Chapter 5 Acupuncture

Initial Examination

Client Report: Richard has had right lateral elbow pain for 4 months; it is continuing to worsen despite use of nonsteroidal antiinflammatory drugs (NSAIDs). He is currently unable to work and also has great difficulty lifting and carrying objects in his right hand. The onset of his pain was insidious.

Client Goals: Reduce pain, return of full function of the arm, especially gripping objects and driving

Employment: Bus driver

Recreational Activities: Football referee

General Health: Moderate; had shingles 12 years ago and since then suffers from headaches; also complains of left sciatica, right neck pain, and left ankle fracture, which required open reduction internal fixation

Medications: NSAID

Musculoskeletal: Range of motion (ROM): unable to actively extend the elbow because of pain and swelling; passive stretching of the extensor muscle group, and elbow supination and pronation (with the forearm flexed to 90 degrees) all produce pain. Swollen around lateral complex of the elbow.

Neuromuscular: Force generation: unable to test right elbow extension, right wrist extension, or right grip strength because of aggravation of pain. Tests for left arm all scored 5/5 on manual muscle testing.¹

Function: Severe sharp pain, aggravated by any light pressure such as clothes touching his arm, unable to sleep on right side, sharp pain: visual analogue scale (VAS)=8 to 9 out of 10 at worst during movement; and dull throbbing pain: VAS=2 to 3 out of 10 at rest. Activities of daily living (ADL): unable to safely lift and carry heavy objects in his right hand; unable to safely drive.

Plan of Care

The plan of care includes ice, massage, and stretches to the muscles of extensor complex of lateral elbow. The initial home exercise program given was to hold stretch for 10 seconds three to five times per session and repeat three times per day within his limits of pain. Functional activities were not commenced because of the extreme pain, and the client was told to ice and use antiinflammatory gel to control his pain at home.

Reevaluation

After two sessions over 2 weeks little change exists: the client can tolerate only very light pressure around the right elbow. Passive stretching of the extensor muscle group, resisted finger extension of the middle digit, and elbow supination and pronation (with the forearm flexed to 90 degrees) all produce high levels of pain. Self-treatment with ice and antiinflammatory gel has little impact on his pain, and he is unable to comply with the home exercise program.

Incorporating CAM into the Plan of Care

Physical therapy treatment has been limited by this client’s inability to tolerate any level of pressure on or around his right lateral elbow. The client therefore was referred to another therapist who practices acupuncture from a TCM perspective as an alternative to the current plan of care. The therapist carries out a diagnosis from a TCM perspective and notes the following.

TCM Examination

Appearance: Overweight especially around his abdomen; facial expression indicates pain, good vital energy in his eyes

Listening: Normal level of speech

Presenting Tongue: Pale, damp with slight teeth marks

Pulses

Palpation: Extremely tender on palpation along the large intestine (LI) meridian of the right arm; also swollen. Severe pain limits movement and increases with light pressure, which suggests a yin problem.

Meridian/Organ Involvement: Painful along right LI meridian from LI 11 to LI 9 and also LI organ involvement (see bowel function below).

Diet: Majority of his food is fried fatty foods and carbohydrates; chicken, pork, and eggs aggravate his symptoms of irritable bowel syndrome (IBS).

Fluid Intake: Drinks at least three to four cups of tea/coffee daily.

Bowel/Urinary Function: Symptoms of IBS are worse than typical over last 9 months with chronic diarrhea daily (usually preceded by left-sided abdominal cramps) and intermittent constipation. Client is also complaining of abdominal distension after eating food. Increased frequency of urine at night.

Sleep: Suffers from nocturia and sluggishness first thing in the morning; complains of tiredness and energy dips in the afternoon; falls asleep in front of the television by 9 pm every night.

Other Health Problems: Complaining of dizziness and headaches that travel from back of left eye over temporal aspect of his head along the GB meridian (linked to shingles attack 12 years ago).

TCM Diagnosis and Plan of Care

In this case study, internal organ problems and local channel problems appear to overlap.² In TCM, local channel problems may be explained by invasion of a single or a combination of four external pathogenic factors (cold, heat, damp, or wind), which may lead to painful obstructive syndrome or Bi syndrome.³ In this case study, the symptoms of severe pain, which limits movement, and swelling could be explained by an invasion of cold and damp into the body.³ This invasion alters the balance of yin and yang, upsets the circulation of qi in the channel, and causes qi and blood to stagnate. Local stagnation of qi and blood along the LI meridian (Figure 5-1) of this client’s right forearm causes significant pain and swelling and lack of nourishment of the tendons and skin. This type of pain is improved by heat and aggravated by cold, which explains why the use of cryotherapy by the first physiotherapist was unhelpful.³ Another frequent cause of lateral elbow pain, according to Ji,⁴ is local trauma, which could be a likely explanation in this case study and would fit with a Western medical diagnosis of repetitive strain injury (RSI). Obviously in this case study this is linked to the client’s occupation as a bus driver.

Figure 5-1 The 12 main meridians.

From Fritz S: Fundamentals of therapeutic massage, St Louis, 2004, Elsevier.

However, this client also is showing signs of disharmony in several organs, which suggests deficiency of his system and may explain why he was susceptible to an invasion of cold/damp. His reported symptoms of diarrhea/constipation reflect changes in large intestine function. directly linked to his local large intestine channel problem manifested in his elbow. This may be due to an underlying spleen qi deficiency, which causes collapse of the LI. The pattern of spleen qi deficiency is manifested by the symptoms of fatigue and chronic diarrhea and can be seen on his tongue (pale, damp, swollen, and tooth marked, which also may indicate yang deficiency of the kidney),⁵ his body type (overweight, especially the abdomen), and his pulse. He also is showing signs of liver disharmony in his pulses and reports of dizziness and temporal headaches along the GB line. His bowel symptoms, along with abdominal bloating and cramps and his reported intolerance to some foods, are suggestive of IBS. According to Gascoigne⁶ in TCM this corresponds to liver qi stagnation invading the spleen with an underlying kidney deficiency. Kidney deficiency in this case study is seen in the pulses, his sleep pattern, and tongue. A predominance of spleen qi deficiency explains the loose stools, and the abdominal distension and pain are caused by stagnation of liver qi.

Incorporating CAM into the Plan of Care

Using a TCM approach the plan of care is extended from one that treated the local problem (channel problem in TCM) to one that treats the organ disharmonies revealed by the detailed TCM diagnosis. Local channel problems will be treated in this case by use of a combination of local (LI 10, LI 11, LI 12) and distal points (LI 4, LI 5, TE 5). (See Table 5-1 for a list of the 12 main meridians and their corresponding organs.) Several organs show signs of disharmony and are treated accordingly. Use of large intestine points may help to resolve the large intestine organ problems (e.g., diarrhea and constipation).

Table 5-1 The 12 Main Meridians and Their Corresponding Organs

However, the other underlying organ deficiencies already identified in the TCM diagnosis also need to be addressed. For example, spleen qi deficiency should be addressed through a change in diet in addition to the use of specific acupuncture points to strengthen spleen function. The client should avoid dairy products, bananas, refined foods high in sugar, and raw cold food because these all can injure the spleen. In addition he should reduce consumption of fried, greasy foods and alcohol because these can damage the spleen (and liver). A reduction in tea and coffee also may be helpful and can be achieved by a switch to herbal teas and diluted apple juice. During acupuncture treatment, specific points to reinforce the function of the spleen (and kidney) could be used (B 120, ST 36, SP 6, KI 3, KI 6 with moxibustion), if required. Improvement of the flow of liver qi also would be important to address by use of either GB or LIV points (GB 40, LIV 3). In the case study, points were altered as required depending on the client’s response and on reassessment during each visit. In TCM, acupuncture points may have several actions, and points to treat organ disharmony may be useful for treatment of the local problem (and vice versa). For example, LIV 3 and SP 6 aid the movement of qi and blood anywhere in the body and thus reinforce the action of local and distal points along the arm meridian.

This chapter describes the case of a 58-year-old male bus driver with lateral elbow pain, who is unable to work. The client is examined with use of a physical therapy and a traditional Chinese medicine (TCM) approach. The physical therapists, both trained as acupuncturists, consider including acupuncture, using a TCM approach in the plan of care. The decision is based on the physical therapists’ training, in the United Kingdom, where PTs can use acupuncture as an adjunctive analgesic modality after a conventional physiotherapy assessment or as part of treatment after a TCM diagnosis (see Appendix 1).

In this case study the therapists use a TCM approach and acupuncture analgesia (AA). The therapists, also acupuncture researchers, thoroughly review the literature relevant to lateral elbow pain and after a discussion of the findings with the client initiate a course of acupuncture. The investigation of the literature and the therapists’ clinical decision making are described in this chapter.

INVESTIGATING THE LITERATURE

The therapist uses two strategies to investigate the literature. The first is a detailed approach in which preliminary background reading is performed on the pathophysiology of pain and acupuncture therapy, including Eastern and Western perspectives on TCM. Next comes a search of databases and evaluation of the literature with use of reviews and primary sources. The second strategy is the use of the PICO format for a focused search to answer the clinical question generated by the case.

Preliminary Reading

A multitude of publications provide an introduction to acupuncture, many of which start with some form of historical perspective on acupuncture in East Asia,^6,⁷ and how it was introduced to and embraced in the Western world.⁸ For example Pomeranz explains that although acupuncture was first brought to Europe in the seventeenth century, it only recently has been accepted widely because of the clash of Eastern and Western paradigms in health care.⁹ Briefly, acupuncture is a form of treatment derived from TCM, which is more than 2000 years old. Although the term TCM is used throughout this chapter, a great deal of heterogeneity exists in the practice of acupuncture in eastern Asia, and it is not a single, historically stable therapy. For example, whereas many Chinese practitioners insert needles deep into the tissues, Japanese practitioners use shallow needle and noninsertion needling techniques.¹⁰ Although the details of practice may vary, all traditional acupuncture is based on the Daoist concept of yin and yang¹⁰ (see Chapter 4).

To maintain health, yin and yang energies must be balanced; otherwise imbalance will result in disharmony/disease of the human body. This balance of yin and yang is controlled by a vital force or energy called qi (pronounced “chee”), which circulates between the organs along channels called meridians.¹⁰ The surface of the body has 12 regular meridians (Figure 5-1 and Table 5-1), and these correspond to 12 major functions or “organs” of the body. Although they have the same names (e.g., liver, kidney, heart), Chinese and Western concepts of the organs correlate only very loosely. Qi must flow in the correct strength and quality (and direction) through these meridians, which connect to interior organs, for health to be maintained.¹⁰ To stimulate healing and alter the energetic flow of qi and thus maintain the balance of yin and yang, acupuncture needles are applied at external points along the meridians. Each acupuncture point is considered to have a defined therapeutic action (some of which have been confirmed by MRI studies¹¹), and thus particular defined points are chosen to treat a specific condition. Pain along a meridian could indicate a dysfunction of that meridian only or could reflect a dysfunction of the corresponding organ.⁷ In this particular case history, Richard appears to have a dysfunction of the meridian and corresponding organ.

When acupuncture is practiced from a TCM perspective, the interpretation of how the body functions is different from Western medicine, and a complex examination of many systems is carried out to diagnose the location of an imbalance in energy (see Chapter 4).

Western Medical Acupuncture

Many of the health professionals such as physical therapists, medical doctors, and dentists who practice acupuncture have dispensed with these TCM concepts ⁶ and practice “Western medical acupuncture.” In Western medical acupuncture the clinician diagnoses the client from an orthodox point of view and applies acupuncture, based on the published scientific evidence, as an adjunctive technique.¹² Acupuncture points are seen to correspond to physiological and anatomical features such as peripheral nerves and muscular trigger points,¹⁰ and the aim of treatment is to reduce pain and/or deactivate trigger points. Now a large body of scientific evidence details the mechanisms of action of acupuncture, in particular acupuncture analgesia. Several sources can be found on this topic.¹³^–¹⁶

A starting point is an understanding of pain control mechanisms. Additional references provide information on the neuroanatomy of the nociceptive system and neurophysiology of pain and its modulation.¹⁷^–²⁰ To minimize confusion in reading these texts remember that nerve fibers are classified by diameter and conduction velocity. The numerical classification typically is used for muscle afferents, whereas the alphabetical scheme is used for cutaneous nerves (Table 5-2).

Table 5-2 Classification of Nerve Fibers

Scientific research suggests that acupuncture needles activate sensory afferents (variously A delta/Group III, A beta/Group II, and C fiber/Group IV afferents), which send impulses to the spinal cord and activate three centers (spinal cord, midbrain, and hypothalamus-pituitary) to cause analgesia through the release of endorphins and monoamines.¹⁶ Another suggestion is that activation of ergoreceptors in the muscle, which normally signal muscle load and are activated during voluntary muscle contraction, occurs by low-frequency ture. These receptors, which are served by group III muscle afferent fibers, are proposed to play a particularly important role in the production of AA.²¹

The main mechanisms of AA are outlined in the first three points below. The secondary mechanisms of AA are outlined in points four and five. Some of these are less well understood than others, and research to elucidate mechanisms is ongoing.

1. Segmental inhibition: At the spinal cord level, pain relief is produced by blocking incoming pain messages (mainly transmitted along C fibers) through the presynaptic or/and postsynaptic release of endogenous opiates (dynorphins or enkephalins),¹⁶ which can close the “pain gate,” as described by Melzack and Wall.²² Much of the research in this area has used electroacupuncture to investigate these mechanisms. However, manual acupuncture also can block pain in the spinal cord,²³ possibly through similar mechanisms.

2. Descending pain suppression system (DPSS): When appropriately stimulated, ascending afferents from the spinal cord excite the peri-aqueductal grey (PAG) in the midbrain, which releases the opioid enkephalin; this in turn activates other centers in the brainstem, for example, the medulla (the raphe nucleus) and the pons (locus ceruleus) with descending projections onto the spinal cord. These descending projections inhibit the transmission of pain by postsynaptic inhibition of A delta and C fibers at the level of the spinal cord via the synergistic effects of the neurotransmitters serotonin and norepinephrine.¹⁶ These neurotransmitters excite inhibitory interneurons, which inhibit the pain-transmitting fibers through the release of enkephalin.

3. Hypothalamus-pituitary axis: Evidence suggests that hypothalamic nuclei have a central role in mediating the effects of AA (as well as autonomic effects) by releasing beta-endorphin, which reinforces the midbrain DPSS.^14,¹⁶ This system may be activated by vigorous physical exercise with repetitive muscle contractions or low-frequency EA, at sufficiently high intensities to cause muscle contraction. This muscle contraction excites high-threshold and low-threshold mechanoreceptors called ergoreceptors in muscle and other tissues, as described earlier.¹⁴ When activated, the hypothalamus-pituitary releases beta-endorphin by two methods: either into the CSF of the brain to produce AA or into the blood via the pituitary (along with equal amounts of cortisol). The role of beta-endorphin released into the blood is unclear, although the release of cortisol may play an important antiinflammatory role in the body’s tissues.

4. Peripheral effects: Electrical stimulation at intensities likely to recruit A delta fibers can reduce conduction velocity and amplitude of potentials in A delta fibers.²⁴ Presumably EA (at least) can block transmission through this mechanism. In addition, acupuncture has been shown to lead to the release of substances in the periphery (substance P, vasoactive intestinal polypeptide, and calcitonin gene-related pep-tide), which are likely to result in vasodilatation, and in increased nutrition from improved blood flow, and thus may accelerate the removal of pain-inducing substances.¹⁵

5. Oxytocinergic system: Acupuncture and muscle exercise release endogenous opioids and oxytocin.¹⁴ The oxytocinergic system is activated by mild, nonpainful sensory stimulation such as a 2-Hz EA, massage, vibration, and thermal stimulation and affects beta-endorphin release,¹⁵ which mediates AA in the hypothalamus-pituitary axis.

The choice of acupuncture points is important. Activation of acupuncture analgesia is believed to depend on several factors: the stimulation of the sensory afferents, the length of time the needles are retained, the location of the needles relative to the site of pain, and the intensity/method of stimulation.¹⁶ First, a dull ache, numbness, or heaviness indicates that the sensory afferents have been activated as a result of insertion and stimulation of the needle, and because maximum acupuncture analgesia occurs after 20 minutes of retention, needles should be retained for at least this time period.^16,²⁵

Second, needles can be stimulated in two ways: by hand, termed manual acupuncture, or by the use of electrical current at either low or high frequencies (EA). The majority of evidence on the mechanisms of AA is based on studies of EA in laboratory animals or transcutaneous electrical nerve stimulation (TENS) on the skin overlying acupuncture points, as opposed to manual acupuncture. The reason for this is that the stimulation parameters can be controlled carefully and precisely quantified with use of EA. The centers activated in AA (using EA) depend on the method and site of stimulation (i.e., within the segment of pain or extrasegmentally). Needles placed in the same segment as the pain can produce effects through all three principal mechanism described above, whereas needles placed distally produce analgesia via the hypothalamus and brainstem only. Local segmental needling therefore gives a more intensive analgesia than distal nonsegmental needling.¹⁶

Early experiments were seminal: they did establish that opioids were released in response to acupuncture needle insertion and stimulation. However, much debate still exists about the influence of parameter choice (for electrical stimulation) and the types of opioids released. Two main forms of EA have been explored: low-frequency, high-intensity needling, which activates all three principal mechanisms, and high-frequency, low-intensity needling, which activates the spinal cord and brainstem only.¹⁶ Low-frequency, high-intensity electrical stimulation produces pain relief through the release of beta-endorphin and enkephalins, whereas high-frequency currents produce analgesia via the opioid dynorphin.^26,²⁷ However, other parameter factors such as intensity and pulse duration may influence which opioid is released in the spinal cord.²⁸ More research is required to explore these mechanisms in more detail.

Finally, the majority of scientific evidence for AA is based on EA in animals, and this has been extrapolated to provide evidence for AA in humans. However, other forms of evidence, such as laboratory studies and clinical studies in humans, which have explored the analgesic effects of EA and manual acupuncture, have shown conflicting results. Systematic review evidence for using EA in human laboratory studies (using acute pain models) suggests that a genuine analgesic effect exists; however, the evidence to date has not been able to show a similar clear effect for manual acupuncture.¹³ Moreover, although a systematic review of the effectiveness of acupuncture (EA and manual acupuncture) for chronic pain in clients demonstrated a clear analgesic effect compared with no treatment, inconsistent results have been reported compared with placebo, sham, or other treatments.²⁹ Further research in humans therefore is required to establish definitively the mechanism for acupuncture-mediated analgesia.

Typical Acupuncture Treatment

The experience of the client during the first acupuncture treatment may differ depending on whether the clinician is using Western medical or TCM acupuncture. In the Western medical approach, acupuncture is used mainly as a pain-relieving modality after an orthodox diagnosis of the client. In contrast, a more complex whole system diagnosis takes place with TCM, and the explanations for effects given to the client may be different from those given by the Western acupuncture clinician. In Western acupuncture, points are chosen within the segment of pain and extrasegmentally: however, the choice of specific points for pain relief is not considered important. In TCM, acupuncture points may have multiple functions, as described for this case study in the section on plan of care and in Table 5-6 on p. 69, and may treat the local problem by moving stagnation of qi and blood (and thus reduce pain and swelling) and treat the organ disharmony.

Table 5-6 Location and Action of the Points Used for Elbow Pain

ACUPUNCTURE POINTS	ANATOMICAL LOCATION	ACTION
LI 4	On the dorsum of the hand between the first and second metacarpal bones, approximately in the middle of the second metacarpal on the radial side	Distal point for elbow pain
LI 5	On the radial side of the wrist, in the anatomical snuff box between the tendons of extensor pollicis Longus and brevis	Distal point for elbow pain
LI 10	2 cun distal from LI 11 in a line between LI 11 and LI 5	Local point for elbow pain
LI 11	When the elbow is flexed in the depression at the lateral end of the transverse cubital crease, midway between LU 5 and the lateral epicondyle of the humerus	Local point for elbow pain
LI 12	When the elbow is flexed, 1 cun above LI 11, in a line between LI 11 and LI 15	Local point for elbow pain
LU 5	In the depression on the radial side of the tendon of biceps in the cubital crease	To resolve swelling and pain in elbow
TE 5	2 cun proximal to the dorsal crease of the wrist, on the line connecting TE 4 and the tip of the olecranon, between the radius and the ulna	Distal point for elbow pain
Ashi	Any tender point	Local points for elbow pain
ORGAN DISHARMONY
SP 6	Meeting point of three yin meridians of the leg, 3 cun above the tip of the medial condyle of the ankle, behind the fibula	Strengthens spleen, resolves damp, promotes liver function and smooth flow of liver qi, tonifies the kidneys, nourishes blood and yin, benefits urination, stops pain, moves blood, and eliminates stasis
ST 36	3 cun below ST 35	Tonifies qi and blood, regulates the intestines, expels wind and damp, benefits stomach and spleen
LIV 3	1 cun in a dip between the fourth and fifth metatarsals of the foot	Promotes smooth flow of qi, calms abdominal pain, moves local stagnation of qi and blood
KI 3	Level with the tip of medial condyle of the ankle in a depression between the condyle and the Achilles tendon	Tonifies the kidneys in any deficiency Pattern

Regardless of the approach, a combination of points is used and a typical treatment entails the insertion of 3 to 15 needles, which are left in place for up to 30 minutes (Figure 5-2). Usually clinicians activate the needles to produce needle sensation or de qi because this is considered important from a Western and an Eastern perspective. De qi refers to a deep ache, a numbness, or a distending feeling around the point where the needle is inserted. Western medical acupuncturists interpret this as the activation of sensory afferents, which will produce AA, whereas TCM clinicians consider that the “arrival of de qi at each point” is important because it will help to open the channel, move qi, and rebalance the body’s energies.