-vided with an information leaflet regarding the use of acupuncture, and its effects, side effects, precautions and contraindications. A consent form was completed during the session prior to the commencement of acupuncture treatment, as per department policy, and valid, verbal con-sent was obtained at each subsequent session. It was ensured that the subject was suitably clad and in a comfortable position, and that the therapist had clean hands prior to needling. Sterile, single- use needles were employed, and these were inserted using a guide tube.

The acupuncture point selections and treat-ment outcomes are shown in Tables 1 and 2, respectively. The outcome measures included a visual analogue scale (Boonstra et al. 2008), functional outcomes (i.e. sit- stands, arm raises and step- ups), and the EuroQol – Five Dimensions – Five Levels questionnaire (EuroQol Group 1990; Brooks 1996; Öster 2009; Herdman et al. 2011; van Hout et al. 2012; Janssen et al. 2013).

Rationale for acupuncture point selectionThe subject’s main problems were pain and fatigue. There had been no change in her symptoms after four sessions of standard

physiotherapy; these had included education, strengthening exercises, and general advice regarding pacing and a gradual increase in nor-mal activity levels. Subjectively, she reported no changes in overall function; however, objectively, there had been some increase in functional out-comes. Because of the lack of improvements in her symptoms, the subject was keen to explore other options in the management of her pain. Therefore, it was agreed that acupuncture would be used in an attempt to reduce her symptoms and allow her to increase her function in a paced way, so as to improve her quality of life in the long term.

The subject had previously undergone acu-puncture for low back pain, and had found this to be beneficial in the short term. There is a great deal of evidence to support the use of acupuncture to treat chronic pain. A study by Witt et al. (2006) found that acupuncture combined with usual care (where this includes physiotherapy and exercise) produces a clinically relevant reduction in symptoms. In a review of the evidence, Dorsher (2011) found that there is considerable evidence to support the clini-cal efficacy of the use of acupuncture to treat chronic pain in a variety of conditions, and although there are limited findings to demon-strate the effectiveness of acupuncture in MS, the principles of chronic pain management can still be applied.

In the present case, there were two main considerations to be taken into account prior to commencing acupuncture treatment.

First, one of the subject’s main problems was fatigue caused by the MS. Although there is evidence to suggest that acupuncture can be used as an effective treatment for chronic fatigue syndrome (Wang et al. 2009), increased fatigue is a common side effect if an incorrect dosage is used (AACP 2015). Therefore, only four needles were used in the first session, and these were applied for no more than 10 min. This was done in order to gauge the subject’s response and minimize the potential for adverse reactions. White et al. (2008) suggested that the treatment dose should be adjusted depending on the degree to which the nervous system is sensitized in each individual, and therefore, a



Tab

le 1

. A

cupu

nctu

re p

oint

sel

ectio

n an

d te

chni

que:

(B

L)

Bla

dder

; (SI

) Sm

all I

ntes

tine;

(L

I) L

arge

Int

estin

e; (

GV

) G

over

nor

Ves

sel;

(GB

) G

all B

ladd

er; a

nd (

+)

stro

ng D

e Q

i

Acu

punc

ture

poi

nts

Nee

dle

size

(m

m)

Nee

dlin

g te

chni

que

Dep

th

(mm

)R

estim

ulat

ion

De

Qi

Tim

e (m

in)

Adv

erse

eff

ects

Adv

ice

give

n

Sess

ion

1B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10O

nce

at 5

min

Yes

10N

one

Gen

eral

adv

ice

in c

ase

of a

dver

se

effe

cts;

adv

ised

to

cont

inue

with

hom

e ex

erci

se p

lan

BL

14 (

bila

tera

l)0.

25 ×

25

Obl

ique

tow

ards

spi

ne10

Onc

e at

5 m

inY

es

Sess

ion

2B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10N

one

Yes

20N

one

Adv

ised

to

cont

inue

with

hom

e ex

erci

se p

lan

BL

14 (

bila

tera

l)0.

25 ×

25

Obl

ique

tow

ards

spi

ne10

Non

eY

esSI

9 (b

ilate

ral)

0.25

× 4

0Pe

rpen

dicu

lar

20O

nce

at 1

0 m

inY

es

Sess

ion

3B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10

Onc

e at

10

min

Yes

20N

one

Adv

ised

to

cont

inue

with

hom

e ex

erci

se p

lan

BL

14 (

bila

tera

l)0.

25 ×

25

Obl

ique

tow

ards

spi

ne10

Onc

e at

10

min

Yes

LI4

(bi

late

ral)

0.25

× 2

5Pe

rpen

dicu

lar

10O

nce

at 1

0 m

inY

es+

Sess

ion

4B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10O

nce

at 1

0 m

inY

es20

Non

eA

dvis

ed t

o co

ntin

ue w

ith h

ome

exer

cise

pla

nB

L14

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10O

nce

at 1

0 m

inY

esL

I4 (

bila

tera

l)0.

25 ×

25

Perp

endi

cula

r10

Onc

e at

10

min

Yes

Sess

ion

5B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10E

very

5 m

inY

es20

Min

imal

diz

zine

ss,

ease

d af

ter

2 m

in

whe

n ne

edle

s re

mov

ed

Gen

eral

adv

ice

in c

ase

of a

dver

se

effe

cts;

adv

ised

to

cont

inue

with

hom

e ex

erci

se p

lan

and

to r

est

on r

etur

n ho

me

BL

14 (

bila

tera

l)0.

25 ×

25

Obl

ique

tow

ards

spi

ne10

Eve

ry 5

min

Yes

LI4

(bi

late

ral)

0.25

× 2

5Pe

rpen

dicu

lar

10E

very

5 m

inY

esG

V14

0.25

× 2

5O

bliq

ue in

a c

epha

lic d

irect

ion

10E

very

5 m

inY

esG

B34

(bi

late

ral)

0.25

× 4

0Pe

rpen

dicu

lar

10–2

0E

very

5 m

inY

es

GB

20 (

bila

tera

l)0.

25 ×

40

Obl

ique

tow

ards

opp

osite

eye

10E

very

5 m

inY

es

Con

tinue

d/

K. Biss


Acu

punc

ture

poi

nts

Nee

dle

size

(m

m)

Nee

dlin

g te

chni

que

Dep

th

(mm

)R

estim

ulat

ion

De

Qi

Tim

e (m

in)

Adv

erse

eff

ects

Adv

ice

give

n

Sess

ion

6B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10E

very

5 m

inY

es20

Non

eA

dvis

ed t

o co

ntin

ue w

ith h

ome

exer

cise

pla

nB

L14

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10E

very

5 m

inY

esL

I4 (

bila

tera

l)0.

25 ×

25

Perp

endi

cula

r10

Eve

ry 5

min

Yes

GV

140.

25 ×

25

Obl

ique

in a

cep

halic

dire

ctio

n10

Eve

ry 5

min

Yes

GB

34 (

bila

tera

l)0.

25 ×

40

Perp

endi

cula

r10

–20

Eve

ry 5

min

Yes

G

B20

(bi

late

ral)

0.25

× 4

0O

bliq

ue t

owar

ds o

ppos

ite e

ye10

Eve

ry 5

min

Yes

Sess

ion

7B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10E

very

5 m

inY

es, m

uscl

e tw

itch

on

right

20M

inim

al d

izzi

ness

, ea

sed

afte

r 2

min

w

hen

need

les

rem

oved

Adv

ised

to

cont

inue

with

hom

e ex

erci

se p

lan

and

to r

est

on r

etur

n ho

me

BL

14 (

bila

tera

l)0.

25 ×

25

Obl

ique

tow

ards

spi

ne10

Eve

ry 5

min

Yes

LI4

(bi

late

ral)

0.25

× 2

5Pe

rpen

dicu

lar

10E

very

5 m

inY

esG

V14

0.25

× 2

5O

bliq

ue in

a c

epha

lic d

irect

ion

10E

very

5 m

inY

esG

B34

(bi

late

ral)

0.25

× 4

0Pe

rpen

dicu

lar

10–2

0E

very

5 m

inY

es

GB

20 (

bila

tera

l)0.

25 ×

40

Obl

ique

tow

ards

opp

osite

eye

10E

very

5 m

inY

es, m

uscl

e tw

itch

Sess

ion

8B

L11

(bi

late

ral)

0.25

× 2

5O

bliq

ue t

owar

ds s

pine

10E

very

5 m

inY

es20

Min

imal

diz

zine

ss,

ease

d af

ter

2 m

ins

whe

n ne

edle

s re

mov

ed

Adv

ised

to

cont

inue

with

hom

e ex

erci

se p

lan

and

to r

est

on r

etur

n ho

me

BL

14 (

bila

tera

l)0.

25 ×

25

Obl

ique

tow

ards

spi

ne10

Eve

ry 5

min

Yes

, mus

cle

twitc

hL

I4 (

bila

tera

l)0.

25 ×

25

Perp

endi

cula

r10

Eve

ry 5

min

Yes

+G

V14

0.25

× 2

5O

bliq

ue in

a c

epha

lic d

irect

ion

10E

very

5 m

inY

esG

B34

(bi

late

ral)

0.25

× 4

0Pe

rpen

dicu

lar

10–2

0E

very

5 m

inY

esG

B20

(bi

late

ral)

0.25

× 4

0O

bliq

ue t

owar

ds o

ppos

ite e

ye10

Eve

ry 5

min

Yes

Tab

le 1

. (C

ontin

ued)



low dose was chosen to minimize any adverse response. Witt et al. (2011) stated that an increased acupuncture effect can be found in patients with chronic pain, and attributes such as being a female and the failure of other previ-ous therapies, and therefore, the initial dose was also limited because of this. In the second session, when it was certain that the subject had experienced no adverse reactions, the dos-age was increased to 20 min, which has been reported to be an adequate length of treatment (White et al. 2007).

Secondly, the subject was taking aspirin to help with the management of her MS- related fatigue. Aspirin is a drug that thins the blood; however, unlike warfarin, it is classed as an antiplatelet medication rather than an anti-coagulant, and therefore, does not carry the same associated risk when acupuncture is employed (NHS Choices 2016). She reported no problems with blood clotting or bleeding dis-orders, and so it was decided that it was safe to continue.

Points local to the subject’s pain were chosen for the first session because her symptoms were thought to be primarily myofascial in origin. Elements of the layering method proposed by Bradnam (2003, 2007), in which treatment is individualized depending on the underlying pain mechanism were used, in deciding which points to use. According to Bradnam (2003, 2007, p. 24), “fewer needles should be used in cases of intense acute nociceptive pain, since the seg-ment will already be sensitized by the painful afferent input from the injury”. Therefore, only four points were chosen.

At the second session, the subject reported that she had experienced some reduction in her symptoms, and so two additional needles were added, although these were still local to the area of her pain. Since De Qi was maintained at both Bladder points bilaterally, only the Small Intestine (SI) points were re- stimulated at 10 min. Overstimulation was avoided in an attempt to avoid aggravating her fatigue.

Since there had been no adverse reactions, Large Intestine 4 was added at the third ses-sion. This was intended to increase the supra-spinal effects, and therefore, boost pain relief; the activation of descending pain inhibitory systems is thought to give pain relief that has longer- lasting effects (Lundeberg et al. 1988). When the pain is centrally evoked, it is recom-mended that the activation of these pathways is done extrasegmentally “to avoid overloading the sensitized segment” (Bradnam 2003, 2007, p. 25). The use of these “big points” has also been recommended in order to effectively activate central autonomic responses. Because of patient positioning and comfort, SI9 was not used during this session. All points were stimulated at 10 min so as to maintain De Qi. The same points and timings were used in the fourth session.

Since there had been no change in the sub-ject’s symptoms and she had experienced no adverse reactions, the number of needles was increased for the fifth session, as was the level of stimulation. Governor Vessel 14 was added as an additional local point because it is believed to be beneficial in the treatment of postural, cervicothoracic junction problems. Gall Bladder

Table 2. Treatment outcomes

Outcome measure Initial assessment Final treatment Improvement

Visual analogue scale 6/10 4/10 2/10Functional outcomes (1 min each): sit- stands arm raises step- ups

91511

152014

653

EuroQol – Five Dimensions – Five Levels questionnaire: mobility self- care usual activities pain/discomfort anxiety/depression index value

1 1 2 3 1 0.767

1 1 1 2 2 0.768 0.001

K. Biss


(GB) 34 was added bilaterally as an additional “big point”. In traditional Chinese medicine, GB34 is said to be an influential point for muscles and tendons that restores homeostasis, and a strong relaxation point (Norris 2011). On arrival at this session, the subject reported that she had experienced a flare- up in her upper neck pain, and therefore, GB20 was added bilaterally. When the needles were removed at the end of treatment, she reported increased dizziness; however, this side effect was short- lived and no other adverse effects occurred.

At the three subsequent sessions, the nee-dles, times and stimulation were kept the same because the subject reported a reduction in her pain levels with no adverse reactions, apart from minimal dizziness at the end of each treatment.

DiscussionAs mentioned above, the evidence for the use of acupuncture in MS is limited, and therefore, the present case report is interesting because it demonstrates a reduction in pain and an increase in function when acupuncture is used in combi-nation with standard physiotherapy treatment. The subject presented with pain and fatigue as a result of a chronic, progressive condition, but she also had several biopsychosocial issues such as a poor understanding and acceptance of her diagnosis, which may have contributed to her symptoms.

However, as with any study, there are some limitations. First, the improvement in the subject’s symptoms may have been limited by the slow increase in the dosage used because of concerns about causing an increase in her fatigue levels. Acupuncture has been found to increase nocturnal melatonin secretion, and reduce insomnia and anxiety (Spence et al. 2004). However, the exact level of insomnia reduc-tion and, thus, increased drowsiness is unclear, and will vary for each individual. Therefore, to prevent a worsening of the subject’s symptoms, the dosage was increased very slowly. Secondly, because of patient and clinician holidays, there was a break of almost 3 weeks between the fourth and fifth treatments. White et al. (2007, p. 384) stated that acupuncture was “‘adequate’

if it consisted of at least six treatments, at least one per week”. Repeated electroacupuncture (EA) has been found to have a cumulative effect on chronic pain by relieving spinal spasticity and creating “a plastic change in the release and metabolic rate of spinal opioid peptides” (Luo 1996, p. 241). The longer period between acupuncture treatments that occurred in the present study might have meant that this cumu-lative effect could have been reduced, leading to slower progress. A study by Luo (1996) also suggests that the present subject might have experienced better results if EA had been used rather than standard acupuncture.

The reduction in the subject’s symptoms and the increase in function are believed to be the result of the combination of needling, and the functional exercises and education that she was given. Acupuncture has been shown to be most beneficial when combined with usual care (Witt et al. 2006), and its effects may enhance physiotherapy performance in musculoskeletal rehabilitation (França et al. 2008). The reduction in her pain levels may have allowed the subject to increase her function, and this would have led to a further lessening of her symptoms. It is hoped that this will continue, aiding the long- term management of her symptoms.

Since a variety of both local and extra-segmental points were used as the treatment progressed, this suggests that several different mechanisms of action produced the overall result. These mechanisms are outlined in the introduction above.

When the dosage was increased in the later sessions, the subject reported some dizziness for a few minutes following the removal of the needles. Dizziness is a recognized adverse reaction associated with the use of acupuncture, but it is generally transient and mild (Yamashita 2004). It could be a result of the effect that acu-puncture is believed to have on the autonomic system (Sakai et al. 2007). Because this adverse reaction was short- lived and had no lasting detrimental effect on the subject, treatment was continued at the same dosage.

A more rapid increase in the dosage might have led to a stronger overall response with respect to the symptoms. Another approach



to acupuncture treatment could have been to needle more myofascial trigger points. However, because the subject had MS, this was thought to be risky since it could have reduced the muscle tone that she relied on to maintain her posture. Needling trigger points is believed to evoke segmental anti- nociceptive effects (Srbely et al. 2010).

Future sessions with this subject may involve a similar number of needles in comparable posi-tions if her symptoms continue to improve, or these might feature an increase in the number of needles locally if her symptoms persist, with the potential to add further “big points” if no increase in adverse reactions occurs.

The present study shows that acupuncture has some degree of a positive effect on pain in a patient with MS, although further research is needed to demonstrate a stronger relationship between these two factors.

AcknowledgementsI would like to thank the subject of the present study, my fellow coursemates and my tutor for helping me to begin practising acupuncture.


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K. Biss


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Kay Biss works as a physiotherapist for Sandwell and West Birmingham Hospitals NHS Trust, and is rota-tional throughout musculoskeletal outpatients. She has a particular interest in the management of chronic pain.



CASE REPORT

Acupuncture treatment for a 50- year- old female with fibromyalgia suffering from a whiplash injury following a road traffic accident

C. HamerAssessment and Rehabilitation Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK

AbstractThis case study describes the treatment of a 50- year- old female with fibromyalgia who suf-fered from a whiplash injury following a road traffic accident. Current evidence, guidelines and assessment findings informed the choice to include acupuncture within the physiotherapy treatment plan. The primary aims of the acupuncture treatment were to produce analgesic effects, and to enable training to begin for the subject’s upcoming goal of completing the Inca Trail to Machu Picchu in Peru. Massage, heat therapy, lumbar and cervical spine range of motion (ROM) exercises, and core- strengthening exercises were included to improve her symptoms over six weekly sessions. The outcome measures included lumbar and cervical spine ROM, a Numerical Rating Scale to measure subjective pain, and the EuroQol – Five Dimensions – Five Levels questionnaire about quality of life. Improvement was demon-strated in all outcomes after treatment, and the subject was able to return to her hobby of spinning classes and begin hiking practice for the Inca Trail.

Keywords: acupuncture, fibromyalgia, road traffic accident, whiplash injury.

IntroductionStux & Pomeranz (1995) reported that acupunc-ture can be used to treat musculoskeletal (MSK) pain, and stated that neck pain is one of the three most commonly reported complaints of the MSK system.

A whiplash injury is defined as a musculo-ligamental sprain or strain of the cervical spine caused by hyperextension and/or hyperflexion (Radanov et al. 1995). This occurs when people are not prepared for sudden trauma, and it causes soft- tissue damage, muscle strain and trauma to the joint capsule (Greenwood et al.

1988). The result is pain and stiffness in the neck, shoulder and back, and possible head-aches and nerve- root pain extending down one or both arms.

According to Hurtig et al. (2001), the major-ity of patients with fibromyalgia report pain and stiffness in their neck and shoulder mus-cles, a lower threshold for mechanical pain (i.e. allodynia), and exaggerated pain responses to noxious stimuli (i.e. hyperalgesia). Both indi-viduals with chronic pain after whiplash injury and those with fibromyalgia have been found to display exaggerated pain after sensory stim-ulation. This amplified perception of pain has been attributed to possible hyperexcitability of the central nervous system (CNS). Banic et al. (2004) tested the hypothesis that patients with chronic whiplash pain and those with fibro-myalgia display a facilitated withdrawal reflex,

Correspondence and present address: Charlotte Hamer, Physiotherapy Department, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Whinney Heys Road, Blackpool FY3 8NR, UK (e-mail: [email protected]).

Whiplash injury following a road traffic accident


and therefore, spinal cord hypersensitivity. The nociceptive withdrawal reflex is a spinal reflex of the lower extremities that can be elicited by painful stimulation of a sensory nerve (Willer et al. 1979). Central hypersensitivity could explain the amplification of the nociceptive signal by the hyperexcitable neurons.

Peripheral injury and inflammation cause plasticity changes in the CNS that result in neur onal hyperexcitability (Woolf & Salter 2000). Inflammation produces the release of cyclooxygenase- 2 (COX- 2) in the spinal cord, leading to prostaglandin production and neuronal hyper excitability (Ichitani et al. 1997). Pharmacological inhibition of COX- 2 can pro-vide relief from the symptoms of inflammation and pain. Non- steroidal anti- inflammatory drugs exert their effects through inhibition of COX- 2. Elevated levels of substance P and excitatory amino acids have been found in the cerebro spinal fluid of individuals with fibromyalgia, raising the possibility that these substances can cause generalized spinal cord hypersensitivity (Larson et al. 2000). It is not known whether similar biochemical changes occur in the cerebrospinal fluid of the victims of whiplash.

Dubner & Ren (1999) suggested that spinal cord hyperexcitability elicited by trauma or inflammation is influenced by the descend-ing facilitatory and inhibitory pathways. The involvement of serotonin in descending modu-lation suggests that genetic factors account for the imbalance of descending pain modulation that leads to enhanced pain reactivity (Li & Zhuo 2001). Peripheral inflammation induces gene expression in the dorsal root ganglion, resulting in an increased synthesis of peripheral receptors. This causes a reduced threshold for pain within the injured area.

The nociceptive withdrawal reflex was elec-trophysically measured to quantify the excit-ability of spinal neurons in a study of patients with fibromyalgia by Banic et al. (2004). These authors found that the electrical stimulation bypassed the peripheral receptors and activated the nerve fibres, demonstrating that the low reflex and pain thresholds identified were not the result of peripheral sensitization, but rather,

altered spinal cord sensitivity. The presence of spinal cord hypersensitivity in cases of whiplash and fibromyalgia, which are two very different pain syndromes, suggests that this theory may also relate to other chronic MSK pain conditions.

Acupuncture is one of the most frequently used alternative medical interventions, and evidence demonstrates that it reduces pain and improves the quality of life of patients with fibromyalgia (Targino et al. 2008). The stud-ies that have been completed predominantly involved Caucasian women, meaning that gen-eralizations cannot be made. Stux & Pomeranz (1995) found that patients with chronic neck pain reported immediate and short- term pain relief following acupuncture, and argued that the modality prevents or modifies the perception of pain. These authors proposed that acupuncture alters physiological functions, including pain control, when it is used to treat certain dysfunc-tions of the body.

Emotions are often classified as either posi-tive or negative. In society, it is often believed that the expression of negative emotions is inappropriate, which can lead to these becom-ing repressed, resulting in muscle tightening or disease in some part of the body. This is known as an “energy block” in traditional Chinese medicine, and it is believed to manifest in any weakened area of the body. A whiplash injury becomes an ideal focal point for this, and acu-puncture induces an overwhelming feeling of intensity that enables the expression of these feelings. Emotions also increase muscle tension in the neck, and may prolong the condition. Patients who do not recover after a few months become labelled as neurotic, and if symptoms persist, the issue conflates itself with chronic pain syndrome.

In addition, these patients usually have legal suits pending in which there is a financial advantage to having a severe prolonged dis-ability (Greenwood et al. 1988). Acupuncture is increasingly being used in the West as a tool for pain relief, and Greenwood et al. (1988) stated that its effectiveness is no longer questioned. It has been successfully used to treat whiplash injuries.

C. Hamer


Case reportBackgroundThe present subject was a 50- year- old female who lived with her husband and two children. She worked as a service redesign manager for the National Health Service. The subject enjoyed fitness training, and attended a spinning class three times a week. As a charity fundraiser, she had arranged to complete the Inca Trail to Machu Picchu in Peru in March 2016.

The subject had been involved in a road traffic accident in September 2015. She initially experienced stiffness in her neck and back, severe pain, dizziness, and pain radiating down her right arm. The neck pain had subsequently become more centralized and was resolving. However, her low back pain (LBP) was still severe, although more so on her right side than on her left. She had already received treatment from two physiotherapists, but reported no major improvement in her condition. The sub-ject was involved in an ongoing legal suit.

She had a past medical history of fibro myalgia and chronic fatigue syndrome. For medication, she took gabapentin and amitriptyline.

Clinical impressionThe subject experienced neck pain [Numerical Rating Scale (NRS) = 6/10] that was aggravated by prolonged periods of sitting at her desk dur-ing working hours. Her peripheral symptoms and dizziness had now stopped. The pain was becoming more centralized, but remained in her right trapezius muscle. This was eased by heat.

The subject also experienced LBP (NRS = 9/10). This was also aggravated by prolonged periods of sitting at work. She was unable to participate in spinning classes because of her pain, and experienced an increase in symptoms after long walks. The LBP pain was also eased by heat.

During a cervical spine assessment, full range of motion (ROM) was noted, along with reproduction of pain during left- side flexion, left rotation and cervical flexion. There was no shoulder involvement, and no red flags or signs of vertebrobasilar insufficiency. In a lumber spine assessment, tenderness was noted on

palpation over L4, L5, L6 and the surrounding right- side soft tissue. Reproduction of pain occurred during trunk rotation to the right and side flexion to the left. All other lumbar movements were performed at full range with no discomfort. A straight leg raise test proved negative. There was no hip involvement, and no red flags. Regarding yellow flags, there had been reduced responsiveness to previous treatment, and the ongoing lawsuit was considered. The subject’s EuroQol – Five Dimensions – Five Levels (EQ- 5D- 5L) questionnaire score was 55/100.

TreatmentThere were no contraindications to acupunc-ture treatment. The subject had previously undergone acupuncture for right knee pain and reported a successful outcome. Treatment com-menced following the clinical assessment, and after the theory of acupuncture and its possible side effects had been discussed and a consent form had been signed.

The acupuncture treatment sessions are sum-marized in Table 1.

Rationale for acupuncture point selectionThe initial acupuncture treatment should be reasonably conservative, and involve between four and eight points (White et al. 2008). This is to ensure that the patient is comfortable and to see how he or she responds to acupuncture (Dupuis 2015).

Bladder (BL) 23 and BL24 were used as local points, and inserted bilaterally to increase the dosage. These were chosen because the subject’s LBP following her whiplash injury was the most intense source of her discomfort; therefore, this was prioritized since only a small number of needles were used initially. As a precaution, the positioning of the internal organs (e.g. the kidneys) was considered throughout. The aim of using local points from the outset is to allow the patient to have confidence in the treatment, which may not happen when needling occurs away from the injured area. This approach also stimulates a local response, which has been shown to contribute to pain relief.



Langevin et al. (2007) suggested that a chronic local increase of stress in the tissues can lead to microinjury and inflammation,

and a consistent lack of stress leads to fibrosis, adhesions and contractures. These processes can lead to changes in connective tissue. Connective

Table 1. Summary of acupuncture treatment sessions: (LI) Large Intestine; (GB) Gall Bladder; (BL) Bladder; and (LBP) low back pain

Acupuncture points

Needle size (mm) Angle

Treatment time (min) Dosage Effect of treatment

Session 1LI4 (bilateral)GB34 (right)BL23 (bilateral)BL24 (bilateral)

25 × 0.2540 × 0.2540 × 0.2540 × 0.25

PerpendicularPerpendicularPerpendicularPerpendicular

10

Rotated × 2

No adverse effectsResponded well to treatment

Session 2LI4 (bilateral)GB34 (right)BL23 (bilateral)BL24 (bilateral)BL25 (bilateral)BL40 (right)

25 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.25

PerpendicularPerpendicularPerpendicularPerpendicularPerpendicularPerpendicular

15

Rotated × 3

Reported an initial increase in painTolerated increase in needles wellStrong De Qi achieved at BL40

Session 3LI4 (bilateral)GB34 (right)BL23 (bilateral)BL24 (bilateral)BL25 (bilateral)BL40 (right)BL62 (right)BL10 (bilateral)GB21 (bilateral)

25 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2525 × 0.2513 × 0.1825 × 0.25

PerpendicularPerpendicularPerpendicularPerpendicularPerpendicularPerpendicularOblique towards the lateral malleolusOblique towards the lamina of C2Perpendicular

20

Rotated × 4

Reported a short period of pins and needles around left LI4 after treatmentLow back pain improving, so able to begin to include cervical points

Session 4LI4 (bilateral)GB34 (right)BL23 (bilateral)BL24 (bilateral)BL25 (bilateral)BL40 (right)BL62 (right)BL10 (bilateral)GB21 (bilateral)

25 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2525 × 0.2513 × 0.1825 × 0.25

PerpendicularPerpendicularPerpendicularPerpendicularPerpendicularPerpendicularOblique towards the lateral malleolusOblique towards the lamina of C2Perpendicular

20

Rotated × 4

Reported an improvement in both neck and LBP

Session 5LI4 (bilateral)GB34 (bilateral)BL23 (bilateral)BL24 (bilateral)BL25 (bilateral)BL40 (bilateral)BL62 (bilateral)

25 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2540 × 0.2525 × 0.25

PerpendicularPerpendicularPerpendicularPerpendicularPerpendicularPerpendicularOblique towards the lateral malleolus

20

Rotated × 4

Neck pain has resolvedBilateral distal points needled to increase the extrasegmental effect for LBP

Session 6 LI4 (bilateral) GB34 (right) BL23 (bilateral) BL24 (bilateral) BL25 (bilateral) BL40 (right) BL62 (right)

25 × 0.25 40 × 0.25 40 × 0.25 40 × 0.25 40 × 0.25 40 × 0.25 25 × 0.25

Perpendicular Perpendicular Perpendicular Perpendicular Perpendicular Perpendicular Oblique towards the lateral malleolus

20

Rotated × 4

Patient reported that she is now pain- free Outcomes measured again No further treatment required

C. Hamer


tissue fibrosis and myofascial trigger points are detrimental because these lead to tissue restric-tion and impairment in the long term (Tough et al. 2009). Connective tissue is richly innervated by nociceptive neurons, and Aδ and C- fibres (Corey et al. 2011). Evidence suggests that acupuncture stimulates these Aδ and C- fibres, which communicate with the dorsal horn in the spinal cord, the brainstem, and higher centres such as the hypothalamus and periaqueductal grey matter. This leads to endogenous opioid mechanisms stimulating descending noxious inhibitory pathways, which causes an analgesic effect (Zhao 2008).

Acupuncture consists of needle insertion into muscle tissue, followed by twirling of the needle to elicit a distinct sensation of heaviness or numbness known as De Qi (Cheng 1987). De Qi means “the arrival of energy”. It is produced when the axon reflex in the terminal network of Aδ fibres is stimulated, causing a release of several substances, and resulting in improved blood flow, the promotion of heal-ing and pain relief (White et al. 2008). De Qi was achieved during each treatment session in the present study. Needle stimulation has been shown to increase blood flow in patients with fibromyalgia (Sandberg et al. 2005). As well as having pain- alleviating properties, acupuncture has also been shown to improve cutaneous microcirculation and tissue healing in MSK con-ditions (Ernst & Pittler 1998). Upon activation, Aδ and C- fibres release vasoactive substances such as calcitonin gene- related peptide and substance P. These are conducted antidromically from the relevant peripheral nerve terminals by axon reflex mechanisms that are known to be part of neurogenic inflammation (Holzer 1998). Calcitonin gene- related peptide is a very potent vasodilator that increases blood flow.

Large Intestine (LI) 4 was chosen because it is often used in experimental studies of the effects of acupuncture analgesia, and is frequently used in clinical practice as a point for pain (Wang & La 2007). It is known as the pain point in the body, and is indicated as a point to use for any type of pain (Berman et al. 2004). The subject reported a short period of pins and needles at the LI4 point 1 h after the second treatment

session ended, but the symptoms resolved that night. Targino et al. (2008) reported that 5.8% of their fibromyalgia acupuncture group developed temporary oedema, and pins and needles at the LI4 point on the left hand. Similarly, McCartney et al. (2000) described a case of bilateral hand oedema, and pins and needles after the use of bilateral LI4 acupuncture points to treat chronic LBP and sciatica. Large Intestine 4 is a major point for extrasegmental acupuncture.

The rationale for adding points further away from the pain was to elicit segmental effects. It is believed that acupuncture modulates spinal signal transmission and the perception of pain in the brain. The release of enkephalins and endorphins from acupuncture treatment exerts an inhibitory effect on nociceptive reflexes at the segmental level (Furlan et al. 2005). Enkephalin is a naturally occurring peptide with analgesic properties that is released by neurons in the CNS (Zhao 2008). The Bladder meridian is primarily used when treating LBP because it has points local to the spine, but it can also be used to achieve a segmental effect. The Bladder and Gall Bladder meridians follow dermatome levels corresponding to spinal levels. It is believed that the analgesic effect from acupuncture is enhanced by using points that share a common spinal segment (Bradnam- Roberts 2010). Moffet (2006) suggested that using local acupunc-ture points induces segmental pain ascending inhibitory effects through the spinal gait control mechanism stimulating Aδ and C- fibres. This releases opioids from inhibitory neurones in the dorsal horn of the spinal cord.

Distal points were added to provoke an extrasegmental effect. Acupuncture can induce pain relief throughout the whole body. Descending pain inhibition occurs in the periaqueductal grey matter, which is activated by endorphins released from the hypothalamus. The descending pain inhibition system is activated in the brainstem by neuromodulators, particularly noradrenaline and serotonin. Serotonin is an important transmitter of pain control (White et al. 2008). The limbic and paralimbic, hypo-thalamus, and subcortical grey matter structures have been identified as important factors in the mediation of the effects of acupuncture and De



Qi. The De Qi sensation is believed to be related to clinical efficacy, with strong sensations induc-ing strong deactivation of the limbic system and producing a clinically beneficial effect (Yang et al. 2013). Magnetic resonance imaging has demon-strated that acupuncture suppresses neurological output across the limbic system, suggesting that the emotive element of pain can be reduced (Zeng et al. 2012). Research into the permanent changes to emotional centres is being developed. This is in order to explore the possibility that the chronicity of pain may be related to the subcon-scious retention of pain in the memory, which acupuncture may play a role in resetting.

The total treatment time was gradually increased to 20 min by the third week to maxi-mize its effects (White et al. 2008). By the final treatment, the subject reported a significant decrease in her pain levels, an improvement in her quality of life and a return to her hobby of spinning. Her compliance with ROM exercises was evident, and all physiotherapy goals were achieved.

Patient profile after treatmentAfter six acupuncture treatment sessions had been completed, the subject reported that she no longer suffered from neck pain (NRS = 0/10). She rated her LBP as 1/10 at its worst on the NRS. The subject had resumed spinning classes three times a week, and had started training for the Inca Trail to Machu Picchu.

Objective assessmentDuring a cervical spine assessment, full ROM was noted with no reproduction of pain throughout. During a lumbar spine assessment, no tenderness was noted on palpation over the lumbar region or surrounding right- side soft tis-sue. There was slight reproduction of minimal pain during side flexion to the left. All other lumbar movements were achieved at full range with no discomfort.

The subject’s EQ- 5D- 5L score was 90/100.

DiscussionThe selection of appropriate points is fundamen-tal to obtaining a therapeutic effect from clinical

acupuncture (Lee et al. 2013). In the present case, distal points were used to induce strong analgesic effects by stimulating the release of serotonin and oxytocin from the hypothalamus, hippocampus and periaqueductal grey matter to inhibit pain further (Moffet 2006). Oxytocin blocks the memory of pain, and therefore, is useful for chronic pain conditions.

The present subject experienced significant improvements after completing a course of acupuncture treatment with additional physio-therapy. Six treatment sessions were planned and completed to good effect. Limitations to this study include the sample size and time since, although the treatment was completed, only short- term effects could be analysed. Further research is required to investigate the long- term effects of acupuncture. The subject in this study had three pain syndromes: neck pain and LBP, and the underlying comorbidity of fibromyalgia. In this case, both spinal mechanical pains were treated together because of time restraints, and the subject experiencing severe pain in both areas. Further development is required in the present author’s practice to research the effects of this, and to consider the effects of treating specific pains individually, not simultaneously.

An alternative to using the traditional points to treat cervical and lumbar pain following a whiplash injury would be to use myofascial trig-ger points. By stimulating certain points on the body, acupuncture contracts intraspindle muscle and produces myoelectricity. Secondary impulses reach the central brain, producing the needling sensation. Current Western thinking attributes the effect of the needling to stimulation of the motor endplate in the transverse motor band near the centre of a muscle, thereby releasing muscle spasm. Endorphin release also contrib-utes to pain relief (Greenwood et al. 1988).

The present subject had previously received acupuncture treatment for a different condition with positive effects. This may have influenced the outcome, and the placebo effect in acupunc-ture, which involves the limbic system, cannot be ignored. Kalauokalani et al. (2001) reported that patients who had greater expectations of acupuncture treatment were found to have bet-ter outcomes.

C. Hamer


Exaggerated pain after peripheral stimulation is common in cases of whiplash and patients with fibromyalgia (Sheather- Reid & Cohen 1998). The present subject suffered from both conditions. Further research is required to investigate the effects of acupuncture for MSK injuries when fibromyalgia is a comorbidity.

Current evidence does agree that acupunc-ture is beneficial for whiplash and patients with fibromyalgia. The present case study has demonstrated that acupuncture is effective in reducing pain, and improving quality of life and function.

AcknowledgementsI would like to thank the present subject for giving her permission for the publication of this study, allowing her condition and treatment to be further researched and documented.

My gratitude also goes to the instructors on the AACP Foundation Course for sharing their clinical expertise and wisdom with my cohort.

Finally, I wish to thank AACP for providing the informative course handbook that was con-sulted throughout this case study.

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Sandberg M., Larsson B., Linberg L.- G. & Gerdle B. (2005) Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work- related trapezius myalgia. European Journal of Pain 9 (5), 497–510.

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Charlotte Hamer graduated from the University of Salford with a BSc(Hons) in Physiotherapy in 2012. She currently works as a band 7 rehabilitation coordina-tor at Blackpool Teaching Hospitals NHS Foundation Trust, where she assesses patients and signposts them to the most appropriate local rehabilitation pathway. Charlotte practises acupuncture privately in her own clinic at a local personal training company.


Correspondence: Ben Bradford, Pure Physiotherapy Ltd, 6 City Road, Norwich NR1 3AL, UK (e- mail: [email protected]).


CASE REPORT

Electroacupuncture in the treatment of patellar tendinopathy in a 52- year- old male

B. BradfordPrivate Practice, Norwich, UK

AbstractA 52- year- old male software engineer with a 3- month history of anterior knee pain was referred for physiotherapy by his general practitioner. The pain had started insidiously, and was now particularly troublesome when he ascended stairs and during sustained periods of sitting. Clinically, the subject presented with highly specific pain at the inferolateral pole of the patella. This was aggravated when he performed a squat. Structural tests were all negative. The subject was treated with five sessions of electroacupuncture. The aim was to reduce his pain in order to facilitate appropriate loading of the tendon, as per the current evidence base for the treatment of tendon dysfunction. The subject reported significant improvements in pain (on the Numeric Rating Scale) and knee function after three sessions, and full resolution of the problem after the fifth.

Keywords: electroacupuncture, patellar tendinitis, patellar tendinopathy.

IntroductionPatellar tendinopathy is a chronic, disabling insult of the patellar tendon at its tendon–osse-ous attachment to the inferior pole of the patella (Kongsgaard et al. 2009). The prevalence of this condition is high in both recreational and elite athletes, particularly in sports requir-ing repetitive knee extension torque, such as running, athletics and volleyball (Larsson et al. 2012). Sedentary patients can also be affected (Brukner & Khan 2012), particularly now that more is known about systemic risk factors in tendinopathy, such as central adiposity and gen-der (Gaida et al. 2009).

Patellar tendinopathy is believed to occur as a result of repetitive tendon overload (Maffulli & Longo 2008). Tendon overload is thought to occur a result of macroscopic damage to

collagen myofibrils under stress. Insufficient repair of this damage can lead to a scenario in which cumulative microtrauma and degenera-tion of the tendon occurs (Croisier et al. 2001; Langberg et al. 2005). This process is believed to be hastened by the hypovascular environment of the tendon, since vessels appear to grow into the tendon only from the ventral surface (Neal & Longbottom 2012). The term “degenerative tendinopathy” was first suggested by Cook & Purdam (2009) as the characteristic structural degradation of the extracellular matrix (ECM) of pathological tendons, in which disorientation of collagen myofibrils, the presence of scattered neurovascular ingrowth and tenocyte apoptosis have all been demonstrated by histological and sonographic studies (McCreesh et al. 2013; Malliaras et al. 2013).

Although histopathological investigation has aided understanding of the pathophysiology of patellar tendinopathy, the underlying cause of chronic patellar tendon pain often remains

Electroacupuncture for patellar tendinopathy


unclear (Woodley et al. 2007). As a result, it has been difficult to establish which treatments are effective for patients with patellar tendinopathy, with many conservative management options often demonstrating unpredictable levels of success (Langberg et al. 2005).

In musculoskeletal practice, electroacupunc-ture (EA) has been shown to be an effective treatment for various acute and chronic pain disorders, including myofascial pain syndrome(s) and osteoarthritis (Leung et al. 2012; Tobbackx et al. 2012). The physiological basis of acupunc-ture analgesia has been the subject of extensive research, and is a manifestation of the integra-tive neurophysiological mechanisms at different levels of the central nervous system (CNS) that respond to the stimulation of Aβ and Aδ affer-ent fibres at specific neuroanatomical points located around the body (Shen 2001; Zhao 2008). The most efficacious inhibition of pain is believed to occur when acupressure points are selected that correspond either to the der-matomal or myotomal pathway that supplies the primary site of the pain. Segmental analgesia is the result of highly complex inhibitory changes in the postsynaptic membrane potential in trans-mission cells located in the dorsal root ganglion (Leung 2012). The secretion of β- endorphins and enkephalins has a modulatory effect on the transmission of noxious stimuli from the periphery to the higher centres of the CNS, resulting in a segmental hypoalgesic response (Hui et al. 2005).

Both clinical and laboratory studies have also demonstrated that EA induces a local vasodilatory effect in the myofascial structures close to the site of penetration, secondary to the secretion of a variety of local, endogenous opioid peptides. Since angiogenesis appears to be intricately linked to the ability of a tendon to heal, it has been proposed that treatments that augment tendon vascularity, such as acupunc-ture and platelet- rich plasma, may enhance the optimal environment needed for tendon repair (Neal & Longbottom 2012). Langevin et al. (2007) suggested that acupuncture does indeed enhance soft- tissue microcirculation. They con-cluded that stimulation of the needle resulted in microscopic disruption of mast cell formation,

and the release of several “pro- inflammatory” peptides, namely β- endorphins and chemokines, all of which have a vasodilatory effect on the local capillary network.

There has also been a noticeable increase in research into the beneficial effects of EA on the synthesis and organization of the ECM in pathological tendons. De Almeida et al. (2012) examined the levels of glycosaminoglycans and hydroxyproline (a marker of collagen concentration) in an investigation of the effects of EA on the composition of the ECM of the Achilles tendon in rats. Birefringence was used to demonstrate a higher concentration of type 1 collagen in the group of participants treated with EA, and a significant increase in the concentration of hydroxyproline in the same group. De Almeida et al. (2012) concluded that EA offers a potentially therapeutic benefit in the treatment of tendinopathy by inducing an increase in the rate of collagen synthesis and augmenting the molecular organization of the ECM. These authors then built upon their earlier promising results by developing a reasoned hypothesis for the anti- inflammatory and mechanotransduction molecular pathways underpinning structural tendon changes fol-lowing EA (de Almeida et al. 2014). They con-cluded that, when at least one needle is in close anatomical proximity to the tendon, stimulation of that point will lead to upregulation of the cell via activation of filamentous actin (F- actin). An integral part of the cytoskeleton, F- actin is responsible for allowing transmission of ten-sion through the cytoskeleton to the cell nuclei, whereby mechanical stimulus is analysed and an appropriate biochemical response initiated. Type 1 collagen synthesis is one example of this appropriate cellular response to the mechanical stimulus of EA, which may, therefore, influence the hierarchical nature of the ECM.

Case reportBackgroundThe subject of the present case report was a 52- year- old male with a 3- month history of anterior knee pain. He reported that he had experienced a considerable increase in pain

B. Bradford


and a decrease in knee function over the past 3 months, and that the pain was now interfering considerably with his daily life.

Subjective assessmentThe subject presented with insidious, highly localized left anterior knee pain. In his role as a software engineer, he regularly travels to the USA, and was now finding that both sitting for prolonged periods on flights and ascending stairs significantly aggravated his symptoms. The sub-ject reported that his pain was 5/10 on a visual analogue scale (VAS), rising to 7/10 after pro-longed sitting or ascending stairs. He described a highly specific ache at the inferior pole of the patella that worsened during the activities men-tioned above. The subject reported no episodes of locking, giving way or swelling, and had no history of any previous knee pain or injury. His past medical history was unremarkable. He takes no regular prescription medications.

Objective assessmentOn inspection of the subject’s left knee, there was no evidence of redness, swelling or deformity. There was an onset of pain over the patellar tendon at 140°, i.e. end- of- range flexion (VAS = 5/10). There was mild reproduction of pain with resisted knee extension, but no loss of power was evident. The single- leg squat test reproduced the subject’s anterior knee pain

(VAS = 7/10). There was palpable tenderness at the inferior pole of the patella (VAS = 7/10) that was aggravated when tilting the patella superiorly to expose the ventral fibres.

TreatmentFive weekly sessions of electroacupuncture (EA) following the treatment schedule shown in Table 1 were provided. The outcomes of each treatment session are displayed in Table 2. All risks and contraindications were considered, and a thorough explanation of the likely ben-eficial effects of EA was given to the subject at the initial assessment. Verbal consent was given prior to each session. The subject was positioned in long sitting, and his left knee was flexed to approximately 80° and supported with one pillow. Two, 0.25 × 40- mm Classic Plus acu-puncture needles (HMD Europe Ltd, Chipping Norton, Oxfordshire, UK) were inserted at Stomach (ST) 35 (Dubi) and Extra Point Lower Extremities (Ex- LE) 4 (Neixiyan) to allow electrical flow between the sites. The current was then supplied by a Cefar Acus 4 EA unit (Cefar Medical AB, Lund, Sweden). Current was generated at a mixed frequency stimulation of 2–80 Hz, with a pulse duration of 180 μs, and the subject was instructed to increase the amplitude to the maximum tolerable intensity (a strong, but not painful sensation of De Qi) from 0 to 12 mA.

Table 1. Treatment schedule: (ST) Stomach; and (Ex- LE) Extra Point Lower Extremities

Acupuncture points Frequency (Hz)

Pulse duration (μs)

Stimulation frequency (s)

Treatment time (min)

Needle size (mm)

Depth of penetration (cm)

De Qi/sensation of electroacupuncture

Session 1ST35 Ex- LE4

2–80

180

3

10

0.25 × 40

1.5

Mild to moderate

Session 2ST35Ex- LE4

2–80 180 3 20 0.25 × 40 1.5 Moderate

Session 3ST35Ex- LE4

2–80 180 3 20 0.25 × 40 1.5 Moderate to strong

Session 4ST35Ex- LE4 2–80 180 3 20 0.25 × 40 1.5 Strong

Session 5 ST35 Ex- LE4

2–80 180 3 20 0.25 × 40 1.5 Strong



Tab

le 2

. O

utco

me

of t

reat

men

t se

ssio

ns: (

VA

S) v

isua

l ana

logu

e sc

ale

Func

tion-

spec

ific

subj

ectiv

e ou

tcom

e af

ter

sess

ion

VA

S sc

ore

Kne

e ra

nge

of m

otio

n (o

nset

of

pain

)Pa

lpat

ion

of in

ferio

r po

le

Sing

le- le

g sq

uat

Sess

ion

1T

he s

ubje

ct w

as t

reat

ed f

or 1

0 m

in w

ith e

lect

roac

upun

ctur

e, a

s de

scrib

ed in

the

tre

atm

ent

sche

dule

(T

able

1).

Bec

ause

thi

s w

as t

he in

itial

ass

essm

ent,

time

was

tak

en t

o as

sess

the

kne

e jo

int,

and

dete

rmin

e th

e in

tens

ity o

f th

e pa

in r

epor

ted

by t

he s

ubje

ct (

as m

easu

red

on a

VA

S)

usin

g th

ree

spec

ific

obje

ctiv

e ou

tcom

e m

easu

res:

pal

patio

n at

the

infe

rior

pole

of

the

pate

lla;

durin

g a

sing

le- le

g sq

uat;

and

knee

flex

ion

and

exte

nsio

n. T

he o

nset

of

pain

was

mea

sure

d w

ith

a go

niom

eter

in o

rder

to

asse

ss a

ny im

prov

emen

ts in

pai

n th

roug

h ra

nge.

The

sub

ject

rep

orte

d a

mild

- to-

mod

erat

e se

nsat

ion

of D

e Q

i dur

ing

the

10- m

in t

reat

men

t se

ssio

n, w

hich

he

desc

ribed

as

a “

gent

le p

ulsi

ng s

ensa

tion”

bet

wee

n po

ints

.

7/10

7/10

0–11

4° fl

exio

n (V

AS

= 5

/10)

Sess

ion

2T

he s

ubje

ct r

epor

ted

an im

prov

emen

t in

his

pai

n fo

llow

ing

the

prev

ious

tre

atm

ent

sess

ion.

In

par

ticul

ar, h

e fo

und

asce

ndin

g st

airs

eas

ier

beca

use

of a

red

uctio

n in

the

inte

nsity

of

the

pain

. He

repo

rted

no

adve

rse

effe

cts

afte

r th

e fir

st s

essi

on. T

he s

ubje

ct w

as a

gain

set

tled

in

long

sitt

ing,

and

the

tre

atm

ent

give

n in

ses

sion

1 w

as r

epea

ted.

The

onl

y di

ffer

ence

was

an

incr

ease

in t

he t

reat

men

t du

ratio

n to

20

min

, as

per

the

prev

ious

ly d

iscu

ssed

rec

omm

enda

tions

fr

om t

he li

tera

ture

. The

sub

ject

rep

orte

d a

mod

erat

e se

nsat

ion

of D

e Q

i at

the

ante

rior

knee

, an

d de

scrib

ed t

his

as a

pul

satin

g se

nsat

ion

betw

een

poin

ts a

cros

s th

e te

ndon

. Obj

ectiv

ely,

ther

e w

as a

n im

prov

emen

t in

pai

n in

tens

ity (

VA

S) o

n pa

lpat

ion

of t

he p

atel

lar

tend

on, a

nd a

n im

prov

emen

t in

kne

e ra

nge

from

126

to

132°

(V

AS

= 4

/10)

, but

the

sin

gle-

leg

squa

t V

AS

scor

e re

mai

ned

the

sam

e.

6/10

7/

10 0–

121°

flex

ion

(VA

S =

4/1

0)

Sess

ion

3T

he s

ubje

ct r

epor

ted

an o

ngoi

ng im

prov

emen

t in

pai

n fo

llow

ing

the

seco

nd s

essi

on. H

e de

scrib

ed a

slig

ht in

crea

se in

pai

n fo

r 1

day

follo

win

g th

e se

ssio

n, b

ut a

ttrib

uted

thi

s to

the

lo

nger

tre

atm

ent

dura

tion

and

a m

ore-

sign

ifica

nt s

ensa

tion

of D

e Q

i dur

ing

it. D

espi

te t

his,

the

subj

ect

repo

rted

a s

igni

fican

t im

prov

emen

t in

kne

e pa

in f

rom

bas

elin

e. H

e no

w r

ated

his

pa

in w

hen

asce

ndin

g st

airs

as

3/10

on

the

VA

S, a

nd s

aid

that

he

coul

d no

w o

ccas

iona

lly a

scen

d st

airs

with

out

any

pain

, whe

reas

he

prev

ious

ly n

oted

pai

n ev

ery

time

he a

scen

ded

a st

airc

ase.

O

bjec

tivel

y, th

ere

was

a s

igni

fican

t im

prov

emen

t in

pai

n in

tens

ity (

VA

S), w

ith fi

rm, d

irect

pa

lpat

ion

of t

he p

atel

lar

tend

on, a

nd d

urin

g a

sing

le- le

g sq

uat.

The

sam

e tr

eatm

ent

appr

oach

w

as u

tiliz

ed, b

ut a

str

onge

r, un

com

fort

able

sen

satio

n of

De

Qi w

as n

oted

, whi

ch t

he s

ubje

ct

desc

ribed

as

a fir

m “

twis

ting,

pul

satin

g” f

eelin

g be

twee

n po

ints

whe

n in

crea

sing

the

am

plitu

de

abov

e 5.

0 m

A.

3/10

5/10

0–12

5° fl

exio

n (V

AS

= 1

/10)

Con

tinue

d/

B. Bradford


Func

tion-

spec

ific

subj

ectiv

e ou

tcom

e af

ter

sess

ion

VA

S sc

ore

Kne

e ra

nge

of m

otio

n (o

nset

of

pain

)Pa

lpat

ion

of in

ferio

r po

le

Sing

le- le

g sq

uat

Sess

ion

4T

he s

ubje

ct r

epor

ted

a su

bsta

ntia

l im

prov

emen

t in

his

left

kne

e pa

in a

nd f

unct

ion.

He

stat

ed

that

he

was

ver

y pl

ease

d w

ith t

he p

rogr

ess

mad

e so

far

, and

was

del

ight

ed t

hat

he c

ould

now

as

cend

a s

tairc

ase

with

min

imal

pai

n. H

e de

scrib

ed t

he d

isco

mfo

rt o

n as

cend

ing

stai

rs a

s a

“tw

inge

as

oppo

sed

to p

ain”

, and

had

als

o fo

und

that

sitt

ing

for

long

per

iods

whi

le d

rivin

g pr

ovok

ed o

nly

min

imal

dis

com

fort

ove

r th

e pa

tella

r te

ndon

(V

AS

= 1

–2/1

0). O

bjec

tivel

y, th

ere

was

a s

igni

fican

t im

prov

emen

t in

pal

pabl

e di

scom

fort

ove

r th

e pa

tella

. The

sub

ject

rat

ed t

his

pain

as

only

1/1

0 on

the

VA

S, a

nd s

aid

that

pal

patio

n w

as s

imila

r to

the

asy

mpt

omat

ic k

nee.

T

here

was

als

o an

impr

ovem

ent

in s

ingl

e- le

g sq

uat

rang

e (V

AS

= 3

/10)

, but

aga

in, h

e sa

id t

hat

this

was

mor

e of

a t

win

ge in

the

kne

e, a

s op

pose

d to

fra

nk p

ain.

Thi

s w

as a

lso

the

first

ses

sion

in

whi

ch t

he s

ubje

ct r

epor

ted

no d

isco

mfo

rt d

urin

g fle

xion

and

ext

ensi

on, w

hich

was

now

equ

al

in r

ange

to

the

asym

ptom

atic

sid

e. T

he s

ame

trea

tmen

t re

gim

e w

as a

pplie

d, a

nd t

he s

ubje

ct w

as

enco

urag

ed t

o in

crea

se t

he a

mpl

itude

to

the

max

imal

tol

erab

le in

tens

ity o

f 7.

2 m

A. D

e Q

i was

ag

ain

felt

stro

ngly

at

this

am

plitu

de, a

nd h

e de

scrib

ed it

as

a “p

ulsi

ng, t

wis

ting”

fee

ling

betw

een

poin

ts.

1–2/

10 3/

10 0–

130°

flex

ion*

(V

AS

= 0

/10)

Sess

ion

5 A

t th

e fin

al s

essi

on, t

he s

ubje

ct s

tate

d th

at h

e no

w h

ad m

inim

al is

sues

with

his

left

kne

e, a

nd

felt

that

the

re w

as a

lmos

t co

mpl

ete

reso

lutio

n of

the

pro

blem

. He

stat

ed t

hat

he h

ad h

ad o

nly

one

epis

ode

of k

nee

pain

in t

he p

revi

ous

10 d

ays,

whi

ch h

e de

scrib

ed a

s a

mom

enta

ry t

win

ge

whe

n qu

ickl

y as

cend

ing

two

step

s at

a t

ime.

The

sub

ject

sta

ted

that

, com

pare

d to

the

sev

erity

of

the

sym

ptom

s at

bas

elin

e, h

e no

w “

didn

’t no

tice”

any

rem

aini

ng k

nee

pain

. He

rate

d hi

s ov

eral

l im

prov

emen

t at

> 9

0% a

nd f

elt

read

y fo

r di

scha

rge.

Obj

ectiv

ely,

the

phys

ioth

erap

ist

was

un

able

to

elic

it an

y pa

in o

n pa

lpat

ion

of t

he p

atel

lar

tend

on a

t th

e in

ferio

r po

le o

f th

e pa

tella

, an

d th

e su

bjec

t sa

id t

hat

the

left

sid

e no

w f

elt

the

sam

e as

the

rig

ht. A

sin

gle-

leg

squa

t di

d no

t pr

oduc

e pa

in, a

nd d

emon

stra

ted

an e

qual

ran

ge t

o th

e as

ympt

omat

ic s

ide.

Ple

asin

gly,

ther

e w

as

still

a f

ull r

ange

of

knee

flex

ion

and

exte

nsio

n w

ithou

t an

y pa

in.

0/10

0–1/

10

0–13

0° fl

exio

n* (

VA

S =

0/1

0)

*Ful

l ran

ge –

equ

al t

o as

ympt

omat

ic s

ide.

Tab

le 2

. (C

ontin

ued

)



DiscussionThe rationale for the use EA in the present case was influenced both by the growing body of literature supporting the use of this modal-ity in promoting beneficial structural change in pathological tendons (Neal & Longbottom 2012; Speed 2015), and the frequency- dependent release of opioid neuropeptide secretion by the CNS in response to peripheral electrical stimu-lation (Zhang et al. 2014).

Opioid neuropeptides play an important role in brain function in relation to pain. Electroacupuncture can facilitate the release of these neurotransmitters, which has resulted in a surge in research into the specific frequencies necessary for such a phenomenon to occur. Therefore, the decision to select EA alternat-ing between frequencies of 2–80 Hz for each treatment session was guided by the plethora of recent neurophysiological research suggesting that low- frequency EA (2–15 Hz) inhibits the transmission of noxious stimuli more effectively than high- frequency EA, but that high- frequency EA (80–100 Hz) is preferable for the release of greater amounts of opioid secretion in the CNS (Kuo et al. 2013). Although research has not been able to establish a “gold standard” in terms of frequency of EA for optimal levels of analgesia, the best available evidence suggests that alternating between frequencies may result in more- efficacious inhibition of pain (Zhang et al. 2014).

The above appears to support the earlier work of Han (2003) and Lin et al. (2002), who both concluded that different physiological mechanisms are responsible for analgesia at differing frequencies of EA. Through the use of opioid- specific antagonists, Han (2003) was able to conclude that analgesia induced by low- frequency EA is modulated by both μ- and δ- opioid receptors, and high- frequency EA by κ- opioid receptors, suggesting that different opioid neuropeptides are synthesized under different conditions. In addition, to determine whether the hypoalgesic response initiated by stimulation at 2 or 100 Hz was modulated in the spinal cord by enkephalin and dynorphin, Han (2003) performed an experiment to cre-ate a protein complex by binding the opioid

neuropeptide to its antibody in order to induce a loss of its biological function as it approaches the receptor site. A subsequent injection of an enkephalin inhibitory substance resulted in a significant reduction in the hypoalgesic response initiated at 2 Hz, but this effect diminished as the frequency was increased to 128 Hz, again suggesting a supraspinal mechanism of opioid secretion at higher frequencies.

This is supported by earlier the work of Lin et al. (2002), who discovered a 61% decrease in morphine requirement in a group of patients receiving high- frequency EA following bowel surgery, as compared to a 43% decrease in the low- frequency EA group. These findings again suggest effective but differing secretion of enkephalins and dynorphins across the two frequencies.

The selection of ST35 and Ex- LE4 was guided primarily by their anatomical proximity to the patellar tendon. This is particularly rel-evant given that the aim of the treatment was not only to reduce pain, but also to attempt to facilitate structural changes in the pathological ECM by stimulating the local tendon cellular network. There has been a noticeable increase in research into the effects of EA on the structural degeneration of pathological tendons, and recent high- quality evidence suggests that, through a specific action on tenocyte activity, EA can both upregulate type 1 collagen synthe-sis and enhance the molecular organization of the ECM (de Almeida et al. 2012, 2015). Similar results were reported by Inoue et al. (2015), who recorded a statistically significant increase in total cell count and basic fibroblast growth factor with the use of EA in a ruptured, degen-erative rat Achilles tendon.

The mechanotransduction molecular mecha-nism of EA proposed by de Almeida et al. (2014) stipulates that when the needle is either inserted into or in close approximation to the paratendinous sheath of the tendon, then acti-vation of the cell nuclei occurs via stimulation of F- actin fibres within the tendon cytoskeleton. The frequency and amplitude of this stimulus then provokes a suitable biological response from the nucleus, including the synthesis and reorganization of type 1 collagen fibres. This

B. Bradford


logic and research was applied during the inser-tion of the needles, which were introduced obliquely and upwardly towards the paratendi-nous sheath at the inferior pole of the patella to elicit the desired molecular response during EA treatment.

The treatment time was limited to 10 min for the first session in order to assess the subject’s tolerance and monitor for any potential adverse effects. The decision to increase the treatment time was influenced by the subject’s positive response to the initial session, and clinical evi-dence supporting the efficacy of EA under dif-fering durations of stimulation. Mori et al. (2014) produced an interesting piece of research that concluded that both skin blood flow and muscle blood volume increased significantly in the EA group in comparison to baseline. Furthermore, > 10 min of EA treatment to the rectus femoris muscle was of sufficient duration to induce a statistically significant response in intramuscular blood flow where this was a desired clinical outcome. Similarly, encouraging evidence was published by Kimura et al. (2015), who meas-ured muscle oxygenation of the tibialis anterior muscle using near- infrared spectroscopy after 15 min of EA at 1–20 Hz. These researchers concluded that there was a statistically significant increase in muscle oxygenation levels in the recovery period after 15 min of EA at 20 Hz, which again suggests that a treatment time of ≥ 15 min is sufficient to induce an increase in myofascial blood flow. Although the conclu-sion of both pieces of research was that EA of > 15 min in duration is sufficient to facilitate an increase in muscle blood flow/oxygenation, it could well be possible that the effects of such an intervention could be extrapolated to tendinous tissue, particularly when an increase in blood flow is desirable.

ReferencesBrukner P. & Khan K. (2012) Brukner and Khan’s Clinical

Sports Medicine, 4th edn. McGraw- Hill Australia, North Ryde, NSW.

Cook J. L. & Purdam C. R (2009) Is tendon pathology a continuum? A pathology model to explain the clini-cal presentation of load- induced tendinopathy. British Journal of Sports Medicine 43 (6), 409–416.

Croisier J.- L., Forthomme B., Foidart- Dessalle M., Godon B. & Crielaard J.- M. (2001) Treatment of recurrent tendinitis by isokinetic eccentric exercise. Isokinetics and Exercise Science 9 (2–3), 133–141.

De Almeida M. dos S., de Aro A. A., Guerra F. da R., et al. (2012) Electroacupuncture increases the concen-tration and organization of collagen in a tendon heal-ing model in rats. Connective Tissue Research 53 (6), 542– 547.

De Almeida M. dos S., Guerra F. D. R., de Oliveira L. P., Vieira C. P. & Pimentel E. R. (2014) A hypothesis for the anti- inflammatory and mechanotransduction molecular mechanisms underlying acupuncture tendon healing. Acupuncture in Medicine 32 (2), 178–182.

De Almeida M. dos S., de Freitas K. M., Oliveira L. P., et al. (2015) Acupuncture increases the diameter and reorganisation of collagen fibrils during rat tendon healing. Acupuncture in Medicine 33 (1), 51–57.

Gaida J. E., Ashe M. C., Bass S. L. & Cook J. L. (2009) Is adiposity an under- recognized risk factor for tendi-nopathy? A systematic review. Arthritis and Rheumatism 61 (6), 840–849.

Han J.- S. (2003) Acupuncture: neuropeptide release pro-duced by electrical stimulation of different frequencies. Trends in Neurosciences 26 (1), 17–22.

Hui K. K. S., Liu J., Marina O., et al. (2005) The inte-grated response of the human cerebro- cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. NeuroImage 27 (3), 479–496.

Inoue M., Nakajima M., Oi Y., et al. (2015) The effect of electroacupuncture on tendon repair in a rat Achilles tendon rupture model. Acupuncture in Medicine 33 (1), 58–64.

Kimura K., Ryujin T., Uno M. & Wakayama I. (2015) The effect of electroacupuncture with different frequen-cies on muscle oxygenation in humans. Evidence- Based Complementary and Alternative Medicine 2015: 620785. DOI: 10.1155/2015/620785.

Kongsgaard M., Kovanen V., Aagaard P., et al. (2009) Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine and Science in Sports 19 (6), 790–802.

Kuo C.- C., Tsai H.- Y., Lin J.- G., Su H.- L. & Chen Y.- F. (2013) Spinal serotonergic and opioid receptors are involved in electroacupuncture- induced antinociception at different frequencies on ZuSanLi (ST 36) acupoint. Evidence- Based Alternative and Complementary Medicine 2013: 291972. DOI: 10.1155/2013/291972.

Langberg H., Ellingsgaard H., Madsen T., et al. (2005) Eccentric rehabilitation exercise increases peritendi-nous type 1 collagen synthesis in humans with Achilles tendinosis. Scandinavian Journal of Medicine and Science in Sports 17 (1), 61–66.

Langevin H. M., Bouffard N. A., Churchill D. L. & Badger G. J. (2007) Connective tissue fibroblast response to acupuncture: dose- dependent effect of



bidirectional needle rotation. The Journal of Alternative and Complementary Medicine 13 (3), 355–360.

Larsson M. E. H., Käll I. & Nilsson- Helander K. (2012) Treatment of patellar tendinopathy – a systematic review of randomized controlled trials. Knee Surgery, Sports Traumatology, Arthroscopy 20 (8), 1632–1646.

Leung L. (2012) Neurophysiological basis of acupuncture- induced analgesia – an updated review. Journal of Acupuncture and Meridian Studies 5 (6), 261–270.

Lin J.- G., Lo M.- W., Wen Y.- R., et al. (2002) The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. Pain 99 (3), 509–514.

McCreesh K. M., Riley S. J. & Crotty J. M. (2013) Neo-vascularity in patellar tendinopathy and the response to eccentric training: a case report using Power Doppler ultrasound. Manual Therapy 18 (6), 602–605.

Maffulli N. & Longo U. G. (2008) How do eccentric exercises work in tendinopathy? Rheumatology 47 (10), 1444–1445.

Malliaras P., Barton C. J., Reeves N. D. & Langberg H. (2013) Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Medicine 43 (4), 267–286.

Mori H., Kuge H., Tanaka T. H. & Taniwaki E. (2014) Influence of different durations of electroacupuncture stimulation on skin blood flow and muscle blood vol-ume. Acupuncture in Medicine 32 (2), 167–171.

Neal B. S. & Longbottom J. (2012) Is there a role for acu-puncture in the treatment of tendinopathy? Acupuncture in Medicine 30 (4), 346–349.

Shen J. (2001) Research on the neurophysiological mecha-nisms of acupuncture: review of selected studies and methodological issues. The Journal of Alternative and Complementary Medicine 7 (Suppl. 1), 121–127.

Speed C. (2015) Acupuncture’s role in tendinopathy: new possibilities. Acupuncture in Medicine 33 (1), 7–8.

Tobbackx Y., Meeus M., Wauters L., et al. (2012) Does acupuncture activate endogenous analgesia in chronic whiplash- associated disorders? A randomized crossover trial. European Journal of Pain 17 (2), 279–289.

Woodley B. L., Newsham- West R. J. & Baxter G. D. (2007) Chronic tendinopathy: effectiveness of eccentric exercise. British Journal of Sports Medicine 41 (4), 188–198; discussion 199.

Zhang R., Lao L., Ren K. & Berman B. M. (2014) Mechanisms of acupuncture–electroacupuncture on persistent pain. Anaesthesiology 120 (2), 482–503.

Zhao Z.- Q. (2008) Neural mechanism underlying acupunc-ture analgesia. Progress in Neurobiology 85 (4), 355–375.

Ben Bradford has worked solely in musculoskeletal physiotherapy since qualifying in June 2014. He has a clinical interest in lower- limb tendinopathy, having completed his undergraduate dissertation on the efficacy of eccentric exercise for patellar tendinopathy in athletes.


Correspondence: Gemma Parry MSc, Sports Science and Medicine Department, Birmingham City Football Club, 300 Redhill, Birmingham B38 9EL, UK (e- mail: [email protected]).


CASE REPORT

Use of acupuncture to treat an academy football player with ankle impingement

G. Parry

Sports Science and Medicine Department, Birmingham City Football Club, Birmingham, UK

AbstractA 15- year- old male academy football player at a championship club sustained an ankle impingement injury following a tackle. Acupuncture was selected as an adjunct to a rehabili-tation programme and conservative measures. The Gall Bladder (GB) 34, GB40, Spleen (SP) 5, SP6, SP9, Stomach (ST) 36, ST41 and Kidney 7 acupoints were used to treat the subject. A visual analogue scale, the Lower Extremity Functional Scale, and the weight- bearing lunge or knee- to- wall test were used as objective markers. The subject began a graded return to football training within 30 days after a reduction in pain and a restoration of range of motion (ROM) were achieved. There is potential for acupuncture to be used as a cost- effective adjunct in combination with a rehabilitation exercise programme for the treatment of ankle impingement to reduce inflammation and pain, and restore active ROM. Western medical and traditional Chinese medicine rationales are discussed.

Keywords: academy football, acupuncture, ankle impingement, Lower Extremity Functional Scale.

IntroductionAcupuncture has been used to treat a variety of pathologies for over 3000 years (Lin et al. 2013). While needling techniques remain broadly the same, there are two main rationales for its use: Western medical acupuncture (WMA) and tradi-tional Chinese medicine (TCM) (Bradnam 2003, 2007). From a TCM perspective, acupuncture points are located on a network of meridians that are located longitudinally along the surface of the skin, allowing the flow and conduction of a form of energy known as Qi (Suko et al. 2011). While the aim of the TCM approach is to restore the “yin and yang” balance, and

the flow of Qi, WMA point selection adopts this approach to modulate the imbalances between sympathetic and parasympathetic activ-ity (Lin et al. 2013). By utilizing points within the area of injury, WMA aims to alter pain perception in the brain at levels such as the hypothalamus and descending pain inhibitory pathways. This induces segmental pain relief (Lin & Chen 2008; Lin et al. 2013), and also increases blood circulation locally and opti-mizes the inflammatory processes (Zijlstra et al. 2003).

The present case study explores both WMA and TCM approaches to acupuncture during the treatment of a male academy football player at a championship club. The subject had suffered ankle impingement as a result of a traumatic tackle during a game, and had an extensive his-tory of ankle sprains. Because of the demands

Acupuncture for ankle impingement


of the game and the skill required to play it at this level, youth players run a high risk of trauma. Ankle injuries account for 10–18% of incidents (Woods et al. 2003; Ekstrand et al. 2011), predominantly as a result of making or being on the receiving end of a tackle (Giza et al. 2003). Waldén et al. (2013) stated that ankle impingement syndromes comprise 3% of all ankle injuries. Anecdotally, it has been noted that footballers continue to play with such symptoms, and regularly do not refer for treat-ment unless these are severe, which means that research into injury management is scarce.

Although infrequent, ankle impingement injuries occur as a result of forced plantar flexion, supination and tractions to the anterior capsule, and forced compression of the pos-terior ankle (Tol & van Dijk 2006). Following prolonged torsional joint stresses and repetitive trauma where bony impingement can occur between the talus and distal tibia, hypertrophy of the bone and soft tissues through repeated fibrosis, fibrocartilage proliferation and poten-tial osteophyte development can lead to limited dorsiflexion and altered joint mechanics over time (Amendola et al. 2012), with accumulation of scar tissue in the anteriolateral gutter and around the anterior talofibular ligament (ATFL).

Traditionally, a conservative, non- operative approach to management is advocated, and surgical intervention is only recommended in cases where such measures are unsuccessful. For example, arthroscopic debridement is a key approach for soft- tissue- related impinge-ment because it involves a short period of recovery and a rapid return to sporting activity (Vaseenon & Amendola 2012). A search of the Ovid and PubMed databases yielded no results regarding the use of acupuncture to treat ankle impingement syndromes. There is a larger body of evidence for the use of acupuncture in ankle sprains, which can be a predisposing and or contributing factor for the development of impingement (Anderson et al. 2014).

A systematic review and meta- analysis by Park et al. (2013) determined that, while the evidence was insufficient for acupuncture use at the ankle, this was attributed to the small num-bers of participants involved in the publications

available. With regard to the immediate reduc-tion of pain on a visual analogue scale (VAS), several high- quality primary studies have pro-posed that acupuncture significantly alleviates pain in comparison to other forms of manual therapy. Sun & Ju (2011) also showed that the use of acupuncture in conjunction with func-tional exercise reduces the time taken to return to normal function by 3–4 days, and that it may be more clinically advantageous than functional exercise alone. It should be noted that all authors suggest that acupuncture is a safe form of treatment for ankle pathology, and while the methodology of the studies may be poor, acupuncture can be a statistically significant adjunct to improve global symptoms of ankle pain in comparison to stand- alone treatments (Park et al. 2013).

Thickening and fibrosing of the ATFL occur during ankle sprain and impingement (Anderson et al. 2014). Thus, it is not unreasonable to sup-pose that the rationale for the use of acupunc-ture to treat ankle sprain may also transfer to its effective application in ankle impingement since the same soft tissues are affected in a similar way.

Case reportSocial history and backgroundThe present study describes the case of a 15- year- old male academy football player at a championship club. Following a tackle during a game, the subject’s left foot was maximally plan-tar flexed and inverted following a strike from an opponent, and he felt a searing, burning pain in the anterior aspect of his ankle. Unable to bear weight, he was immediately removed from the field of play, where ice, medial and lateral J- shaped pads, and Tubigrip (Mölnlycke Health Care Ltd, Oldham, UK) for compression had been applied. The subject was placed in an Aircast boot (DJO Global, Vista, CA, USA) and provided with two elbow crutches for ease of ambulation because he recorded his pain as 2/10 on a VAS.

Upon examination 48 h later, the subject continued to report a pain score of 4/10 on the VAS on walking, and palpation of the ATFL

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and retinaculum. There was swelling over the lateral, anteromedial and posterior portions of his left ankle, reduced active range of motion (AROM) in all directions, and pain on too much pressure of the end of range during passive inversion and dorsiflexion. Ankle strength was also reduced through all ranges and graded at 3/5 on the Oxford Grading Scale (OGS). Ligamentous stability tests could not be com-pleted because of the subject’s apprehension. His gait was disrupted, and there was no heel- to- toe pattern and a lack of left- knee extension. He was provided with gentle AROM exercise in all directions, non- weight- bearing gluteal and core exercises, and also regular ice and compression via a Game Ready system (Game Ready Global UK Ltd, Redhill, Surrey, UK). A diagnosis of ankle sprain was made, and the subject remained in the Aircast boot.

Although he could mobilize unaided in the Aircast boot by day 6 after the injury, the subject’s symptoms remained in status quo, and minimal improvements in pain, ROM and muscle strength were noted. An ultrasound scan was completed by the club doctor that showed intracapsular swelling and thickening of the surrounding soft tissues, and fluid in the anterior retinaculum. Therefore, the subject was diagnosed with ankle impingement.

Outcome measuresOutcome measures are an important aspect of the management of a patient’s injury, and a vital part of patient- centred care (Abbot & Schmitt 2014). The Lower Extremity Functional Scale (LEFS) (Binkley et al. 1999) was selected because it has proven validity and reliability as an indicator of lower- limb function in the nor-mal and sporting populations (Abbot & Schmitt 2014). A VAS was used to monitor the intensity of the subject’s pain (Hawker et al. 2011). The weight- bearing lunge or knee- to- wall test was selected to assess ankle ROM and replication of impingement mechanisms because it has proven test- related reliability as a dorsiflexion measure (Cejudo et al. 2014). At the initial assessment, the subject’s ankle pain was 4/10 on the VAS and scored 17/80 on the LEFS, which indicates high levels of dysfunction and disability.

TreatmentSession 1 (9 days post- injury). In the first treatment session, six needles (0.25 × 25 mm) were used over five points, two distally and four locally. Phoenix metal needles (Phoenix Medical Ltd, Chelmsford, Essex, UK) used in this and all subsequent treatments (Table 1). The acupunc-ture points were selected in order to reduce

Table 1. Summary of acupuncture treatment sessions: (ROM) range of motion; (GB) Gall Bladder; (SP) Spleen; (KI) Kidney; and (VAS) visual analogue scale

Objective Acupuncture points De QiNeedle size (mm)

Time (min) Comments

Session 1Reduce pain, increase active ROM at ankle and reduce swelling

GB34 (bilateral)SP5 (unilateral)SP6 (unilateral)SP9 (unilateral)KI7(unilateral)

YesYesNoYesYes

0.25 × 250.25 × 250.25 × 250.25 × 250.25 × 25

1515151515

TinglingHeavy ache towards toesPain reduced to 1/10 on VAS

Session 2Full, pain- free ROM at the ankle to reduce swelling

GB34 (bilateral)GB40 (bilateral)SP5 (unilateral)SP6 (unilateral)

YesYesYesYes

0.25 × 250.25 × 250.25 × 250.25 × 25

20202020

De Qi strongest at SP5 and SP6Felt very heavy in the leg, dull warm ache towards toes

Session 3Full passive and active ROM at the ankle to increase strength and reflect the patient’s phase of rehabilitation

GB34 (bilateral) GB40 (bilateral) SP5 (unilateral) SP6 (unilateral) ST36 (unilateral) ST41 (unilateral)

Yes Yes No Yes Yes Yes

0.25 × 25 0.25 × 25 0.25 × 25 0.25 × 25 0.25 × 25 0.25 × 25

20 20 20 20 20 20

Warm, tingling sensation at ST36 and ST41 Erythema seen at ST36 and ST41



pain and swelling, and increase ankle ROM. Since Ceccherelli et al. (2014) demonstrated that there is no significant difference in terms of therapeutic effect and anti- nociceptive efficacy between three and 11 needles, six needles were employed because this was what the subject could comfortably tolerate. Bilateral needling of Gall Bladder (GB) 34 was selected: from a TCM perspective, this is one of the most significant points for the alleviation of stagnation and re- regulation of Qi; and from a WMA standpoint, it is crucial to the treatment of musculoskeletal soft- tissue pathology, and also strengthens and relaxes the subject via analgesic modulation of sympathetic activity (Zhang et al. 2009). The Spleen meridian was selected because of the overuse and overstrain nature of an impinge-ment injury, which is likely to be attributed to Qi deficiencies, and weakness in the sinews and soft tissues. This leaves the subject prone to Wind, Cold and Damp invasion, and subsequent Zang Fu disharmony (Young 2005). Spleen (SP) 5, SP6 and SP9 were selected because of the segmental effects of peroneal nerve afferent impulse generation, which provides analgesic relief along the L4–5 dermatomes. These points are recommended for the alleviation of pain, weakness and atrophy in the ankle and foot (Jarmey & Bouratinos 2008). Finally, Kidney 7 was selected because of its purported efficacy in moving oedema and interstitial fluids (Jun et al. 2000). Needles were inserted for 15 min and manipulated every 5 min in order to promote a local inflammatory healing response (Zhou et al. 2012).

Session 2 (15 days post- injury). The subject was able to mobilize without the Aircast boot 6 days after the first treatment session. However, he was still experiencing pain on twisting movements, and graded this at 2/10 on the VAS. Palpation of the retinaculum continued to elicit a pain score of 2/10 on the VAS. Full AROM had returned, with the exception of dorsiflexion, which was restricted to three- quarters range. The results of the knee- to- wall test had increased by 2 cm. Swelling was greatly reduced all around the area, with only a small pocket of oedema remaining at the anterolateral gutter.

Because of these results, the previously selected points were utilized again, but the length of the needle insertion was increased to 20 min, with manipulation every 5 min. The purpose of the second treatment session was to eliminate the last of the swelling and further increase AROM. The focus was on manipulation of the local needles to stimulate β- endorphin release and achieve a local, short- term analgesic segmentation effect. The insertion and manipu-lation of needles during acupuncture induces changes in the perforated tissue near the site of penetration. It has been proposed that stimula-tion of the Αδ and C- fibres creates vasodilative effects and calcitonin peptide release. This small dose is important because of the potential anti- inflammatory actions (Zijlstra et al. 2003) and subsequent improvement in tissue function.

In addition, from a WMA perspective, GB40 was added as a local point to optimize the subject’s perception of pain around the ankle area via the effect on the cortex (Xue et al. 2011). From a TCM standpoint, the inclusion of GB40 contributed to the “eyes” of the ankle “surrounding the dragon”, which clears Dampness and promotes Qi within the Gall Bladder channel (Jarmey & Bouratinos 2008). Strong De Qi responses were noted.

Session 3 (17 days post- injury). On examination 2 days later, the subject denied having any pain, and reported a VAS score of 0/10 and full AROM at the ankle. His muscle power had increased to +4/5 on the OGS, and the result of the knee- to- wall test had increased to 3 cm. Because of the strong De Qi response in previ-ous treatment sessions, the subsequent changes in parasympathetic activity, adaptive changes in responsiveness to neurotransmitters and alleviation of the autonomic response (Lin et al. 2013) potentially contributed to the reduction in pain and restoration of ROM. Because of this improvement in function, the previous points were selected again, and Stomach (ST) 36 and ST41 were also added to optimize and reflect the current phase of the subject’s rehabilitation. Stomach 41 is located at the anterior aspect of the ankle, at the junction of the dorsal foot and leg, and is considered to be very important for

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vertical alignment and strongly associated with lower- limb strengthening (Jarmey & Bouratinos 2008). Zhou et al. (2012) demonstrated that unilateral use of manual acupuncture at ST36 improved muscle strength throughout the lower- limb dorsiflexors. After this treatment session, the subject experienced no pain on palpation of the ankle, and the result of the knee- to- wall test had increased to 3.5 cm, which was almost equal to the unaffected side. The LEFS score had also increased to 73/80, clearly demonstrat-ing the improvements in disability and function.

DiscussionDespite the severity of the symptoms caused by ankle impingement, management of this condition is only sparsely documented within the research literature, and there is no “gold standard” protocol; conservative treatment is favoured over surgical management by clinicians in all cases.

Over the 8- day period in which the three acu-puncture sessions described in the present study were conducted, it appears that the subject’s level of pain score reduced significantly from 4/10 to 0/10 on the VAS. Furthermore, his ankle ROM and strength were restored, and there were improvements in function. The subject’s reported reduction in pain was similar to that reported in a Chinese study by He & Xu (2006, cited by Park et al. 2013), who found an immediate reduc-tion in ankle pain after treatment, during further sessions and at 2- year follow- up.

The outcome measures selected for the pre-sent study may represent limitations. Although the LEFS is a validated measure of both pain and function, the VAS, while widely used in clinical practice, is restricted to subjective inter-pretation. Research by Boonstra et al. (2008) sug-gested that those who report moderate levels of musculoskeletal pain underestimate its impact on function. This question of validity was also supported by more recent work by Bailey et al. (2014) involving children of a similar age to the present subject. Range of motion was measured before and after the present treatment using a goniometer and improvements in this outcome measure were reinforced by the functional

knee- to- wall test, which has previously been used as a reliable and valid method of moni-toring ankle dorsiflexion in sporting contexts (Cejudo et al. 2014).

Muscle strength was recorded using the clinician- subjective OGS. To increase reliability, this could have been determined in a more standardized way. Electromyography was suc-cessfully used by Costa & de Araujo (2008) and Hübscher et al. (2010) to measure increases in dorsiflexion strength following acupuncture treatment. However, time and equipment restraints meant that this was not suitable in the context of the present study.

While the restoration of the subject’s function may be attributable to normal healing pattern times, and the rehabilitation exercise programme undertaken at the football club, acupuncture played an important role as an adjunct treatment. This was especially the case during the first week of rehabilitation, which focused only on a PRICE [Protection, Rest, Ice, Compression and Elevation] regime and muscle activation via non- weight- bearing gentle AROM because of the inflammation and pain restrictions. These non- analgesic effects may have been explained by the work of Helene Langevin (Langevin et al. 2006; Langevin 2013), who suggested that the utiliza-tion of local acupuncture points (as selected in the present study) creates “skin tenting” or mechanical connection to the needle of the connective tissues. This cellular mechanotrans-duction, or the conversion of mechanical signals to biomechanical responses by cells, along with cross- sectional reorganization of fibroblasts, optimizes cytoskeleton reorganization. Such a process could account for the improvement in the present subject’s thickened and scarred soft tissues, and subsequent increase in ROM.

The healing and analgesic effects of acupunc-ture are well addressed in the literature, and its enhancement of athletic performance is becom-ing a more prominent subject of research. Athletes are highly susceptible to “overuse injuries” such as ankle impingement, even from an early age, and fatigue and weakness of the skeletal muscles are often identified as contribu-tory factors. Muscle fatigue has been linked to a drop in carnitine levels. Research by Toda



(2012) demonstrated that acupuncture increases carnitine levels within muscle tissue, potentially counteracting muscle fatigue, and may account for the improved strength and performance experiences by the present subject after the final acupuncture session. Although beyond the realms of this case study, further research into the effects of acupuncture on muscular fatigue in relation to overuse injuries may be an impor-tant avenue of investigation.

Calder et al. (2009) proposed that athletes with ankle impingement injuries are able to return to training and then full sporting activi-ties at 34 days and within 41 days, respectively. The present subject resumed training at 30 days and was available for selection at 35 days. This suggests that acupuncture is a useful adjunc-tive treatment that can return players to match fitness in a shorter time frame than previously documented. This is a similar result to that reported by Sun & Ju (2011), who demon-strated that electroacupuncture (EA) in addition to functional exercise reduces the time taken to return to function by 3–4 days. While EA was not selected in the present study because of the subject’s age and concerns regarding consent, it could be utilized in future work as an alternative approach to treatment.

ConclusionOver the 8 days of treatment, it appears that acupuncture in combination with a rehabilitation exercise programme for the treatment of ankle impingement had a good effect on reducing inflammation and pain, and restoring AROM. The evidence suggests that both WMA and TCM approaches to segmental, peripheral and local effects alleviate pain via analgesic effects, and improve cytoskeleton reorganization through optimization of fibroblast cellular response. To develop and support these uses further, random-ized controlled trials of the physiological and performance rationales need to be conducted.

AcknowledgementsI would like to thank all the staff and players at Birmingham City Football Club for their guid-ance and input throughout this process.

Conflicts of interestNo conflicts of interest influenced the imple-mentation and conduct of the study, or the publication of this article.

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Zhang J.- H., Li J., Cao X.- D. & Feng X.- Y. (2009) Can electroacupuncture affect the sympathetic activity, esti-mated by skin temperature measurement? A functional MRI study on the effect of needling at GB 34 and GB 39 on patients with pain in the lower extremity. Acupuncture and Electro- Therapeutics Research 34 (3–4), 151–164.

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Gemma Parry graduated with an MSc in Physiotherapy from the University of Birmingham in 2011, and has worked in both the National Health Service and private practice. She has a range of sporting experience, includ-ing rugby and football, and following a stint with GB Boxing, she completed her MSc in Sports Rehabilitation at the University of Salford, Manchester. Gemma is currently employed as Birmingham Royal Ballet’s senior physiotherapist.


Correspondence: Ms Louisa Bennett, Oxford Circus Physiotherapy, 33 Great Titchfield Street, London W1W 7PA, UK (e- mail: [email protected]).


CASE REPORT

Acupuncture as an adjunct to standard physiotherapy in the management of adhesive capsulitis

L. BennettPrivate Practice, London, UK

AbstractThis case study documents the use of acupuncture in the treatment of a 53- year- old female with adhesive capsulitis of the right shoulder. It also emphasizes the role of acupuncture as an adjunct to physiotherapy treatment in this condition. The outcome measures used included the Numeric Pain Rating Scale, the Constant–Murley Assessment (CMA), and active and passive range of motion (ROM). The subject was initially treated with conserva-tive physiotherapy modalities for four sessions before acupuncture was delivered. The Triple Energizer 14, Large Intestine (LI) 15 and LI4, Stomach 38, Gall Bladder 34, and Small Intestine (SI) 9 and SI12 acupuncture points were used. After six sessions of acupunc-ture, the woman’s pain had reduced, the CMA score had increased and shoulder ROM had improved greatly. Acupuncture is an effective treatment for adhesive capsulitis, and it may be used as an adjunct to standard physiotherapy treatment.

Keywords: acupuncture, adhesive capsulitis, frozen shoulder.

IntroductionAdhesive capsulitis, also known as frozen shoul-der, is a common condition that is characterized by gradual onset of pain within the shoulder, and restriction of active and passive gleno-humeral range of motion (ROM). Typically, the condition restricts ROM by less than 25% in at least two directions, particularly in shoulder abduction and external rotation (Kelley et al. 2009). Current literature indicates that adhesive capsulitis progresses through three overlapping phases (Jewell et al. 2009):(1) 2–9 months: Progressive stiffening and

reduced ROM in the shoulder joint with increasing pain on movement, which may

be worse at night. Commonly referred to as the freezing or painful phase.

(2) 4–12 months: Gradual decrease in pain, but stiffness remains and there is a consider-able restriction in shoulder ROM. Usually known as the frozen phase.

(3) 12–42 months: Improvement in shoulder ROM. Known as the thawing or resolution phase.

Adhesive capsulitis is more prevalent in women and those aged 40–65 years (Walmsley et al. 2009), and occurs in approximately 2–5% of the general population (Gaspar & Willis 2009). Research has found that associated risk factors for this condition include diabetes, trauma, pro-longed immobilization, thyroid disease, stroke, myocardial infraction and autoimmune disease (Bal et al. 2008).

Although there are different views about the pathophysiology of adhesive capsulitis,

Management of adhesive capsulitis


there are certain consistent findings that have been identified and appear to be specific to its pathology. Bunker (2009) reported that there is a significant increase of fibroblasts, which lay down scar tissue and myofibroblasts, in the fibrous capsule surrounding the glenohumeral joint, which results in reduced joint volume, and consequently, restricts shoulder ROM. In addition, pathological studies have identified the presence of inflammatory cells, mast cells, T- cells, B- cells and macrophages, which sug-gests that a process of inflammation leads to scarring (Hand et al. 2007). Adhesive capsulitis is a self- limiting condition, and while it can take up to 2–3 years for the symptoms to resolve, some patients may never fully regain full ROM (Blanchard et al. 2010). Consequently, it is imperative for patients to undergo treatment for pain, reduced ROM and loss of function in place of the wait- and- see approach.

Several treatments for adhesive capsulitis have been tried, including analgesia, manual therapy, corticosteroid injection, exercises, acupuncture and surgery. A review by Cleland & Durall (2002) suggested that many patients diagnosed with adhesive capsulitis benefit from physio-therapy, and show a reduction in symptoms and an increase in ROM, and/or functional improvement. On the other hand, a Cochrane Review by Green et al. (2003, p. 2) concluded that there is “no evidence that physiotherapy alone is of benefit for adhesive capsulitis”. A recent Cochrane Review by Page et al. (2014) concluded that no one treatment has been proved to be unrivalled, and that higher-quality randomized controlled trials (RCTs) are required. Regardless of the vast amount of research, the lack of validity, and poor standardization of ter-minology, methodology and outcome measures of the studies weakens the clinical application of the results (Cleland & Durall 2002). For that reason, there is a need for further RCTs comparing different treatments so that defini-tive guidelines for the treatment of adhesive capsulitis can be formulated (Brue et al. 2007). It has been argued that the primary treatment for this condition should be based on physio-therapy and anti- inflammatory methods (Brue et al. 2007). Nevertheless, these outcomes are

not always greater than those achieved by other treatments (Kelley et al. 2009).

Case report

BackgroundA 53- year- old female presented to a private physiotherapy clinic with pain and restricted movement in her right shoulder. Her symptoms were intermittent and aggravated by shoulder movement. No yellow or red flags were identi-fied. The patient was systemically well, but her past medical history included hypothyroidism, which was being treated by levothyroxine.

Clinical examinationThe present subject’s pain was localized to her right shoulder, and she described it as a dull ache that was worsened with shoulder move-ment. She reported that her symptoms eased with rest and ibuprofen. Her pain had begun 6 months ago with a gradual onset and no spe-cific cause. The subject’s pain score was 8/10 on the Numeric Pain Rating Scale (NRPS) (Downie et al. 1978), and she stated that her stiffness was worsening. On examination, active and passive ROM was reduced globally in the right shoul-der, particularly on abduction, and external and internal rotation, as shown in Table 1.

Based on the subjective history and clinical findings, a diagnosis of adhesive capsulitis was made.

TreatmentPrior to acupuncture, the subject had under-gone four treatment sessions that had included a supervised exercise regimen. A Cochrane Review by Green et al. (2005) reported that such a routine is beneficial for mixed shoulder disorders in both the short and long term. The

Table 1. Active and passive range of motion (ROM) at the initial consultation: (N/A) not applicable

Variable Active ROM Passive ROM

Forward flexion 100 105Abduction 90 95Lateral rotation 10 20Internal rotation Lumbosacral junction N/A

L. Bennett


home exercise programme included a pendulum exercise, passive supine forward elevation, pas-sive external rotation, and active assisted ROM in shoulder extension, abduction and internal rotation. The exercises were selected because a study by Kelley et al. (2009) found that these were effective in treating adhesive capsulitis. The subject was advised to complete the exercises within her pain limits so as to avoid exacerbat-ing the pain (NZGG 2004), and to ensure that adequate analgesia was taken so that she would be able to tolerate the movements. She was also advised to avoid movements that aggravated the pain, such as overhead movements and vigorous stretching, but to continue her regular ROM.

The subject received grade III posterior glenohumeral glides at each session to help improve ROM and alleviate pain. Vermeulen et al. (2006) stated that high- grade mobilization techniques are found to be helpful in improving shoulder ROM in patients who have suffered from adhesive capsulitis for at least 3 months.

After the four physiotherapy sessions, the subject reported feeling a slight reduction in pain (NRPS score = 7/10). On examination, she now had slightly improved ROM.

Acupuncture treatmentBefore acupuncture treatment began, con-traindications were eliminated and precautions were taken, the potential effects of treatment were made clear to the subject, and she was also briefed about the possible side effects of acupuncture and adverse reactions to treatment.

De Qi, a sensation experienced during needle stimulation, is commonly described as a sore, numb, distended, heavy, electric and warm feel-ing (Zhu et al. 2013). The Aδ and C- fibres in the tendinomuscular layers appear to be involved in the pricking, dull and pressing sensations experienced (Beissner et al. 2010). The subject signed an acupuncture consent form once all the relevant information had been provided, and she believed that she was able to make an informed decision.

The 30- min treatment sessions occurred on a weekly basis, and the needles were left in place for 20 min and stimulated every 5–10 min.

The point selection and treatment dose can be viewed in Table 2.

The aim of the acupuncture treatment was to induce a pain- relieving response at the local, segmental and central levels. Locally, the insertion of needles into soft tissue causes a microinjury; this results in a local inflammatory response that enhances local microcirculation by increasing the diameter and blood flow velocity of peripheral arterioles (Komori et al. 2009). Kim et al. (2008) also reported that acupuncture reduces inflammation by promoting the release of vascular and immunomodulatory factors.

Needle insertion and manipulation also stim-ulates the Aδ fibres in the skin, and type 2 and 3 muscle fibres (White et al. 2008). This stimulus travels to the dorsal horn in the spinal cord, and activates the intermediate cells to produce enkephalin, which blocks nociceptive input from C- fibres at that spinal segment (Hans 2011). Continuing up from the spinal cord, the signal is transmitted to the brain, activating the two descending pathways. The first pathway releases serotonin at the dorsal horn, which stimulates intermediate cells to release met- enkephalin, thereby adding to the inhibition of pain. The second pathway releases noradrenalin through-out the dorsal horn at every segmental level, resulting in direct inhibition of postsynaptic cell membrane transmission (White et al. 2008).

Rationale for point selectionTriple Energizer 14 and Large Intestine 15 were chosen for local effects because these were located close to the subject’s problem-atic area, and when both are combined these points form the “Eyes of the Shoulder”. Large Intestine 4 was prescribed bilaterally for its strong pain- alleviating and relaxation effects. Traditional Chinese medicine (TCM) considers this to be one of the master points for pain, and it has been suggested that stimulation of the distal point activates supraspinal mecha-nisms, inducing descending pain inhibition from the hypothalamus and the release of natural opioids, such as β- endorphins and enkephalins (Bradnam 2003, 2007). Stomach (ST) 38 is recommended for adhesive capsulitis by TCM,



and research has found that it is more effective in improving shoulder function and alleviating shoulder pain when combined with physiother-apy than physiotherapy alone (Vas et al. 2008). Gall Bladder (GB) 34 was selected because of its role in TCM, in which it is considered to be influential on muscle and tendons, and a strong relaxation point. A further justification is that, in TCM, GB34 has a reputation for its soothing and moistening effect, and since the subject’s capsule was contracted, this action

was considered to be an important part of healing the disorder. Small Intestine (SI) 9 and SI12 were added to increase local effect, and in addition, the Small Intestine meridian passes through the shoulder area.

Outcome measuresThe Constant–Murley Assessment (CMA) was used to assess functional performance. The CMA score is a reliable and valid instrument for assessing overall shoulder function, and has

Table 2. Acupuncture treatment: (TE) Triple Energizer; (LI) Large Intestine; (ST) Stomach; (GB) Gall Bladder; (SI) Small Intestine; (T + T) twist and twirl; (L + T) lift and thrust; (ROM) range of motion; and (NPRS) Numeric Pain Rating Scale

Acuuncture points

Size and angle of needle

Needling technique Treatment response

Session 1TE14LI15LI4 (bilateral)

40 mm, oblique40 mm, oblique30 mm, perpendicular

T + TT + TT + T

Mild lightheadedness and relaxation felt after treatmentStrong De Qi felt at all pointsNo adverse effects reported

Session 2TE14LI15LI4 (bilateral)ST38

40 mm, oblique40 mm, oblique30 mm, perpendicular40 mm, perpendicular

T + TT + TT + TL + T, T + T

Pain reduced for 3 days, then returned to how it wasStrong De Qi felt at all pointsNo adverse effects reported

Session 3TE14LI15LI4 (bilateral)ST38GB34

40 mm, oblique40 mm, oblique30 mm, perpendicular40 mm, perpendicular40 mm, perpendicular

T + TT + TT + TL + T, T + TL + T, T + T

Pain reduced for 4 days, then returned to how it wasImproved shoulder ROMStrong De Qi felt at all pointsNo adverse effects reported

Session 4TE14LI15LI4 (bilateral)ST38GB34SI12

40 mm, oblique40 mm, oblique30 mm, perpendicular40 mm, perpendicular40 mm, perpendicular30 mm, oblique

T + TT + TT + TL + T, T + TL + T, T + TT + T

Pain reduced since last appointment, NPRS score = 6/10Improved shoulder ROMStrong De Qi felt at all pointsNo adverse effects reported

Session 5TE14LI15LI4 (bilateral)ST38GB34SI12SI9

40 mm, oblique40 mm, oblique30 mm, perpendicular40 mm, perpendicular40 mm, perpendicular30 mm, oblique40 mm, perpendicular

T + TT + TT + TL + T, T + TL + T, T + TT + TT + T

Improved shoulder ROMStrong De Qi felt at all pointsNo adverse effects reported

Session 6 TE14 LI15 LI4 (bilateral) ST38 GB34 SI12 SI9

40 mm, oblique 40 mm, oblique 30 mm, perpendicular 40 mm, perpendicular 40 mm, perpendicular 30 mm, oblique 40 mm, perpendicular

T + T T + T T + T L + T, T + T L + T, T + T T + T T + T

Improved shoulder ROM Pain reduced, NPRS score = 5/10 Strong De Qi felt at all points No adverse effects reported

L. Bennett


low inter- rater and intra- rater error rates (Kemp et al. 2012). It is a 100- point scale that is com-posed of four domains: pain, activities of daily living, ROM and power. At the initial assess-ment, a CMA score of 59 was recorded. After the conservative treatment, the CMA score was 68, and at the final acupuncture session, a score of 86 was reported.

The NPRS was used to assess the severity of the subject’s shoulder pain before and after each treatment session. The NPRS score was reported as 8/10 at the initial assessment, 7/10 after standard physiotherapy treatment and 5/10 at the final acupuncture session.

Active and passive ROM of the shoulder was measured using a standard goniometer before and after each treatment. Global ROM had improved throughout treatment, and the results can be viewed in Table 3.

DiscussionThe present subject responded very well to the acupuncture treatment that she received. The acupuncture point selection was logical and aimed at resolving the complaints expressed by her. Employing a conservative treatment approach did bring about some short- term relief; however, using acupuncture as an adjunct to this treatment meant that the desired effects lasted for longer.

Research has found acupuncture to be an effective treatment for adhesive capsulitis when combined with standard Western approaches. A randomized, double- blind, placebo- controlled trial by Sun et al. (2001) explored the use of acupuncture in patients with adhesive capsulitis. Thirty- five participants were randomly allo-cated to an exercise group or an exercise plus

acupuncture group and treated for 6 weeks. Compared with the exercise group, the exercise plus acupuncture group experienced significantly greater improvements with regard to pain, func-tional mobility and power.

Ma et al. (2006) conducted a study that inves-tigated the clinical effects of physiotherapy and acupuncture for adhesive capsulitis. Participants were randomly allocated to a physiotherapy group, an acupuncture treatment group or a physiotherapy plus acupuncture treatment group. The study showed that all groups expe-rienced improved quality of life, but pain was better controlled with acupuncture although ROM improved following physiotherapy. Ma et al. (2006) concluded that a combination of physiotherapy and acupuncture is the most effective form of treatment.

A double- blinded RCT conducted by Cheing et al. (2008) compared the addition of electro-acupuncture or interferential electrotherapy to shoulder exercise. The authors found that both intervention groups experienced a greater improvement than those who received no inter-vention, and the effect lasted until the 6- month follow- up.

On the other hand, an n- of- 1 study by Longbottom & Green (2009) assessed the effects of acupuncture at a single point, ST38, compared to exercise alone on shoulder ROM, pain and disability in four patients with adhesive capsulitis. The results were inconclusive, and offered only limited evidence of the efficacy of ST38 for improving pain, stiffness and func-tional impairment in patients suffering from adhesive capsulitis.

A Cochrane Review including nine RCTs assessed the current evidence for acupuncture in the treatment of adhesive capsulitis and other

Table 3. Outcome measures

Outcome measure Initial session After conservative treatment Final acupuncture session

Active forward flexion 100 110 150Passive forward flexion 105 115 160Active abduction 90 110 160Passive abduction 95 115 170Active lateral rotation 10 15 35Passive lateral rotation 20 25 45Active internal rotation Lumbosacral junction Waist (L3) Interscapular (T7)



causes of shoulder pain (Green et al. 2005). The authors concluded that, because of the small number of clinical and methodologically diverse trials, there is little evidence to support or dis-prove the use of acupuncture for shoulder pain, although there may be a short- term benefit with respect to pain and function.

LimitationsIt is important to be aware of the limitations of the present case study. Acupuncture was added as an adjunct at a later stage of the reha-bilitation, and therefore, it is hard to determine whether exercise, acupuncture or natural recov-ery was responsible for the improved outcomes. Because of the nature of the private setting, the subject was not seen on a weekly basis for follow- up appointments. Weekly follow- up appointments would have allowed closer moni-toring of her progress. Therefore, more- regular patient follow- up appointments and the use of acupuncture alone might have strengthened the quality of this case study.

Future researchFurther research in the form of RCTs is needed to identify the full benefits of acupuncture in the treatment of adhesive capsulitis, and sup-port the wider use of the modality in this group of patients. Current research into the efficacy of acupuncture as a treatment for adhesive capsulitis is limited because it is impossible to blind the acupuncturist, and therefore, this creates bias and reduces the reliability of the study. It was further limited as a result of the difficulties in the use of appropriate controls, such as placebo and sham acupuncture groups. In addition, as mentioned above, there is also a requirement for further research into develop-ing treatment guidelines for adhesive capsulitis.

ConclusionIn the presence of adhesive capsulitis, acupunc-ture could be a suitable adjunct to physiother-apy treatment including exercise. Acupuncture should be considered for patients who have been diagnosed with adhesive capsulitis.

ReferencesBal A., Eksioglu E., Gulec B., et al. (2008) Effectiveness

of corticosteroid injection in adhesive capsulitis. Clinical Rehabilitation 22 (6), 503–512.

Beissner F., Brandau A., Henke C., et al. (2010) Quick dis-crimination of Adelta and C fiber mediated pain based on three verbal descriptors. PLoS ONE 5 (9): e12944. DOI: 10.1371/journal.pone.0012944.

Blanchard V., Barr S. & Cerisola F. L. (2010) The effec-tiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy 96 (2), 95–107.



Brue S., Valentin A., Forssblad M., et al. (2007) Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surgery, Sports Traumatology, Arthroscopy 15, (8), 1048–1054.

Bunker T. (2009) Time for a new name for frozen shoulder – contracture of the shoulder. Shoulder and Elbow 1 (1), 4–9.

Cheing G. L. Y., So E. M. L. & Chao C. Y. L. (2008) Effectiveness of electroacupuncture and interferential electrotherapy in the management of frozen shoulder. Journal of Rehabilitation Medicine 40 (3), 166–170.

Cleland J. & Durall C. J. (2002) Physical therapy for adhesive capsulitis: systematic review. Physiotherapy 88 (8), 450–457.

Downie W. W., Leatham P. A., Rhind V. M., et al. (1978) Studies with pain rating scales. Annals of the Rheumatic Diseases 37 (4), 378–381.

Gaspar P. D. & Willis F. B. (2009) Adhesive capsu-litis and dynamic splinting: a controlled, cohort study. BMC Musculoskeletal Disorders 10: 111. DOI: 10.1186/1471- 2474- 10- 111.

Green S., Buchbinder R. & Hetrick S. E. (2003) Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD004258. DOI: 10.1002/14651858.CD004258.

Green S., Buchbinder R. & Hetrick S. (2005) Acupuncture for shoulder pain. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD005319. DOI: 10.1002/14651858.CD005319.

Hand G. C. R., Athansou N. A., Matthews T. & Carr A. J. (2007) The pathology of frozen shoulder. The Journal of Bone and Joint Surgery 89 (7), 928–932.

Hans J. S. (2011) Acupuncture analgesia: areas of con-sensus and controversy. Pain 152 (3, Suppl.), S41–S48.

Jewell D. V., Riddle D. L. & Thacker L. R. (2009) Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Physical Therapy 89 (5), 419–429.

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Kelley M. J., McClure P. W. & Leggin B. G. (2009) Frozen shoulder: evidence and a proposed model guiding rehabilitation. Journal of Orthopaedic and Sports Physical Therapy 39 (2), 135–148.

Kemp K. A. R., Sheps D. M., Beaupre L. A., et al. (2012) An evaluation of the responsiveness and discriminant validity of shoulder questionnaires among patients receiving surgical correction of shoulder instabil-ity. The Scientific World Journal 2012: 410125. DOI: 10.1100/2012/410125.

Kim H.- W., Uh D.- K., Yoon S.- Y., et al. (2008) Low- frequency electroacupuncture suppresses carrageenan- induced paw inflammation in mice via sympathetic post- ganglionic neurons, while high- frequency EA sup-pression is mediated by the sympathoadrenal medullary axis. Brain Research Bulletin 75 (5), 698–705.

Komori M., Takada K., Tomizawa Y., et al. (2009) Microcirculatory responses to acupuncture stimulation and phototherapy. Anesthesia and Analgesia 108 (2), 635–640.

Longbottom J. & Green A. (2009) Effectiveness of single- point acupuncture to Stomach 38 (Tiaokou) on pain and disability in subjects with frozen shoulder. Journal of the Acupuncture Association of Chartered Physiotherapists 2009 (Spring), 37–46.

Ma T., Kao M.- J., Lin I.- H., et al. (2006) A study on the clinical effects of physical therapy and acupuncture to treat spontaneous frozen shoulder. The American Journal of Chinese Medicine 34 (5), 759–775.

New Zealand Guidelines Group (NZGG) (2004) The Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders. [WWW document.] URL http://almacen- gpc.dynalias.org/publico/Lesiones%20partes%20blandas%20hombro%20NZG%202004.pdf

Page M. J., Green S., Kramer S., et al. (2014) Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database of Systematic Reviews, Issue

8. Art. No.: CD011275. DOI: 10.1002/14651858.CD011275.

Sun K. O., Chan K. C., Lo S. L. & Fong D. Y. T. (2001) Acupuncture for frozen shoulder. Hong Kong Medical Journal 7 (4), 381–391.

Vas J., Ortega C., Olmo V., et al. (2008) Single- point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial. Rheumatology 47 (6), 887–893.

Vermeulen H. M., Rozing P. M., Obermann W. R., le Cessie S. & Vliet Vieland T. P. M. (2006) Comparison of high- grade and low- grade mobilization techniques in the management of adhesive capsulitis of the shoul-der: randomized controlled trial. Physical Therapy 86 (3), 355–368.

Walmsley S., Rivett D. A. & Osmotherly P. G. (2009) Adhesive capsulitis: establishing consensus on clini-cal identifiers for stage 1 using the Delphi technique. Physical Therapy 89 (9), 906–917.


Zhu S.- P., Luo L., Zhang L., et al. (2013) Acupuncture De- qi: from characterization to underlying mechanism. Evidence- Based Complementary and Alternative Medicine 2013: 518784. DOI: 10.1155/2013/518784.

Louisa Bennett works at Oxford Circus Physiotherapy in London. She trained at the University of the West of England in Bristol, and qualified as a physio-therapist in 2014. Since graduating, Louisa has worked in various private practices, and treated an array of clientele with musculoskeletal conditions. She regularly uses acupuncture as part of her clinical practice, and has developed a further interest in shoulder injuries.


Correspondence: Colin Waldock, Associate Lecturer, Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Anson Building, Central Avenue, Chatham Maritime, Chatham, Kent ME4 4TB, UK (e- mail: C.waldock- [email protected]).


CASE REPORT

Myofascial pain masquerading as neuropathic pain

C. WaldockPrivate Practice, Rainham, and Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Chatham, Kent, UK

AbstractThis study describes the successful treatment of a case of suspected neuropathic pain. Dry needling resolved the patient’s symptoms and led to a reduction in his medication load. This case highlights the value of a comprehensive musculoskeletal assessment, and the need to be aware of myofascial referral patterns and how these can mimic neuropathic symptoms.

Keywords: dry needling, myofascial pain, neuropathic pain.

IntroductionThe purpose of the present case report is to demonstrate how easily myofascial pain can mas-querade as neuropathic pain, which can lead to the prescription of neuroleptic medication and associated forms of analgesia. As an independ-ent prescriber, the present author is cognizant of the drugs that are available for the treatment of musculoskeletal (MSK) pain. He can recom-mend and/or prescribe medication or dosage change, as appropriate, in the best interests of his patients. The author has also specialized in MSK physiotherapy for over 20 years, and uses dry needling to treat myofascial pain. He has found these two skills to be complementary.

Case report

BackgroundThe present subject was a 54- year- old man who first presented at the author’s clinic on

8 August 2016. The patient reported a history of left- sided facial pain that had begun on 15 July 2016. This was associated with altered sen-sation in his left arm and hand. The pain had had a sudden onset in the absence of trauma. Because of concerns that his symptoms might have a possible cardiac origin, the subject was seen in the accident and emergency department of a hospital close to his place of employment in London, UK (Cooper et al. 2010). The find-ings of the examination suggested that he was not suffering from a cardiac event. He was subsequently seen by his general practitioner and referred for physiotherapy assessment.

There was no serious medical history of note. However, the fact that he had suffered from left- sided neck and shoulder pain approximately 2 years previously, and had not received physio-therapy treatment, was of possible significance.

The subject reported that he had been pre-scribed two, 300- mg tabs of gabapentin three times a day to relieve his neuropathic symptoms (i.e. the altered sensation), and also 8/500 mg of co- codamol and Nurofen Plus [Reckitt Benckiser Healthcare (UK) Ltd, Slough, UK] as additional pain relief medication. Nurofen Plus is an over- the- counter medication that combines

Myofascial pain masquerading as neuropathic pain


200 mg of ibuprofen and 12.8 mg of codeine (eMC 2015). He reported that he had no aller-gies and was not taking any other medication, but was suffering from slight constipation. Constipation is a common side effect of non- opioid analgesics and gabapentin, and therefore, this issue may well have been related to his current medication (eMC 2017).

Gabapentin is recommended as a first- line pharmacological option in the presence of signs of neuropathic pain (NICE 2013), which can be treated with medications used to allevi-ate mild- to- moderate pain such as codeine phosphate, paracetamol and nonsteroidal anti- inflammatory drugs (NICE 2015). Gabapentin’s mode of action is via the inhibition of calcium currents, and subsequently, excitatory activity at the dorsal horn (Kremer et al. 2016).

The physical examination revealed that the subject’s neck and shoulders had a normal range of motion (ROM). No abnormalities were detected during the neurological examination, which included testing his reflexes, myotomes, and sensitivity to light touch and vibration. Upper- limb tension manoeuvres did not pro-voke any discomfort or symptoms.

The results of an examination of acces-sory movements in the subject’s neck were unremarkable.

Palpation of the muscles of his neck and shoulder girdle revealed the presence of active myofascial trigger points (MTPs) in his left infraspinatus muscle, and paravertebrally, in the splenius cervicis and capitis muscles of the left side of his neck (Simons et al. 1999, p. 553, Fig. 22.1; Triggerpoints.net 2014a). These find-ings were associated with weakness on resisted external rotation of his left shoulder, suggesting inhibition of the infraspinatus muscle because of the presence of active MTPs (Graven- Nielsen et al. 2002).

The infraspinatus is one of the rotator cuff muscles, and has been implicated in mimick-ing radicular referral to the arm and even the production of paraesthetic symptoms. The splenius cervicis and capitis muscles can pro-duce referral patterns to the side of the face and head (Simons et al. 1999, p. 433, Fig. 15.1B; Triggerpoints.net 2014b).

TreatmentFollowing the examination, the subject agreed to undergo a course of dry needling focused on his left infraspinatus and splenius muscles. These were needled in such a way as to achieve De Qi and muscle twitch, which was noted in both. After treatment, he was advised to con-tinue with his medication for the moment, but if symptoms improved, then he would be able to be weaned off his analgesia. He was told that gabapentin should be reduced gradually over a period of 1–2 weeks, as advised in the summary of the product’s characteristics (eMC 2017), in order to minimize the side effects of sudden withdrawal. The present author followed up the dry needling with advice on stretches for splenius and infraspinatus muscles. This took the form of a home exercise programme com-prised of simple mobility exercises for the neck and shoulder girdle, and isometric rotator cuff strengthening.

On review 7 days later, the subject reported that the paraesthesia in his arm had eased for approximately 1 h. In view of the change in his symptoms, he was keen that the dry needling should be repeated. This was done following further examination and identification of the MTPs in his left infraspinatus and splenius muscles. He was advised to continue his home exercise regime.

The subject reported that he was very happy with his progress when he returned to the clinic 9 days later, and that his symptoms were at least 80% resolved. He commented that, although the present author had been reluctant to discuss the potential of “curing” problems, he felt that his symptoms were so much better that he was now expecting full resolution.

Assessment of his neck and shoulder girdle revealed full active ROM, and no tenderness on palpation of either the infraspinatus or splenius muscles. The subject reported that he had ceased taking co- codamol and Nurofen Plus, and that he had made significant progress in weaning himself off gabapentin: he was only taking one, 300- mg tablet a day and intended to stop that in the next few days. The decision was made to discharge him from physiotherapy, and

C. Waldock


he was instructed to continue with his normal activities.

DiscussionThe present case report highlights the ease with which MSK pain can be erroneously categorized as neuropathic pain because of the presence of paraesthesia. With careful MSK examination, it is possible to enhance the accuracy of the diag-nosis, which is a key component of successful treatment. Accurate clinical MSK diagnosis can often be hindered by the lack of specificity in orthopaedic tests (Hughes et al. 2008). There also remains the issue of inter- rater agreement; Downey et al. (2003) showed that there were considerable differences in the segmental levels of lumbar vertebrae that were identified by physiotherapists on palpation. More recently, a study by Mora- Relucio et al. (2016) suggested that there was a greater correlation in palpation accuracy between experienced clinicians than inexperienced ones.

There will always be limitations to the extent to which one can draw conclusions from a case study; however, it is clear that the present report highlights that it is important to carefully assess and determine the mechanism behind the pain symptom. Is the pain of a neuropathic nature or is it nociceptive? In this case, awareness of the potential referral patterns and behaviours of MTPs led to the successful resolution of the subject’s symptoms, and a return to normal function.

ReferencesCooper A., Calvert N., Skinner J., et al. (2010) Chest

Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin. National Clinical Guideline Centre for Acute and Chronic Conditions, London.

Downey B., Taylor N. & Niere K. (2003) Can manipula-tive physiotherapists agree on which lumbar level to treat based on palpation. Physiotherapy 89 (2), 74–81.

Electronic Medicines Compendium (eMC) (2015) Nurofen Plus. [WWW document.] URL https://www.medicines.org.uk/emc/medicine/23377

Electronic Medicines Compendium (eMC) (2017) Gabapentin Sandoz 300 mg Capsules. [WWW docu-ment.] URL http://www.medicines.org.uk/emc/medicine/25459

Graven- Nielsen T., Lund H., Arendt- Nielsen L., Danneskiold- Samsøe B. & Bliddal H. (2002) Inhibition of maximal voluntary contraction force by experimen-tal muscle pain: a centrally mediated mechanism. Muscle and Nerve 26 (5), 708–712.

Hughes P. C., Taylor N. F. & Green R. A. (2008) Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy 54 (3), 159–170.

Kremer M., Salvat E., Muller A., Yalcin I. & Barrot M. (2016) Antidepressants and gabapentinoids in neuro-pathic pain: mechanistic insights. Neuroscience 338 (2016), 183–206.

Mora- Relucio R., Núñez- Nagy S., Gallego- Izquierdo T., et al. (2016) Experienced versus inexperienced interexaminer reliability on location and classification of myofascial trigger point palpation to diagnose lateral epicondylalgia: an observational cross- sectional study. Evidence- Based Complementary and Alternative Medicine 2016: 8. DOI: 10.1155/2016/6059719.

National Institute for Health and Care Excellence (NICE) (2013) Neuropathic Pain in Adults: Pharmacological Management in Non- Specialist Settings. [WWW document.] URL https://www.nice.org.uk/guidance/cg173/evidence

National Institute for Health and Care Excellence (NICE) (2015) Analgesia – Mild- to- Moderate Pain. [WWW document.] URL http://cks.nice.org.uk/analgesia- mild- to- moderate- pain

Simons D. G., Travell J. G. & Simons L. S. (1999) Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1: Upper Half of the Body, 2nd edn. Williams & Wilkins, Baltimore, MD.

Triggerpoints.net (2014a) Infraspinatus Trigger Point Diagram. [WWW document.] URL http://www.triggerpoints.net/muscle/infraspinatus

Triggerpoints.net (2014b) Splenius Cervicis Trigger Point Diagram. [WWW document.] URL http://www. triggerpoints.net/muscle/splenius- cervicis

Colin Waldock is a physiotherapy independent pre-scriber who works as an extended- scope practitioner for Physiotherapy2fit in Rainham. He is also a support tutor on the postgraduate programme for non- medical prescribing at Medway School of Pharmacy. Colin has 24 years of experience of using acupuncture in a clinical setting, and is currently preparing a PhD on the impact of prescribing on professional practice.

© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy 95


GOOD PRACTICE STATEMENT

Acupuncture for pregnancy- related low back pain and pelvic girdle pain

IntroductionThis statement is based on a synthesis of the best available current evidence. It will be subject to periodic review as the evidence base evolves. It should be noted that the statement offers guidance, and should not be regarded as pre-scriptive; such general advice will always require to be modified in line with the needs of any individual patient and the clinician’s experience.

All acupuncture should be performed accord-ing to the guidelines of the British Acupuncture Council, the British Medical Acupuncture Society and the Acupuncture Association of Chartered Physiotherapists (AACP) (www.acupuncture safety.org.uk).

BackgroundThe incidence of pregnancy- related low back pain (LBP) and pelvic girdle pain (PPGP) is reported to be approximately 20% (Wu et al. 2004; Kovacs et al. 2012; Malmqvist et al. 2012; Pennick & Liddle 2013). It is attributed to multi - factorial changes in posture, hormones, joint laxity, muscle imbalance, asymmetrical mechani-cal dysfunction of the pelvis and the growing baby in utero.

In the general population, acupuncture has been shown to reduce pain levels and improve physical function in adults with LBP (Witt et al. 2006; Haake et al. 2007; Cherkin et al. 2009; Mayer et al. 2010). However, this cannot be extrapolated to pregnancy- related pain without consideration of the safety of this modality in this population.

Safety of acupuncture in pregnancyThe AACP guidelines for safe practice (AACP 2012) state that there is a danger of miscarriage when treating patients in the first trimester of pregnancy. This has not been reported in

supplementary literature, and may be considered to be based on historical practice (Betts & Budd 2011) rather than evidence (Carr 2015). The AACP (2012) defines the forbidden points as Large Intestine (LI) 4, Spleen (SP) 6, and Bladder (BL) 60 and 67 because of the risk of uterine contractions (Betts & Budd 2011; Cummings 2011) since these points are used in traditional Chinese medicine to facilitate induction and turning breech babies. Furthermore, BL31, BL32, BL33 and BL34 (the sacral fora mina) and abdominal points are to be specifically avoided because these may compromise circulation to the developing foetus (Betts & Budd 2011), or potentially approximate the uterus if the needle enters the foramen.

Cummings (2011) theorized that acupuncture is safe to use in pregnancy, and that forbidden points can be employed. Elden et al. (2005, 2008) stated that forbidden points (i.e. LI4, BL32, BL33 and BL60) have not been found to cause serious adverse events, and no significant harm-ful effects were reported in several randomized controlled trials (RCTs) (Wedenberg et al. 2000; Guerreiro da Silva et al. 2004; Kvorning et al. 2004). Carr (2015) stated that objective exami-nation of the scientific literature does not reveal any suggestion of harm following needling at “forbidden” points during pregnancy, despite historical or theoretical concerns. However, it must be noted that the majority of this evidence is collated from research on generally healthy pregnancies. The efficacy and safety of acu-puncture in pregnancies complicated by specific obstetric conditions have yet to be determined.

Langshaw (2011) identified some studies that have reported powerful recordable uterine contractions after strong acupuncture at LI4 and SP6 that never caused early delivery, but could cause patient distress. Bishop et al. (2016)

Acupuncture for pregnancy-related pain

© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy96

reported some minor non- obstetric adverse effects during acupuncture treatment in preg-nancy, including: lightheadedness; fainting; mild bruising at the needle site; worsening of symptoms; vomiting; and pain at the needle site. All of the above might be found in acupuncture of the general population. Similarly, two recent systematic reviews highlighted a low incidence of adverse events that were non- obstetric in nature (Park et al. 2014; Clarkson et al. 2015). In a systematic review, Clarkson et al. (2015) found that there was a 14–17% chance of being affected by an adverse event in the pregnancy acupuncture groups, as compared to one of 15–19% in the non- acupuncture intervention groups. Romer et al. (2013) demonstrated that there was no difference in the occurrence of adverse events between an acupuncture and a control group.

Carr (2015, p. 418) advised clinicians “to treat only where necessary”, and carry out a thorough examination and risk assessment with individual patients. It must be remembered that the opti-mal dose for any intervention is the minimum required to be effective. There is a suggestion that, the greater the amount of needle stimu-lation applied, the greater the incidence of adverse events, although these remain mild to moderate (Wedenberg et al. 2000; Ternov et al. 2001; Kvorning et al. 2004; Elden et al. 2008). Auricular acupuncture resulted in the least num-ber of adverse events (Wang et al. 2009).

Efficacy of acupuncture in pregnancy- related low back pain and pelvic girdle painIn a Cochrane Review, Pennick & Liddle (2013) identified interventions for preventing and treating pregnancy- related LBP and PPGP. These authors found moderate- quality evidence for the efficacy of acupuncture in the treat-ment of PPGP, which significantly reduced evening pain and improved function, especially after 26 weeks, in comparison to usual care or exercise. In a review of eight systematic reviews and nine RCTs, Selva Olid et al. (2013) reiterated that there is moderate evidence for acupuncture in pregnancy- related LBP and PPGP, and a low incidence of adverse events. Research often focuses on pain indicators, but other benefits

that have been noted are increased psychologi-cal well- being (Guerreiro da Silva et al. 2004), and improved mobility and sleep (Ekdahl & Petersson 2010; Gutke et al. 2015).

Three RCTs differentiated pregnancy- related LBP and PPGP as part of the inclusion criteria (Elden et al. 2005, 2008; Lund et al. 2006), and all identified significant benefits as a result of using acupuncture. Six other studies researched women with both pregnancy- related LBP and PPGP, but did not stratify the women by diagnosis before randomization or during the analysis (Wedenberg et al. 2000; Ternov et al. 2001; Guerreiro da Silva et al. 2004; Kvorning et al. 2004; Wang et al. 2009; Ekdahl & Petersson 2010). This prevents a definitive statement being made regarding the response of individual conditions to acupuncture. However, each study showed positive benefits of acupuncture treatment in the sample combining pregnancy- related LBP and PPGP.

A recent systematic review by Gutke et al. (2015) found strong evidence for the use of acupuncture in pregnancy- related LBP. Foster et al. (2015) ran a pilot trial comparing acu-puncture, non- penetrating acupuncture and standard care in pregnancy- related LBP. They found reductions in pain and disability in the two acupuncture arms of the trial that were sig-nificantly greater than those in the standard care group. Non- penetrating acupuncture or “sham” acupuncture may show benefits because of the effects of acupressure, contact with a therapist or a potential placebo effect. Elden et al. (2008) reported that sham acupuncture also provided positive benefits and that needling may not be necessary, but regular contact with a health professional may be just as beneficial.

The evidence supporting the use of acupunc-ture in the management of LBP and PPGP in pregnancy does seem to be encouraging, and there is an emphasis on individual patient examination and risk assessment in each case.

Good practice pointsThe AACP (2012) defines the traditional forbid-den points as LI4, SP6, BL60 and BL67, which should be used with caution given that these are historically contraindicated in pregnancy. The


© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy 97

employment of traditionally forbidden points without any significant adverse outcomes was noted in all RCTs reviewed that had assessed for this outcome in pregnancy-related LBP and PPGP (Wedenberg et al. 2000; Kvorning et al. 2004; Elden et al. 2005, 2008; Lund et al. 2006). Bladder 31, BL32, BL33 and BL34 (the sacral foramina), abdominal points, the wall of the uterus, and strongly stimulating De Qi should be avoided.

A reduction in visual analogue scale pain scores has been seen in two, 30- min sessions (Ternov et al. 2001). Good outcomes with regard to pain and functional ability have been found with an average of eight to 12 sessions on at least a weekly basis, and using at least 10 needles for 25–30 min (Wedenberg et al. 2000; Guerreiro da Silva et al. 2004; Kvorning et al. 2004; Elden et al. 2005, 2008; Lund et al. 2006; Ekdahl & Petersson 2010). Increasing the amount of stimulation and the depth of needling did not appear to have a significant positive impact on the efficacy of the acupuncture; however, this did increase the number of mild to moderate adverse events.

ConclusionsBishop et al. (2016) reported a lower use of acupuncture by physiotherapists for the treat-ment of pregnant patients than for those with general musculoskeletal pain conditions. They suggested that this may indicate a lack of confidence, concerns about safety and a lack of specific guidelines for physiotherapists about the use of acupuncture in pregnancy. The evidence for the safety of acupuncture in preg-nancy, including the use of traditional forbidden points, has increased (Romer et al. 2013; Park et al. 2014; Carr 2015; Clarkson et al. 2015), and should support it as an option in the treatment of PPGP (Pennick & Liddle 2013; Wild 2014) and pregnancy- related LBP (Gutke et al. 2015). Current evidence lacks the validity and reliability that is required to establish specific guidelines on precise treatment parameters, mainly because of a lack of comparability between the inter-ventions used in RCTs. Overall, acupuncture for pregnancy- related LBP and PPGP is recom-mended since it can be a safe and efficacious

treatment modality for reducing pain scores (Vleeming et al. 2008), improving sleep and mobility (Ekdahl & Petersson 2010), and increas-ing functional capacity (Guerreiro da Silva et al. 2004). It can also be combined effectively with other physiotherapy interventions.

The following recommendations are made:

•Following a thorough examination and risk assessment, acupuncture is a safe treatment modality for LBP and PPGP in uncompli-cated pregnancies.

•Avoid abdominal points, or any approxima-tion of the uterine wall and sacral foramina (BL31, BL32, BL33 and BL34).

•Avoid very strong stimulation of acupuncture points in pregnancy.

•Caution may be exercised in using traditional “forbidden points”, i.e. LI4, SP6, BL60 and BL67.

•Treatment parameters, such as frequency, duration, and the number of points used, may depend on individual patient assessment and local practice restrictions.

•Monitor for any adverse events, and record any such issues in your treatment documentation.

Pelvic, Obstetric and Gynaecological Physiotherapy


(AACP) (2012) Guidelines for Safe Practice. [WWW document.] URL http://www.aacp.org.uk/member- h o m e / r e f e r e n c e s / g u i d e l i n e s / c l i n i c a l / 2 3 9 - guidelines- for- safe- practice/file

Betts D. & Budd S. (2011) “Forbidden points” in preg-nancy: historical wisdom? Acupuncture in Medicine 29 (2), 137–139.

Bishop A., Holden M. A., Ogollah R. O. & Forster N. E. (2016) Current management of pregnancy- related low back pain: a national cross- sectional survey of UK physiotherapists. Physiotherapy 102 (1), 78–85.

Carr D. J. (2015) The safety of obstetric acupuncture: forbidden points revisited. Acupuncture in Medicine 33 (5), 413–419.

Cherkin D. C., Sherman K. J., Avins A. L., et al. (2009) A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine 169 (9), 858–866.

Clarkson C. E., O’Mahony D. & Jones D. E. (2015) Adverse event reporting in studies of penetrating acu-puncture during pregnancy: a systematic review. Acta Obstetricia et Gynecologica Scandinavica 94 (5), 453–464.


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Cummings M. (2011) ‘‘Forbidden points’’ in pregnancy: no plausible mechanism for risk. Acupuncture in Medicine 29 (2), 140–142.

Ekdahl L. & Petersson K. (2010) Acupuncture treatment of pregnant women with low back and pelvic pain – an intervention study. Scandinavian Journal of Caring Sciences 24 (1), 175–182.

Elden H., Ladfors L., Olsen M. F., Ostgaard H.- C. & Hagberg H. (2005) Effects of acupuncture and sta-bilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. BMJ 330 (7494), 761.

Elden H., Fagevik- Olsen M., Ostgaard H.- C., Stener- Victorin E. & Hagberg H. (2008) Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double- blinded controlled trial comparing acupuncture with non- penetrating sham acupuncture. BJOG: An International Journal of Obstetrics and Gynaecology 115 (13), 1655–1668.

Foster N. E., Bishop A., Bartlam B., et al. (2015) Evaluating Acupuncture and Standard carE for pregnant women with Back pain (EASE Back): a feasibility study and pilot randomised trial. Health Technology Assessment 20 (3), 1–236.

Guerreiro da Silva J. B., Nakamura M. U., Cordeiro J. A. & Kulay L., Jr (2004) Acupuncture for low back pain in pregnancy – a prospective, quasi- randomised, controlled study. Acupuncture in Medicine 22 (2), 60–67.

Gutke A., Betten C., Degerskär K., Pousette S. & Olsén M. F. (2015) Treatments for pregnancy- related lum-bopelvic pain: a systematic review of physiotherapy modalities. Acta Obstetricia et Gynecologica Scandinavica 94 (11), 1156–1167.

Haake M., Müller H.- H., Schade- Brittinger C., et al. (2007) German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel- group trial with 3 groups. Archives of Internal Medicine 167 (17), 1892–1898.

Kovacs F. M., Garcia E., Royuela A., González L. & Abraira V. (2012) Prevalence and factors associated with low back pain and pelvic girdle pain during preg-nancy: a multicentre study conducted in the Spanish National Health Service. Spine 37 (17), 1516–1533.

Kvorning N., Holmberg C., Grennert L., Aberg A. & Akeson J. (2004) Acupuncture relieves pelvic and low- back pain in late pregnancy. Acta Obstetricia et Gynecologica Scandinavica 83 (3), 246–250.

Langshaw W. (2011) Acupuncture and its use in the management of low back and pelvic girdle pain in pregnancy. Journal of the Association of Chartered Physiotherapists in Women’s Health 108 (Spring), 24–34.

Lund I., Lundeberg T., Lönneberg L. & Svensson E. (2006) Decrease of pregnant women’s pelvic pain after acupuncture: a randomized controlled single- blind study. Acta Obstetricia et Gynecologica Scandinavica 85 (1), 12–19.

Malmqvist S., Kjaermann I., Andersen K., et al. (2012) Prevalence of low back and pelvic pain

during pregnancy in a Norwegian population. Journal of Manipulative and Physiological Therapeutics 35 (4), 272–278.

Mayer J. M., Haldeman S., Tricco A. C. & Dagenais S. (2010) Management of chronic low back pain in active individuals. Current Sports Medicine Reports 9 (1), 60–66.

Park J., Sohn Y., White A. R. & Lee H. (2014) The safety of acupuncture in pregnancy: a systematic review. Acupuncture in Medicine 32 (3), 257–266.

Pennick V. & Liddle S. D. (2013) Interventions for pre-venting and treating pelvic and back pain in pregnancy. Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD001139. DOI: 10.1002/14651858.CD001139.pub3.

Römer A., Zieger W. & Melchert F. (2013) Verbotene Akupunkturpunkte in der Schwangerschaft – überholte Tradition oder beachtenswerter Existenznachweis?: Ergebnisse der retrospektiven Studie der Universitätsfrauenklinik Mannheim. [Prohibition of acupuncture points during pregnancy – an outdated tradition or objective evidence?: Results of a retro-spective study from Department of Gynaecology and Obstetrics, University Hospital Mannheim.] Deutsche Zeitschrift für Akupunktur 56 (3), 10–13. [In German.]

Selva Olid A., Martínez- Zapata M. J., Solà I., et al. (2013) Efficacy and safety of needle acupuncture for treat-ing gynecologic and obstetric disorders: an overview. Medical Acupuncture 25 (6), 386–397.

Ternov N. K., Grennert L., Åberg A., Algotsson L. & Åkeson J. (2001) Acupuncture for lower back and pelvic pain in late pregnancy: a retrospective report on 167 consecutive cases. Pain Medicine 2 (3), 204–207.

Vleeming A., Albert H. B., Östgaard H. C., Sturesson B. & Stuge B. (2008) European guidelines for the diagno-sis and treatment of pelvic girdle pain. European Spine Journal 17 (6), 794–819.

Wang S.- M., DeZinno P., Lin E. C., et al. (2009) Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study. American Journal of Obstetrics and Gynecology 201 (3), 271.e1–271.e9.

Wedenberg K. A. J., Moen B. & Norling Å. (2000) A prospective randomized study comparing acupuncture with physiotherapy for low- back and pelvic pain in pregnancy. Acta Obstetricia et Gynecologica Scandinavica 79 (5), 331–335.

Wild E. (2014) Use of acupuncture as an adjunct tool in the management of pelvic girdle pain in preg-nancy. Journal of the Acupuncture Association of Chartered Physiotherapists 2014 (Spring), 83–92.

Witt C. M., Jena S., Selim D., et al. (2006) Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture in chronic low back pain. American Journal of Epidemiology 164 (5), 487–496.

Wu W. H., Meijer O. G., Uegaki K., et al. (2004) Pregnancy- related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal 13 (7), 575–589.



Book reviews

Daoist Reflections from Scholar SageBy Damo Mitchell and his studentsSinging Dragon, London, 2016, 312 pages, paperback, £18.99ISBN 978- 1- 84819- 321- 5

As a complete novice in the field of Daoism, I tackled this book review with some trepidation, but also with interest. Having practised acu-puncture for many years, I have a great deal of respect for traditional Chinese medicine (TCM). However, I have never ventured into the realms of meditation, spiritualism or the martial arts, and so I was keen to find out how relevant Daoist Reflections from Scholar Sage would be to physiotherapy and acupuncture practice.

This book is a compilation of the most popular articles that have appeared on the

Scholar Sage Online Magazine website (www.scholarsage.com), and is designed to provide a wide range of information on Daoism and the internal arts. Generally, each chapter is inde-pendent of the others, and so this is a collec-tion that can be delved into at any point, which makes for easier reading.

Chapter 1 discusses the Ding (Cauldron) and Lu (Furnace), and how these work together to influence the body’s three powers of Jing (Body), Qi (Breath) and Shen (Mind). Clear information is backed up by easily understood diagrams, allowing readers to comprehend a mystifying subject.

The very short second chapter describes the processes by which Fire and Water meet in the body, which involve the mixing and reversing of the Dragon and Tiger on three different levels. The ultimate result is pure yin and yang, with the removal of Fire and Water and the production of Heaven and Earth, which brings harmony to the body.

Chapter 3 has the somewhat off- putting title of “Worms”. The theory is that three worms (Sanchong), representing “desires and wanting”, “attachments and regrets”, and “unconscious habits”, reside within the head, chest and sacrum, respectively. The worms can move in and out of the body of their own accord. The reader is taught how Daoism pulls together these physical, energetic, spiritual and psycho-logical models.

The following three chapters go on to discuss meditation, and how to overcome the challenges of the acquired mind. Alchemy is the system of meditation referred to in this book. The tricks played by the acquired mind are discussed, as are emotions, which “are simply a form of energy shifting in response to the movements of your mind [and are] why therapies such as acupuncture can directly affect your emotional state” (p. 50).

Chapters 7 and 8 discuss the importance of the balance between inhalation and exhalation

Book reviews


that allows Qi to move through the body. The cyclical relationship of Jing and Qi discussed in the Daoist poem “The Classic of Breath and Qi Consolidation” is simply explained, and the entire work is broken down into sections, which allows the reader to grasp its meaning more easily.

Various religions and the way in which Daoism has grown more complex are discussed in chapter 10. Traditional Chinese medicine is not only supposed to help with ailments, but also to realign a person with his or her spiritual path. In an age in which personal cultivation is all but ignored, and material gains are key measures of success in life, it is no wonder that much of the beauty of the art of TCM has been lost.

In chapter 14, the martial art of Taijiquan is discussed. It is of interest that this ancient form of combat revolves around the connective tis-sue and fascia that are of such scientific interest today. The connective tissue lines are known to carry energy, and are referred to as the riverbed of the meridians.

Chapter 21 is a very interesting account of the importance of the pineal gland in history and religion worldwide. It also provides fascinating information about the adverse effect of fluoride on the pineal gland and how to keep it healthy.

This book even tackles healthy eating in chapter 23, which is entitled “Food Energetics”. Here, various categories of food are discussed in relation to the effect of these on our body’s energies. As with acupuncture, some foods will stimulate while others will calm. There is also advice on the effects of different ways of cooking food, as well as the influence that its temperature has. All this is definitely food for thought!

Finally, there is a helpful glossary of Pinyin Chinese terms at the back of the book that provides the reader with clear and concise translations.

Interspersed with entertaining anecdotes and illustrated with straightforward, comprehensive diagrams, this book contains thought- provoking statements, and gives wise words of advice about the way in which practitioners in the West use Eastern practices, adapting them, often unwisely or incorrectly, to suit their methods.

This book is well written and stimulating. It takes a complex subject and explains it in an understandable and readable way. It is easy to follow, but doesn’t gloss over the depth of the subject being discussed.

I would recommend Daoist Reflections from Scholar Sage to anyone who, like myself, is interested in a straightforward and enlightening introduction to Daoism and the internal arts. It would also serve as an easily accessible refer-ence book for those who already are immersed in the ways of Daoism.

Wendy RarityBook Review Editor

The Yellow Monkey Emperor’s Classic of Chinese MedicineBy Damo Mitchell and Spencer HillSinging Dragon, London, 2016, 272 pages, paperback, £17.99ISBN 978- 1- 84819- 286- 7

In The Yellow Monkey Emperor’s Classic of Chinese Medicine, much of which is in comic- strip form, a horse complains about his chest being as tight as a bear’s embrace, a goat bleats about suffer-ing from skin that is as dry as parchment and a rat describes his urine as being darker than soy sauce. These lively characters and their friends then seek diagnostic help from wise animal sages, and the Yellow Monkey Emperor himself.

The preface explains that TCM is largely concerned with identifying the underlying causes of disharmony in the body. The book is divided into sections based on the seasons that are relevant to the ailments that these cover.

This interesting and entertaining book explains meridian point locations according to TCM and associated terms, including Zang Fu syndromes. It illustrates 78 of these syndromes, and states that anything that might be out of balance can be assessed once these are learned. The 78 key Zang Fu syndromes of disharmony are presented in ways that are easy to absorb. It is advisable to use the connections between the imagery, humour and symptoms in the comic strips to commit each syndrome to memory.

The representation of the organs is important for understanding their classification because it

Book reviews


enables the reader to understand how the body was viewed in TCM. It explains the correspond-ences between the ailments of the internal organs and physical symptoms or personality clues in the form of a parable.

The challenge of TCM is the huge amount of memorization required to retain all the meridians and treatment points. The cartoons included in the book are employed to aid comprehension and recall of the subject matter. The illustrations do this by condensing a complex concept into

a single drawing, thereby enabling the reader to remember what is being taught. A single image or a collection of drawings can make a list of terms easier to memorize. Each acupuncture point has an image associated within its name (e.g. Bladder 1: Jing Ming, “Bright Eyes”), and this appeal to the visual aspect of the brain enables the information to be more easily com-mitted to memory. The authors’ emphasis is not only on physical symptoms, but also those associated with behaviour and mood. However, many of the symptoms included in the book must be memorized without the aid of an accompanying illustration.

While acupuncture needles are referred to in the discussion of treatments, no detail is given about appropriate points. The book is diagnos-tic in nature and not a treatment manual. It would have been more complete if the authors had suggested treatment points for the condi-tions covered, but as it is, it needs to be used in conjunction with other acupuncture books or literature.

The Yellow Monkey Emperor’s Classic of Chinese Medicine is fast reading, entertaining and holds the attention, and many concepts explained in a simple visual form. It could be used as a start-ing point for learning about acupuncture, and gives the reader a good idea of what TCM is about in a very simple and amusing style.

Thelma CooperSpecialist Pelvic Health Physiotherapist

Department of PhysiotherapyBoglestone Clinic

Port GlasgowRenfrewshire

UK



News, views and interviews

From disempowerment to control: patients’ perceptions of acupuncture and moxibustion for lymphoedemaA recently published open- access paper by de Valois et al. (2016), reports that acupuncture and moxibustion (acu/moxa) can facilitate the transition from disempowerment to improved well- being and self- care for cancer survivors with lymphoedema.

“‘The monkey on your shoulder’: a qualita-tive study of lymphoedema patients’ attitudes to and experiences of acupuncture and moxibus-tion” was a runner- up in the Scientific Article Prize Competition awarded at the International Society for Complementary Medicine Research (ISCMR) conference in Berlin, Germany, in May 2017. This contest celebrates the best research in the complementary and alternative medicine (CAM), and integrative medicine (IM) field, and establishes such work as a legitimate area of investigation. The ISCMR is a worldwide scientific organization of researchers, practi-tioners and policy- makers that fosters CAM/IM research, and provides a platform for knowledge and information exchange to enhance interna-tional communication and collaboration.

De Valois et al. (2016) describe the results of focus group research nested in a three- step, mixed- methods observational study. This was carried out at the Mount Vernon Cancer Centre in Northwood, Middlesex, UK, and funded by the National Institute for Health Research (Grant Reference Number PB- PG- 0407- 10086) (de Valois et al. 2012). This qualitative work explored the way in which patients with lym-phoedema secondary to cancer treatment per-ceived and experienced acu/moxa. It involved 23 survivors of breast (n = 17), or head and neck (n = 6) cancer who had received up to 13 acu/moxa treatments. The present author, who was the principle investigator and also an acu-puncturist in the clinical study, worked with a

team including a qualitative researcher from the Peninsula Medical School at the University of Exeter, Exeter, UK.

Characterized by chronic swelling that is cur-rently incurable, lymphoedema is a consequence of cancer treatment that has a significant impact on health- related quality of life (QoL). Multidisciplinary approaches are needed to address the complex physical, psychological and psychosocial problems associated with a chronic condition in patients with multiple co- morbidities (Lymphoedema Framework 2006). In addition to specialist care, management of lymphoedema requires a significant commit-ment to daily self- care on the part of the patient (Keeley 2000).

Acupuncture is valued for its contribution symptom control and improved coping by people with chronic diseases, including cancer (Paterson & Britten 2003; Seers et al. 2009). Moxibustion, i.e. the use of heat to stimulate acupuncture points, is less well- known and researched in the West; however, the first paper to report using traditional Chinese medicine (TCM) in the management of lym-phoedema utilized moxibustion (Kanakura et al. 2002).

De Valois et al.’s (2016) overall study inves-tigated the feasibility of using acu/moxa to promote well- being and improve QoL for patients with breast, and head and neck cancer who had cancer- treatment- related secondary lymphoedema. In their qualitative study, the participants described feeling disempowered by cancer treatment and the subsequent diagnosis of lymphoedema, which was the “last straw” for some. Disabling, disfiguring and distressing, participants described a range of physical and psychosocial consequences of the condition that seriously affected their QoL. For many, the opportunity to have acu/moxa treatment came when they felt it was worth trying anything that might help, although a fear of needles was a concern.



The participants expressed their gratitude for the cancer treatment that they received from the National Health Service. However, they felt that conventional medical treatment focused solely on the disease, while they perceived the acu-puncturists to have a “whole person” approach. In particular, they appreciated the individual-ized treatments as well as the time spent with a practitioner who cared about, listened to and responded to their needs. Not all participants received treatment involving moxibustion, and there were mixed responses. Some enjoyed it immensely and found it very relaxing, while oth-ers were ambivalent and preferred acupuncture.

In the focus groups, of which there were six in total, the participants described physical changes including an increase in energy and a reduction in troublesome symptoms (e.g. sleep problems and musculoskeletal pain), as well as changes in lymphoedema- related symptoms including a reduction in pain, an increase in mobility and a perceived reduction in swelling. Many reported feeling more relaxed, less anx-ious and more motivated.

The emergent themes indicated a transition from feelings of disempowerment, disablement and disfigurement to ones of empowerment, control and acceptance. Many participants felt that their lives had changed because of the acu/moxa treatment, perceiving it to have had a sub-stantial and positive impact on their well- being, and giving them a sense of being once more in control of their lives. One survivor of breast cancer described this as follows:

“The biggest thing that it’s done for me is to put me back in balance . . . it [lymphoedema] doesn’t let you forget the cancer I think, because it’s a physical reminder of the fact that at one point in your life you were so very vulnerable. So it’s a bit like a monkey sitting on your shoulder, most of the time he’s on your shoulder but every now and then he comes and slaps you in the face. I just feel I can slap him back now, you know.” (de Valois et al. 2016, p. 9)

Acupuncture and moxibustion could also act as a catalyst that generated the motivation to take a more active part in self- care, a necessary step to manage a chronic condition such as lymphoedema.

Building on these findings, de Valois et al. (2016) propose a model of acu/moxa as a process for long- term healthcare. They suggest that this form of treatment has the potential to reduce troublesome symptoms and increase energy, which increases motivation and improves self- care in turn, leading to possible improve-ments in long- term health and well- being.

More research is needed to explore the poten-tial of the proposed model. In the meantime, acupuncturists and their patients might broaden their expectations of this treatment modality, and consider its wider effects on well- being and motivation, rather than the more frequently expected outcome of reducing lymphoedema swelling.

This is the first qualitative study to explore lymphoedema patients’ perceptions of acu/moxa treatment. Furthermore, de Valois et al. (2016) address overall well- being, rather than focusing on a single physiological symptom (usually the reduction in swelling reported in previous studies of lymphoedema). Their study also included survivors of head and neck cancer with lymphoedema, who represent an under- researched group of patients.

De Valois et al. (2016) indicate that acu/moxa has the potential to benefit some people with cancer- related upper body lymphoedema who present with several symptoms related to, and in addition to, lymphoedema. Their participants valued acu/moxa treatment: many reported that it facilitated a transformation from the feeling of disempowerment engendered by their cancer diagnosis and the consequences of its treatment to a sense of empowerment and having more control over their lives.

Beverley de Valois PhD LicAc FBAcCSupportive Oncology Research Team

Lynda Jackson Macmillan CentreMount Vernon Cancer Centre

NorthwoodMiddlesex

UKE- mail: [email protected]

ReferencesDe Valois B. A., Young T. E. & Melsome E. (2012)

Assessing the feasibility of using acupuncture and



moxibustion to improve quality of life for cancer sur-vivors with upper body lymphoedema. European Journal of Oncology Nursing 16 (3), 301–309.

De Valois B., Asprey A. & Young T. (2016) “The monkey on your shoulder”: A qualitative study of lymphoedema patients’ attitudes to and experiences of acupuncture and moxibustion. Evidence- Based Complementary and Alternative Medicine 2016: 4298420. DOI: 10.1155/2016/4298420.

Kanakura Y., Niwa K., Kometani K., et al. (2002) Effectiveness of acupuncture and moxibustion treat-ment for lymphedema following intrapelvic lymph node dissection: a preliminary report. The American Journal of Chinese Medicine 30 (1), 37–43.

Keeley V. (2000) Clinical features of lymphoedema. In: Lymphoedema (eds R. Twycross, K. Jenns & J. Todd), pp. 44–67. Radcliffe Medical Press, Abingdon, Oxfordshire.

Lymphoedema Framework (2006) Best Practice for the Management of Lymphoedema. International Consensus. MEP, London.

Paterson C. & Britten N. (2003) Acupuncture for people with chronic illness: combining qualitative and quanti-tative outcome assessment. The Journal of Alternative and Complementary Medicine 9 (5), 671–681.

Seers H. E., Gale N., Paterson C., et al. (2009) Individualised and complex experiences of integrative cancer support care: combining qualitative and quanti-tative data. Supportive Care in Cancer 17 (9), 1159–1167.

Misguided guidelinesA recent invited commentary by Dr Hugh Macpherson raises some important issues about the National Institute for Health and Care Excellence (NICE) guidelines, which now do not recommend acupuncture for osteoarthritis (NICE 2014) or low back pain (LBP) (NICE 2016). In “NICE for some interventions, but not so NICE for others: questionable guidance on acupuncture for osteoarthritis and low- back pain” (Macpherson 2017), he raises three key points.

First, the prior scoping process for Low Back Pain and Sciatica in Over 16s: Assessment and Management (NICE 2016) limited the review to some interventions, but not others. Apart from acupuncture, recommendations about the latter interventions were made according to the previ-ous version of the guidelines (NICE 2009).

Secondly, a new methodological approach was used for Osteoarthritis: Care and Management (NICE 2014). A new concept, minimum

clinically important difference (MCID), was introduced that required interventions within the scope of the update (e.g. acupuncture) to show an MCID in effect size of at least 0.5.

Thirdly, NICE specified that this MCID of ≥ 0.5 should be applied to a comparison between the intervention (i.e. acupuncture) and the placebo. It is significant that the only inter-vention that achieves an MCID of more than 0.5 when compared with the placebo is opioid treatment.

However, NICE did not apply its criteria to all the interventions included, and very few of those that were recommended met their requirements.

What should be of clinical relevance are the results of a comparison between an intervention and usual care. Vickers et al. (2012) presented high- quality evidence from a meta- analysis that showed that acupuncture is effective for LBP in comparison to usual care.

Macpherson (2017) concludes that NICE can be considered to be inconsistent, and that the recommendations could not only be detrimental to the provision of acupuncture, but may also inadvertently drive up use of opioids.

Rosemary LillieNews Editor

ReferencesMacPherson H. (2017) NICE for some interventions,

but not so NICE for others: questionable guidance on acupuncture for osteoarthritis and low- back pain. The Journal of Alternative and Complementary Medicine 23 (4), 1–2.

National Institute for Health and Clinical Excellence (NICE) (2009) Low Back Pain: Early Management of Persistent Non- specific Low Back Pain. NICE Clinical Guideline 88. National Institute for Health and Clinical Excellence, London.

National Institute for Health and Care Excellence (NICE) (2014) Osteoarthritis: Care and Management. NICE Clinical Guideline 177. National Institute for Health and Clinical Excellence, London.

National Institute for Health and Care Excellence (NICE) (2016) Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE Clinical Guideline 59. National Institute for Health and Clinical Excellence, London.

Vickers A. J., Cronin A. M., Maschino A. C., et al. (2012) Acupuncture for chronic pain: individual patient data meta- analysis. Archives of Internal Medicine 172 (19), 1444–1453.



Acupuncture recommended for low back painContrary to the recent NICE (2016) recom-mendations (see above), acupuncture has been endorsed in the treatment of low back pain by the American College of Physicians (ACP), one of the largest medical organizations in the USA (Quaseem et al. 2017).

The membership of ACP is made up of “internists – specialists who apply scientific knowledge and clinical expertise to the diagno-sis, treatment, and compassionate care of adults across the spectrum from health to complex ill-ness” (ACP 2017). With over 150 000 members, it is “the largest medical specialty organization and second- largest physician group in the United States” (ACP 2017).

In April 2017, the ACP updated their recom-mendations for the treatment of LBP (Quaseem et al. 2017):

“Recommendation 1. Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate- quality evidence), massage, acupunc-ture, or spinal manipulation (low- quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti- inflammatory drugs or skeletal muscle relaxants (moderate- quality evidence). (Grade: strong recommendation)

“Recommendation 2. For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness- based stress reduction (moderate- quality evidence), tai chi, yoga, motor control exercise, pro-gressive relaxation, electromyography biofeedback, low- level laser therapy, operant therapy, cognitive behavioural therapy, or spinal manipulation (low- quality evidence). (Grade: strong recommendation)” (Quaseem et al. 2017, p. 514)

It is very encouraging to see this strong rec-ommendation from the ACP for the use of acupuncture, and one can only hope that, considering this, the NICE guidelines may be successfully challenged.


ReferencesAmerican College of Physicians (ACP) (2017) ACP Facts.

[WWW document.] URL https://www.acponline.org/acp- newsroom/acp- facts

National Institute for Health and Care Excellence (NICE) (2016) Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE Clinical Guideline 59. National Institute for Health and Clinical Excellence, London.

Quaseem A., Wilt T. J., McLean R. M., et al. (2017) Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 166 (7), 514–530.

Acupuncture and infantile colicIn a recent multicentre, three- armed, single- blind, randomized controlled trial (RCT), Landgren & Hallström (2017) reported the effects of minimal acupuncture on infantile colic. Their aim was to evaluate two types of acupuncture, i.e. minimal acupuncture at Large Intestine (LI) 4 (Hegu) and semi- standardized individual acupuncture inspired by TCM, against no acupuncture. One hundred and forty- seven infants were included in the trial, and acupunc-ture was administered by trained medical staff. The goal of the study was to investigate whether it was both practical and effective to administer acupuncture in children’s health centres in the Swedish public health system. Previous studies by Reinthal et al. (2008, 2011) and Skjeie et al. (2013) had only examined treatments that had been administered in private clinics, which could have resulted in inbuilt bias.

The TCM- inspired points used were any combination of Extra Upper Extremity 10 (Si Feng), Stomach 36 (Zu San Li) and LI4. All these points are considered important in treating gastrointestinal symptoms and infantile colic. The Standards for Reporting Interventions in Clinical Trials of Acupuncture were followed. No placebo was used. The infants received treatment twice a week for 2 weeks.

In comparison with usual care, the results showed a statistically significant reduction in the magnitude of crying in both acupuncture groups.

Landgren & Hallström (2017) suggest that a diet free of cow’s milk protein, and an evalua-tion of the infant crying should be undertaken



to avoid unnecessary treatment. If an infant continues to cry for more than 3 h a day, acupuncture can be considered. Both methods of acupuncture are effective and have no side effects.

Despite the low number of participants involved, this is a useful study that suggests that acupuncture can be effective in treating colic. It also demonstrates the treating infants with acupuncture is safe. The choice of points used was not statistically significant, but it is difficult to compare the two groups because the semi- standardized group did not receive treatment at the same points as those receiving minimal acupuncture at LI4. However, the three points selected are all effective, and could be used in clinical practice.

Further research is necessary, of course.Rosemary Lillie

News Editor

ReferencesLandgren K. & Hallström I. (2017) Effect of minimal

acupuncture for infantile colic: a multicentre, three- armed, single- blind, randomised controlled trial (ACU- COL). Acupuncture in Medicine 35 (3), 171–179.

Reinthal M., Andersson S., Gustafsson M., et al. (2008) Effects of minimal acupuncture in children with infan-tile colic – a prospective, quasi- randomised single blind controlled trial. Acupuncture in Medicine 26 (3), 171–182.

Reinthal M., Lund I., Ullman D. & Lundeberg T. (2011) Gastrointestinal symptoms of infantile colic and their change after light needling of acupuncture: a case series study of 913 infants. Chinese Medicine 6: 28. DOI: 10.1186/1749- 8546- 6- 28.

Skjeie H., Skonnord T., Fetveit A. & Brekke M. (2013) Acupuncture for infantile colic: a blinding- validated, randomized controlled multicentre trial in general practice. Scandinavian Journal of Primary Health Care 31 (4), 190–196.

Acupuncture for chronic prostatitis/chronic pelvic pain syndromeA recent review by Qin et al. (2016) concludes that real acupuncture leads to significant reduc-tions in the pain, urinary symptoms and QoL domains of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH- CPSI). Compared with conventional Western

medicine, acupuncture may be effective in decreasing the total NIH- CPSI score, especially in terms of pain relief.

With regard to urinary symptoms and QoL, there was no significant difference between acu-puncture and conventional Western medicine.

Out of 1054 RCTs searched, only seven studies met the authors’ criteria for their meta- analysis. This demonstrates the paucity of good- quality research that is available. Since the aetiology and pathology of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is poorly understood, the goal of treatment is to control the symptoms that patients experience. Even in the seven studies that were analysed by Qin et al. (2016), there was little heterogeneity in the methods used, the questionnaires, the drug comparisons and whether sham acupuncture was employed. A previous review (Posadzki et al. 2012) included nine Asian RCTs, and concluded that acupuncture was an encouraging therapy for CP/CPPS; however, these trials were pub-lished in Chinese and were not available for data abstraction for Qin et al.’s (2016) study.

This is a useful review of the use of acu-puncture in the treatment of CP/CPPS, and the comprehensive reference list provides further reading and research opportunities for anyone with an interest in this field. This open- access paper is available online (Qin et al. 2016), which is very helpful.

As always, the caveat remains: further research is needed.


ReferencesPosadzki P., Zhang J., Lee M. S. & Ernst

E. (2012) Acupuncture for chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a systematic review. Journal of Andrology 33 (1), 15–21.

Qin Z., Wu J., Zhou J. & Liu Z. (2016) Systematic review of acupuncture for chronic prostatitis/chronic pelvic pain syndrome. Medicine 95 (11): e3095. DOI: 10.1097/MD.0000000000003095.

ErratumTwo amendments need to be made to Janis Short’s Lung meridian masterclass, which was



published in the Winter 2016–2017 edition of the journal (Short 2017):(1) In “Lung 3: Tian Fu, ‘Palace of Heaven’”

section (p. 58, col. 2), the first paragraph should read as follows: “Lung 3 is located 6 cun above LU5 (Chi Ze), on the radial border of the biceps muscle. According to Quirico (2008, p. 3), ‘In the seated posi-tion, have the patient rotate his or her head and take the arm toward the face. The acupuncture point is located where the tip of the nose touches the arm, above the biceps muscle.’ Lung 3 can be needled

perpendicularly to a depth of 0.5–1.0 cun.”(2) In the section on “Lung 9; Tai Yuan, ‘Great

Abyss’” (p. 59, col. 1), the first sentence should refer to “LU9”, not “LU7”.

Val HopwoodClinical Editor

ReferencesQuirico P. E. (2008) Teaching Atlas of Acupuncture, Vol. 2:

Clinical Indications. Thieme, Stuttgart. Short J. (2017) The Lung meridian: the hand Tai Yin

channel. Acupuncture in Physiotherapy 28 (2), 55–61.



Guidelines for authors

IntroductionAlways refer to a recent edition of Acupuncture in Physiotherapy. Please follow the style and layout of an article or item that is similar to your own contribution. If something is submitted for publication, then it is implied that it has not been simultaneously submitted to another journal or any other type of publication. Reprints may be considered, but these must be clearly identified as such and permission must be obtained from the original publisher.

Templates for clinical papers and case reports are available on the AACP website (www.aacp.org.uk), or by e-mail on request. These templates should not be deviated from if used. Manuscripts may be returned to authors if they have not adhered to the guidelines. If necessary, the clinical editor should be consulted in the initial stages for clarification.

Authors may submit clinical papers, literature reviews, clinical commentaries, case reports, book reviews, course reports, news items, letters or photographs for consideration for inclusion in the journal. Academic and clinical papers are subject to review by the editorial committee and may require revision before being accepted.

A Portable Document Format (PDF) file of the final version of any academic article is available free of charge if notice is given to the clinical editor when the article is submitted.

All published material becomes the copyright of the Association.

All submissions should be sent directly to the clinical editor:

Dr Val Hopwood FCSP18 Woodlands CloseDibden PurlieuSouthampton SO45 4JGUK

E-mail: [email protected]

Preparation of manuscriptsAuthors should submit material by e-mail or on CD-ROM. All articles must be typed with wide (3-cm) margins and the pages should be num-bered consecutively. Articles should be a maxi-mum of 7500 words (excluding the abstract, references and tables).

Papers should be arranged as follows:

TitleThe title of the article should be in sentence case, bold and ranged left, as in the main title above: note that there is no full stop and no underlining. The author’s name(s) and institutional affilia-tion(s) should run consecutively below the title. Again, there are no full stops.

Abstract A summary of not more than 250 words outlin-ing the purpose, scope and conclusions of the paper should be submitted. This should be followed by a minimum of three and a maximum of five keywords that best represent the contents.

Text The layout of the journal is that the main heading of each section is in sentence case and bold. Notice that, again, there are no full stops and no underlining.

The first paragraph is left-justified; subsequent paragraphs in the same section are indented, as is this part of the guidelines. When including diagrams and photographs, these should be num-bered in the order in which they appear in the text, and should be submitted in separate files (do not embed images in the text). Any figure captions should be left-justified and run after the author’s biography at the end of the text. Any tables should come after the figure legends, if there are any. Please indicate placement in the text (e.g. “Fig. 1’’ and “Table 1’’). All figures and tables must be referred to in the text.



When using numbers in the text, these should be written out in words up to and including nine unless these are measurements, numbers in tables or units of time. Always use the Inter-national System of Units (SI).

Clinical papers: referencing All clinical papers must be fully referenced and the citations verified by the author. No excep-tions will be made. The reference list must be arranged alphabetically by the name of the first author or editor, following the Harvard style. In the text, give the author(s) and date of publica-tion in brackets [e.g. “(Smith 1998)’’], or if the main author’s name is part of a sentence, then only the year is in brackets [e.g. “as described by Smith (1998)’’]. For more than one author, reference can be made in the text to “Smith et al. (1998)’’ (note the italics). However, when writing the reference list, the convention is as fol-lows: for up to five authors, write all the authors’ names; for six or more authors, write the first three authors’ names, followed by “et al.”

For journals, give the author’s surname and initials, the year of publication, the title of the paper, the full name of the journal, the volume number, the issue number in brackets, and the first and last page numbers of the article (note the correct use of italic, bold, commas and full stops):

Ceccherelli F., Rigoni M. T., Gagliardi G. & Ruzzante L. (2002) Comparison of superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double-blind randomized controlled study. Clinical Journal of Pain 18 (3), 149–153.

For books, give the author’s/editor’s surname and initials, the year of publication, the book title in italics, and the publisher and city of publication:

Williams P. L. & Warwick R. (eds) (1986) Gray’s Anatomy, 36th edn. Churchill Livingstone, Edinburgh.

For a chapter or section in a book by a named author (who may be one of several contributors), both chapter and book title should be given, along with the editor’s name(s), and the first and last page numbers of the chapter:

Bekkering R. & van Bussel R. (1998) Segmental acupunc-ture. In: Medical Acupuncture: A Western Scientific Approach (eds J. Filshie & A. White), pp. 105–135. Churchill Livingstone, Edinburgh.

For references to documents on the World Wide Web (WWW), give the author’s surname followed by all initials, the year of publication in brackets, the document title in italics, an indica-tion that it is a WWW document in square brackets and the complete Uniform Resource Locator (URL):

List D. (2004) Maximum Variation Sampling for Surveys and Consensus Groups. [WWW document.] URL http://www.audiencedialogue.net/maxvar.html

Please adhere strictly to this style of referencing in any contribution to the journal.

Acknowledgements Please state any funding sources, or companies providing technical or equipment support.

Photographs Photographs may be submitted in colour or black-and-white, but will be printed in mono-chrome. Images must be in sharp focus. Photo-graphs should be numbered and their placing indicated in the text. Digital photographs should be of high resolution (i.e. a minimum of 300 dots per inch).

Line illustrations These should follow the style used in the journal, i.e. any labelling text should be in sentence case (10-point, Arial font), graphs should be two-dimensional and all images must be mono-chrome. As with photographs, line illustrations should be numbered and their placement indi-cated in the text. All images should be of high resolution (i.e. a minimum of 1200 dots per inch).

Case reportsThe journal welcomes case reports of up to 3000 words. These should be structured as follows: title, abstract and keywords, a brief



introduction, a concise description of the patient and condition, and an explanation of the assess-ment, treatment and progress, followed finally by a discussion and evaluation of the implications for practice. The study must be referenced throughout. Further guidance is available upon request.

Book reviewsAt the beginning of the review, give all details of the book including the title in bold, the author/editor’s full name(s), publisher, city and year of publication, price, whether hardback or paper-back, number of pages, and ISBN number. The reviewer’s name should appear at the end of the review in bold, right-justified, followed by their title and place of work in italics. Reviews of DVDs and DVD-ROMs should follow the same format. Book reviews and reports are normally

no more than 500 words in length; query for longer.

Please contact the book review editor before writing a review.

General points to notePlease enclose your home, work and e-mail addresses, and telephone number.

It is the author’s responsibility to obtain and acknowledge permission to reproduce any material that has appeared in another journal or textbook.

A brief biographical note about the author(s) should be included at the end of a clinical paper in italics.

All notes and news should have clinical rel-evance to AACP. Please refer at all times to the style and layout of previous issues of the journal for whatever you are writing. Using these guide-lines will save the editorial team time.

The JCM Clinical Mastery Series

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Acupuncture in PhysiotherapyTM

Journal of the Acupuncture Associationof Chartered Physiotherapists

Summer 2017 Volume 29, Number 1

ISSN 2058-3281


TMVolum

e 29, Num

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Documents

AIP 29-1 Text - AACP