Fig. 9.1
Acupuncture involves traditional needle placement based on established meridians, vectors, and locations. Symmetry and trigger points are frequently determinative
Acupuncture purportedly stimulates the nervous system releasing neurochemicals that lead to biochemical changes, thus promoting physical and emotional wellbeing. Specific acupuncture point stimulation has been shown to affect areas of the brain, which reduce sensitivity to pain and stress and or promote relaxation as well as decreasing anxiety, according to the British Acupuncture Council [3]. The general theory of acupuncture is based on the flow of qi; abnormal flow supposedly causes disease. Acupuncture describes a family of procedures intending to rebalance the flow of qi through channels known as meridians. This is accomplished by stimulating specific areas on or under the skin (so called acu points). Currently, acupuncturists use metal needles manipulated manually or with electrical stimulation [4].
Acupuncture for lateral epicondylitis often involves needles placed on the opposite extremity, even if asymptomatic. Acupuncture may address epicondylitis differently depending on whether it is chronic or acute. There are trigger points in the auricular area which may be included. One session weekly for 4 weeks followed by every 2 or 3 weeks, then monthly is recommended [5]. It is important to make sure that there are no underlying intrinsic problems about the elbow joint itself based on examination, X-rays, or other imaging studies such as MRI. Proximal or distal issues should also be ruled out.
Acupuncture (Fig. 9.2) should be distinguished from the technique of dry needling, or insertion of needles into an affected area. This is thought to stimulate blood flow on a microscopic level and potentially lead to a healing process [6]. Stenhouse et al. noted improvement with dry needling alone in a randomized trial, with no additional benefit of autologous conditioned plasma [7].
Fig. 9.2
Acupuncture should be distinguished from the technique of dry needling, or insertion of needles into an affected area
Fink et al. performed a randomized control trial evaluating acupuncture in the treatment of chronic lateral epicondylitis. A group of 23 patients treated with acupuncture were compared to 22 patients who received ‘sham’ acupuncture. There were two treatments per week for a total for ten treatments, and outcome was determined by strength, pain, and disabilities of the arm, shoulder, and hand (DASH) score. The group that received true acupuncture showed significant improvement compared to the sham group at 2 weeks, although both groups noted pain improvement. At 2 and 12 months posttreatment, there were no significant differences between groups. The authors concluded that using accurate acupuncture points had an important effect on short-term outcomes in tennis elbow [8].
Buchbinder et al. presented a literature review of acupuncture for lateral elbow pain in 2008. They searched multiple databases and found four small randomized controlled trials for analysis. One study showed that needle acupuncture alleviated pain longer than placebo. A second study showed improvement in the short-term but no differences in the long-term (defined as 3 or 12 months). A study of laser acupuncture vs. placebo demonstrated no differences. A fourth study from China showed no difference between vitamin B12 injection and acupuncture vs. vitamin B12 injection alone. The authors concluded that there is insufficient evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral epicondylagia.
Vickers and Linde published a meta-analysis of 29 trials examining individual treatment data of acupuncture for chronic pain. Eighteen studies compared acupuncture to no acupuncture control and 20 studies compared acupuncture to sham acupuncture control. They noted that acupuncture had improved outcomes compared with sham acupuncture and no acupuncture as control. They noted reduction of pain after treatment in 30 % for no acupuncture controls, 42.5 % for sham acupuncture and 50 % for acupuncture treatment [9].
Currently both civilian and military institutions are integrating acupuncture into the care they provide. Translational research is also elucidating effects of interventions like meditation and acupuncture on the ventral mechanism of pain perception and processing, regulation of emotion and attention, and placebo responses. Although not yet fully understood, these effects point toward scientifically plausible mechanisms—often unrelated to the traditional mechanistic explanations—by which these interventions might exert benefit [10].
Prolotherapy
Prolotherapy is also known as “proliferation therapy,” “regenerative injection therapy,” [11], or “proliferative injection therapy”. It involves injecting an otherwise nonpharmacological and nonactive irritant solution into the body, generally in the region of tendons or ligaments. It is thought to strengthen weakened connective tissue and alleviate musculoskeletal pain. Theoretically, prolotherapy stimulates a local inflammatory process which facilitates tissue repair of tendons, ligaments, or soft tissue. Possibly, this occurs through the release of local growth factors. A more precise mechanism of action has not been identified. A small volume of irritant solution is injected directly into the painful area. There are several commonly used prolotherapy solutions, which may actually act differently. For example, dextrose may cause osmotic rupture of local cells, phenol-glycerine-glucose may cause local cellular irritation, and sodium morrhuate may result in chemotactic attraction of inflammatory mediators [12].
Prolotherapy was originally described in the 1930s and has become increasingly popular with practitioners using a variety of injection protocols, some of which were formalized in the 1950s by George Hackett [13]. A systematic review including a broad search of human studies assessing prolotherapy revealed 34 case reports and series and two nonrandomized controlled trials [14]. These showed efficacy in many musculoskeletal conditions, but the randomized controlled studies showed conflicting outcomes. These studies did not specifically look at lateral epicondylitis. The authors concluded that further investigation was needed with better-structured studies.
Rabago et al. performed systematic review and noted that the evidence suggested that polidocanol, prolotherapy, autologous blood, and platelet-rich plasma all showed promise in targeting the neovascularity critical to healing tendonopathies. The studies that support this claim included his own work, including randomized pilot studies [15, 16]. A randomized controlled trial of prolotherapy vs. cortisone injection showed no statistical differences between the two groups [17].
Most insurers, including Medicare, do not cover prolotherapy. Websites for Aetna, Blue Cross Blue Shield, Cigna, and United Healthcare state that prolotherapy is not covered for any diagnosis. Medicare reviews took place in September 1992 and then again in September 1999 after increased demand arose. In 1992 reviewers determined that practitioners had not provided “any scientific evidence on which to base a [different] coverage decision,” but expressed willingness to reconsider if presented with results of “further studies on the benefits of prolotherapy” (Health Care Finance Administration). According to its website, Colorado’s worker’s compensation insurer, Pinnacol Assurance does not recommend prolotherapy for any diagnosis, specifically upper-extremity injuries (http://www.sos.state.co.us).
Electro Shock Wave Therapy (ESWT)
ESWT has been studied and published in more traditional orthopaedic journals than either acupuncture or prolotherapy. Initial anecdotal reports of various techniques using ESWT showed promising results [18]. It is thought that ESWT exerts direct pressure or causes cavitation of bone [19]. In a rabbit model ESWT showed increased bone formation and bone mineral density, and improved collagen alignment compared with controls [20]. ESWT has been postulated to improve the biologic environment of the tendon-bone interface via upregulation of TGF-β, VEGF, and BMP [21].
Rompe et al. compared two low-energy doses of ESWT in a prospective study in patients with lateral epicondylitis [22]. One hundred patients who had symptoms for more than 12 months were randomized into two groups: one received a total of 3000 pulses of 0.08 J/mm2 whereas the other group received 30 pulses. Patients were evaluated at 3, 6, and 24 weeks. Based on significant alleviation of pain and improvement of function after treatment, 48 % achieved acceptable results initially and 42 % at final review in group 1 compared with 6 % initially and 24 % at final review in group 2, indicating efficacy at the higher dose.
A multicenter, retrospective study, involving 65 patients showed that the efficacy and safety of ESWT were excellent or good in 74 % of patients 6 months after treatment.
ESWT enjoyed some commercial success, but remained controversial. In 2002, Haake et al. presented a randomized controlled multicenter trial of ESWT in the treatment of lateral epicondylitis [23]. Under local anesthesia, shockwave therapy at 2000 pulses or placebo therapy was used to treat patients who were blinded to the type of treatment. The primary outcome measure was the Roles and Maudsley patient-rated pain score and whether additional treatment was required 12 weeks after the intervention. The authors noted no differences between groups, although both improved over time.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
