Acupuncture in PhysiotherapyTM

Acupuncture in Physiotherapy TM

Journal of the Acupuncture Association

of Chartered Physiotherapists

Spring 2019
Volume 31, Number 1

Volume 31, Number 1, Spring 2019

ISSN 2058-3281
 AACP ANNUAL
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Thomas Lundeberg Saturday 18th May
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Marie-Lore Buidin
4-for-3 GROUP DISCOUNTS ŝƐƐƵĞ͘

Kevin Young
th
BOOK TODAY AT
www.aacp.org.uk

anniversary
Established 1984

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Acupuncture in Physiotherapy
www.aacp.org.uk
Acupuncture 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 email. 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 address
Dr Val Hopwood
18 Woodlands Close
Dibden Purlieu
Southampton SO45 4JG
UK
email: val.hopwood@btinternet.com
The Association
The 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 6000
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 Ltd
Sefton 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
© 2019 Acupuncture Association of Chartered Physiotherapists
Contents
Spring 2019
Editorial.............................................................................. 3
Chairman’s report............................................................. 5
Chief Executive Officer’s report................................... 7
Literature review
Mechanisms and dose parameters of manual
needle stimulation: clinical considerations –
Part 2 by T. Perreault, M. T. Grubb, B. C. Gendron,
J. C. Perez-­Santiago, S. O. Flannagan................................. 9
Paradigm
Acupuncture dosage: adapting treatment
prescriptions for safety and optimal therapeutic
effect by C. Mason...........................................................25
Acupuncture pain and the emotional mind
by J. Wood..........................................................................37
Research
Dry needling alters trigger points in the upper
trapezius muscle and reduces pain in subjects with
chronic myofascial pain by L. H. Gerber, J. Shah,
W. Rosenberger, K. Armstrong, D. Turo, P. Otto,
J. Heimur, N. Thaker, S. Sikdar......................................43
A case report on the effect of Sham acupuncture
by V. L. R. Zotelli, C. M. Grillo & M. da Luz Rosário
de Sousa..............................................................................55
Case reports
The use of acupuncture for the treatment of
lateral elbow tendinopathy by R. Medland...................61
Whiplash associated disorder by Z. Krejcova...............69
The use of acupuncture for the treatment of
supraspinatus tendinopathy by W. Lu.........................81
Is electroacupuncture effective in the treatment of
gluteal tendinopathy? by J. Breese..................................91
The use of acupuncture for the conservative
management of lateral epicondylalgia by
H. Sandelands.....................................................................99
Treatment of non-­union fracture of the fifth
metatarsal with electroacupuncture and manual
acupuncture by S. Bailey...............................................107
Event report
2nd International Symposium on Research in
Acupuncture by V. Hopwood........................................117
Scotland Study Day by W. Rarity................................119
Reviews
Book reviews.................................................................121
News, views and interviews........................................123
Guidelines for authors.................................................125
1
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 Editorial

Welcome to the Spring 2019 edition of

Acupuncture in Physiotherapy. As usual we have a
varied selection of case studies, news, opinions
and research.
Three speakers, now well known to the
AACP, have contributed to the journal this
time. We have a second contribution from Dr
Thomas Perreault (pp. 9–23). He has permitted
Acupuncture in us to publish Part 2 of the book, Dry Needling
by himself and his colleagues. Cheryl Mason
Physiotherapy has written an excellent piece called “Optimum
Dosages” (pp. 25–36) which sheds some valu-
able light on the use of the so-­called ‘Forbidden
www.aacp.org.uk Points’. John Wood, a popular tutor, has written
an intriguing piece entitled “Acupuncture pain
Journal Committee
and the emotional mind” (pp. 37–42).
Clinical Editor We have two pieces of interesting research;
Dr Val Hopwood FCSP
“Dry needling alters Trigger points in the
Corporate Editor Upper Trapezius and reduces Pain in subjects
Bethan Griffiths
(email: bethan@athene-communications.co.uk) with Chronic Myofascial pain” (Gerber et al.
pp.43–53) and a Case report on the “Effect of
Book Review Editor
Wendy Rarity Sham Acupuncture” (Zotelli et al. pp. 55–59)
(email: Wendy.Rarity@hotmail.com) The following six case submissions have been
News Editor received for the Spring Journal: Steve Bailey
Rosemary Lillie (Treating 5th Metatarsal with electroacupunc-
(email: wimbledonphysio@tiscali.co.uk)
ture), Winnie Lu (Supraspinatus Tendinopathy),
Public Relations and Marketing Officer Jordan Breese (Gluteal Tendinopathy), Holly
Chloe Poole Sandelands (Lateral Epicondylalgia), Zuzana
(email: chloe@aacp.uk.com)
Krejcova (Whiplash Associated Disorder) and
AACP Office Manager Rachel Medland (Lateral Elbow Tendinopathy).
Sue Kettle
(email: sue@aacp.uk.com)
News: Rosemary Lillie has found some very
interesting news and views for those treating
fibromyalgia with acupuncture.
AACP Ltd Board Members
Check the back pages for some book reviews.
Chairman: Jon Hobbs We welcome any new textbooks that we may
Lesley Pattenden
Paul Battersby have missed.
Diana Giura There is also a short report from the
Suzanne Nitta
Chris Collier MBE
Bologna Symposium held in October last year.
Wendy Rarity An encouraging message from those engaged in
Caspar van Dongen acupuncture research. It seems we all have the
Chief Executive Officer: Caspar van Dongen
same problem in convincing non-­believers that
Auditor: Rawlinsons, Peterborough we really have some very good science to sup-
Company Secretary: Michael Tolond port what we do.

Dr Val Hopwood FCSP, FAACP

Clinical Editor, Acupuncture in Physiotherapy

© 2019 Acupuncture Association of Chartered Physiotherapists 3

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Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 5–6
Chairman’s report
Welcome to the latest edition of the AACP
journal Acupuncture in Physiotherapy in Spring
2019. 2019 marks the AACP’s 35th Anniversary
year and since its conception in 1984 it has
grown to become not only the largest profes-
sional network within the CSP, but also the
largest professional acupuncture organisation in
the UK, having trained well in excess of 16 000
chartered physiotherapists.
Whilst there are a lot of things planned for
2019, the key date for your diary will be the
AACP’s Annual Conference held on 18th May in
London at the Double Tree Hilton Docklands.
The conference celebrates the AACP’s 35th
Anniversary in style collecting together a truly
international array of speakers including Dr
Thomas Lundeberg, Ian Gatt, Marie Lore
Buidin, Sue Falsone and Dr Gustavo Reque
Rydberg. A very clinically driven line up from
across the world that will be offering insight
into the use of acupuncture in a variety of
settings. Whilst a number of the speakers work
within the sporting arena, the application of
the approaches they will be discussing will have
universal appeal and application.
The AACP are very pleased to welcome
back Dr Thomas Lundeburg, making his long-­
awaited return to the AACP conference, to
present his findings on the use of acupuncture
in rehabilitative medicine. Dr Lundeburg is an
ever-­engaging conference speaker, clinician and
researcher, with an illustrious career in pain
management, who has authored numerous
textbooks and articles in physiology, pain and
acupuncture. Year on year, Dr Lundeburg is also
one of the most requested returning speakers at
the annual AACP conference.
New to the conference this year, from Team
GB, is Ian Gatt. Ian manages the medical ser-
vices for GB Boxing and has attended all major
competitions supporting elite athletes on their
path to success through the London 2012, Rio
2016, and current Tokyo 2020 Olympic Cycles.
Ian is currently undertaking a PhD in wrist
© 2019 Acupuncture Association of Chartered Physiotherapists
biomechanics at Sheffield Hallam University
and is an upper limb injury specialist with the
English Institute of Sport. Ian will be present-
ing an insight into whether acupuncture can
make a difference to acute sport injuries of the
upper limb.
Marie Lore Buidin has a significant back-
ground in acupuncture and clinical practice,
and has invested more than 30 years in treating
adults and children with COPD, asthma and
cystic fibrosis. She has specialized in treating
cardiovascular disease, pulmonary disease and
psycho-­emotional issues and from 2005 till 2015
she worked in a combined western cardiology
and acupuncture clinic. Marie will be discussing
the use of acupuncture in the management of
pulmonary disease.
Also new to the conference this year is
Sue Falsone, a physical therapist and associate
professor at Stills University, Arizona. Sue is an
in-­demand international speaker and holds the
accolade of being the first female head athletic
trainer (sports physiotherapist) in any of the
big four national sports organization in the US
(NFL, NBA, MLB, NHL) and a Nike spon-
sored professional. She has an extensive clini-
cal career and, following ten years of Western
medical acupuncture experience, founded
Structure & Function Education and recently
authored the successful textbook “Bridging the
Gap from Rehab to Performance” which out-
lines her approach to injury management and
rehabilitation. Sue will be presenting a Western
medical acupuncture approach for recovery and
regeneration.
Another international speaker presenting
this year will be Dr Gustavo Reque Rydberg.
Dr Rydberg is a consultant physician currently
practising in the United Arab Emirates and he
will be discussing whether ultrasound can help
the safety and efficacy of the needling of com-
plex and deep structures.
Returning conference speaker Kevin Young
will be discussing the use of acupuncture in the
5
Chairman’s Report
treatment of achilles tendinopathy and plan-
tar fasciopathy. A clinician with an extensive
physio­therapy and traditional Chinese medicine
(TCM) acupuncture background, Kevin is also
the principal physiotherapist for the charity
Arthritis Action.
With this dynamic line up, this year promises
to be an entertaining and informative event.
Conference delegates will also be able to book
a complimentary ticket to the 35th Anniversary
Celebrations, taking place Friday 17th from 7pm.
An evening of fun, food and festivities . . .
with a few surprises! Spaces for the celebra-
tion event are limited and are offered on a first
come first serve basis so please book as soon as
possible.
Another celebratory item for the 35th
Anniversary is the release of the AACP App.
The App is for AACP members only and
is completely free as a member benefit. It
contains a multitude of useful functions and
features including 70+ videos of anatomical
point location indexed by meridian, body part
and pathology, making it an indispensable aid
to clinical practice. Look out for more updates
on this exciting new member feature in future
e-­newsletters.
The AACP will also be presenting a whole
day’s worth of theory sessions at the Elevate,
COPA & Elite Sports Expo on the 8th and
9th May 2019 at the Excel London Docklands.
These open sessions will include presentations
on topics such as the analgesic mechanisms of
acupuncture, electroacupuncture, auricular acu-
puncture and trigger point acupuncture to name
but a few. These sessions will be presented by
a variety of AACP tutors and guest speakers
and be open to anyone in attendance. Please
look for more information on the AACP stand
6 © 2019 Acupuncture Association of Chartered Physiotherapists
at the event and I look forward to seeing you
there.
The AACP’s marketing department also
remains as active as ever across a number of
media platforms promoting the skills and
experience of AACP members to the general
public with statistics showing over 10 million
media contacts made via print and electronic
publications. Look out for a new promotion
coming in 2019 to heighten levels of public
awareness and interest in the use of acupunc-
ture with physio­therapy. More updates on this
exciting new promotion will also be in future
e-­newsletters.
If there is anything more the organisation
can do, then let us know and ensure the AACP
stays relevant as it moves forward. It may also be
a timely opportunity to offer a huge thank you
to all those who have worked tirelessly before
in previous manifestations of the organisation
to bring the AACP and physiotherapy practice
itself to where it is today – 35 years from its
humble beginnings. There are too many to
name, but you know who you are. As always,
the AACP administrative and management team
continue to work hard to support members
and deliver the best member experience pos-
sible. If, however, you feel there are issues the
AACP need to be addressing or you have any
ideas on how you would like to see the AACP
develop or improve, particularly as we reach
another landmark together, then please feel free
to get in touch with the office or me directly
(chair@aacp.uk.com). As ever I look forward
to catching up with you in person at an AACP
event somewhere soon.
Jonathan Hobbs
AACP Chairman
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 7–8
Chief Executive Officer’s report
The great AACP triple–A spring
of 2019
The year 2019 will be (another) great year for
you as a member of the AACP. A number of
exciting milestones are on the calendar for the
Association this year.
Annual Conference
By the time you receive this copy of Acupuncture
in Physiotherapy™ we shall be close to holding
our Annual Conference, in London on 18th May.
We have been able to engage a great range of
British and international speakers, details of
whom you can find on the AACP website. The
evening before the conference we shall be cel-
ebrating our 35th Anniversary at the same venue.
(look at www.aacp.org.uk/events/conferences
to see how you can join the conference and
celebrations too!)
At the AACP’s inaugural meeting in the
autumn of 1984, its first Chairman, Mr Neville
Greaves got together with a dozen or so
members (the total membership). Since then
the AACP has trained over 16,000 Chartered
Physiotherapists to be able to integrate acu-
puncture into their practise.
Thirty-­
five years after its conception, as a
mature organisation the AACP is going strong
in representing your interests and promoting
your acupuncture services to the British public.
Of course, we wouldn’t have been able to do
this without the continued support from you,
our members. I thank both past and present
members for their support of the Association
through all those years. This has made us, and
kept us, the largest acupuncture organisation by
far in the UK.
ask4acupuncture
Also in spring, the AACP will embark on its
most comprehensive PR programme in its his-
tory. This extensive support for your practice,
in print and social media, is designed to reach
© 2019 Acupuncture Association of Chartered Physiotherapists
out to (potential) patients to tell them about
the benefits of acupuncture in physiotherapy.
Our campaign ask4acupuncture™ will represent
some case studies as examples of excellent out-
comes when having acupuncture as a patient.
It will also stress the importance of having a
safe, painless and effective treatment which is
drug free with no chance of drug dependency.
All communication will lead to our web search
function where potential patients will be able to
find you.
So, if you’re not already, make sure you
are visible on our ‘practitioner search’ and
change the settings on your dashboard on the
AACP website! (Dashboard > Personal Details
> Marketing and Privacy).
AACP App
Spring 2019 will also see the advent of our
AACP App. Exclusively for members of course,
this will provide a new and easy access to the
most important AACP member services from
the palm of your hand.
It also incorporates a great new and very use-
ful feature for when you’re practising or study-
ing. Find the app, download and sign in with
your member details to find out more!
Mixed feelings
From reading the above and from your ongoing
AACP membership you will know; there are
many reasons to be a member of the largest
acupuncture organisation in the UK; the AACP.
I have been part of the Association for over
six years now. Not as a member but employed
as your Chief Executive. During those six years
I have enjoyed every day of being part of this
great, energetic organisation. Serving you as our
members and working with a really devoted and
enthusiastic team at the AACP office, some
very committed AACP committee members
and tutors, and my professional colleagues at
the AACP Board.
7
Chief Executive Officer’s report
However, there is a time to come and a Of them, I’ll expect the very best; the same
time to go, and the time to go has come for as the AACP is committed to providing for
me. I have embarked on a new career as a you.
Psychotherapeutic Counsellor, so I’m staying
true to healthcare, but exchanging my employ- Caspar van Dongen
ment with the AACP for a membership of my Chief Executive Officer
new professional organisation BACP.

8 © 2019 Acupuncture Association of Chartered Physiotherapists

Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 9–23

LITERATURE REVIEW

Mechanisms and dose parameters of manual

needle stimulation: clinical considerations –
Part 2
T. Perreault
Northern New England Spine Center, Dover, NH, USA

M. T. Grubb
The University of Tennessee, Chattanooga, TN, USA

B. C. Gendron
Northern New England Spine Center, Dover, NH, USA

J. C. Perez-­Santiago
Northern New England Spine Center, Dover, NH, USA

S. O. Flannagan
Founder One Accord Physical Therapy, Phoenix, AZ, USA

Abstract
Recent studies have shown that acupuncture and dry needling provide mechanical stimula-
tion to connective tissues through the physical prick and manipulation of the same needle,
and both forms of needling produce analgesic effects by activation of identical endogenous
mechanisms. An electronic database search was performed with the aim of completing a
narrative review of the literature to explore the mechanistic effects of manual needle stimu-
lation that lead to pain relief. The majority of studies confirmed that the anti-­nociceptive
effects of needling rely on mechanical stimulation of connective tissues and analgesia will
increase in direct proportion to the intensity of needle stimulation through winding. Multiple
studies confirm a prevailing role of collagen fibers in transmitting the mechanical signals
from needling to the central nervous system. Several studies support that mast cells, fibro-
blasts and sensory nerves detect the mechanical information created by the needle, resulting
in stimulation of H1, purinergic and A1 receptors on ascending nerve fibers by release of
histamine, ATP and adenosine. Collectively the evidence reviewed suggests that the analgesic
effects from needling mainly occur from the spinal release of opioid peptides due to the fir-
ing of dorsal horn neurons from noxious needle stimulation, thus triggering segmental inhi-
bition. Furthermore, manual needling was shown in several studies to activate a supraspinal
histamine-­dependent system that produces descending pain inhibition and projects down to
the mid brain structures and spinal dorsal horn segments. Of clinical consideration, needle
stimulation may be most effective for analgesia when applied within the spinal segmental
distribution (e.g. dermatome, myotome, or sclero­tome) as the location of pain. Importantly,
the majority of studies strongly favour needle winding as the most effective form of needle
manipulation for anti-­nociceptive effects in place of other more aggressive forms such as
pistoning, even in the management of MTrPs.
Keywords: acupuncture, analgesia, needle, pain, stimulation.

© 2019 Acupuncture Association of Chartered Physiotherapists 9

Mechanisms and dose parameters of manual needle stimulation – Part 2
Introduction
Dry needling and acupuncture are useful
modalities administered by modern clinicians
who treat patients with painful neuromuscu-
loskeletal (NMSK) disorders. Both procedures
involve the insertion of needles into the body
for therapeutic purposes and primarily, both
are indicated for treatment of pain, but they
differ in theoretical constructs and historical
origin (Zhou et al., 2015). Acupuncture is one
discipline in a complex tradition of Chinese
medicine, and unlike dry needling, it is used to
treat a wide variety of human conditions beyond
pain. Classical models of acupuncture theory
are compatible with contemporary psychology,
physiology, physics, and neuropharmacology
(Helms, 1995). This review will focus on acu-
puncture and dry needling as they relate to pain.
Although acupuncture has origins in traditional
Chinese medicine (TCM) theory, like dry nee-
dling it is now firmly embedded in a biomedical
framework supported by clinical experience and
ample scientific literature. Another similarity
between the two forms of needling is the high
degree of correspondence in the areas of needle
insertion used between acupuncturists and dry
needling practitioners for the management of
common pain disorders (Liu et al., 2016). That
is, acupuncture points and myofascial trigger
points (MTrPs) often represent that same stimu-
lation sites. Emerging evidence implies that both
acupuncture and dry needling procedures have
similarities in mechanistic effects as they both
provide mechanical stimulation to connective
tissues through the physical prick and manipula-
tion of the same type of needle (Liu et al., 2016,
Butts et al., 2016). Both procedures use various
forms of manual needle stimulation to activate
endogenous mechanisms that are advantageous
for altering sensory perception and decreasing
pain in NMSK disorders (Baeumler et al. 2014;
(Yuan et al., 2016). There is now considerable
evidence supporting the beneficial effects of
needling therapy for the long-­term treatment of
Correspondence: Thomas Perreault, Physical Therapy
Department, Wentworth-­Douglass Hospital, 789
Central Avenue, Dover, NH, USA 03 820 (email:
Thomas.perreault@wdhospital.org)
10
chronic pain (Vickers et al., 2018) (MacPherson
et al., 2017). However, manipulation of the
indwelling needle is crucial for triggering the
analgesic effects associated with dry needling
or acupuncture (Takano et al. 2012; Huang et al.
2012; Kagitani et al. 2010). It is widely accepted
in acupuncture that eliciting the ‘De Qi’
response is important for acupuncture induced
analgesia (Bovey, 2006)(Benham and Johnson,
2009) and the patient reported sensations that
occur during needle manipulation indicate acti-
vation of specific afferent nerve fibers (Zhou
and Benharash, 2014) Eliciting perceived De Qi
sensations of ‘aching’ and ‘soreness’ by manipu-
lation of the needle corresponds to activation
of small diameter afferent nerve fibers, C-­fibers
and Aδ-­fibers, respectively (Zhang et al., 2012b).
Importantly, the therapeutic effect of needling
depends upon interaction with, and involvement
of, C-­fibers (Tobaldini et al., 2014) and Aδ-­fibers
(Zhu et al., 2004) that detect and transmit the
needle stimuli to the central nervous system
(CNS). Rotation of an indwelling needle has
been shown to elicit an aching sensation, a
commonly reported pain descriptor that corre-
lates with the analgesic effect from acupuncture
(Choi et al. 2013). In traditional acupuncture
practice, the most common manual needle
techniques include lift-­thrust, twirling or wind-
ing, shaking, scraping or flicking manipulation
(Zhang et al., 2012b). In dry needling practice
more aggressive forms of needle manipulation
such as fast-­in-­and-­out, or pistoning, are most
frequently used for the de­activation of myofas-
cial trigger points (MTrPs). Yet, the available
literature currently fails to inform clinicians on
the selection of the most effective needling
technique or form of needle manipulation for
reduction of pain in NMSK conditions making
it a topic of extreme clinical importance (Boyles
et al., 2015). Another pressing issue that pervades
the literature at hand is a lack of discernment
between the mechanistic effects of manual
needling and electric needle stimulation and an
assumption that the comparative effectiveness
and specific physiological effects between the
two modes of needle stimulation are identical
even though few studies have examined this
(Langevin et al., 2015). It is the purpose of this
© 2019 Acupuncture Association of Chartered Physiotherapists

article to review the available literature in order
to explore the mechanistic effects of manual
needle manipulation that lead to modulation of
pain locally and at the spinal and supraspinal
levels. Furthermore, this article will explore the
relevant dose considerations that enhance or
alter the therapeutic effects of manual needling.
Materials and Methods
Literature search
Literature for this narrative review was sought
that investigated mechanisms and/or dosage
parameters of manual needle stimulation for
anti-­
nociception. With the intent of perform-
ing a narrative review, included articles were
not limited to randomized controlled trials,
systematic reviews or meta-­ analyses, nor were
they limited to studies only on human subjects.
An electronic database search of PubMed,
MEDLINE, Science Direct and Google Scholar
was performed using the following terms; dry
needling, acupuncture, needling, manual AND
needle stimulation, dry needling AND segmen-
tal, acupuncture AND segmental, acupuncture
AND analgesia. No restrictions were placed on
the date of article publication and only articles
written in English were reviewed. Additionally,
the reference lists of included studies were also
hand searched to identify any articles relevant
to the selected topic. Irrelevant articles were
discarded, to include studies that explored the
mechanistic effects of electric needle stimulation.
Discussion
Manual needling effects are intensity
dependent
Among the various dose parameters, apply-
ing manipulation to the indwelling needle (in
the form of rotation or winding) is essential
and may be the most important parameter to
consider for inducing the therapeutic effects of
dry needling and acupuncture (Langevin et al.,
2001, Choi et al., 2013). Following the physical
prick of the needle and insertion to the desired
depth, clinicians routinely use rotation and
lift-­thrust manipulations to amplify the needle
stimulus and to adjust the dose of treatment.
Langevin et al. (2001) reported that winding of
© 2019 Acupuncture Association of Chartered Physiotherapists
T. Perreault et al.
the needle has advantages over other forms of
manipulation. More specifically, needle winding
creates a coupling effect between the connec-
tive tissues and the needle, which generates a
mechanical signal that is transmitted through
local tissues to nearby cells or even sites remote
to the needled area. Additionally, the mechanical
stimuli from needle rotation likely activates local
sensory receptors and primary afferent nerve
fibers such as Aδ and C-­fibers, leading to the
modulation of pain locally and at the spinal
cord level (Zhao, 2008).
Several studies now support that wind-
ing manipulation within connective tissue is
essential for the production of analgesia with
needling. Kwon et al. (2017) were the first
to report that the needle prick and winding
manipulation produced potent anti-­nociceptive
effects in a formalin-­ induced animal pain
model. Importantly and specifically, the pain
relieving effects increased in direct proportion
to the strength of needle grasp force and result-
ant degree of dermal tissue distortion. Thus,
an increase in needle dosage (i.e. increased
needle stimulation intensity) resulted in better
analgesic effects (Kwon et al., 2017). Yu et al.
(2009) reported that destruction of collagen
fibers by collagenase injection at the needle
location attenuated the analgesic effect of
needle manipulation considerably. Additionally,
winding and lift–thrust manipulation caused
mast cell degranulation only if the treated
collagen fibers were intact (Yu et al., 2009). In
a recent study, collagenase given pre-­treatment
caused destruction of local collagen fibers
and rendered any anti-­inflammatory effects via
lift-­thrust needle manipulation ineffective, due
to abolishing mechanical signal transmission
to nearby cells (Wang et al., 2017a). Previously,
Langevin et al. (2007) reported that fibroblastic
cellular responses increase dose-­ dependently
via both unidirectional and bidirectional nee-
dle rotation, with both types of manipulation
resulting in stretching and deformation of con-
nective tissues. However, the anti-­ nociceptive
effects of needling that depend upon this
mechanical stimulation of connective tissues
has only recently been confirmed (Wang et al.,
2017a). This underscores the important role
11
Mechanisms and dose parameters of manual needle stimulation – Part 2
that collagen fibers play as a force transducer
of the mechanical signal created from needle
winding. Taken together, studies support that
the intensity of manual needle stimulation has
direct correlation to intracellular and extracel-
luar neural pathways that can directly modulate
pain and are dependent on winding manipula-
tion and strength of needle grasp.
Manual needling effects require mast cell
activation
Recent studies now confirm that manual needle
stimulation is converted into nerve impulses
through interaction with – and activation of  –
mast cells that are located near the site of nee-
dle insertion. Kagitani et al. (2005) found that
manually rotating a needle in the lower limb
of rats activates the entirety of afferent nerve
fiber groups (1–4) at the corresponding spinal
segmental level. This was confirmed via nerve
conduction measures taken from the L4 and
L5 dorsal roots (Kagitani et al., 2005, Kagitani
et al., 2010). Interestingly, nerve discharges were
not elicited when the indwelling needle was not
manually manipulated. Yin et al. (2018) con-
firmed that twisting a needle within stomach (ST
36) of the lower leg induces nerve discharges at
the corresponding dorsal spinal root at the spi-
nal segmental level. Furthermore, pre-­treatment
application of sodium cromoglicate (DSCG),
which acts as a mast cell stabilizer, inhibited
the needle-­induced nerve discharges (Yin et al.,
2018). The authors concluded that mast cell
degranulation was impaired by the administra-
tion of DSCG, resulting in altered nerve signal
conduction that prevented the release of mast
cell mediators, namely histamine and adenosine.
In a study using mast cell deficient rats, nee-
dling did not increase mechanical pain thresh-
olds with low intensity bi-­ directional rotation
at ST 36 (Cui et al., 2018). This demonstrated
that a deficiency of mast cells abolishes the
therapeutic effect of needling by lessening the
degranulation effect and preventing the release
of bioactive agents that may modulate pain. In
a recent study it was shown in mice that manual
needle rotation in the periphery triggered excita-
tory neural signals in the dorsal root ganglion
(DRG), spinal dorsal horn and somatosensory
12
cortex levels. However, TRPV1 knockout mice
did not display excitatory signals indicating
that TRPV1 is a key mechanosensitive channel
needed for acupuncture needling effects (Chen
et al., 2018). Taken together, these studies show
that mast cells and mechanosenstive channels
contribute to the detection and subsequent
therapeutic result of needle manipulation.
Manual needling triggers mast cell
release of histamine and adenosine
Mast cell activation and degranulation causes
histamine to be released, resulting in stimulation
of ascending nerve fibers and priming of the
local area to further receive the needle signals
(Wu et al., 2015). Huang et al. (2018) confirmed
that degranulation of mast cells occurs with
needle winding, leading to histamine release
and targeted binding onto the H1 receptor of
sensory nerves; however, acupuncture analgesia
was prevented after blocking the H1 receptor.
Moreover, mice that lacked a mechanorecep-
tor (TRPV-­ 2) on mast cells demonstrated
significant reduction in mast cell degranulation,
preventing acupuncture from raising mechanical
pain thresholds (Huang et al., 2018). Zhang et al.
(2012) confirmed that TRPV-­2 is expressed on
human mast cells (HMC) and that mechanical
stimuli activates TRPV-­ 2 channels, triggering
mast cell degranulation and subsequent hista-
mine release (Zhang et al., 2012a). Interestingly,
chloride channels on HMCs also become acti-
vated via mechanical stretching of connective
tissue and have been shown to contribute to
the degranulation process (Wang et al., 2010).
A previous study found a direct correlation
between needle-­induced analgesia after winding
manipulation and mast cell release of histamine
near the acupoint area (Zhang et al., 2008). Thus,
for clinicians it cannot be overemphasized that
the needle is a physical agent used to deliver a
mechanical stimulus for the purposes of a ther-
apeutic result. Huang et al. (2018) reported that
inhibition of mast cells also eliminated needle-­
induced increases in adenosine concentration
and confirmed that mast cells are also a primary
source of ATP and adenosine. In microdialysis
studies on animals and human models, rotation
of an indwelling needle was found to significantly
© 2019 Acupuncture Association of Chartered Physiotherapists

elevate local tissue adenosine concentrations,
while no increase in adenosine occured without
repeated needle rotation (Goldman et al., 2010,
Takano et al., 2012). Goldman et al. (2010) con-
firmed that acupuncture analgesia occurred via
activation of the A1 receptor on local sensory
nerves as a result of the accumulation of extra-
cellular adenosine caused by needling, but the
main source of adenosine was not confirmed.
Interestingly, adenosine can augment mast cell
secretion through a unique A3 receptor on
the surface of mast cells, creating a positive
feedback loop when binding occurs (Ramkumar
et al., 1993). Of clinical importance, the release
of adenosine and histamine leads to activation
of A1 and H1 nerve receptors in the periphery
to generate excitatory signals that transmit along
sensory nerves to the central nervous system,
triggering the release of opioids. The majority
of adenosine A1 receptors at the spinal cord
level are localized post-­synaptically on selected
intrinsic neurons within the dorsal horn, a region
of lamina 2 known to receive projections from
afferent nerve fibers. Here, A1 receptors are well
positioned to mediate anti-­ nociception when
adenosine is released, which may occur through
pre-­synaptic inhibition and post-­synaptic hyper-
polarization of dorsal horn neurons (Schulte
et al., 2003, Sawynok and Liu, 2003). A recent
study has confirmed β-­ endorphin levels are
elevated in the cerebrospinal fluid after activa-
tion of H1 and A1 receptor during acupuncture;
however, if mast cell degranulation was blocked
or if the H1 receptor was blocked, no increase
in spinal opioids was seen (Huang et al., 2018).
This is the first report in the acupuncture litera-
ture to link activation of peripheral adenosine
and histamine receptors to the central release of
opioid peptides and subsequent analgesic effect.
Manual needling recruits and activates
mast cells to the treatment area
In traditional acupuncture, needles are routinely
inserted into acupuncture points along various
meridians and the points are both described
and prescribed according to traditional Chinese
medicine (TCM) nomenclature and principles,
respectively. However, several authors have
proposed an alternative approach for modern
© 2019 Acupuncture Association of Chartered Physiotherapists
T. Perreault et al.
clinicians. It is suggested that points of needle
insertion into the body should be described by
anatomical locations or treatment areas that
are in proximity to identifiable structures. This
approach allows clinicians to clinically reason
where to insert needles based upon knowledge
that certain areas are more biologically sensitive
and produce a certain physiological effect due
to needle stimuli (Langevin and Wayne, 2018,
Campbell, 1999). For example, mast cells have
been shown to interact dynamically with the
mechanical environment around them by sens-
ing stimuli and releasing secondary messengers.
A recent study conducted on rats found that
mast cells were located in spaces between the
extracellular matrix (ECM) and the margins of
several tissues including skin, hair follicles, blood
vessels, nerve fibers, adipose tissue, and muscle
tissue. In these tissues, mast cells were unevenly
proportioned and amassed along permeable
boundaries that displayed properties of varying
stiffness (Yang et al., 2018). More specifically,
mast cells tended to accumulate in and migrate
toward tissue areas that contained rigidity gra-
dients. Yang et al. (2018) further demonstrated
that tugging on collagen fibers through needle
winding and lift-­ thrust movements signalled
increased mast cell recruitment, thereby trigger-
ing degranulation of mast cells in the treatment
region by altering the stiffness of the ECM.
However, needle insertion alone into the tis-
sue without manipulation did not significantly
increase the number or degranulation ratio of
local mast cells. It is known from animal studies
that traction applied to collagen fibers influ-
ences the rigidity and structural properties of
fibroblasts and the surrounding ECM (Langevin
et al., 2006). It is for this reason (in addition to
providing known analgesic effects) that clini-
cians often use needle stimuli to actively relax
tissues and increase shear plane motion through
targeted internal stretching of collagen fibers
(Langevin, 2014). In summary, multiple tissue
layers, both superficial and deep, contain mast
cells. The delivery of mechanical stimulation
by needle insertion and manipulation to almost
any layer of tissue or body location can create a
therapeutic response by recruiting and activating
mast cells in the treatment area.
13
Mechanisms and dose parameters of manual needle stimulation – Part 2
Manual needling stimulates ATP release
from nerves and fibroblasts
It is well known that winding of connective
tissue around an embedded needle occurs after
needle rotation and this triggers stretch-­induced
responses from fibroblasts and sensory nerves
that lead to analgesic effects (Langevin, 2014).
More specifically, mechanical stimulation to col-
lagen fibers through needling induces transient
receptor potential vanilloid-­ 1 (TRPV1) related
ATP release from connective tissue fibroblasts,
and also from nearby A–δ and C nerve fibers
that contain the same channel (Wu et al., 2014).
Stimulation to this channel by needle winding
creates an intracellular Ca2+ wave propagation
that rapidly increases extracellular ATP levels,
which is then metabolized to adenosine. This
increase in adenosine levels activates A1 adeno-
sine receptors on nerve fibers as mentioned
above (Goldman et al., 2010). Alone, ATP can
bind to several types of purinergic receptors,
including pre-­and post-­synaptic P2X and P2Y
receptors on sensory nerves. These receptors
may assist in generating analgesic effects by
sending noxious stimulation to sensory affer-
ents and neurons in the dorsal horn, thereby
stimulating the release of endogenous opioids
(Tang et al., 2016). Superficial mechanical stimuli
(i.e. needling) to the skin causes epidermal
keratinocytes in humans to release ATP. Local
injury to the skin created by needling may result
in binding of extracellular ATP onto purinergic
receptors of local sensory nerve fibers and
trigger activation of neurons in the dorsal root
ganglion (Koizumi et al., 2004). Mast cells also
release ATP into the extracellular medium via
an intracellular calcium-­dependent process that
occurs in response to physical stimuli (i.e. nee-
dling). ATP levels within mast cells then become
rapidly depleted internally and the rise in extra-
cellular ATP relays the mechanical stimuli from
needling to sensory neurons and nociceptors
for therapeutic purposes (Wang et al., 2013).
Manual needling triggers segmental
inhibition by endogenous opioid release
Winding manipulation of an indwelling needle
stimulates the release of endogenous opioids,
which is considered one of the most potent
14
endogenous neuromodulators for pain sup-
pression in the periphery and at the spinal
cord level (Chou et al., 2012, Zhang et al.,
2014). Hsieh et al. (2016) demonstrated that
distal trigger point needling increases spinal
enkephalin levels at the dorsal horn and raises
β-­endorphin in the blood serum, both in
proximal spinal segmental-­ related muscles and
in dorsal root ganglion (DRG) neurons (Hsieh
et al., 2016). Most importantly, this study used
slow and gentle needle insertion with rotation
to trigger points during a 30-­second period to
elicit the opioid response and this was shown
to increases in a dose dependent manner. That
is, spinal enkephalin increased significantly with
five consecutive daily doses of needling com-
pared to only one dose. Hsieh et al. (2012) used
lift-­
thrust manipulations to elicit local twitch
responses (LTR) in trigger points, which dem-
onstrated enhanced β-­endorphin levels both in
locally needled muscle and serum, as well as a
reduction in DRG substance P (SP) levels after
a single dose. However, five doses of repeated
needle pistoning proved to be counterproduc-
tive for analgesia by reducing β-­endorphin levels
and elevating SP (Hsieh et al., 2012). According
to Perreault et al. (2017) needle pistoning to
elicit the LTR has been shown to be counter-
productive in the management of MTrP pain
and needle rotation is a more therapeutic form
of needle manipulation. Previous studies have
also confirmed that stimulation by needle rota-
tion results in anti-­nociceptive effects that are
naloxone reversible, indicating involvement of
the endogenous opioid system (Kim et al., 2006,
Cidral-­Filho et al., 2011).
In clinical practice, needle stimulation is most
effective for analgesia when applied within the
spinal segmental distribution (e.g. dermatome,
myotome, or sclerotome) as the location of pain
(Srbely et al., 2010b). This is supported in a recent
review by Baeumler et al. (2014), which showed
that needling increased pressure pain threshold
(PPT) in over 80% of acupuncture studies on
patients with pain disorders. Importantly, local
and ipsilateral needling near the pressure meas-
urement sites elicited the strongest effects on
PPT, indicating a prevailing role of spinal seg-
mental inhibitory mechanisms that rely on release
© 2019 Acupuncture Association of Chartered Physiotherapists
 T. Perreault et al.

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Figure 1. Flow diagram on the proposed mechanisms of manual needle stimulation.
(A) Needle insertion followed by winding manipulation creates a coupling between the needle and the surrounding
connective tissues. (B) Mast cells are recruited to the region where needle manipulation occurs and the mechanical stimuli
to collagen fibers activates chloride channels and TRPV2 channels on mast cells leading to degranulation. (C) Mast cell
degranulation results in histamine and ATP release, followed by binding of histamine to H1 receptors and ATP onto
purinergic receptors (P2Y or P2X) located on local nerve fibers. Additionally, ATP is rapidly metabolized into adenosine
and the increase in adenosine levels activates A1 adenosine receptors on nerve fibers. (D) Ascending nerve fibers are
stimulated by release of histamine, ATP and adenosine resulting in firing of intrinsic dorsal horn neurons. (E) Analgesic
effects occur from endogenous opioid peptides, such as spinal enkephalin, that are released from intrinsic dorsal horn
neurons within the same spinal segments receiving innervation from the site of needle stimulation. Anti-­nociceptive effects
are enhanced further by activation of supraspinal descending pain inhibitory mechanisms brought about through the
histaminergic system.
Abbreviations: Transient receptor potential vanilloid 2 (TRPV2), adenosine triphosphate (ATP)

© 2019 Acupuncture Association of Chartered Physiotherapists 15

Mechanisms and dose parameters of manual needle stimulation – Part 2
of endogenous pain modulators locally and at
spinal level (Baeumler et al., 2014). According
to another recent review, patients with chronic
NMSK conditions in the included trials were
frequently given needle stimulation to local and
distal points that coincided with the location of
pain. Moreover, patients who received needling
to local tender points had more significant pain
reduction than patients who received needling
to only traditional acupuncture points (Wong Lit
Wan et al., 2015) underscoring the importance
of matching the location of pain to the location
of needle stimulation. In the clinical practice of
acupuncture, any site on the body that is spon-
taneously painful, or sensitive on palpation, is
called an Ah Shi point. These points are needled
whether or not they are found at classically-­
named locations. Local pain is a physiologic
response of the body, and the painful point is
considered a valid acupuncture point (Helms,
1995). Studies show that mechanical stimulation
from needling – although often noxious – induces
endogenous opioid release in the same spinal
segments receiving innervation from the stimu-
lated area (Lao et al., 2008, Baeumler et al., 2015).
Additionally, a greater effect occurs ipsilaterally
to the needle stimulus and is driven by a neu-
ronal circuit in the dorsal horn, as opioids such
as spinal enkephalin are released from intrinsic
dorsal horn neurons (Song and Marvizón, 2003).
Thus, understanding the segmental architecture
of the body can guide clinicians to clinically
reason the most appropriate areas for needle
insertion and manipulation. In some cases,
even direct stimulation of the periosteum with
a needle can be used trigger segmental, scle-
rotomal effects for the production of analgesia
(Campbell, 1999). Of particular importance, is
the use of a segmental needling approach in the
management of trigger points associated with
NMSK conditions and MPS. More specifically,
recent studies support that spinal pathology
can amplify trigger point sensitivity in muscles
along the same myotome or segmental field
and that trigger points themselves arise due to
dorsal horn sensitization and subsequent release
of pro-­ inflammatory neurotransmitters within
segmentally linked muscle tissue (Duarte et al.,
2019, Srbely et al., 2010a).
16
Trigger points: Pathophysiology
and therapeutic effects of
manual needle stimulation
Pathophysiology of trigger points
Myofascial trigger points (MTrPs) are a prevalent
clinical finding in patients with myofascial pain
syndrome (MPS) and many NMSK disorders
(Chiarotto et al., 2015, Espejo-­ Antúnez et al.,
2017). A MTrP is a hyperirritable nodule within
a taut band of skeletal muscle fibers that when
palpated or stimulated by needle pressure can
reproduce pain that is familiar to the patient.
The most accepted theory supporting the patho-
physiology of MTrPs is the integrated trigger
point hypothesis which suggests that facilitation
of acetylcholine release occurs at motor end
plates that perpetuates sarcomere shortening in
the muscle, leading to the formation of a taut
band (Simons, 2004). Consequently, compres-
sion of local blood vessels ensues from the
sustained contraction at MTrPs, resulting in
ischemia and hypoxia that is then followed by
release of sensitizing substances and increased
lactate within the muscle (Dommerholt et al.,
2006, Shah and Gilliams, 2008, Ge and Arendt-­
Nielsen, 2011). Recent evidence from doppler
imaging has linked the pathophysiology of
MTrPs to blood flow abnormalities (Sikdar et al.,
2009, Ballyns et al., 2011) and through microdi-
alysis studies, significantly higher concentrations
of sensitizing substances and increased acidity
have been found in MTrPs (Shah et al., 2005,
Shah et al., 2008) and in patients with chronic
myalgia (Gerdle et al., 2014). Endogenous release
of these substances, such as substance P (SP)
and calcitonin gene related peptide (CGRP)
are linked to chemical activation and sensitiza-
tion of muscle nociceptors causing local pain
and hyperalgesia (Shah and Gilliams, 2008)
and may enhance motor endplate activity that
contributes to the motor component of the taut
band (Gerwin et al., 2004, Mense, 2008). More
specifically, the formation of the taut band may
involve activation of extrafusal muscle fibers,
but more likely through input from muscle
spindle afferents that have spinal synaptic con-
nections to beta motor neurons in the spinal
cord (Partanen, 2016). Evidence for increased
© 2019 Acupuncture Association of Chartered Physiotherapists

muscle spindle input to the α-­motor neuron
pool from MTrPs was found in one study (Ge
et al., 2009). However, a reflex loop between
muscle spindle afferents (intrafusal fibers) and
β-­motor neurons in the spinal cord has been
hypothesized and seems more likely given the
lack of studies on MTrPs and α-­motor neuron
activity (Partanen et al., 2010).
Histological studies of MTrPs have given
rise to the concept that afferent nerve fibers
accumulate in the MTrP region and these local
nociceptors become sensitized and are respon-
sible for excessive spontaneous electrical activity
(SEA) and mechanical hyperalgesia of the MTrP
region (Meng et al., 2015b, Hong et al., 1997). A
recent study confirmed that sensory neurons in
the spinal dorsal horn associated with a periph-
eral MTrP were smaller in diameter (character-
istic of nociceptive nerve fibers) and displayed
higher expression of glutamine receptors and
receptor activity at the dorsal horn, compared
to non-­trigger point control sites (Meng et al.,
2015a). Interestingly, targeted receptor blocking
in these small diameter nerve fibers resulted in
reduction of glutamine receptor expression and
partially reversed the size changes of the dorsal
horn neurons, potentiating central sensitization.
The authors concluded that afferent fibers are
involved in the pathophysiology of MTrP for-
mation. Conceptually, these studies support that
persistent nociceptive excitation from MTrPs
contributes to central sensitization and perpetu-
ate hyperalgesia resulting from increased expres-
sion and up-­regulation of glutamate receptors
in the dorsal horn (Meng et al., 2015a, Mense,
2003).
Therapeutic effects of trigger point
needling: A new perspective
Trigger point dry needling, manual acupuncture
and injection are commonly applied interven-
tions for MTrP pain and MPS (Kuan, 2009,
Wang et al., 2017b). In addition to local MTrP
needling, clinicians routinely use needling of
paraspinal muscles to treat NMSK conditions
that are caused by – or perpetuate from –
sensitized spinal segments (Couto et al., 2014, Ga
et al., 2007). For this procedure, multiple needles
are inserted within the paraspinal muscles and
© 2019 Acupuncture Association of Chartered Physiotherapists
T. Perreault et al.
manipulated – using lift-­thrust and/or winding
techniques – at the affected segmental levels in
order to reduce hyperalgesia and pain (Shah and
Thaker, 2015). Simultaneously, deep needling
to trigger points is combined with needling
of segmentally related acupuncture points,
or tender points to amplify the therapeutic
effect based on a clinically reasoned segmental
logic for the chosen points, and not to simply
enhance the treatment dose by using more
needles (Ceccherelli et al., 2014, Ceccherelli
et al., 2010, Couto et al., 2014). In traditional
acupuncture practice local and distal needling is
commonly used together on the same ‘channel’
or ‘meridian’ and is thought to have an additive
effect in the treatment of musculoskeletal pain
(Hobbs, 2017). The above approaches make
sense considering studies support that inserting
more needles within the segmental distribution
of pain leads to a more rapid analgesic response
(Paley and Johnson, 2014) and deep needle
insertion into trigger points provides better pain
reduction than superficial stimulation in the
treatment of myofascial pain (Ceccherelli et al.,
2000, Ceccherelli et al., 2002). In the clinical
management of myofascial pain related to trig-
ger points manual needling has been shown to
provide significant benefit in the reduction of
pain with up to eight treatments recommended
(Wang et al., 2017b) and is most effective when
applied within the spinal segment connected to
the dermatome, myotome or scleratome where
the MTrPs are located (Couto et al., 2014)
Typically, practitioners using manual acupunc-
ture or dry needling employ a multiple rapid
needle insertion technique – also known as nee-
dle pistoning – into muscular trigger points to
induce single or multiple local twitch responses
(LTR) that are triggered by pricking of local
nociceptors with a needle. Based on evidence
suggesting individual motor unit partitioning
(English et al., 1993) (Davies et al., 2012) when the
LTR is elicited with dry needling, it may simply
indicate muscle spindles are present in the local
region and a localized stretch reflex is triggered
that may not offer any therapeutic value in and
of itself. According to one author, dry needling
may simply have its therapeutic effect through
the mechanical disruption of muscle spindle
17
Mechanisms and dose parameters of manual needle stimulation – Part 2
capsules via dry needling or injection, facilitating
the removal of inflammatory substances away
from muscle spindle afferents helping to allevi-
ate symptoms (Partanen et al., 2010). Of clinical
consideration, recent literature has confirmed
that needle pistoning to elicit the LTR dose
dependently results in increased levels of post
needling soreness (Martin-­Pintado-­Zugasti et al.,
2018), elevated levels of inflammation within
muscle fibers (Hsieh et al., 2012), and mechanical
injury at the neuromuscular junction (Domingo
et al., 2013). Furthermore, the production of
the LTR offers little to no advantage when
compared to needle manipulation that does not
elicit the LTR for immediate, short or long term
reduction of pain in patients with any type of
NMSK disorder (Fernandez-­Carnero et al., 2017,
Perreault et al., 2017). Importantly, the therapeu-
tic value of needling within muscular trigger
points may be from the local increase in blood
flow that results from this procedure leading to
a ‘wash out’ effect of sensitizing substances that
activate afferent nerve fibers (Shah and Gilliams,
2008). Dry needling to trigger points in animal
models has been shown to decrease substance P
levels in the treated muscle, dorsal root ganglion
and dorsal horn segments along the associated
spinal segmental distribution (Hsieh et al., 2014,
Hsieh et al., 2012). Dry needling to MTrPs in
human subjects has been shown to reduce the
concentrations of the neuropeptides CGRP
and substance P when measured during the
recovery period after needle manipulation (Shah
et al., 2005, Shah and Gilliams, 2008, Shah et al.,
2008). This is further supported by evidence that
shows manual needle manipulation, without the
production of a LTR, increases the local circula-
tion near the site of needle insertion (Sandberg
et al., 2004, Sandberg et al., 2005, Ohkubo et al.,
2009, Cagnie et al., 2012) and blood flow has
been shown to increase with dry needling in a
dose dependent manner and remains elevated
for sustained periods without the report of
a LTR (Shinbara et al., 2008). Interestingly,
increased blood flow from needle stimulation is
the result of an axon reflex, causing the release
of CGRP and other local vasodilators (Shinbara
et al., 2013) such as nitric oxide (Shinbara et al.,
2015).
18
Manual needling triggers supraspinal
analgesic effects
The mechanical stimuli created by needle inser-
tion and manipulation is transmitted into chemi-
cal and electrical information that is received by
the nervous system. By activating H1 receptors
on nearby afferent nerves, endogenous hista-
mine (a secondary messenger) promotes rapid
influx and up-­ regulation of cation currents,
thereby triggering action potentials along sen-
sory nerve fibers and firing of spinal segmen-
tally related sensory neurons in the dorsal horn
(Zhou et al., 2006, Yin et al., 2017). Importantly,
this neuronal depolarization is essential for
the anti-­nociceptive effect associated with dry
needling and is dependent upon both intact
collagen fibers and local mast cell degranulation
to initiate the up-­stream signal (Yin et al., 2018,
Cui et al., 2018)
Huang et al. (2012) reported that blocking of
the H1 receptor with an antagonist suppressed
the analgesic effects that occur with needling
but had no effect on degranulation of mast cells.
The authors concluded that the analgesic effects
of needling are histaminergic (Huang et al.,
2012). A selective group of C-­fibers containing
H1 receptors are activated by histamine binding
and relay information pertaining to ‘itch’ sensa-
tions from the periphery into the central nerv-
ous system (CNS). More specifically, in lamina 1
of the dorsal horn, there are histamine-­selective
neurons that are positioned to receive itch and
noxious chemical signals but not mechanical or
thermal input from the skin and other tissues
in the periphery. The signals are carried from
these histamine-­containing spinal neurons and
projected along the spinothalamic tract (STT) to
the thalamus and further into other supraspinal
centers, where the fibers originate to produce
the analgesic effect. (Andrew and Craig, 2001,
Huang et al., 2012).
This histamine system begins in the tubero­
mamillary nucleus (TMN) of the posterior
hypothalamus and extends along a descending
pathway into the medial longitudinal fasciculus,
projecting its fibers to the periaqueductal gray
(PAG) and raphe nuclei (RN) of the brain stem
and then to the spinal cord (Haas et al., 2008).
© 2019 Acupuncture Association of Chartered Physiotherapists

Histaminergic neurons from the TMN also
project to local regions of the brain such as the
paraventricular nucleus (PVN) and supraoptic
nucleus (SON) in the hypothalamus. In this
region, histamine may amplify or even trigger
descending pain inhibitory actions by its ability
to stimulate secretion of arginine vasopres-
sin (AVP) and oxytocin through excitatory
actions on local neurons (Knigge et al., 2003).
Additionally, both noradrenergic neurons in
the locus coeruleus of the pons that project
to the brain stem and spinal cord as well as
seratonergic neurons in the RN of the medulla
are excited by histamine through H1 receptor
activation (Haas et al., 2008). Specific neurons
in the PAG have been shown to suppress both
nociceptive information and the itch sensation
induced by histamine (Mochizuki et al., 2003).
Importantly, this implies that needling can
be applied non-­locally to the site of pain and
need not always be noxious to trigger analgesia,
so long as the needle manipulation is able to
induce mast cell degranulation and histamine
release. Collectively, these studies support the
involvement of the supraspinal and descending
pain inhibitory effects brought about through
the histaminergic system, which can be activated
by needle insertion and manipulation.
Conclusion
The anti-­nociceptive effects of manual needling
largely depend upon collagen fibers to transmit
the mechanical signals created by needle wind-
ing. Initially, recruitment and activation of mast
cells occurs in the needled area, but only after
manipulation. Mast cells, fibroblasts and sensory
nerves detect the mechanical information cre-
ated by the needle, resulting in stimulation of
ascending nerve fibers by release of histamine,
ATP and adenosine. From here, analgesic
effects occur from spinal release of opioid
peptides and activation of supraspinal descend-
ing pain inhibitory mechanisms brought about
through the histaminergic system, which can be
activated by needle insertion and manipulation.
Interestingly, the therapeutic value of needling
within muscular trigger points is from the local
increase in blood flow that results from needle
manipulation leading to a ‘wash out’ effect
© 2019 Acupuncture Association of Chartered Physiotherapists
T. Perreault et al.
of sensitizing substances that are known to
activate afferent nerve fibers. Several studies
support that manual needling is most effective
for treatment of MPS and NMSK conditions
when applied within the spinal segment related
to the dermatome, myotome or scleratome
where pain is located. Importantly, the majority
of studies strongly favour needle winding as
the most effective form of needle manipulation
for anti-­nociceptive effects in place of other
more aggressive forms such as pistoning, in the
management of MPS and NMSK disorders. Of
clinical consideration, needling stimulation inten-
sity through winding is the most important dose
parameter as it relates to the anti-­ nociceptive
effects of manual needle stimulation.
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T. Perreault et al.
H3 receptor in substantia nigra pars reticulata. J
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Dr Thomas Perreault graduated with a BSc in
Kinesiology from The University of Maine in 2004
and earned his Doctoral Degree in Physical Therapy
from Franklin Pierce University in 2008. Dr Perreault
is a graduate of the Institute of Orthopedic Manual
Therapy Clinical Fellowship in Woburn, Massachusetts
and he is a Board Certified Orthopedic Specialist
through the American Physical Therapy Association.
He is also a Member of The Acupuncture Association
of Chartered Physiotherapists and has practiced in the
outpatient orthopedic setting for 10 years. Dr Perreault
is currently a Clinical Specialist at Wentworth Douglass
Hospital in Dover, New Hampshire for The Northern
New England Spine Center with a focus on Dry
Needling for chronic spinal pain, temporomandibular
disorders and headache. He lectures internationally on
Dry Needling for Management of Musculoskeletal
Disorders. Dr Perreault is also lead author on a
recent publication ‘The local twitch response during
trigger point dry needling: Is it necessary for successful
outcomes’, which is published in the ever popular Journal
of Bodywork and Movement Therapies.
23
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 25–36

PARADIGM

Acupuncture dosage: adapting treatment

prescriptions for safety and optimal therapeutic
effect
C. Mason
Private Practice, Leeds, UK

Abstract
Clinical Problem: Acupuncture may offer a valuable treatment bringing relief at a time
when pharmacological options are restricted or contraindicated for pregnancy. The ‘forbid-
den’ points written in classical texts have contributed to confusion as to whether acupunc-
ture is really safe for this client group at all.
Aim: Based on available evidence, each of the main contraindicated points are reviewed to
decipher real or theoretical risks.
Results: Certain acupuncture points have been studied and acknowledged as having a strong
enough effect to start labour at any stage of gestation. Some of the lesser known contra­
indicated points for pregnancy still have little evidence available but are still wise to avoid
due to their physiological location or their known strong neuroendocrine effects.
Conclusion: The issue of administering an optimal ‘dose’ in acupuncture has been under-
estimated in importance by the acupuncture world and the research arena alike. Practitioners
can improve outcomes for all patients by considering factors such as appropriate point com-
binations, accurate location of points, degree of needle stimulation, choice of needle gauge
and total time with needles insitu. Planning the total number of treatments and optimal
spacing between sessions allows acupuncture a fair chance to perform at it’s best.
Keywords: Dosage of acupuncture treatments, optimising treatment effects, pregnancy, research
issues, safety.

Introduction contraindicated for pregnancy. Physiotherapy

Whenever the topic of acupuncture for preg-
nancy is under the spotlight then the issue of
safety springs to mind. It is a time associated
with vulnerability and any intervention for this
client group comes under extra scrutiny. We
have two patients to consider – the Mother
and her unborn child. Acupuncture may offer
a valuable treatment bringing relief at a time
when pharmacological options are restricted or
Correspondence: Cheryl Mason, Clinic Suite 1, Regent
House, 15 Hawthorn Road, Chapel Allerton, Leeds,
West Yorkshire LS7 4PH (email: cheryl.mason@
btopenworld.com)
has a long history of creating sustained changes
using natural drug free methods of treatment,
so it seems particularly relevant to have acu-
puncture to offer patients in pregnancy.
Historically, the so called ‘forbidden’ points
written in the acupuncture ancient and classi-
cal texts have contributed to confusion as to
whether acupuncture is really safe for this client
group at all. The tenet ‘do no harm’ is our con-
cern here in this article, so although I am offer-
ing my thoughts and opinions, where possible it
is interwoven with new knowledge from studies.
Science and medical technology have served us
well in advancing our understanding of how

© 2019 Acupuncture Association of Chartered Physiotherapists 25

Acupuncture dosage: adapting for safety and optimal therapeutic effect
certain acupuncture points affect physiological
functioning on a neurological and endocrine
level. We even have MRI scans demonstrating
the pain modifying areas of the brain that are
lit up and activated from acupuncture needle
insertion (MacPherson 2014). Consideration of
some of the emerging themes from research
into the extent of potential harm or benefit
of some of these classical forbidden points,
assists us in our job of tailoring individualised
point prescriptions with greater confidence so
that pregnant women do not miss out on the
potential of acupuncture at a time when other
treatment modalities are so limited.
There are patients with pregnancy related
conditions that are sometimes treated in the
general physiotherapy clinics. For this reason,
a basic knowledge of treating this group is
extremely useful to all physiotherapists. There
will always be those patients who may be
attending for other conditions but are also
pregnant. It is common to see patients who
are also incidentally attempting to conceive or
are undergoing assisted fertility treatments and
some may even be unsure if they are already
in the early stages of pregnancy. A knowledge
of how to approach these patients and whether
we need to adapt any of our usual acupuncture
point prescriptions is relevant to the generalist,
not just the specialist in this area.
What we do know is that acupuncture does
have a good safety profile as applied to the
general population and is considered to have a
superior benefit to harm ratio. Indeed, as the
better quality research is surfacing, compared
to standard care, acupuncture usually con-
cludes as effective or better than standard care
options (Bauer 2016). Supporting our cause,
The American College of Physicians published
a landmark paper based on systematic reviews
between April 2015 and November 2016 which
led them to strongly recommend acupuncture
for acute and subacute low back pain (Qaseem
et al. 2017). This announcement came as a sooth-
ing balm to the acupuncture community here in
the UK as we were still nursing the wounds of
the unexpected U-­turn to the NICE Guidelines
in 2016, having previously actively promoted
acupuncture for back pain. The effects of this
26
blow rippled out with shockwaves and some of
the more sceptical decision makers and man-
agers seized the chance to restrict or remove
acupuncture from the repertoire on grounds of
insufficient evidence base.
The conclusions by the study undertaken by
the American College of Physicians were drawn
from more current research and so supersedes
the research utilized for the NICE guidelines.
Some groups have actively disputed the criteria
used for the NICE guidelines that are supposed
to be impartial, claiming that the panel had
made some crucial flaws in their review of the
literature. It has been a subject of contention
with specialist groups such as the ‘Acupuncture
Now Foundation’, tackling what they describe
as unfairness by the NICE guidelines commit-
tee in their handling and interpretation of the
data. So, whilst those debates are still ongoing,
the American Guidelines at least have given us
more ammunition to justify the evidence base
to managers so we can continue to receive the
support and funding to maintain acupuncture as
a valuable tool in the physiotherapist’s clinical
kit.
When it comes to pregnancy related condi-
tions though, we have less research base avail-
able. However, enough has emerged over recent
years to give us sufficient insight into the key
question of safety for this group.
First, let us examine those contraindicated
points. Again I will attempt to highlight any
relevant research but where this is scanty or
absent, I will endeavour to offer my profes-
sional opinion and insights gained through my
own clinical experience as an ex midwife and
acupuncturist trained in both Western and tra-
ditional Chinese acupuncture.
The AACP Safe Practice Guidelines (2017)
advise caution with needling Large Intestine
(LI) 4, especially if there is a strong stimulation
that may create a corresponding sympathetic
response. The list also includes Spleen (SP) 6,
Bladder (BL) 60 and BL 67 to be used with cau-
tion. The sacral foraminal points BL 31, 32, 33, 34
and abdominal points are advised to be avoided
completely during pregnancy. Reassuringly, these
cross over with many of those listed in the classic
acupuncture textbooks, though the emphasis in
© 2019 Acupuncture Association of Chartered Physiotherapists

traditional Chinese medicine (TCM) is to avoid
needling altogether rather than proceeding with
caution.
It is worth further scrutiny of these lists of
‘forbidden points’ because there seems to have
been much confusion and uncertainty around
whether in fact they are potentially harmful for
the pregnant patient.
Originally, the Chinese doctors transmitted
knowledge of these points through word of
mouth to students who learnt acupuncture
through an apprenticeship system. These points
were collated and eventually transcribed into
ancient texts. It was generally thought that these
points were discovered through observation of
their effect on individual caseloads of patients
at the time. The effect may be related to many
other considerations though. For example,
the earliest ‘needles’ were made of whittled
fishbones and one can imagine the gauge was
somewhat thicker than our fine precision cut
surgical stainless-­steel needles that are often
silicone coated to glide in with minimal tis-
sue trauma. We can speculate that with the
coarser needles, the stimulation would have
been stronger and the effects more dramatic on
patients whose system was more vulnerable or
susceptible. So, the context and type of needling
adopted may have led to more caution. It is par-
ticularly in the last 20 years or so that we have
seen practitioners going against the accepted
norm by openly questioning the wisdom of
‘The Masters’. Acupuncture apprentices were
expected to respect the authority of the ancient
teachings but with the advent of evidence-­based
medicine, we have seen a trend in a healthy re-­
examining of some of our assumptions around
contraindicated points.
One of the earlier studies by Birch (1990)
examined 35 classical and modern textbooks for
any acupuncture points that were recommended
to be avoided in pregnancy and found the
following acupoints were the most commonly
cited: LI 4, SP 6, Ren 5 and Gall Bladder (GB)
21.
Large Intestine 4
This popular point between the first and second
metacarpals is described in classical texts as
© 2019 Acupuncture Association of Chartered Physiotherapists
C. Mason
promoting labour. There have been a number
of studies that have used LI 4 as part of a
set of points for stimulating labour with posi-
tive results. Even utilizing acupressure appears
to be successful on these points particularly
when combined with SP 6 (Mollart et al.
2015).
Spleen 6
This point is 3 cun above the medial malleolus
and is reported to be linked to ripening the cer-
vix making it more favourable and encouraging
swifter labour progress (Mafetoni et al. 2015).
In 2017, the Cochrane Database looked at acu-
puncture and acupressure for inducing labour. It
concluded from 22 randomized controlled trials
(RCT) involving 3,456 women, that acupuncture
improves cervical maturity making it more ripe
and favourable to start labour (Smith et al. 2017).
Many of the possible contraindicated point
combinations were used alongside SP 6, so tri-
als varied tremendously, but the review shares
that recurring theme that the actual ‘dose’ of
acupuncture is often overlooked in research and
in the clinical setting.
Conception / Ren 5
It is two cun inferior to the umbilicus and the
classical texts have perpetuated a bad reputa-
tion, grimly reporting that it may cause sterility
in women. It usually therefore has the warning
to avoid this point on all women. But there
are a few accounts of acupuncturists using this
point at the patient’s request for contraception
but then reporting it as unsuccessful, as the
women had then conceived after all. Having
acknowledged that, Ren points can be tricky to
locate accurately so it is often hit and miss as
the amount of flesh and stretched contours on
many patients mean we have to alter the meas-
urement to find their unique location on that
person. So, we don’t have any modern evidence
to go on either, but the Chinese medicine view
is that energetically, it is a powerful front mu
collecting point for the triple heater (San Jiao)
channel that can achieve many things including
regulating the lower abdomen, assisting prolapse
treatment and correcting amenorrhoea. So
perhaps it is this latter potential function, even
27
Acupuncture dosage: adapting for safety and optimal therapeutic effect
theoretically on a long list of other functions,
that caused this point to find its way on the list.
The concept of the Dantian in Eastern
philosophy including medicine and martial
arts, regard this area as a sacred storehouse of
energy, which for women relates to the ability to
conceive and hold a pregnancy. Two cun below
the umbilicus also corresponds to the location
of this energetic powerhouse, so perhaps relates
to superstitions that this was not an acupoint to
be meddled with.
On reflection, I am more interested in the
location of all the Ren points of the lower
abdomen in pregnancy. They are on the central
line and not only is the developing foetus likely
to be under some of these acupoints on this
meridian, but we must consider the impact of
a stretched or separated linea alba (a common
occurrence in pregnancy) and therefore reduc-
tion in barrier between the needle and the
structures below. Interestingly, Ren (CV) 3, 4,
6, 7, 10, and 11 are all on Birch’s sublist rather
than main list of most common forbidden
points, but all the issues around location over
the growing foetus apply.
Gall Bladder 21
This point is a classic trigger point midway
between the acromian process and C7 on the
height of the upper trapezius muscle. It is
described as strongly descending Qi in traditional
texts. It is hard for non-­ traditionally trained
practitioners to ascertain why this point is on the
pregnancy caution list other than this theory of
moving the Qi too strongly. One would assume
that other than the usual cautions of avoiding
perpendicular needling due to it being over the
apex of the lungs, there is no obvious medi-
cal reason to avoid needling if we dismiss the
Chinese theory of Qi. However, a number of
studies have utilised this point in their protocols
to induce labour and it has been found to stim-
ulate the labour hormone oxytocin in sufficient
quantities to affect, induce and augment uterine
contractions (Mafetoni et al. 2015; Mollart et al.
2015). Even acupressure and no needling on a
set of points that included GB 21 was found to
affect uterine contractions favourably in labour
(Calik & Komurcu 2014). It is unknown if
28
these points independently would still produce
the same result so in the meantime, it is wise to
avoid them as suspicious until proven safe. If
the woman is full term and 37 weeks gestation
or over, then if these contraindicated points are
deemed to be beneficial for the patient’s current
condition, there would only be a theoretical risk
of inadvertently triggering the labour. This may
actually be welcomed should the mother already
be booked in for medical induction, especially
if over her due dates in an otherwise healthy,
uncomplicated pregnancy.
Another area worth mentioning is that of
making clear our role in treating the presenting
condition such as Pelvic girdle pain or other
musculoskeletal condition and making that the
focus. If, however, the mother is full term or
overdue and any of the contraindicated points
are deemed particularly useful for that present-
ing condition, then I often then include them
as part of the prescription with the mother’s
consent and understanding that they may tip her
into labour over the coming hours or couple of
days.
In the Birch study (1990) many other points
appeared on a sublist including the following:
Stomach (ST) 25, ST 12, BL 60, BL 67, Kidney
(KI) 21, SP 1, Ren (CV) 3, 4, 6, 7, 10 and 11.
Stomach 25
This is located two cun lateral to the umbilicus.
The growing foetus pushes the height of the
fundus, the uppermost area of the uterus, to
approximately the umbilicus at around 24 weeks
gestation. So, from this stage onwards, needling
those points that have the distended uterus, with
baby insitu directly below, would be inappropri-
ate. Although we can also note many other
points on the abdomen that specifically mention
a contraindication in pregnancy, so we may need
to dig deeper to the traditional Chinese function
of this point. Classic texts mainly suggest ST
25 for balancing digestive disharmony, whether
constipation or loose stools, but there is no
research that I’ve found that has used the point
in pregnancy. However, this point is also used
for irregular periods and amenorrhoea. Although
not tested scientifically, a practitioner should be
aware that any point that is claimed to stimulate
© 2019 Acupuncture Association of Chartered Physiotherapists

a period suggests a theoretical risk of triggering
labour. We know that some of the points on the
main list stimulate circulating levels of prosta-
glandins and oxytocin, two hormones involved
in uterine contractions and cervix ripening, so
it may be that until we know the extent of any
endocrine response we have a second reason to
avoid this point. But a third issue with using this
point in pregnancy is that it is documented to be
useful to move the large intestine for constipa-
tion. Perhaps the issue here is a theoretical risk
of creating strong peristalsis to the extent of
niggling the uterus which is in close proximity
to the bowel. Traditional midwifery used enemas
right up until the 1970’s for this very effect as
it was believed to assist with stimulating and
augmenting labour. So, any point that claims to
move large intestine stagnation or masses could
potentially encourage the downward bearing and
nudge the uterus into cramping. I have not found
any research on the sole use of ST 25 point on
pregnant women. Any studies here would have
ethical concerns, as with many other abdominal
points because of the proximity of the underly-
ing baby to needling tip. Meta-­analysis of studies
that include ST 25 as a main point or use the
point as part of protocols for functional con-
stipation problems on the general population,
suggest it is indeed a powerful point for stimu-
lating defecation (Wang 2015). So, we are sensi-
ble to yet again avoid the point on both these
counts.
Stomach 12
This point is in the mid-­point of the supraclav-
icular fossa and generally used for local clavicular
pain and respiratory disorders. Apart from the
usual cautions pertaining to the delicate struc-
tures and arteries in the vicinity, I have found
no obvious reason why ST 12 is assigned to the
sublist of contraindicated points for pregnancy,
other than a mention that the point activates
the Stomach Meridian. Considering that many
other points are similarly said to move and acti-
vate the whole channel, and remembering that
the Stomach points particularly link to digestive
system movement it may only be that this was
perhaps thought to do so with more gusto than
other points that it warranted caution, because
© 2019 Acupuncture Association of Chartered Physiotherapists
C. Mason
any strong peristaltic bowel action may, in those
susceptible, stimulate the uterus to contract.
Again, we have no formal supporting evidence
and we are left to speculate why some texts
issued a cautionary warning. Thankfully, acu-
puncture has so many other useful points that
if one point is high risk, then there is usually
one or more alternative points that will do the
job intended.
Bladder 60
This is an extremely useful and versatile point
that can be used locally for ankle or heel pain
but also in Chinese medicine, as a distal point
to benefit lumbar pain, headache, neck stiffness,
dizziness and as a point to ease difficult labour.
So, it is easy to see how the Western rather than
Eastern trained therapist may be baffled as to
how a point on the foot has anything to do with
the uterus. Yet perhaps the Chinese had devel-
oped their twelve energetic meridians knowing
that the body is a unit of interconnected struc-
tures and tissues and what happens in the outer
ankle at Bladder 60 may influence further up the
leg and into the pelvis and its contents such as
the uterus. The work of Myers (2013) described
the 12 Myofascial meridians and the Lateral line
starting with the outer edge of the foot running
through the fibular head , the Ilio tibial band,
and Tensor fasciae latae, the Gluteus maximus,
Quadratus Lumborum and upwards through
the Obliques and intercostals on to Sternocleido
Mastoid. So, tension in the foot, ankle or leg
may create tension further up and influence
the back and pelvis. The first five muscles on
the list have attachments to the pelvis so we
know that releasing lines of tension further
down may stimulate alignment and functioning
further up the line. If we use the analogy of
the London Underground tube network, then
it’s rather like instigating an intervention (i.e.
putting a needle in or acupressure) at Oxford
circus to release congestion, knowing that the
line is positively affected further along, say at
Notting Hill Gate. The Lateral Line follows
the majority of the Bladder channel in Chinese
medicine until the channel veers posteriorly on
the back yet still affecting those muscle groups
listed on the lateral sling. The Bladder channel
29
Acupuncture dosage: adapting for safety and optimal therapeutic effect
only fully seeming to deviate from the lateral
sling at the neck area where the bladder channel
runs posterior to the skull to track anteriorly
to its origin, BL 1, at the inner canthus of
the eye.
So, as we develop Western medicine
knowledge of trigger points and acupuncture
traditional points, we can see that not only do
the meridians overlap with anatomy trains but
71% of trigger points directly correlate with
acupuncture points described in the ‘Wall &
Melzack’s Textbook of Pain’ (MacMahon et al.
2013). In a later study using graphics software
to log trigger points and overlay the acupunc-
ture points digitally, 93.3% were found to
have anatomically corresponding point pairs
(Dorsher & Fleckenstein 2007). Knowledge of
how fascia affects the muscles and connects
to the deeper fascia surrounding the internal
organs is beginning to make links with how a
fascial line of abnormal tension or scarring can
potentially result in visceral dysfunction, includ-
ing the uterus. So, if the distal points such as
BL 60 are viewed as trigger points for fascial
lines of tension, then perhaps we have clues to
the possible mechanism of action through the
musculoskeletal system. However, the point has
been frequently included in the point prescrip-
tions for research demonstrating acupressure
and acupuncture success rates for inducing and
augmenting labour. Calik & Komurcu (2014)
found BL 60 combined with BL 67, GB 21
and LI 4, SP 9 and SP 6 responds favourably
to acupressure by stimulating contractions via
the effect on oxytocin (a labour hormone)
production. There is no singular research on
the validity of this one point for this purpose.
Some researchers may see this as a weakness
but there is also weight in researching true to
life acupuncture point combinations. BL 60 is
never usually employed in isolation but in com-
bination with other contraindicated points as
induction treatment on women who are at full
term of pregnancy.
Bladder 67
This point is used especially for malposition of
foetus and to hasten a difficult labour. Again,
we can make links with the physical location
30
and its distal origins as it begins at the lateral
edge of the fifth metatarsal nail bed so we can
theorise again a possible link to Myer’s lateral
fascial sling meridian. We know that this point
does increase foetal activity which the research-
ers suggest is responsible for the increased
chances of turning a malpositioned foetus. The
randomized trial by Cardini (1998) found that
stimulating BL 67 with just moxibustion, the
smouldering herb being held near the point
so the recipient feels heat, encourages enough
movement for the baby to wriggle into a new
position, which for this study was 66% of the
breech presentations turning spontaneously after
treatments. The significance of it appearing on
the contraindicated list would make sense that
we don’t want to nudge a perfectly positioned
baby into poor position. Mostly though, babies
do virtual somersaults in utero until they are
such a size that by 34 to 36 weeks they require
more space and usually achieve this by settling
head down in the pelvis. A few babies decide
to settle bottom down or even arm or leg can
settle as the presenting part. This point would
then be very indicated but with moxa rather
than needling. Using acupuncture on BL 67
tends to be reserved for the general popula-
tion specifically for headache, eye pain or nasal
congestion, and then only with a superficial
needling of just 0.1 cun depth. Sarah Budd,
is the renowned midwife and acupuncturist
who in 1988 set up the first NHS acupuncture
clinic for pregnancy conditions in the UK, at
Derriford hospital , Plymouth. During a visit I
made there in 2003, I was fortunate to shadow
her for a couple of days in the hospital and she
revealed how the hospital had cardiotocography
(CTG) monitorings demonstrating how moxa
on BL 67 increased foetal activity during the
treatment sessions. This was one explanation
why the extra wriggling of baby may encour-
age a baby to find it’s way into a more optimal
head down cephalic presentation from 34 weeks
onwards, as found in Cardini’s clinical trial.
More recently, Van den Berg et al. (2010) found
moxibustion a cost effective option for turning
breech babies and avoiding the more expen-
sive and higher risk intervention of caesarean
sections.
© 2019 Acupuncture Association of Chartered Physiotherapists

Kidney 21
This point is on the abdomen, albeit high up at
six cun above the umbilicus and 0.5 cun lateral to
the midline. Still the height of the uterus reaches
this level for many women in the last trimester.
The needling depth is usually no more than 0.3
to 0.7 cun to avoid injuring the liver, and in
pregnancy, the uterus would also be a potential
risk below the needle. Other than the anatomi-
cal location in later pregnancy, the point has no
other clues to being on the contraindicated list.
Interestingly it is listed for digestive pain and
bloating, indigestion and diarrhoea. There is
no mention of constipation though so that risk
of triggering strong peristaltic movements does
not apply and some sources actually actively
recommended for nausea and morning sickness
in particular. So, rather than the issue being with
its purported action, it is more the location,
particularly in the last trimester that heralds
caution.
Spleen 1
This point mirrors BL 67 in that it is on the
lateral corner of the nailbed but of the big toe
nail rather than the fifth nailbed. It is reported
to be excellent to stop unexpected or irregular
bleeding from menorrhagia, haematuria and
bloody stools or spotting metorrhagia in the
woman’s cycle. Chinese acupuncture trained
practitioners have reported success in even
arresting bleeding during a threatened miscar-
riage through holding a stick of smouldering
moxibustion herb near the point. This point
was studied by Betts et al. (2016) and found
to be a feasible intervention with statistically
significant reduction in threatened miscarriage
symptoms. It is cheering to know that it can
assist where medical interventions have little to
offer. As to why it appears on the contraindi-
cated list? This may be due to its strong effect
on the uterus that although may be beneficial
for the miscarriage symptoms, may be a case of
creating imbalance on the healthy pregnancy;
so a case of ‘if it ain’t broken, don’t fix it’
type approach. Given the proven effect of this
point on the uterus then it makes sense that
this would potentially have an adverse effect
on a pregnancy if the treatment were carried
© 2019 Acupuncture Association of Chartered Physiotherapists
C. Mason
out on a viable pregnancy with no bleeding
symptoms.
Sacral Foramen Points Bladder 31, 32,
33, 34
All these four points are used for lumbar pain
and all are reported to improve uterine prolapse
in Chinese medicine. There are numerous sup-
portive Chinese studies, but research is scarce
from the West.
BL 32 additionally aids urinary problems,
painful menstruation and infertility. Again, the
Chinese approach is that it influences the uterus
and therefore could interfere with the harmony
of the uterus in pregnancy, so these points are
sometimes added to the contraindicated lists.
From a physiological viewpoint, the sacrum and
its foramen are indeed linked to the uterus. The
Uterosacral (sometimes called the sacrocervical
or recto-­ uterine) ligaments attach the cervix
and uterus onto the anterior surface of the
sacrum and act to support the uterus and hold
its position. The pelvic splanchnic nerves lay on
top of the uterus. Many women gain relief of
period pain and labour pain through acupunc-
ture or acupressure on these sacral points, and
osteopathy and chiropractic use sacral release to
encourage or induce labour. In my own practice,
I engage some of the sacral points as part of
a protocol for inducing overdue babies with
excellent effect. Women are often encouraged
to seek acupuncture by their midwives in order
to avoid the more medicalised induction with
its higher risk. Usually, if the treatment is given
at 40 weeks plus, the labour starts within in 24
hours of me giving a treatment. Many report a
strong sensation on these Sacral points in par-
ticular. I sometimes add in BL 31 and BL 32
from 37 or 38 weeks gestation (when the baby
is technically full term) for women with severe
Pelvic girdle or back pain as they are so effective
for this condition. But only after discussion that
they could theoretically tip the scales with the
hormone levels which may start up labour in the
hours following the treatment. Often women are
delighted if that were to happen but occasion-
ally they are not emotionally or practically ready
and want to delay. So, I only needle these points
at full term with full informed consent.
31
Acupuncture dosage: adapting for safety and optimal therapeutic effect
Discussion
So, we have evidence for some of the most
commonly cited contraindicated points as hav-
ing the very real potential of stimulating labour,
particularly if engaged with other points on the
primary list. The secondary list of points is less
likely to be used in physiotherapy practice and
have variable levels of evidence. Considering
that so many of the primary list points have
proven to have an authentic affect matching
the Chinese medicine claims on pregnancy, it
goes to say that just because we don’t have the
evidence yet, the sub list still warrants caution.
Be reassured that labour is a hormonal
process and if the mother were to have an
increased surge in oxytocin and prostaglandins
due to introducing one or two of the points
on the list at full term gestation then, even if
conditions are favourable in the mother’s body,
this is unlikely to take effect until a few hours
after treatment. The cervix needs to be soft and
ripe enough and the woman requires sufficient
receptor cells to be switched on in the uterus
to respond to any elevated levels of oxytocin.
These cells switch on gradually as the placenta
ages and the pregnancy reaches full term. So,
adding in the occasional contraindicated point
at this late stage may likely only take affect if
conditions are favourable in the mother. As
Buckley (2014) explains, it is the four main birth
hormones oxytocin, endorphins, catecholemines
and prolactin that all interplay to trigger and
regulate labour. Betts & Budd (2011) state that
the effects of using certain points that can
increase blood flow to the uterus or influence
hormonal levels in the first twelve weeks, may
have a detrimental effect as the foetus requires a
low oxygen environment and sufficient maternal
progesterone hormone until around this time.
So, caution is particularly warranted in this first
trimester and in the last few weeks of gestation
when a treatment may have a stronger effect
on the mother who is more susceptible to the
acupuncture effects at these times.
We know from studies on acupuncture for
induction of labour, generally it is when a
selection of the major contraindicated points
are engaged simultaneously and stimulated
32
sufficiently and the mother’s body is ready that
contractions have a chance to be gently started.
(Betts & Budd, 2011).
It is also an interesting but controversial fact,
that in China where the one child policies have
made a culture of abortion commonplace, the
use of traditional acupuncture has been offered
as an alternative to conventional treatment in
this field. As a result, Chinese studies on the
success rates for inducing contractions in the
preterm patient have been published. Amaro
(2000) observed that when LI 4 was used in
conjunction with SP 6, abortion is generally
realised within twenty-­ four hours. Jin & Zhu
(2005) claim a 75.46% first trimester success
rate and 30.9% in the mid trimester weeks. The
treatments do involve strong stimulation manu-
ally or using electroacupuncture, so in the light
of this knowledge, we are sensible to proceed
with caution in our own clinics to ensure we
are aware of whether a patient is confirmed as
being pregnant or even potentially so.
On the positive side, acupuncture can also be
used as a treatment option for a threatened mis-
carriage. Betts et al. (2012) remind us that 50 to
70% of miscarriages occur due to chromosomal
abnormalities and nature will often persist in
a miscarriage despite our efforts. But with
the interest in fertility research, acupuncture
demonstrates beneficial hormonal responses
to improve outcomes for those patients with
a viable healthy pregnancy, but a vulnerable
system, to help decrease the rate of miscarriage.
The research is coming through clearer than
ever that acupuncture creates a neuroendocrine
response as well as the usual known local effects.
Pregnancy and labour create a heightened sen-
sitivity to this system creating the cascade of
hormone responses necessary for birthing. What
the ancient texts seemed to have documented
are those points that are particularly sensitive
in triggering this system. There is still so much
more research to be done to clarify and under-
stand the complex interplay of mechanisms
involved. It seems that isolated points may have
an impact, but certain patients may also be
more susceptible or sensitive to the treatment
depending on their own constitution, stage of
pregnancy and other factors such as degree of
© 2019 Acupuncture Association of Chartered Physiotherapists

needle stimulation. The classic contraindicated
point combinations appear to also have a syn-
ergistic effect, so when needled simultaneously,
they strengthen the overall treatment and thus
the ability to trigger or sustain labour. Although
it would be easy to simply dismiss these points
as Chinese medicine folklore, it is prudent to
now review our attitude to them because we
know many of the points have a real potential
to influence the pregnancy for better or worse.
One theme that has emerged around the topic
of contraindicated points is that of treatment
‘dosage’. It is not necessarily just which points
to be cautious around for this client group, but
other factors are part of the equation too. These
include the needling depth, length of time of
treatment, needle thickness gauge and the level
and type of stimulation of the points, all of
which interplay to affect the chances of these
listed points stimulating uterine contractions.
In the light of this knowledge, some
Traditional Chinese Acupuncturists offer this
service for women who are over their due
dates to avoid the risks of a medical induc-
tion of labour. So, we can see the potential
for acupuncture on a selection of these points
for preparing the cervix to ripen, assisting with
turning the baby into an optimal position ready
for birth or stimulating labour hormones as an
alternative to medical interventions for induc-
tion with its associated higher risks. Of course,
this is an extended role of practice and usually
beyond the remit of the physiotherapist’s role
and training but there is potential to collaborate
with other health disciplines to create such a
service and ease the burden on the NHS of the
high number of women who receive obstetric
interventions to attempt to bring on labour.
But there are also arguments that attempt-
ing to stimulate labour in women who are past
their due dates can be counterproductive and
lead to more complications and interventions
during labour. This appears to be more related
to the medical induction process. Acupuncture
induction tends to be gentler as it is stimulat-
ing one’s own hormonal cascade to follow the
pathway of a natural labour progression. If the
woman’s body is not sufficiently ready it tends
to not work or just niggle a pre-­labour scenario
© 2019 Acupuncture Association of Chartered Physiotherapists
C. Mason
of mild surges that wear off and are insuf-
ficient in strength to trigger full labour. Some
authorities (Amis 2014) prefer where possible to
avoid inducing labour and allow it to begin on
its own, claiming healthier outcomes for mother
and baby.
So, the fact remains that certain acupuncture
points have been studied and acknowledged as
having a strong enough effect to start labour
at any stage of gestation. Therefore, we are to
remain cautious on those same points because
there will always be a patient who is suscepti-
ble to an early preterm labour or who may be
vulnerable to miscarriage in the first trimester
especially. Even if a miscarriage was about to
happen and nothing to do with our treatment,
we know we are not at risk of blame, in the
event of a complaint, if we have avoided the
points known to potentially stimulate those
hormones.
Some anomalies from the Birch study
An interesting observation highlighted in the
Birch study (1990) is that none of the Japanese
textbooks made any reference to those origi-
nal four points that are commonplace in the
Chinese texts. The anomaly may have its roots
in the very different approaches demonstrated
in the Japanese clinic compared with the
Chinese. The Chinese textbooks tend to advo-
cate a much deeper insertion depth to these
points whereas the Japanese styles of needling
are hallmarked by a reduced number of needles
overall, a shallow and minimal pain insertion
method and little or no manipulation of the
needle to stimulate De Qi. Indeed, LI 4 and SP
6 are suggested as being 50% deeper needling
depth in the Chinese texts. The Japanese texts,
rather than discouraging SP 6, sometimes even
advocate its use with moxa on the needle, to
help the mother and baby prepare for labour
after the fifth month (Kuwahara 1990).
So, what we may interpret from the findings
in the Birch study is that when it comes to
assessing the impact of needling any particular
point, whether the patient is pregnant or not,
the details of how that point is needled, the
depth and stimulation appear to be important.
This brings us to an issue that has often been
33
Acupuncture dosage: adapting for safety and optimal therapeutic effect
accused of being largely ignored by practitioners
over the years but is beginning to rear itself as
a key to treatment success; namely the issue of
correct therapeutic dosage in the clinical setting.
Acupuncture Dosage
Now let’s examine what exactly we mean by a
‘therapeutic dose’ of acupuncture. It seems the
issue of giving a correct ‘dose’ of acupuncture
has been largely underplayed in importance
by the acupuncture world. This has had major
implications for the research world too and key
campaigns are emerging to raise awareness of
the impact it has had on research results. This
follows the early years of confused research
results which left many of us clinicians scratch-
ing our heads because the research did not
match up to the results we have seen on our
patients. At its worst, poor quality research that
did not address how incorrect acupuncture
dosage could influence the outcome of a trial,
has prevented acceptance of acupuncture as a
clinical option. It has prejudiced many decision
makers to withdraw or restrict its use, based on
flawed evidence. Acupuncture has even been
defamed as little more than a placebo. In some
cases, this resulted in decisions to deny funding
or support its use. So, acupuncture has all too
often lost the rightful credibility and widespread
acceptance in the wider medical community that
it deserves.
When we see the huge heterogeneity in
research as to reporting of dosage, then we can
see how the results of many of the trials have
been a lottery. In the early days in particular,
there were countless research trials that failed to
even report the number and names of points
selected and many of the finer details of the
intervention. So, of course, the results were
blurred, and sceptics were quick to jump on
these confused findings as more evidence that
acupuncture must just be placebo. Many studies
have compared verum or real (true) acupuncture
to a so-­ called placebo like control and called
this the acupuncture ‘sham’ group. This has
been detrimental to the promotion and accept-
ance of acupuncture within the medical world.
The tragedy is that we now know so many of
the ‘sham’ treatments were not actually inert.
34
Rather, sham needles were used that still actually
touched the skin or even pierced the subcutane-
ous level of tissue. Some protocols used other
adjacent areas as sham points that were thought
to not have any therapeutic value when clearly
they did. In the end, oftentimes the sham treat-
ments were actually partially active to the degree
that it created a beneficial effect on the patient.
Worse still, the results were then interpreted as
showing that the treatment was a placebo effect
because there was a success in both groups
when compared, even if the placebo was less
powerful. In reality, what we were seeing was
normal acupuncture compared with badly done
acupuncture. This would be akin to doing a trial
on aspirin and giving a low dose of the drug to
the sham group, and, finding that both groups
had some positive reaction, then dismissing the
results as largely placebo.
So, the future of acupuncture research relies
on clinical trials reporting the basis of the treat-
ments more thoroughly to include not only the
points used but the finer details of how the ther-
apeutic ‘dosage’ was controlled. The STRICTA
and CONSORT non-­pharmacological guidelines
give details of a more standardised reporting
of treatments and are designed to improve the
quality of acupuncture research. We have not
seen acupuncture performing at its best and
have instead witnessed many studies which
contaminate the research arena and tarnish the
reputation of this amazing tool.
For our pregnant patients, if we avoid the
known and suspected contraindicated points
and provide an appropriate ‘dose’ with a sen-
sible treatment that any reasonable practitioner
would consider using, then there is no need to
avoid using acupuncture on otherwise healthy
pregnant patients (except for those seen as hav-
ing unusually high risk of potential miscarriage).
Dosage here relies on the skill of the practi-
tioner in selecting a treatment protocol that
maximises effectiveness without compromising
safety.
Both in clinics and in research, there are
instances where the patient or research partici-
pant is given a suboptimal dose of acupuncture
(too weak or too strong) with poor choice of
points, incorrect point location or ineffective
© 2019 Acupuncture Association of Chartered Physiotherapists

choice of needle gauge or length and ineffec-
tive needling technique. There is all too often a
massive gap between treatments, where a better
approach would have been to plan the spacing
of treatments to encourage maximum effect. In
particular, we should consider the total number
and frequency of the spacing between treat-
ments, the optimal length of time and interval
between each treatment, factoring in the unique
requirements of individual patients.
Bauer (2016) suggests that 16 or more treat-
ments has been the minimal required to gain the
much higher success rates and demonstrate the
full longer term effects of acupuncture. This
may seem a lot but if the results are showing
best outcomes and more sustained results over
time then it is worth rethinking how we can
achieve this for optimal results. When a patient
says acupuncture did not work it is often simple
things like the incorrect dosage that has played
its part. As a suggestion, if we are only given
funding for 10 sessions, then perhaps the first
couple could be full length treatments and then
drop to half time. So, you may have shorter
time but more treatment sessions available to
achieve the minimum required to demonstrate
sustained improvements. The spacing between
treatments often works best with top heavy at
the beginning, thus offering two or three treat-
ments weekly for the first couple of weeks or
so, then dropping down to one or two a week
and then fortnightly as the condition improves.
This acts as an initial concentrated boost to the
treatment.
Consider the needle gauge and length along-
side the type and amount of stimulation to
the needles given during treatment. A stronger
dosage of treatment may be achieved by
stimulating needles via manual manipulation of
needles at intervals during the treatment session
for example, or considering the use of electro­
acupuncture where appropriate.
The practitioner may wish to think about
installing new habits of documenting these
additional variables in the patient notes. This can
stimulate reflection in and on practice, and also
creates transparency of the intended dosage to
other colleagues who may need to pick up the
treatment caseload in your absence. When we
© 2019 Acupuncture Association of Chartered Physiotherapists
C. Mason
introduce the concept of altering the dosage of
acupuncture treatments to suit the patient then
we have many options to increase or reduce the
intended therapeutic strength of acupuncture.
Acupuncture ‘dosage’ is one area we can focus
our attention on by making small changes to
yield better results that improve outcomes for
all our patients.
References
AACP (2017) Safe Practice Guidelines for Acupuncture
Physiotherapists, V3, Acupuncture Association of
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Amaro J. (2000) The forbidden points of Acupuncture.
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Amis D. (2014) Healthy Birth Practice 1: Let labour begin
on its own. Journal Perinatal Education 23 (4), 178–187
Bauer M. (2016) Acupuncture Now Foundation www.
acupuncturenowfoundation.org
Betts D. & Budd S. (2011) Forbidden Points in Pregnancy:
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bmj.com/ on November 6, 2015 – Published by group.
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Betts D., Smith C. A. & Dahlen H. G. (2016) Does
acupuncture have a role in the treatment of threatened
miscarriage. Findings from a feasibility randomized and
semi structured participant interviews. BMC Pregnancy
and Childbirth 16, 298
Birch S. (2006) The problem of acupoint contraindications in
pregnancy. [WWW document]. Paradigm Publications.
URL http://www.paradigm-­pubs.com/Birch-­Contra
Buckley S. (2014) Hormonal Physiology of Childbearing:
Evidence and Implications for Women, Babies, and Maternity
Care, New York, Childbirth Connections
Calik K. Y. & Komurcu N. (2014) Effects of Sp 6
Acupuncture point stimulation on Labour pain and
duration of labour. Iranian Red Crescent Medical Journal
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Kuwahara (1990) cited in Birch S. (2006) The problem of
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pubs.com/Birch-­Contra
MacPherson H. on Trust me I’m a Doctor, (2014). [TV
programme] BBC 2, Series 2, Episode 1, Oct 2014,
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the effect on the brain. Link: https://www.youtube.com/
watch?v=uT7GpVgUme4
MacMahon S. B., Koltzenburg M., Tracey I. & Turk D. C.
(2013) Wall and Melzack’s Textbook of Pain, 6th edn.
Elselvier Saunders, Philadelphia
Mafetoni R. R. & Shimo A. K. (2015) Effects of
Acupressure on Progress of labour and cesarean section
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version by acupuncture-­ type interventions on BL
67, including moxibustion, for women with a breech
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Cheryl Mason has previous experience in Nursing,
Midwifery and Pain Management teams within the
NHS, where she became interested in dry needling
and acupuncture for chronic pain. She graduated
with a Masters degree from the Northern College of
Acupuncture, York. For six years, Cheryl was a lecturer
and clinical supervisor on the Acupuncture degree course
at Leeds Metropolitan (Beckett) University, during which
time she gained her PGCHE teaching qualification. She
continues in private clinical practice and enjoys teaching
professional development courses for the Acupuncture
Association of Chartered Physiotherapists.
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 37–42

paradigm

Acupuncture pain and the emotional mind

J. Wood
Private Practice, Sheffield, UK

Abstract
This article explores acupuncture as a tool to modulate pain and considers the role emotions
may play in that process. It will consider emotions from a traditional Chinese acupunc-
ture (TCA) perspective and draw parallels with the continually developing Western medical
concept of ‘interoception’ which is made up of two forms of perception: proprioception
(signals from skin and musculoskeletal structures) and visceroception (signals from the inner
organs). Acupuncture is able to create sensations which can be experienced as being deep
within the body that appear able to modulate both emotional and physical pain. The article
considers how various emotional states relate to relative levels of sympathetic and parasym-
pathetic activity and the impact this has on the extent to which pain is experienced. It con-
siders the relationship between emotional pain and pain experienced as a body sensation and
the impact treatment with acupuncture can have on this dynamic. The relationship between
emotional and physical pain will be discussed with reference to how best to adapt the prac-
tice of acupuncture in order to take full advantage of beneficial pain-­relieving pathways.
Keywords: emotions, insular-­
cortex, interoception, proprioception, sentient-­
self, summate,
visceroception.

Introduction Imbalances in emotions can lead to illness.

The organ-­based nosology used in East Asian
medicine might be considered a metaphor for
which the primary referent is not a particular
anatomic organ but an emotion, diagnosed
based on the patterns of somatic symptoms.
Thus, East Asian medicine could be considered
to be built on a symptom-­based language rather
than an organ-­based language (Lee et al. 2017).
The Heart in TCA is considered to be the
most important of all the internal organs. It is
called the Monarch of the 5 Yin and the 6 Yang
organs and is said to be the residence of the
mind (Maciocia 1997).
Correspondence: John Wood, Sheffield Physiotherapy,
476 Ecclesall Road, Sheffield, S11 8PX (email: john@
sheffieldphysiotherapy.co.uk)
When someone suffers emotional stress, then
the proper circulation and direction of Qi is
impaired. Each emotion is thought to be unique
in its effect on the circulation of Qi:
• Anger makes Qi rise
• Joy slows down Qi
• Sadness dissolves Qi
• Fear makes Qi descend
• Shock scatters Qi
• Pensiveness knots Qi
Our experience of these different emotions
involves sensations perceived as coming from
within the body. When there is deep sadness the
Qi dissolves perhaps leaving us ‘feeling numb’,
fear makes Qi descend maybe ‘rooting us to the
spot’, while over-­thinking and worry can lead to

© 2019 Acupuncture Association of Chartered Physiotherapists 37

Acupuncture pain and the emotional mind
a sensation of a ‘knot in the pit of the stomach’.
As such our subjective experience of different
emotions in some way perhaps match what is
thought to be occurring to the Qi according to
TCA theory.
The condition of the organs is also thought
to affect our emotional state. As such it can be
seen that within TCA theory the emotions effect
the organs and conversely the organs effect the
emotions. The Huangdi Neijing describes five
emotions and the specific Yin organs these
affect (Maciocia 2007):
• Anger and the Liver
• Joy and the Heart
• Pensiveness and the Spleen
• Worry and the Lungs
• Fear and the Kidney
From personal experience we know that our
thoughts are intimately connected to our feel-
ings. In Western medicine, the process ‘visceral
cognition’ is called interoception and is con-
sidered to be a function of the limbic system
(emotional mind).
The limbic system
The limbic system is the emotional centre for
the brain. It includes, among other structures,
the hippocampus, amygdala, insular cortex,
anterior cingulate cortex (ACC) & nucleus
accumbens.
Hippocampus
The hippocampus might be considered to be at
the centre of the sensory aspect of the brain’s
function. The cells within the hippocampus
demonstrate a form of neural plasticity known as
long-­term potentiation (LTP) which is believed
to be one of the main neural mechanisms by
which memories are stored. It is proposed that
there is a two-­stage process by which memories
are created. Initially short-­
term memories are
formed within the hippocampus and these are
then later transferred to the neocortex during
sleep. This process occurs via ‘sharp waves’
which it is suggested drive Hebbian synaptic
changes (mechanism for synaptic plasticity) in
the target cell of hippocampal output pathways
within the neocortex.
38
Insular cortex
An insular cortex exists on each side of the
brain and are believed to be involved in con-
sciousness. They play a role in diverse functions
linked to emotion and the regulation of the
body’s homeostasis. Interoceptive awareness
sometimes referred to as the ‘sentient-­self ’, is
the conscious perception of the physical body.
The insular cortex has a viscerosensory func-
tion which is the mapping of visceral states that
are associated with an emotional experience,
giving rise to conscious feelings (this is an
example of embodied cognition).
In addition, they also have a visceromotor
function, being able to induce changes within
the viscera in response to changing circum-
stances encountered (for example when there
is a perception of danger or something good
happens). As such they are able to both gener-
ate and perceive sensations within the viscera. It
appears that they contain a form of reverbera-
tory circuit, self-­sustaining in nature helping to
maintain our state of mind.
It is within the insular cortex that the sensa-
tion of pain is judged as to its degree. This also
functions when a person imagines pain when
looking at images of painful events while think-
ing about them happening to one’s own body.
As such the insular cortex plays a significant
role in forming empathy with another person’s
situation. Ultimately, it is involved in the pro-
cessing of information to produce an emotion-
ally relevant context for sensory experience.
Trust and the insular cortex
A study by Adolphs (2002) used fMRI imaging
to look at the relative activation levels of the
left and right insular cortex when subjects were
shown a picture of presidential candidates (Al
Gore and Barack Obama) and asked to rate
their trustworthiness. Politics was chosen for
the study as it tends to be a particularly polar-
izing topic in which people become emotionally
invested. The results demonstrated that the left
insula is associated with trust (happy thoughts)
and has connections to stimulate the parasym-
pathetic nervous system, while the right insula
is associated with distrust (fear and depres-
sion) and has connections to stimulate the
© 2019 Acupuncture Association of Chartered Physiotherapists

sympathetic nervous system. Further these two
sides are in reciprocal-­
opposition/competition
with one another.
Increased sympathetic activity when it reaches
extreme levels has been demonstrated to be
able to cause stress induced analgesia, which is
generalised and profound, however, short lived.
Acupuncture analgesia which is associated with
increased parasympathetic activity is derived via
activation of endogenous opiates and tends to
be longer lasting and more nuanced.
Amygdala
The amygdalae are two olive size structures
which sit adjacent to each hippocampus and
perform primary roles in the formation and
storage of memories associated with emotional
events. Amygdala activity at the time of encod-
ing information correlates with retention for
that information and this correlation depends
on the relative ‘emotionality’ of the informa-
tion. ‘Fear conditioning’ is a type of memory
that is impaired following amygdala damage.
Emotional markers appear to be added to
memories which are then able to be read back
when the memory is recalled. The real beauty
of this system is that it allows for a very quick
emotional appraisal to be made of any given
situation as events unfold. For example, seeing
a spider nearby, causes the brain to draw on
the memories associated with spiders. As these
memories are recalled the emotional markers
which are attached create an output from the
insular cortex which is then experienced via the
sensory cortex as well as the insular cortex itself
as an overall ‘feeling’ about spiders. Maybe in
this example there is a primary feeling of fear,
worry or fright. At times however, there may
be a mixture of emotions (feelings, sensations
in the body) evoked. For example, if someone
mentions a much-­loved relative who has passed
away, then there would be the conflicting emo-
tions of love and sadness evoked simultane-
ously. As the left and right insular cortex are
in reciprocal opposition (competition) with
one another, then the relative strength of the
emotions will summate in order to determine
the overall level of sympathetic and parasympa-
thetic activity which ultimately results.
© 2019 Acupuncture Association of Chartered Physiotherapists
J. Wood
It can be seen then that the sensations in the
body give a very quick, yet accurate emotional
context, which evolves moment by moment
as events unfold. This emotional context takes
place outside of conscious awareness and is
a key driver for behaviour. For example, we
behave very differently when we feel frightened,
from when we feel joyous in a situation in
which we find ourselves. Furthermore, as the
sensations in the body are also perceived within
the insular cortex they will tend to linger in a
self-­
perpetuating manner. Put simply, feeling
bad makes us feel bad, while, feeling happy
makes us feel happy. Interestingly individuals
with larger amygdalae tend to have larger and
more complex social networks. This is possibly
due to the fact that they are better equipped to
respond to elevated levels of emotional com-
plexity in a more nuanced fashion.
Tactile C fibres and pleasant
situations
Tactile C fiber afferents are unmyelinated low
threshold mechanoreceptors. They respond
optimally to low force and velocity stimulus
moving across the receptive field. Intriguingly,
there is a positive correlation between the fir-
ing rate of tactile C fibers and how pleasant
people subjectively rate the sensation. Tactile C
fibers project to the posterior insula cortex via
the Lamina 1 spinal pathway. Tests on patients
with neuropathy affecting their large myelinated
afferents, but with intact C fibers, indicate that
the conscious sensation elicited by stimulation
of tactile C fibers is rather week. This raises the
question as to whether conscious sensation is in
fact their main function? (Pawling et al. 2017).
Intriguingly, the sensation of a holding and
drinking a hot drink, is likely to make us feel
an interpersonal warmth towards others so that
we will interpret their intentions as friendlier
and kinder. It is postulated that the warm drink
mimics the body’s interoception (visceroception)
related to being in the company of someone
with friendly and kind intentions. It is possible
that the warmth of the drink in the hands
and body causes activation of the left insula
and therefore causes a positive feedback loop
39
Acupuncture pain and the emotional mind
via activation of the parasympathetic nervous
system.
We refer to our feelings consciously in order
to give an emotional context to an experience,
yet as these sensations invariably blend with the
physical sensations of touch and proprioception
it appears possible for externally evoked sensa-
tions to be misinterpreted as our own emotional
feelings. This seems to be particularly the case
with a feeling of warmth where for example the
body heat experienced while hugging someone
you love seems to reinforce the warm feeling
evoked on the inside. Interestingly, escalating
parasympathetic activity is associated with an
increase in peripheral circulation, with related
sensations of warmth and a subjective heighten-
ing of awareness of our limbs and face. These
body sensations combined with viceroception
are effectively generated via our thoughts, how-
ever their merger with other forms of physical
sensation seems to occur so seamlessly that we
appear unable to clearly differentiate them from
one another. As a consequence, we never think
to ourselves “I only feel this way about the situ-
ation because I’m drinking a hot cup of tea”
(Williams et al. 2008).
Because the sympathetic and parasympathetic
nervous system have a reciprocal relationship with
one another, a situation that is perceived as being
negative will result in an increase in sympathetic
activity and a shutting down of the peripheral
blood flow, in extreme cases giving a somewhat
numb feeling in the limbs. When we comfort
a person who is sad, we intuitively gently rub/
stoke their head and/or body and/or hug them,
(activating the tactile C fibres). It is postulated
that this is creating sensations that are able to
activate the left insular cortex. This activity begins
to reverberate, and further pleasant sensations are
evoked. In a sense we are able to hijack the lim-
bic brain via creating body sensations within the
sad person’s body, which we intuitively know will
be perceived by them as positive emotions. So, as
they begin to feel better, they feel more positive
and brighter about their situation, which from
an objective perspective hasn’t in point of fact
changed, yet the emotional lens through which it
is perceived will have shifted so they ‘see things
in a more positive light’.
40
Is acupuncture providing
artificial emotions?
When giving scores of between 3 and 6 on the
Visual Analogue Scale (VAS) most subjects feel
a sensation of aching fullness, pressure, numb-
ness and dull pain, which are widely considered
as the representative feelings of De Qi. Needle
manipulation causes a prominent decrease of
fMRI signal in the amygdala, hippocampus and
insular cortex along with other limbic structures
with a sensation of De Qi. In marked contrast,
sharp pain caused a marked increase in the sig-
nal in the somatosensory cortex as well as the
insular cortex and other limbic structures (Hui
et al. 2000).
Much has been written about the effects of
acupuncture on the brain. Numerous studies
have mapped the pathways that are activated or
inhibited with activation of a De Qi sensation
and this has been compared with the effect
of a ‘sharp needles’ sensation. However, there
is as yet little in the way of an explanation for
these observed affects. In a strange way we
find ourselves in the incongruous situation of
knowing much about how acupuncture works
yet remaining unclear as to why acupuncture
works in this way. There is increasing scientific
interest in interoception and the way in which
internally generated sensations (emotions) effect
the brain’s input and output functions.
It seems that this is an area of study which
might enlighten us as to as to why acupuncture
works. From what has been covered so far it
seems reasonable to postulate that acupuncture
generates sensations which are perceived as
occurring deep within the body, as the brain
has no previous experience of such sensations
being generated via external stimulation. The
central nervous system is constantly bombarded
with sensory input via the five senses and in
order to prevent being overwhelmed these
afferent inputs are deleted (via competition for
onward transmission at synapses), distorted and
generalised within the central nervous system.
As the De Qi sensation is perceived as flowing
and radiating in nature it might possibly be able
to super-­activate the right insular cortex as it
is perceived as a novel, pleasurable sensation
© 2019 Acupuncture Association of Chartered Physiotherapists

(emotion). Due to the reverberatory nature of
the insular cortex’s function, repeated applica-
tions eventually rebalance the parasympathetic/
sympathetic activity and provide a new more
positive emotional cortex (lens) through which
the brain perceives a previously painful body
part. In a way nothing has objectively changed,
yet the brain perceives things in a more positive
way and increases the production of opiates to
reduce the conscious minds perception (context)
of danger or threat. This increased parasympa-
thetic activity will also increase local blood flow
to the injured body part while simultaneously
reducing local muscle tone, promoting tissue
healing and repair, creating a virtuous cycle as
treatment and tissue healing progresses.
A traditional Chinese
acupuncture perspective
It is said within TCA texts that the glory of the
heart is manifested on the face, since the blood
fills up the vessels. Vigorous Heart Qi and
ample Blood result in a strong and regular pulse
and a rosy complexion. Conversely, if the Heart
Qi and Blood are deficient, then the pulse will
be weak and thready and the complexion pale.
This correlates with a western medical model
of health being associated with a balance within
the autonomic nervous system as indicated by
such tests as ‘heart rate variability’ which gives
an indication of the relative levels of activity of
the sympathetic and parasympathetic nervous
systems. Negative mental states such as depres-
sion are associated with sustained overactivity
of the sympathetic nervous system resulting
in sub-­optimal blood-­flow to the viscera with
consequential reduction in visceral-­ organ per-
formance and repair potential.
The heart’s function to ‘house the mind’
depends on adequate nourishment from Blood
and, conversely the heart’s job of governing
the Blood depends on the mind. Therefore
the ‘emotional mind’ (which is called the lim-
bic system in Western medicine) is intimately
linked with the heart, both as an organ and as a
meridian. When Heart Qi (energy/metabolism)
is strong, the Blood will also be in good condi-
tion. This will be reflected by a full and regular
© 2019 Acupuncture Association of Chartered Physiotherapists
J. Wood
pulse however, when the Heart Qi is weak, the
pulse will be feeble and irregular.
TCA holds that acupuncture can in some
instances be used to treat the root causes of
both diseases and painful conditions and not
just the symptoms. The TCA concept of the
heart ‘housing the mind’ therefore emphasizes
how a person feels emotionally both in general
terms and also specifically in relation to an
injury or illness is particularly important.
Conclusions
At the core of TCA is the concept that, for
any organ or part of the body to function
optimally, and resist degenerative and disease
processes, then it must receive a generous flow
of well-­oxygenated blood; any less than this
and trouble will ensue at some point. The heart
organ and meridian play a pivotal role in this
process. There is some evidence to support the
contention that acupuncture may create sensa-
tions that are sufficiently close to the sensations
that the brain is generating within the body via
the insular cortex that it does not differentiate
them as something external to the body. Once
initiated these sensations/feelings/emotions
seem to reverberate in a self-­ sustaining man-
ner. Consequentially, when treating patients, the
therapists’ soft-­
skills of being reassuring and
ensuring patient warmth and comfort during
physiotherapeutic and acupuncture treatment
should be recognized for their impact on the
relative success of such treatment. That the
patient should experience the De Qi sensation
as opposed to a sharp pain should also be
ensured. It is interesting to contemplate the
extent to which interoception may in fact be at
the very heart of how acupuncture affects the
body.
References
Adolphs, R. (2002) Trust in the brain. Nature neuroscience, 5
(3), 192
Hui, K. K., Liu, J., Makris, N. et al. (2000) Acupuncture
modulates the limbic system and subcortical gray
structures of the human brain: evidence from fMRI
studies in normal subjects. Human brain mapping,  9 (1),
13–25
41
Acupuncture pain and the emotional mind
Lee, Y. S., Ryu, Y., Jung, W. M. et al. (2017) Understanding
Mind-­Body Interaction from the Perspective of East
Asian Medicine. Evidence-­Based Complementary and
Alternative Medicine 2017, Article ID 7618419
Maciocia G. (1997) The Foundations of Chinese Medicine: A
Compressive Text for Acupuncturists and Herbalists. Churchill
Livingstone, Edinburgh, 71
Maciocia G. (2007) The Practice of Chinese Medicine: The
Treatment of Diseases with Acupuncture and Chinese Herbs,
2nd edn. Churchill Livingstone, Edinburgh
Pawling, R., Cannon, P. R., McGlone, F. P. & Walker,
S. C. (2017) C-­tactile afferent stimulating touch carries
a positive affective value. PLOS ONE  12 (3), Article
ID 0173457.
Williams, L. E. & Bargh, J. A. (2008) Experiencing physi-
cal warmth promotes interpersonal warmth. Science, 322
(5901), 606–607.
42
John Wood qualified as a physiotherapist in 1988, and
completed a 2-­year part-­time diploma in acupuncture in
1998. He is an advanced member of AACP and an
accredited tutor, he has been involved in training physio­
therapists in how to use acupuncture as part of their
practice since 1999. In 2016 he was awarded an ‘Excel­
lence in Innovation’ award by the AACP. He works full
time as the clinical director and lead therapist of a private
physiotherapy clinic in Sheffield and personally specialises
in treating chronic and complex spinal and sports inju-
ries. John is passionate about helping physio­therapists to
integrate acupuncture into their clinical practice effectively
so that it enhances both the clinical outcomes that they
achieve and the patient’s therapeutic experience.
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 43–53

RESEARCH

Dry needling alters trigger points in the upper

trapezius muscle and reduces pain in subjects
with chronic myofascial pain
L. H. Gerber, J. Shah, W. Rosenberger, K. Armstrong, D. Turo,
P. Otto, J. Heimur, N. Thaker, S. Sikdar
Center for the Study of Chronic Illness and Disability, George Mason University,
Fairfax, VA, USA

Abstract
Objective: To determine whether dry needling of an active myofascial trigger point (MTrP)
reduces pain and alters the status of the trigger point to either a non-­spontaneously tender
nodule or its resolution.
Design: A prospective, non-randomized, controlled, interventional clinical study.
Setting: University campus.
Participants: A total of 56 subjects with neck or shoulder girdle pain of more than
3 months duration and active MTrPs were recruited from a campus-­wide volunteer sample.
Of these, 52 completed the study (23 male and 33 female). Their mean age was 35.8 years.
Interventions: Three weekly dry needling treatments of a single active MTrP.
Main Outcome Measures: Primary Outcomes: Baseline and post-treatment evaluations
of pain using a verbal analogue scale, the Brief Pain Inventory, and the status of the MTrP
as determined by digital palpation. Trigger points were rated as active (spontaneously pain-
ful), latent (requiring palpation to reproduce the characteristic pain), or resolved (no palpable
nodule).
Secondary Outcomes: Profile of Mood States, Oswestry Disability Index, and Short Form
36 scores, and cervical range of motion.
Results: Primary outcomes: A total of 41 subjects had a change in trigger point status
from active to latent or resolved, and 11 subjects had no change (P < .001). Reduction in all
pain scores was significant (P < .001). Secondary outcomes: Significant improvement in post-
treatment cervical rotational asymmetry in subjects as follows: unilateral/bilateral MTrPs
(P = .001 and P = 21, respectively); in pain pressure threshold in subjects with unilateral/
bilateral MTrPs, (P = .006 and P = .012, respectively); improvement in the SF-­36 mental
health and physical functioning subscale scores (P = .019 and P = .03), respectively; and a
decrease in the Oswestry Disability Index score (P = .003).
Conclusions: Dry needling reduces pain and changes MTrP status. Change in trigger point
status is associated with a statistically and clinically significant reduction in pain. Reduction
of pain is associated with improved mood, function, and level of disability.

Correspondence: Lynn H. Gerber, Center for the Study Introduction

of Chronic Illness and Disability, George Mason Myofascial pain syndrome (MPS) is a common
University, CCID, 4400 University Drive, Fairfax, and significant clinical problem, accounting for
VA 22 030, USA. (email: ngerber1@gmu.edu) 15% of general medical visits (Skootsky et al.

© 2015 American Academy of Physical Medicine and Rehabilitation 43

Dry needling for myofascial pain
1989). MPS negatively affects function and
participation in life activities (Gerber et al. 2013;
Tekin et al. 2013).
MPS has generated controversy in part because
there has been disagreement about diagnostic
criteria. The syndrome has had many names,
including fibrositis, myofasciitis, and myogelosis
(Llewellyn 1913; Schade 1921), reflecting a lack
of agreement about etiology, pathophysiology,
and the primary tissue involved. MPS has been
confused with other pain syndromes such as
fibromyalgia and neuropathic pain, and although
confusion remains, there is general acceptance
of the term ‘myofascial pain syndrome’ and its
diagnostic components (Travell & Simons 1983;
Borg-­Stein & Simons 2002; Bennet 2007).
There is active debate about whether the
myofascial trigger point (MTrP) is a neces-
sary condition for the diagnosis of MPS, and
whether it should be the target for pain relief.
This article explored this relationship in part
because there seems to be agreement that the
MTrP is an objective finding associated with
MPS, that is reliably identified and useful in
assessing pain (Simons 2004; Simons et al. 1999;
Mense & Masi 2011; Tough et al. 2007).
In this study, we used Travell and Simons’
definition of MPS, namely a regional pain
syndrome in which there is a palpable, discrete
nodule within a taut band of skeletal muscle that
is spontaneously painful (Simons 2004; Simons
et al. 1999). This is referred to as an active trig-
ger point (a-­MTrP), defined as a spontaneously
painful nodule. A latent myofascial trigger point
(l-­MTrP) is a trigger point that is not sponta-
neously painful and that requires palpation or
motion/activity to induce pain.
Dry needling is a nonpharmacological treat-
ment for MPS that is commonly used for
reducing pain associated with a-­MTrPs (Tough
et al. 2009; Kietrys et al. 2013). It is frequently
performed by a clinician using a 32-­ gauge
acupuncture needle inserted into the palpably
painful nodule using a superficial (10-­20 mm) or
deep (25-­40 mm) needling technique. Elicitation
of one or more local twitch responses is a goal
of dry needling and often benefits individu-
als with pain secondary to MTrPs (Tekin et al.
2013).
44 © 2015 American Academy of Physical Medicine and Rehabilitation
The effectiveness of dry needling has been
difficult to demonstrate due to a lack of objec-
tive measures of pain. Currently, assessment
of patients with MPS relies upon patient self-­
reports of pain. Patient-­ reported outcomes
(PROs) are reliable measures, but their sensitiv-
ity to change, the variety of ways of expressing
pain by individual patients, correlations with
physical findings, and other objective measures,
have made validation difficult.
Our research team used the status of the
MTrP as the treatment target and an outcome
measure to assess the changes that resulted
from treatment, and to determine whether
change in its status correlated with change in
post-­treatment level of pain.
This article presents the results of a pro-
spective, interventional clinical study designed
to assess whether dry needling of an a-­MTrP
alters patient-­reported pain and contempora-
neously alters the status of the trigger point.
We selected a technique that is widely used in
clinical practice and that has been shown to
be effective in reducing MPS, but the effect of
which on the MTrP is not known (Tekin et al.
2013; Tough et al. 2007; Kietrys et al. 2013). We
also measured the impact of dry needling on
self-­reports of mood and function.
To our knowledge, this is the first study to
investigate the association between dry needling
and its effect on pain reduction and MTrP
status.
Methods
The study was approved by the Chesapeake
Institutional Review Board. Subjects were
recruited by posting flyers around a university
community. No remuneration was offered to
participants. All provided consent.
Study entry required that participants were
adult (aged 18–65 years) and had experienced
pain without provocation for at least three
months in the neck/shoulder girdle region and
a palpable MTrP in one or both of the specific
locations of the upper trapezius. The spontane-
ous pain had to be in the area of the prescribed
MTrP locations, and its palpation had to exac-
erbate pain. Radiation to head, neck, or face on
palpation was acceptable but was not required

for inclusion. All evaluations and treatments
were performed by two experienced clinicians,
each with more than 20 years of treatment
experience. Patients selected which day of the
week was preferable for treatment and follow-
up, and were assigned to the physician who
­ active (spontaneously painful). This status was
treated on a specific day of the week. That
is, physician one treated on Fridays and physi-
cian two on Thursdays. Occasionally, patients
were seen on the alternative day if scheduling
required a change.
Interobserver reliability for the two treating
physicians was tested using 14 treatment-­naive
volunteers with and without pain. Each pro-
vided informed consent for evaluation. Two
sites were examined independently by each of
the two examiners and scored as active, latent,
or nonpainful nodule/normal. Interrater reli-
ability was assessed using a κ statistic. The κ
statistic for site two is 0.74 (P = .003) and for
site three is 0.87 (P < .001).
Entry exclusions included the following:
chronic fatigue syndrome, fibromyalgia, chronic
Lyme disease, cervical radiculopathy, head/
neck/shoulder girdle surgeries, new medication
or change within six weeks, and current use of
acupuncture.
All study subjects received three successive
dry needling sessions weekly. Post-­ treatment
evaluations were performed at three weeks.
Treatment technique was standardized as fol-
lows: four predetermined examination areas
were palpated and point(s) were identified
(Gerber et al. 2013). They were 2 cm medial to
the acromioclavicular joint on the left and right
sides and at two additional sites in the upper
trapezius as it turns cephalad lateral to the
spinous process of C7. Trigger points reported
to be spontaneously painful were considered
to be a-­MTrP; those not spontaneously painful
but painful upon palpation were designated as
l-­
MTrPs. Only one a-­ MTrP was selected for
treatment. If there was more than one a-­MTrP,
we selected the most symptomatic site for dry
needling. Hence, there may have been untreated
a-­MTrPs.
Some subjects had a-­MTrPs on only one side,
which we defined as “unilateral.” Some subjects
had at least one a-­MTrP on each side, which we
© 2015 American Academy of Physical Medicine and Rehabilitation
L. H. Gerber et al.
defined as “bilateral.” We defined “responders”
as patients whose status changed from a-­MTrP
to l-­MTrP, or a-­ MTrP to an asymptomatic
palpable nodule or no nodule palpable. “Non-­
responders” were those whose a-­MTrP remained
determined by a treating physician (not always
the one who performed the dry needling treat-
ment) who palpated and assessed whether the
findings were consistent with a-­MTrP, l-­MTrP,
nonpainful nodules, or no palpable nodule.
The selected a-­MTrP was prepared by wiping
the area with an alcohol pad, and a 32-­gauge
needle with its plastic guide tube in place, was
placed over the a-­ MTrP (see Fig. 1). A tap-
ping motion was used to advance the needle.
Occasionally, needle movement was performed
around the nodule following a four-­points-­of-­
the-­compass technique with rotation along its
long axis in an effort to elicit a small muscle
twitch. This was achieved in approximately 70%
of subjects on the first, 66% on the second, and
50% on the third treatment. Change in verbal
analogue scale (VAS) score was not statistically
correlated with eliciting the twitch response.
All evaluations were performed at baseline
and after the third treatment at three weeks.
Primary outcomes were measures of pain
reduction and change in trigger point status
from a-­MTrP to either l-­MTrP or no palpable
nodule. A VAS was used for pain assessment.
It was scored from 0 to 10 (0 = no pain, 10
= unbearable pain). The question was asked as
follows: “Are you having pain now? Please rate
Figure 1. Demonstration of needle insertion into
myofascial trigger point.
45
Dry needling for myofascial pain
it on a scale of 0–10. Do you have pain on the
right side of your neck? Please rate this 0–10.
Do you have pain on the left side of your neck?
Please rate this 0–10.” Palpation was performed
on four standard sites. Nodules were either
active (spontaneously painful), latent (required
overpressure to elicit pain), or not palpable (and
no pain associated with palpation).
Secondary outcomes included range of
motion (ROM) which was determined in
three planes of movement (flexion/extension,
side bending, and rotation) using the Deluxe
Cervical Range of Motion Instrument (CROM),
model 12–1156 (Fabrication Enterprises, White
Plains, NY). A ratio of measures of ROM over
the normal range was determined for the left
and right sides. The asymmetry was evaluated
at baseline and at the end of treatment (three
weeks). Two additional measures of pain
included a measure of pain pressure threshold
(PPT) and the Brief Pain Inventory (BPI) (Daut
et al. 1983). PPT was obtained at four sites,
following a standard procedure for assessing
relative comparisons among the anatomical
sites using a pressure algometer (Commander
Algometer, Tech Medical, Salt Lake City, UT)
(see Fig. 2). Subjects were instructed to identify
the moment at which symptoms underwent a
qualitative shift from pressure to pain during
algometer compression. The reading at that time
Figure 2. Algometer used for measuring pain pressure
threshold (Tech Medical, Salt Lake City, UT).
46
was determined to be the PPT score. A high
score, namely that which requires more pressure
to be applied to produce pain, was associated
with improved pain symptoms.
Additional measures included the Oswestry
Disability Index, a measure of disability second-
ary to the spine and adjacent musculoskeletal
system. Subjects were instructed to reply with
reference to the neck and upper thoracic area
in terms of limitations (Fairbank et al. 1980).
The MOS 36-­Item Short-­Form Health Survey
(SF-­36), a health status questionnaire (Ware &
Sherbourne 1992) was used, as well as a short
version of the Profile of Mood States (POMS)
(Shacham 1983), a symptom checklist of mood
that included such items as anxiety and depres-
sive symptoms. Subjects with high scores on
the Oswestry Disability Index, POMS, and VAS
were considered to be more symptomatic or
more disabled. A high score on the SF-­36 was
considered to indicate better health status.
Sample size was determined to be 90 sub-
jects, with the assumption that 5% of patients
would spontaneously improve their MTrP status
without dry needling. We wished to detect an
increase of 10% for responders post-­treatment.
We conducted a conditional power analysis
after 56 patients were accrued and determined
the study to be substantially overpowered, and
our hypothesized percentage of responders was
underestimated (Proschan et al. 2007).
StatXact (Cytel Statistical Software and
Services) was used to conduct an exact binomial
test that the percentage of responders exceeded
5% at the 0.05 (2-­sided) α level. Paired t-­tests
compared pain and variables of interest before
and after treatment. These variables included
both objective and self-­reported outcomes.
Analysis of covariance was used to detect
changes in outcome measures for responders
versus non-­responders.
Changes from baseline in VAS, BPI, and
PPT scores were analyzed, and were adjusted
for baseline value, age, gender, group (unilat-
eral/bilateral), and exercise status, based on
response to treatment, using regression analysis.
For all models, studentized residual plots were
inspected. For VAS scores and BPI scores,
the residuals appeared homoscedastic with no
© 2015 American Academy of Physical Medicine and Rehabilitation
 L. H. Gerber et al.
outliers. For PPT scores, one subject was con- Table 1. Characteristics of study subjects
sidered as an outlier. A Q–Q plot of residuals Active Myofascial Trigger Points
exhibited no indication of nonnormality. Characteristic n %
Each model was adjusted for gender, age, and Gender
exercise status, and none of these characteristics  Male 23 41.1
 Female 33 58.9
was significant in any of the models. Regression Age, y
diagnostics were graphically depicted, including   Mean (range) 35.8 (20–62)
checks for outliers and heteroscedasticity, and Pain distribution
Q–Q plots to verify the normal error assump-  Bilateral 42 75
  Unilateral (right/left) 9/5 16.1/8.9
tion. There were no outliers, and no transfor- Pain duration, y
mations were deemed necessary. All regression   <3 21 37.5
analyses were conducted using SAS software,   >3 35 62.5
Use of medication
version 9.3 (SAS Institute, Cary, NC).
 Analgesic 37 66
 Mood 11 19.6
Results  Sleep  1  1.8
In all, 52 subjects were included in the study. A  Opioid/Narcotic  0 0
 Supplements/vitamins 30 53.6
total of 56 were originally eligible and under- Use of nonpharmacological
went study baseline procedures. Two subjects treatment
did not complete three weekly dry needling  Exercise 43 76.6
sessions and dropped out for unknown reasons.   Physical Modalities (heat, 32 57
  cold, electrical stimulation)
One subject started new treatments after the  Massage 17 30
first study treatment, and one subject did not  Chiropractic  8 14
have complete follow-­up data for analysis. Table
1 presents the distribution of the descriptive respectively). ROM extension and flexion had
variables and a summary of treatments that not improved. There was a significant change in
subjects had selected for their pain before study side-­bending ROM in the unilateral group only
entry. (P = .001) and a significant improvement in
Table 2 presents the frequencies for the pri- PPT at the treated site in both groups (P = .006
mary outcome in bilateral and unilateral groups, and P = .012, respectively). The baseline and
respectively. There were 41 responders and 11 follow-­up characteristics for pain measurements
non-­responders (P < .001). A conditional power and self-­reports showed a significant reduction
analysis was conducted. Under the current trend in BPI scores (P < .001). There was a significant
of the data, under the hypothetical trend of the reduction in VAS on the treated side in both the
data, and under the null hypothesis, the condi- unilateral and bilateral groups (P < .001), and on
tional power was one, meaning that there was the untreated side only in the bilateral group
no positive probability of a nonsignificant result (P < .001). There was a significant increase in
using the full sample size. the SF-­36 pain subscale score (P = .002) and
Table 3 presents baseline and follow-­up char- a decrease in the POMS tension and mood
acteristics for physical findings, pain, and self-­ scores (P = .012 and P = .013, respectively).
reports. We measured a significant improvement These represented improvements. There was
in rotational asymmetry in both the unilateral significant improvement in the scores of the
and bilateral groups (P = .001 and P = .021, SF-­36 mental health and physical functioning

Table 2. Primary outcome for treated subjects with bilateral and unilateral active trigger points
Bilateral Active Trigger Points Unilateral Active Trigger Points
Baseline Follow-­up Count Baseline Follow-­up Count
Active Active  7 Active Active  4
Active Latent 12 Active Latent 14
Active Normal  6 Active Normal  9

© 2015 American Academy of Physical Medicine and Rehabilitation 47

Dry needling for myofascial pain
Table 3. Baseline and follow-­up characteristics: Physical findings, pain and self-­reported outcomes (mean ± SD)
Characteristic n Baseline Follow-­up P value
Physical finding
  Cervical ROM extension (") 51 73.8 ± 12.8 74.3 ± 12.0 .741
  Cervical ROM flexion (") 51 55.2 ± 11.0 57.1 ± 8.3 .192
  Rotation asymmetry unilateral (") 27   8.1 ± 6.3   3.1 ± 5.4 .001
  Rotation asymmetry bilateral (") 24   5.4 ± 4.4   2.4 ± 3.2 .021
  Side bending unilateral (") 27   5.6 ± 3.8   2.7 ± 2.9 .001
  Side bending bilateral (") 24   5.5 ± 6.4   3.1 ± 3.2 .109
  PPT treated site unilateral (lb) 27   7.6 ± 3.3   9.4 ± 3.7 .006
  PPT treated site bilateral (lb) 24   6.7 ± 3.0   8.4 ± 3.1 .012
Pain scores
 BPI 49   3.4 ± 1.6   2.3 ± 1.9 <.001
  VAS treated side unilateral 27   3.5 ± 2.4   0.9 ± 1.3 <.001
  VAS treated side bilateral 25   3.0 ± 1.4   0.9 ± 1.2 <.001
  VAS untreated side unilateral 27   1.0 ± 1.9   0.4 ± 1.1 .203
  VAS untreated side bilateral 25   2.6 ± 1.2   0.9 ± 1.2 <.001
  SF-­36 pain 50 62.5 ± 18.4 69.3 ± 16.5 .002
Self-­reported outcomes
  POMS confusion 49   0.28 ± 0.39   0.23 ± 0.35 .418
  POMS depression 49   0.11 ± 0.23   0.07 ± 0.18 .151
  POMS fatigue 49   0.77 ± 0.81   0.54 ± 0.69 .056
  POMS tension 49   0.47 ± 0.50   0.28 ± 0.33 .012
  POMS mood 49   0.29 ± 1.91 –0.38 ± 1.79 .013
  POMS vigor 49   1.49 ± 0.94   1.58 ± 0.93 .261
  POMS anger 49   0.15 ± 0.35   0.08 ± 0.27 .12
  SF-­36 general health 50 76.9 ± 19.1 76.8 ± 18.6 .913
  SF-­36 mental health 50 75.9 ± 11.8 79.1 ± 11.4 .017
  SF-­36 physical functioning 50 88.5 ± 14.3 91.4 ± 11.3 .03
  SF-­36 emotional 50 83.4 ± 21.5 88.8 ± 16.3 .051
  SF-­36 physical role 50 85.1 ± 17.0 86.9 ± 16.7 .471
  SF-­36 social functioning 50 87.8 ± 16.9 89.7 ± 15.9 .253
  SF-­36 vitality 50 58.7 ± 17.0 60.7 ± 16.9 .258
  Oswestry Disability Index score 50 10.8 ± 6.0 8.5 ± 7.1 .004
BPI = Brief Pain Inventory; PPT = pressure pain threshold; POMS = Profile of Mood States; ROM = range of motion; SF-­36 = MOS 36-­Item Short-­
Form Health Survey; VAS = verbal analogue scale.

Table 4. Change from baseline on VAS, BPI, and PPT

VAS score BPI score PPT (lb)

Responders -­2.87 ± 0.16 -­1.32 ± 0.22 2.12 ± 0.5

Non-­responders -­1.00 ± 0.30 0.04 ± 0.38 0.85 ± 0.96

Data are least-­squares means ± standard errors of change from baseline of VAS, BPI, and PPT, and are adjusted for baseline, site, gender, age, and exercise
status.
VAS = verbal analogue scale; BPI = Brief Pain Inventory; PPT = pain pressure threshold.

subscales (P = .019 and P = .03, respectively)
and the Oswestry Disability Index scores
(P = .003). The regression model was signifi-
cant for VAS scores (model F = 32.37, P < .001,
R2 = 0.81, n = 52). Baseline values for VAS were
also significant (P <  .001). Other adjustment
variables were not significant. For BPI scores,
the regression model was marginally significant
(model F = 2.36, P = .047, R2 = 0.25, n = 49).
For PPT, the regression model was not sig-
nificant (model F = 2.13, P = .069, R2 = 0.22,
n = 51). Only baseline PPT was significant in
the model.
Table 4 presents the least-­squares means
(standard errors) for change from baseline in
VAS, BPI, and PPT among responders and
non-­responders from the adjusted regression
models. The mean change from baseline in
VAS score was 2.87 ± 0.16 for responders and
-­
1.00 ± 0.30 for non-­responders. The means
were significantly different (P < .001). The
mean change from baseline in BPI score was

48 © 2015 American Academy of Physical Medicine and Rehabilitation


-­1.32 ± 0.22 for responders and 0.04 ± 0.38 for
non-­ responders. The means were significantly
different (P = .002). The mean change from
baseline in PPT was not statistically significantly
different in responders and non-­responders
Discussion
Much has been written about MTrPs and their
possible relationship to MPS (Fricton et al. 1985;
Bron & Dommerholt 2012; Gerwin et al. 2004;
Stecco et al. 2013). The contribution of the
MTrP in the pathogenesis of MPS is an area
of active investigation and has raised important
questions about muscle and fascia in inciting
and perpetuating soft tissue pain (Mense 2003;
Mense et al. 2000; Mense 2010). Debate con-
tinues as to whether the MTrP is necessary for
MPS diagnosis and whether it needs to be the
target of treatment.
The pathogenesis of the MTrP is elusive,
and current explanations about its relationship
to MPS remain incomplete. Trauma, muscle
overload, and muscle overuse have been cited as
etiologic agents, with trauma being one of the
leading contenders (Stecco et al. 2013; Mense
2003). Tissue injuries result in the release of
noxious substances that bind to, sensitize, and/
or activate nociceptors. This leads to the trans-
mission of signals that indicate tissue damage
and inflammation, and may set up persistent
pain states (Mense et al. 2000). The relative con-
tributions of the central and peripheral nervous
systems in generating and perpetuating pain
are not yet fully understood, although there is
preliminary evidence for pain dysregulation in
MPS (Sluka et al. 2001; Niddam et al. 2007; Ge
et al. 2011). Disrupted descending inhibition in
individuals with chronic musculoskeletal pain
may lead to a muscle pain complaint, irrespec-
tive of peripheral tissue damage (Ge et al. 2011).
To explore relationships between MTrPs and
MPS, we reasoned that if treatment directed
at the MTrP was shown to improve myofas-
cial pain (Tekin et al. 2013; Kietrys et al. 2013;
Baldry 1995; Dommerholt 2011; Cummings
& White 2001; Lucas et al. 2009), we could
measure changes in pain and MTrP status
at the same time. We elected to use a single
MTrP in a defined anatomical area and to use
© 2015 American Academy of Physical Medicine and Rehabilitation
L. H. Gerber et al.
experienced ‘calibrated’ examiners to study
it carefully. The examiners participated in a
test of interrater reliability that demonstrated
no statistically significant differences between
their clinical assessments. This approach would
provide an opportunity to assess pain related to
the MTrP and would allow us to determine the
relationship, if any, between pain reduction and
MTrP status change. We used objective meas-
ures of the MTrP (palpation and size) (Ballyns
et al. 2011), and correlated these with patient
self-­reports of pain, mood, health status, and
disability. One review article addressing the reli-
ability of palpation suggests that it varies widely
(Lucas et al. 2009). However, none of these nine
studies used examiners who had demonstrated
interrater reliability and performed evaluation
and treatment on a single muscle.
Our major findings were that pain reduction,
as measured using all three of the pain assess-
ments, is significantly correlated with change
in the MTrP status as determined by MTrP
palpation from active to latent or normal (no
palpable nodule) after dry needling. We noted
that there was a clinically significant improve-
ment in pain scores (a drop of ≥2) on the VAS
(Todd 1996). Treatment was correlated with
a significant, clinically relevant reduction in
pain compared with baseline values, as well as
improvements in mood and function. Needling
was also positively correlated with a significant
increase in cervical ROM attributable to the
upper trapezius (i.e., side bending and rotation).
There was a significant decrease in asymmetry
between the left and right sides after treatment.
We are aware of some concerns about the
reliability of pain measures and therefore used
three instruments. One of these, the PPT, is an
instrumented measure. All showed significant
reduction after treatment.
The mean baseline measurement of pain for
subjects with unilateral MTrP was VAS 3.5 (±
SD 2.4), which is considered moderate pain
(Collins et al. 1997). The group with bilateral
MTrPs had VAS score of 3.0 (± 1.4), indicat-
ing mild pain. Some clinicians may not wish
to treat MTrP and myofascial pain if the level
is mild. The decision to treat often depends
upon several factors, including frequency and
49
Dry needling for myofascial pain
persistence, intrusion into daily activities, and
peak pain levels. The measure at baseline was
determined at a moment in time, and the entry
criterion was reportable pain; the clinical severity
did not determine whether the research subject
was to receive dry needling. After criteria were
met, our primary outcome was a change in pain
score, and the change was significant.
Appropriate measurement is critical to ensure
the validity and reliability of this clinical study.
Pain evaluations are not objective assessments,
and consensus about which pain assessment
tools are best to use for this study group has not
been reached. This study used standard, system-
atically applied, and frequently used evaluations
to assess patients with MPS. We used the BPI
and algometry to assess the level and nature of
pain. Although both the BPI and VAS measured
pain intensity at the time of administration,
the BPI also measured the impact of pain on
daily functions, pain relief, pain quality, and the
patient’s perception of the cause of the pain.
The statistical analysis showed that VAS and
BPI adjusted means scores were significantly
different after treatment, and that PPT scores
were not. In the regression model, VAS was
significant, BPI was marginally significant, and
PPT was not. We support the use of the VAS
for assessment of treatment of MPS. PPT may
be useful and has been shown to be reliable in
evaluating MPS, but it lacks sensitivity (Park
et al. 2011). In this study, we have defined a
positive response to treatment as a statistically
significant decrease in pain from baseline and
improvement in MTrP status. The change was
also clinically significant, that is a decrease in
two points on the VAS.
We recommend a careful, systematic, and
comprehensive approach to the evaluation
of patients with MPS. This approach should
include objective measures of cervical spine
ROM, trigger point palpation and self-­reports
of pain, fatigue, mood, disability and health
status, which have been shown to be sensitive
to change and to provide important informa-
tion about the impact of MPS on issues of
importance to patients.
One review examined the level of evidence
for dry needling in MPS (Kietrys et al. 2013).
50 © 2015 American Academy of Physical Medicine and Rehabilitation
The authors identified the data as level 1a
because the reports were randomized, placebo-­
controlled trials. The outcomes were self-­reports,
did not include objective measures, and did not
link response to trigger point status.
To the best of our knowledge, this is the first
report to demonstrate that there is a significant,
contemporaneous change in the level of both
pain and the status of the MTrP after dry
needling. Dry needling is likely to provide pain
reduction and resolution of the a-­ MTrP. We
report that dry needling has a significant effect
in reducing pain as measured by VAS, BPI, and
PPT; and in decreasing disability as measured
by the Oswestry Disability Index in individuals
with MPS and a-­MTrPs. A randomized, placebo-­
controlled, blinded trial is the gold standard and
is required to definitively demonstrate effective-
ness. Our group is planning to conduct such a
trial.
There are some limitations to this study. MPS
has long been considered a local or regional pain
syndrome, implying that the inciting factors for
pain are local rather than resulting from central
sensitization (Treaster et al. 2006; Fernández-­de-­
las-­Peñas & Dommerholt 2014). This study did
not address this question. The results of this
study do not answer questions about patho-
genesis, etiology, and relative contributions of
various regulatory mechanisms for developing
or resolving MPS or MTrPs. However, the data
advance our understanding of this complex
syndrome by linking improvement in symptoms
with objective measures of MTrP and establish
a relationship between MTrP and MPS.
Subjects for this study were recruited on a
university campus, and possibly represent an
atypical cross-­ section of people with MPS.
Nonetheless, computer-­based activity is used by
most of our subjects and has been reported to
be a significant risk factor for developing MPS
(Hoyle et al. 2011).
Finally, this study was not a randomized,
placebo-­controlled, blinded clinical trial; hence
it cannot prove effectiveness. The treating clini-
cians also evaluated the subjects, creating poten-
tial bias despite their being experienced and
standardizing their technique (Chu & Schwartz
2002; Kalichman & Vulfsons 2010). The two

treating physicians evaluated and treated the
subjects based on scheduling convenience, and
any bias introduced as a result cannot be ruled
out. Not all subjects responded with a twitch
to the dry needling. Some investigators believe
that this is an important part of the therapeutic
effect (Tekin et al. 2013; Chu & Schwartz 2002).
The elicitation of the twitch response did
not distinguish the responders from the non-­
responders in this study.
This study also had advantages. The study
was a carefully conducted, systematic prospec-
tive study using valid instruments designed
to measure soft tissue pain and disability to
which objective measures were also applied.
This permitted us to develop a properly sized
and designed clinical effectiveness trial for dry
needling using self-­ reported outcomes and
objective measures.
Conclusion
A 3-­ week course of dry needling had a sig-
nificant effect on pain reduction in MPS. Pain
reduction was significantly related to change in
trigger point status from active (spontaneously
painful) to latent or resolution. Importantly,
pain reduction was significantly correlated with
improvement in cervical spine side bending and
rotation, in patient self-­reports of improved
physical and emotional well-­ being and mood;
and reduction in disability.
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Disclosure
L. H. G. Center for the Study of Chronic Illness and
Disability, George Mason University, CCID, 4400
University Dr, Fairfax, VA 22030. Address cor-
respondence to: L. H. G.; email: ngerber1@gmu.edu
Disclosure: nothing to disclose
J. S. Rehabilitation Medicine Department, Clinical
Center, National Institutes of Health, Bethesda, MD
Disclosure: nothing to disclose
W. R. Department of Statistics, George Mason University,
Fairfax, VA Disclosure: nothing to disclose
K. A. Center for the Study of Chronic Illness and
Disability, George Mason Uni-­versity, Fairfax, VA
Disclosures related to this publication: grant from
National Institutes of Health
D. T. Department of Bioengineering, George Mason
University, Fairfax, VA Disclosure: nothing to disclose
P. O. Department of Bioengineering, George Mason
University, Fairfax, VA Disclosure: nothing to disclose
J. H. Rehabilitation Medicine Department, Clinical
Center, National Institutes of Health, Bethesda, MD
Disclosure: nothing to disclose
N. T. Rehabilitation Medicine Department, Clinical
Center, National Institutes of Health, Bethesda, MD
Disclosure: nothing to disclose
S. S. Department of Bioengineering, George Mason
University, Fairfax, VA Disclosures related to this
publication: grant support for study from National
Institute of Arthritis and Musculoskeletal and Skin
Diseases, National Institutes of Health
Disclosures outside this publication: travel support for
workshop presentation from Canadian Academy of
Physical Medicine and Rehabilitation, International
Symposium of Ultrasound for Regional Anesthesia and
Pain, and American Academy of Physical Medicine &
Rehabilitation
Funding for this study was provided by the National
Institute of Arthritis and Musculoskeletal and
Skin Diseases, National Institutes of Health (grant
#1R01AR057348).
Peer reviewers and all others who control content have
no relevant financial relationships to disclose.
Submitted for publication September 20, 2014; accepted
January 18, 2015.

This is an open-­ access article distributed under the
terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by/4.0/). The
use, distribution or reproduction in other forums is per-
mitted, provided the original author(s) and the copyright
owner are credited and that the original publication in
this journal is cited, in accordance with accepted aca-
demic practice. No use, distribution or reproduction is
permitted which does not comply with these terms.
© 2015 American Academy of Physical Medicine and Rehabilitation
L. H. Gerber et al.
This article is reprinted from PM&R, the official
Journal of the American Academy of Physical Medicine
and Rehabilitation (AAPM&R). Original publication:
Gerber L., Shah J., Rosenberger W., et al. (2015)
PM&R 711–720. http://dx.doi.org/10.1016/j.
pmrj.2015.01.020
53
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 55–59

research

A case report on the effect of Sham

acupuncture
V. L. R. Zotelli, C. M. Grillo & M. da Luz Rosário de Sousa
Piracicaba Dental School, University of Campinas, Piracicaba, Brazil

Abstract
When nausea, an extremely unpleasant symptom, is experienced during dental treatment, it
generates disorders and obstacles for both the patient and the professional, compromising
the good quality of dental care. Clinical studies have confirmed the antiemetic action of
acupuncture and shown its use for the treatment of nausea and vomiting. In the scientific
literature there are several recent studies that address the placebo effect of acupuncture. The
aim of this manuscript is to present a case report of a 46-­year-­old Caucasian male patient,
who had severe symptoms of nausea while undergoing dental care. Treatment with sham
acupuncture (acupuncture simulation) obtained a positive result of nausea prevention. We
will discuss three possible hypotheses concerning this result: (1) there was action of De Qi;
(2) high expectations of the patient; and (3) association with specific learned response. The
patient in this case report received nonpenetrating sham acupuncture at acupoint Neiguan
(PC 6), which resulted in the complete remission of nausea during an intra-­oral impression-­
taking procedure, but it is unclear whether the placebo effect was triggered by the action of
De Qi, the high expectations of the patient, an association with a learned response, or by
the interaction of all these factors.
Keywords: acupuncture, antiemetics, dentistry, nausea, placebo.

Introduction The trigger factors for nausea may be of

When nausea, an extremely unpleasant symp-
tom, is experienced during dental treatment,
it can hinder or even prevent the necessary
dental procedures from being performed. This
especially applies when intra-­ oral impressions
are being taken, as this is capable of inducing
vomiting. This clinical situation generates disor-
ders and obstacles for both the patient and the
professional, jeopardizing the quality of dental
care.
Correspondence: Vera Lucia Rasera Zotelli, Community
Dentistry Department, Piracicaba Dental School,
University of Campinas, Avenida Limerira, 901
Areão, CEP 13 414–903, Piracicaba, Sao Paulo,
Brazil (email: vera.rasera@hotmail.com)
local, systemic, anatomical, psychological, and
iatrogenic origin (Kumar et al. 2011). Thus,
the etiology of nausea is considered to be
multifactorial.
According to Western medicine, nausea is the
conscious recognition of excitation of a brain
area that is associated with the vomiting (eme-
sis) center (Ku & Ong 2003). Nausea is defined
as a “stimulated, protective, reflex response to
prevent material from entering the mouth or
oropharynx. Gagging stimuli can be physical,
auditory, visual, olfactory, or psychologically
mediated and the muscular contractions caused
may result in vomiting” (Dickinson & Fiske
2005). According to traditional Chinese medi-
cine, nausea and vomiting are explained as an

© 2016 Medical Association of Pharmacopuncture Institute 55

A case report on the effect of sham acupuncture
upward Qi (energy) of the stomach in rebellion
and the PC 6 acupuncture point has the effect
of redirecting the Qi counterflow (Somri et al.
2001).
The antiemetic action of acupuncture has
been confirmed in clinical studies that have
shown its use in the treatment of nausea and
vomiting in postoperative chemotherapy and
pregnancy (Vickers 1996; Kim et al. 2011; NIH
Consensus Conference 1998).
Acupuncture is defined as the insertion of
needles into specific body parts (acupoints) for
prevention, therapy, or maintenance of health
(Sari & Sari 2010; NIH Consensus Conference
1998). The acupuncture theory is based on
the existence of patterns of energy flow (Qi)
through the body that are essential for health;
and imbalances in the flow of this energy are
responsible for diseases.
A clinical study has shown that acupuncture
with actual penetration into the skin was more
effective in treating pain than a similar treat-
ment using a placebo needle at the same point
(Kleinhenz et al. 1999). This suggests that the
actual penetration of the needle is an important
component of acupuncture treatment (White
et al. 2001).
In the scientific literature there are several
recent studies that address the placebo effect in
acupuncture (Enck et al. 2010; Liu & Yu 2011;
Colagiuri & Smith 2012). Placebo effects are the
responses obtained in clinical trials, when some
substances or procedures that are designed to
serve only as control conditions in the study,
produce some effect on the results. These
indirect effects produced by biologically inert
substances or by inactive procedures are con-
sidered within the term “placebo effect” (Oken
2008).
The aim of this manuscript is to present a
case report of a patient with the symptom of
nausea during dental care, who was treated with
sham acupuncture (acupuncture simulation) and
obtained a positive result.
Case report
This article describes the case of a patient, a
46-­year-­old Caucasian man, who had a severe
symptom of nausea while undergoing dental
56
care. This patient participated in a larger, double
blind clinical study with 33 volunteers, divided
into two groups (test and control), to evaluate
the control of nausea by acupuncture. The study
was conducted at the Piracicaba Dental School,
State University of Campinas (Unicamp), in
Piracicaba, São Paulo, Brazil.
The inclusion criteria were as follows: vol-
unteer patients, adults of both sexes, aged 18
to 85 years, who reported previous unpleasant
nausea during dental procedures, hindering or
preventing the dental treatment from being
carried out properly. The exclusion criteria
were: pregnant patients and patients who had
been taking antiemetic drugs or medications
that could produce nausea. The test group
(n = 17) was treated with real acupuncture at
acupoint Neiguan (PC 6), using an acupuncture
needle size 30 mm × 0.25 mm, (Qizhou Brand,
Wujiang City Shenli Medical & Health Material
Co. Ltd, Wujiang, Suzhou, Jiangsu, China). The
control group (n = 16) were treated with sham
nonpenetrating acupuncture (noninvasive) at
the same acupoint, using the Streitberger sham
needle (Asia-­ Med brand, Asia-­ med GmbH
& Co. KG, Pullach, Germany), measuring
0.30 mm × 30 mm. This needle is retractable and
has a blunt tip, therefore, it does not penetrate
the skin; however, when it touches the skin, the
patient feels a stinging sensation (Streitberger &
Kleinhenz 1998). A circular intermediate device
(ring), 1 cm in diameter, made of resin, was
used to fix the sham needle in the acupuncture
point and this device was also used in the real
acupuncture group. This device was attached to
the skin by means of hypoallergenic micropo-
rous adhesive tape, 0.12 cm wide, (Nexcare; 3M,
Sumaré, São Paulo, Brazil). When the sham nee-
dle is inserted through the micropore it touches
the skin but does not penetrate. In both groups,
the needles were inserted by the same experi-
enced acupuncturist. To evaluate the degree
of nausea, two maxillary impressions were
taken (the first was taken before acupuncture
and the second after acupuncture) and in both
groups, nausea was assessed by the researcher.
Neither the researcher nor the patient knew to
which group the patient belonged. To ensure
this, once the needles were inserted the patient
© 2016 Medical Association of Pharmacopuncture Institute

was covered with a disposable blue sheet and
remained covered until they were discharged.
Nausea was evaluated by the researcher after
the first impression was taken (without acu-
puncture) and after the second impression
(with acupuncture). Nausea was evaluated using
the gagging severity index (GSI) and gagging
prevention index (GPI), indexes proposed in
the study by Fiske and Dickinson (2001). The
GSI was used in the first impression (without
acupuncture) to assess the degree of nausea
severity, which ranged from I (mild nausea and
controlled by the patient) to V (very severe
nausea, impossible to perform the treatment).
The GPI was used in the second impression
(after real or sham acupuncture) to evaluate the
degree of nausea prevention, i.e., the effective-
ness of the treatment. This scale ranged from
I (reflex controlled, successful treatment) to V
(severe nausea reflex, being unable to perform
any treatment). The volunteers’ expectation of
nausea reduction through acupuncture was also
evaluated using a 5-­point Likert scale with the
following options: no, I do not think so, maybe,
I think so, yes. For more details, see the 2014
article by Zotelli et al.
In this study, acupuncture with real needle
insertion was shown to be more effective
than sham acupuncture in controlling nausea.
However, one particular positive outcome of a
patient from the sham acupuncture group was
highlighted. This patient reported symptoms
of nausea in almost all the dental procedures
to which he had previously been submitted in
his life. He said he had felt nausea for over
35 years. He also stated that prior to this study
he had been submitted to an acupuncture treat-
ment during a dental cleaning procedure and
had a very positive result. Due to this previous
experience, he believed acupuncture would also
effectively control his nausea problem when
impressions were taken. Thus, the patient
had highly positive expectations regarding the
treatment.
When the first impression was taken (with-
out acupuncture), the patient had a maximum
degree of nausea severity (GSI = 5), which com-
pletely hindered the procedure. However, when
the second impression was taken (after sham
© 2016 Medical Association of Pharmacopuncture Institute
V. Zotelli et al.
acupuncture), he had a maximum degree of
nausea prevention (GPI = 1), with full control
of the nausea, which allowed the impression-­
taking procedure to be performed without any
difficulty.
When he was asked whether he had felt any
sensation at the site of needle insertion, the
patient reported he felt “a small electric shock,
a slight tingling sensation, and had no adverse
effect.”
When the data was collected and the results
were being tabulated, to our surprise, we
observed that in the random draw, this patient
had been allocated to the control group, in
which there was only a simulation of acupunc-
ture without needle penetration, thus, this result
was unexpected. Therefore, we consider that it
was a placebo effect of acupuncture.
Discussion
According to scientific literature, there are some
hypotheses to try to explain the placebo effect
that occurred: that is to say, full control of nau-
sea during intra-­oral impression taking, despite
the fact that the above-­ mentioned patient
underwent a pseudo-­ needling. We will discuss
the three possible hypotheses: (1) there was
action of De Qi; (2) high expectations of the
patient; and (3) association with specific learned
response.
The first hypothesis would be explained by
De Qi which is described as a specific sensa-
tion that presents itself as soreness, numbness,
warmth, heaviness, or distention around the area
where a needle is inserted. It can be radiated
along the path of the meridian to which the
acupuncture point belongs (Chernyak & Sessler
2005). Moreover, it may also present itself as the
feeling of a mild electric shock (Lu et al. 2000).
Most acupuncturists consider the phenomenon
of De Qi to be crucial to achieve the effective-
ness of acupuncture (Chernyak & Sessler 2005).
From the perspective of neurophysiology, the
complex pattern of De Qi sensations suggests
involvement of a wide spectrum of myelinated
and unmyelinated nerve fibers, particularly the
slower conducting fibers in tendinomuscular
layers (Hui et al. 2007). Thus, because De Qi is
generated by stimulation of the nervous system,
57
A case report on the effect of sham acupuncture
it can be said that the noninvasive needles pro-
duce a minimum De Qi effect because they do
not penetrate the skin and therefore cause mini-
mal activation of neural receptors (Liang et al.
2013). In our study, De Qi with the placebo
needle may have been caused by the pressure of
the circular resin device and fixing adhesive, psy-
chological influences, or by pressure on the pain
receptors in the skin (Streitberger & Kleinhenz
1998). Note that in the same control group,
another patient also complained of a tingling
sensation but showed no improvement in the
symptom of nausea. Thus, in our view, it is not
clear that the De Qi effect was responsible for
the improvement in nausea of the highlighted
patient.
The second hypothesis is explained by the
influence of the patient’s high expectations in
relation to the action of acupuncture, which may
have affected the outcome because although the
patient believed he had received real acupunc-
ture, he did not actually know which group
he was in. Some research findings support the
essential role of beliefs and expectations regard-
ing the effectiveness of acupuncture. One study
found that the effectiveness of acupuncture
was significantly associated with the highest
expectations (Linde et al. 2007). However, in our
main study (Zotelli et al. 2014), the Spearman
correlation test was applied and there was no
correlation between the expectations of patients
and the control of nausea in either of the two
groups. In addition, it is worth noting that in
our main study, some patients who had also
reported high expectations regarding treatment
had no significant improvement in nausea.
Therefore, from our point of view, it is unclear
whether high expectations were or were not a
decisive factor in the outcome.
The third hypothesis is based on the asso-
ciation with positive memories previously
experienced by the patient. According to the
literature, past negative experiences or beliefs
learned by the patient himself, or heard about
from a friend or relative are also factors that
increase the possibility of occurrence of nausea
(Ramsay et al. 1987). Based on this concept,
taking the opposite direction (i.e., the associa-
tion with a previous positive experience), could
58
elicit a placebo effect to control nausea. The
central nervous system is the primary site and
mediator of the physiological basis of placebo
effects, through its role in learning and memory,
its effects on sensory, motor, and autonomic
pathways, and its effects on the immune and
endocrine systems. There are individual charac-
teristics that predispose people to be more or
less receptive to certain stimuli; the interaction
between the learned associations of a clinical
situation and the particular biology of a person
produces a response. The response may be a
basic physiological process such as modulation
of sensory processing, release of neurotransmit-
ters, or alterations in the hypothalamic-­pituitary-­
adrenal axis and the immune system activity.
The placebo response can also be a complex
process, including change in mood, motivation,
or cognitive alterations (Oken 2008). We believe
that this hypothesis of an association with
the previous positive acupuncture experience
is the most consistent with the placebo effect
observed, however, this was also not clear in
our study.
Greene et al. (2009) pointed out that clini-
cians need to be aware of the powerful impact
of the placebo effects that are embedded in
therapeutic interactions.
For the patient in this case report, nonpen-
etrating sham acupuncture at acupoint Neiguan
(PC 6) resulted in complete remission of the
symptom of nausea during intra-­ oral impres-
sion taking.
This effect may not refer to a placebo effect,
but instead to an effect comparable with that
of acupressure, probably caused by the pressure
of the micropore tape and the resin ring that
were used to support the sham needle, in addi-
tion to having the needle touch the skin. These
may be sufficient stimuli to trigger a good
effect on patients who are more receptive to
acupuncture.
Nevertheless, it is unclear whether the placebo
effect was triggered by the action of De Qi, the
patient’s high expectations, or because of an
association with a learned response (memory),
or by the interaction of all these factors. More
specific studies to elucidate placebo effects are
needed.
© 2016 Medical Association of Pharmacopuncture Institute

Disclosure Statement
The authors declare that they have no conflicts
of interest and no financial interests related to
the material of this manuscript.
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This is an Open-­ Access article distributed under the
terms of the Creative Commons Attribution Non-
Commercial No Derivatives License (CCBYNCND),
which permits unrestricted non-commercial use, distribu-
tion, and reproduction in any medium, provided the
original work is properly cited.
This article was originally published in the Journal
of Acupuncture and Meridian Studies. Original publi-
cation: Zotelli V., Grillo C., and M. da Luz Rosário
de Sousa (2016) A Case Report on the Effect of Sham
Acupuncture. Journal of Acupuncture and Meridian
Studies, 9(5):275–278. https://doi.org/10.1016/j.
jams.2016.07.005
59
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 61–67

case reports

The use of acupuncture for the treatment of

lateral elbow tendinopathy
R. Medland
Private Practice, Launceston, UK

Abstract
Lateral elbow tendinopathy (LET) is typified by pain over the lateral epicondyle of the
humerus. The onset is usually gradual and can be caused by repetitive use of the arm or
acute trauma (Farren 2012). There is some evidence to suggest that acupuncture is of ben-
efit in the treatment of LET in the short term only. This case study is based on a healthy
42-­year-­old male who presented to the physiotherapy clinic with a seven-­month history of
left lateral arm pain. He was treated for four sessions using a combination of acupuncture,
taping, stretches and eccentric loading exercises for the common extensor origin. The Quick
Dash outcome measure was used to subjectively measure physical function and symptoms.
Extensor carpi radialis brevis (ECRB) muscle strength was used as an objective measure at
each session. There was an improvement in pain levels, an increase in ECRB strength and
an improvement in the Quick Dash quality of life score by the end of the final session.
However, it is recognised that due to limitations of the study including the use of a single
sample, more research is indicated.
Keywords: acupuncture, elbow, lateral elbow tendinopathy, pain

Introduction of tennis players will suffer an episode of LET

Lateral elbow tendinopathy (LET), also known
as tennis elbow, is typified by pain over the
lateral epicondyle of the humerus. Pain may
also be felt further down the arm towards the
wrist (Kraft 2017). The onset is usually gradual
and can be caused by repetitive use of the arm
or acute trauma (Farren 2012). Lateral elbow
pain is associated with repeated gripping and/
or wrist extension activities. Such actions are
prevalent in racquet sports as well as certain
occupations including bricklaying, carpentry and
keyboard work. Unaccustomed activities and
repetitive wrist movements are thought to be
the main cause. It is believed that up to 50%
Correspondence: Rachel Medland, Private Practitioner,
Physio Fix, Launceston, UK (email: rachelvaughan1@
hotmail.com).
due to altered biomechanics and the frequent
use of the backhand stroke (Bandaru 2017).
The annual incidence of tennis elbow in
general practice is between four and seven cases
per 1000 patients, with a peak in patients aged
35–54 years. A typical episode can last from
six months to 24 months, with the majority of
patients (89%) recovering within 12 months.
It is a chronic condition that can be challeng-
ing to treat in the primary care setting (Farren
2012).
Lateral elbow tendinopathy is primarily a
tendinitis, although muscles and bones of the
epicondyle joint may also be involved (Murtagh
1988). The ECRB tendon is the most com-
monly implicated tendon. The extensor digito-
rum may also be involved if the middle finger
extension test is more provocative than the

© 2019 Acupuncture Association of Chartered Physiotherapists 61

Acupuncture for the treatment of Lateral Elbow Tendinopathy
wrist extension test (Bruckner & Khan 2017).
Typically, the primary pathology is tendinosis
of the ECRB tendon 1-­2 cm distal to its attach-
ment on the lateral epicondyle. The tendons
are relatively hypovascular and it is theorised
that this hypovascularity may predispose the
tendon to hypoxic tendon degeneration (Walrod
2017). Microscopic examination of the tendons
shows an excess of fibroblasts and blood ves-
sels. Microscopic partial tears can develop with
continued use (Bruckner & Khan 2017).
No single treatment is totally effective in the
management of LET. A number of different
therapies are currently used to treat LET includ-
ing electrotherapy, exercise, ice, manual therapy,
bracing, corticosteroid injections, analgesics and
surgery.
According to the latest NICE guidelines,
acupuncture is not recommended for tennis
elbow because evidence on its effectiveness is
limited and conflicting. Comparisons between
studies were limited by the different forms of
acupuncture used (NICE 2015).
Farren (2012) conducted a review of the
literature on needle acupuncture in the treat-
ment of lateral epicondylitis. Three randomized
controlled trials (RCT’s) were chosen for the
review because they were deemed to be of high
quality using the five-­point Jadad score (Jadad
et al. 1996). Farren’s study concluded that “the
literature available at present on acupuncture for
lateral epicondylitis does not allow for a defini-
tive conclusion to be drawn” (2012, p. 31). This
was due to discrepancies in the points used, the
frequency and duration of treatments as well as
the outcome measures used.
However, there are some studies that sup-
port the use of acupuncture for pain relief
in the short term when compared with sham
acupuncture. Fink et al. (2002) evaluated the
effects of real and sham acupuncture in
patients with chronic epicondylitis. 23 patients
received real acupuncture versus 22 patients
who received sham acupuncture. Patients were
reassessed at two weeks, two months and one
year. There were significant improvements in
pain levels at the two weeks follow up for the
real acupuncture group compared to the sham
acupuncture group. However, these differences
62
were no longer significant at the two month and
one year follow ups. It is noted that this study
involved a small number of subjects, which is a
limitation.
Green et al. (2002) conducted a large-­ scale
literature review of the effectiveness of acu-
puncture for lateral elbow pain. They searched
MEDLINE, CINAHL, EMBASE, SCISEARCH
and the Cochrane Clinical Trials database from
1966 to 2001. Four small RCT’s formed the
basis of the review. One trial demonstrated that
needle acupuncture was more likely to result in
overall improvement for the patient compared
to the placebo in the short term. No significant
differences were found in the longer term
after three or 12 months (Haker 1990). Green
et al. (2002) concluded that there is insufficient
evidence to either support or refute the use of
acupuncture in the treatment of lateral elbow
pain. No benefit lasting more than 24 hours
following treatment was demonstrated in the
review.
Trinh et al. (2004) also carried out a large-­scale
review of acupuncture for the alleviation of lat-
eral epicondyle pain. They concluded that there
is strong evidence to suggest that acupuncture
is effective in the short term, supporting the
previous research by Green et al. (2002).
In summary, the research appears to suggest
that acupuncture is of benefit in the treatment
of lateral epicondyle pain in the short term only.
Case description
The case study is based on a 42-­year-­old gentle-
man who presented to the physiotherapy clinic
with a seven-­month history of left lateral elbow
pain. The patient was diagnosed with tennis
elbow by an osteopath four months previously.
The effects of treatment by the osteopath were
short lived. The patient is extremely health
conscious and is reluctant to take medication or
to have a cortico-­steroid injection. Therefore, it
was decided to try a course of acupuncture.
Acupuncture was suggested as a way of
reducing pain, utilising local, segmental effects
and central effects. It was also recommended to
encourage healing in a relatively avascular area,
thus facilitating compliancy with the patient’s
HEP.
© 2019 Acupuncture Association of Chartered Physiotherapists

The Quick Dash outcome measure was used
to measure the patient’s symptoms and physical
function. It was chosen because it is a reliable,
valid tool which is responsive to change (Farren
2012).
Clinical Diagnosis: Left lateral elbow tendinopa-
thy involving ECRB.
R. Medland
Patient’s Goals: To be pain free, to strengthen
left upper limb, to regain full function in the left
upper limb, specifically to be able to carry 20 kg
comfortably whilst at work.
Following assessment, a proposed treatment
plan was discussed with the patient including
the use of acupuncture. The local effects of
needling were discussed along with the potential

Table 1. Current situation.

Patient and present condition Pleasant 42-year-old male presenting with left lateral elbow pain. Patient has a kyphotic lordotic
posture type.
History of present Patient reports a 7-­month history of left lateral elbow pain. Pain of gradual onset, intermittent in
condition nature. Pain is described as an intense dull ache and is aggravated by holding a trowel in the left
hand whilst plastering. This action requires wrist extension to spread the plaster across the surface.
The pain began during a period of intense plastering in March this year and has remained the same.
There is no history of trauma. Patient consulted his GP who prescribed anti-­inflammatories. Patient
sought help from an osteopath locally who diagnosed tennis elbow. Moderate improvements were
made with localized treatment by the osteopath, however these were short lived. Patient has tried
wearing an epiclasp at work with no effect.
24-­hour picture: Occasional sleep disturbance when lying on elbow.
AM-­Pain on waking 4/10 VAS
Through Day-­Pain increases to 6/10 VAS, depending on activity.
Aggravating Factors: Plastering, holding the trowel, lifting with left upper limb e.g. 10 kg slate in left
hand
Easing Factors: Rest, analgesics, ice.
Past medical history Nil of note
Drug history Nil of note
Social history Patient is a self-­employed, full time builder who is otherwise fit and well. Patient enjoys mountain
biking, swimming and riding motor bikes in his spare time. Patient has continued with all ADL’s
despite left elbow pain.
Clinical assessment and Patient has an athletic build. Small postural scoliosis to the left. Right scapula elevated by °7.
examination findings Increased tone right upper trapezius compared to the left. Left ear forward of shoulder, slight
chin poke. Shortened pectoral muscles, narrowing at front of chest. Cervical spine and GH jt were
cleared and pain free.
Increased muscle bulk left extensor carpi radialis brevis (ERCB) on the left compared to the right.
Tender+ over ERCB, 1” away from elbow.
Full AROM elbow, increased pain with combined extension of the left elbow and left wrist.
Patient’s pain reproduced with resisted wrist extension 6/10 VAS, increasing to 8/10 VAS with
resisted middle finger extension. Reduced strength ECRB with muscle testing 3+/5 compared to
the right.

Table 2. Session 1.
Outcome measure pre-­Rx: pain 6/10 VAS. Pain middle finger extension test. Taping to offload ECRB tendon and Extensor Digitorum,
stretches to ECRB given as part of the HEP. Sterile technique used with sharps bin and cotton buds next to couch for any bleeding.

Date of Acupuncture Angle of Depth of

treatment Point Needle Size needle needle Time De Qi

5/10/17 LI 4 bilaterally 30mm P 1cm 10 minutes, Moderate

LI 11 40mm P 2cm Limited STU De Qi achieved
LI 10 40mm P 1cm
TE 5 30mm P 1cm Patient had strongest
response at LI 11.
Rx position: °7 upright sitting with left UL supported on a pillow.
Post Rx: Patient felt ‘quite relaxed’ immediately after Rx. No adverse effects noted. Pain 3/10 VAS. Minimal pain with middle finger extension test.
Considerations for next Rx: Patient responded well to first acupuncture Rx with no adverse effects. Therefore, increase the number of points used. Consider
Ll 15 and TE 14, ’eyes of the shoulder.’

© 2019 Acupuncture Association of Chartered Physiotherapists 63

Acupuncture for the treatment of Lateral Elbow Tendinopathy
Table 3. Session 2.
Patient stated that his elbow feels “pretty good” overall. However, patient lifted 10 kg of lead at work this week with his left UL which
aggravated the problem. Patient also reports an ache over the dorsal aspect of the left wrist this week.
Outcome measure pre Rx-­4/10 VAS. Pain with middle finger extension test. Taping to offload ECRB tendon and Extensor Digitorum,
stretches to ECRB given as part of the HEP.
Sterile technique used with sharps bin and cotton buds next to couch for any bleeding.

Date of Acupuncture Angle of Depth of

treatment Point Needle Size needle needle Time De qi

12/10/17 LI 4 bilaterally 30mm P 1cm 10 minutes, Strong De

LI 11 40mm P 3cm Limited M Cti achieved all
LI 10 40mm P 2cm points.
TE 5 30mm P 2cm
LI 15 40mm Oblique 3cm
downwards
TE 14 40mm Oblique 2cm
downwards

Rx position: °7 upright sitting with left UL supported on a pillow.

Post Rx: Patient reported that he felt hot during treatment and appeared slightly sweaty after the insertion of TE 5. Patient also described a deep ache in
the left shoulder after the insertion of TE 5, prior to the insertion of LI 15 and TE 14 (eyes of the shoulder). Patient stated that he is pain free post Rx.
No pain with the middle finger extension test.
Considerations for next Rx: Patient appears to have responded well to Rx again this week with some strong central effects. Consider LI 9 as patient
describing an ache slightly distal to LI 10.

Table 4. Session 3.
Patient reports 50% improvement in his symptoms.
Outcome measure pre-­Rx: pain 3/10 VAS. Pain middle finger extension test. No reports of left wrist pain this week. Taping to offload
ECRB tendon and Extensor Digitorum, stretches to ECRB given as part of the HEP.
Sterile technique used with sharps bin and cotton buds next to couch for any bleeding.

Date of Acupuncture Angle of Depth of

treatment Point Needle Size needle needle Time De Qi

19/10/17 LI 4 bilaterally 30mm P 1cm 10 minutes, Strong De Qi

LI 11 40mm P 3cm strong stim achieved all points.
LI 10 40mm P 2cm
TE 5 30mm P 2cm
LI 15 40mm Oblique 3cm
downwards
TE 14 40mm Oblique 2cm
downwards
LI 9 40mm P 1cm

Rx position: °7 upright sitting with left UL supported on a pillow.

Post Rx: Patient stated that he is pain free post Rx. Objectively, patient pain free with middle finger extension test.
Considerations for next Rx: Patient has tolerated the session well therefore increase the treatment time. Consider LI 14 for segmental effects.

risks and side effects. The patient was issued
with an acupuncture handout from the clinic,
providing an overview of the treatment modal-
ity. The patient was cleared of all contraindica-
tions and precautions for acupuncture as listed
in the course manual. The clinic to date does
not have a detailed contraindications and pre-
cautions form. The clinic form is a more general
screening form and does not include questions
specific to acupuncture such as infected, thin,
fragile skin, needle phobia, pacemaker and
previous malignancy. The patient gave verbal
and written consent to the use of acupuncture.
Rationale for point selection and
treatment dose
According to a study by Greenfield & Webster
(2002), a thorough cervical spine examination
and radial nerve tension tests are needed when
assessing the elbow joint as symptoms can be
referred from the neck. The patient was cleared

64 © 2019 Acupuncture Association of Chartered Physiotherapists


Table 5. Session 4.
Patient stated that he was pain free for 24 hours following the last treatment. The pain was very minimal for the following two days
before gradually building again.
Outcome measure pre-­Rx: pain 3/10 VAS. Pain middle finger extension test. No reports of left wrist pain this week. Taping to offload
ECRB tendon and Extensor Digitorum, stretches to ECRB given as part of the HEP.
Sterile technique used with sharps bin and cotton buds next to couch for any bleeding.
Date of Acupuncture
treatment Point Needle Size
26/10/17 LI 4 bilaterally 30mm
LI 11 40mm
LI 10 40mm
TE 5 30mm
LI 15 40mm
TE 14 40mm
LI 9 40mm
LI 14 40mm
Rx position: °7 upright sitting with left UL supported on a pillow.
Post Rx: Patient pain free. Objectively, patient pain free with middle finger extension test and left wrist extension test. Patient has full pain free ROM at the
left elbow. ECRB strength test 4+/5 on the left, 5/5 on the right.
of the above and did not have any neurological
symptoms. It was therefore decided to treat the
problem from a local perspective. The mecha-
nism of pain was also considered prior to treat-
ing the patient. The patient’s pain was thought
to be myogenic, nociceptive in nature. It was
also chronic rather than acute, the patient being
symptomatic for seven months. Nociceptive pain
has been demonstrated to respond positively to
acupuncture (Lundeberg et al. 1988). Bradnam’s
layering technique for acupuncture check list
was used to aid point selection (Bradnam 2007.)
Five needles were used for the initial treat-
ment as it was the patient’s first experience
of acupuncture. White et al. (2008) defined
acupuncture as adequate if it consisted of at
least four points. Ceccherelli et al. (2010) looked
at the relevance of the number of needles with
respect to cervical myofascial pain. The same
therapeutic outcome was achieved with both
five and 11 needles. Nine needles were therefore
used for this case study.
The large intestine (LI) meridian was chosen
initially as the patient’s pain was located along
the C6 dermatome which complements this
meridian.
LI 4 was used bilaterally during the initial
treatment as it is a master point for pain, tar-
geting the descending inhibitory pain control
system. It is suggested that needling adductor
© 2019 Acupuncture Association of Chartered Physiotherapists
R. Medland
Angle of Depth of
needle needle Time De Qi
P 1cm 20 min, strong Strong De
P 3cm stim Qi achieved all
P 2cm points.
P 2cm
Oblique 3cm
downwards
Oblique 2cm
downwards
P 1cm
P 2cm
pollicis LI 4 stimulates the hypothalamus to
produce endorphin which acts on the midbrain.
Endorphin activates the descending tracts.
Serotonin is released by one pathway descend-
ing from the mid brain. Serotonin, in turn
stimulates the dorsal horn to release met-­
enkephalin which inhibits the substantia gelati-
nosa which inhibits pain. A second descending
pathway releases noradrenaline at every dorsal
horn throughout the spine, inhibiting the pain
pathway. The patient also complained of poor
sleep and tiredness, the result of becoming
a recent father. LI 4 was thus selected for its
calming effects. Haker et al. (2000) looked at
the effect of needling LI 4 on sympathetic and
parasympathetic activities in healthy subjects.
They reported an increase in parasympathetic
activity which caused relaxation and calm in
their subjects. Triple Energizer (TE) 5 was also
used during the initial treatment to enhance the
effects of LI 4. TE 5 is also a strong autonomic
point. TE 5 was also chosen to influence the
posterior interosseous nerve which supplies the
affected tissue (Bradnam 2007).
The patient presented with localised lateral
elbow pain. A major goal of the case study was
to promote healing in the damaged tissue. LI
11 and LI 10 and LI 14 were therefore selected
for their local and segmental analgesic effects.
It is theorised that needling local to the site of
65
Acupuncture for the treatment of Lateral Elbow Tendinopathy
injury will cause the release of neuropeptides.
Neuropeptides cause an increase in local blood
supply which can aid healing in the hypovascular
tendon. Stein et al. (2001) reported an increase in
local endorphins a few days after acupuncture.
Due to the chronicity of the condition, it was
decided that local needling to the area would be
acceptable.
Research also supports segmental needling
for patients with lateral elbow tendinopathy
(Trinh et al. 2004). The segmental effects of LI
11, LI 10 and LI 14 causes inhibition of the
nociceptive pathway at the same level in the
dorsal horn. This occurs through the release
of encephalin which blocks the transmission
of pain in the substantia gelatinosa cells (White
et al. 2008).
The patient reported an improvement in pain
and function at the start of the second treat-
ment. LI 15 and TE 14 (eyes of the shoulder)
were therefore added for their segmental anal-
gesic effects. The depths of the needles were
increased during session two as the patient had
no adverse effects from the initial session.
LI 9 was added during the third session
to enhance the local and segmental analgesic
effects. Bradnam (2007) proposes using more
needles in the segment for chronic nociceptive
pain.
Discussion
A favourable outcome was achieved follow-
ing the final treatment session in the clinic.
Subjectively, the patient was pain free, resisted
left wrist extension test and the middle finger
extension test were also pain free. This com-
pares to a pain score of 6/10 on the VAS at
the start of treatment 1. Resisted tests to the
left wrist and middle finger also reproduced
the patient’s pain before the first acupuncture
treatment. The Quick Dash outcome measure
was used to measure physical function and
symptoms in the patient at the start and at the
end of the case study. The Quick Dash was
chosen as studies have found it to be a reliable
and valid patient reported outcome measure
(Leblanc et al. 2014). The Quick Dash is a 19
item questionnaire which covers symptoms and
66
the ability to perform certain tasks. A higher
final score indicates greater disability. The
patient scored 30/100 before the treatment
sessions began. This figure dropped to 13/100
following the final session, indicating an overall
improvement. It is interesting to note that at
the start of session four, the patient reported
that he had remained pain free for 24 hours
following the last session of acupuncture.
A limitation of the study is that only four
treatments were carried out. This was due to
time constraints and annual leave. It would have
been interesting to progress the sessions by
adding more points including LU 3, LU 4 and
LI 8 for segmental analgesia. Another limita-
tion of the study is the limited experience of
the therapist. I was reluctant to add too many
needles due to time issues. I am still rather slow
at locating the points and time constraints of
the clinic meant that fewer needles were used. It
is hoped that with more experience, I will work
with greater efficiency and confidence. It is
recognised that as a condition progresses from
acute to chronic, more needles can be added
into a segment (Lundeberg 1998).
It is also important to consider the combined
effects of therapy on the patient’s symptoms.
The patient was managed with taping, stretches
and a HEP of eccentric loading exercises for the
common extensor origin. It is therefore difficult
to evaluate the effectiveness of the acupuncture
as it was not used in isolation, another limita-
tion of the study.
A hand grip dynamometer would have been
a nice way to objectively measure grip strength.
Unfortunately, such equipment was not avail-
able to use in the clinic. Muscle testing of
ECRB strength at the start of the study was
3+/5 compared to 4+/5 at the end of the
last session, an improvement. However, a hand
grip dynamometer is perhaps a more objective
measurement of strength.
It was interesting to note that at the start of
the final session, the patient reported that he
had remained pain free for a period of 24 hours
following the last treatment. Symptoms then
built up again during the course of the week.
This subjective report corresponds to findings
from key pieces of research including the Green
© 2019 Acupuncture Association of Chartered Physiotherapists

et al. (2002) large scale literature review which
also concluded that there was no benefit lasting
more than 24 hours following acupuncture for
lateral elbow pain. It would be nice to review
the patient again in three months, six months
and 12 months to see the long-­term effects of
acupuncture.
It is clear that more research is needed into
the effects of acupuncture in the treatment
of lateral elbow pain, including studies with
adequate sample sizes in properly designed
RCT’s. It is recognised that this study was based
on a single subject, another limitation.
References
Bandaru S. (2017) Case Study – Tennis Elbow. [WWW
document.] URL www.aacp.org.uk .
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Bruckner P. & Khan K. (2017) Clinical Sports Medicine (5th
ed.) McGraw Hill Education, Sydney.
Ceccherelli F., Gioioso L., Casale R. & Giuseppe G.
(2010) Neck pain treatment with acupuncture: does the
number of needles matter? Clin J Pain 26 (9), 807–12.
Farren E. (2012) Literature Review: Needle acupuncture
in the treatment of lateral epicondylitis. Journal of
the Acupuncture Association of Chartered Physiotherapists,
Spring, 25–31.
Fink M., Wolkenstein E., Luennemann M., et al. (2002)
Chronic epicondylitis: effects of real and sham
acupuncture treatment: a randomised controlled
patient and examiner blinded long term trial. Forsch
Komplementarmed Klass Naturheilkd. 9 (4), 210–5.
Green, S et al. (2002). Acupuncture for lateral elbow pain.
The Cochrane Library. https://www.cochranelibrary.com/
cdsr/doi/10.1002/14651858.CD003527
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Greenfield C. & Webster V. (2002) Chronic lateral epi-
condylitis: survey of current practice in the outpatient
departments in Scotland. Physiotherapy 88 (10), 578–594.
Haker E., Egevist H. & Bjerring P. (2000) Effect of
sensory stimulation (acupuncture) on sympathetic and
parasympathetic activities in healthy subjects. J Auton
Nerv Syst 79(1), 52–9.
Haker E. and Lundeberg T. (1990) Acupuncture treat-
ment in epicondylalgia: a comparative study of two
acupuncture techniques. Clinical Journal of Pain Sep;
6 (3):221–6.
Jadad A.R, Moore R.A, Carroll D., et al. (1996) Assessing
the quality of reports of randomized clinical trials: is
blinding necessary? Controlled Clinical Trials 17 (1), 1–12.
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nis elbow. Medical News Today DOI: 175848
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Validation of quick dash outcome measure in breast
cancer survivors for upper extremity disability. Arch
Physical Medical Rehabilitation 95(3), 493–498.
Lundeberg T., Hurtig T., Lundeberg S. & Thomas M.
(1988) Long term results of acupuncture in chronic
head and neck pain. Pain Clinic 2 (1), 15–31.
Lundeberg T. (1998) The physiological basis of acupuncture.
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Conference, Christchurch, New Zealand, August 1998.
Murtagh J. (1988) Tennis elbow. Aust Fam Physician 17
(90–1), 94–5.
Stein C., Machelska H., Binder W. & Schafer M. (2001)
Peripheral Opioid Analgesia. Curr Opin Pharmacol 1(1),
62–5.
Trinh K. V., Phillips S. D., Ho E. & Damsma K. (2004)
Acupuncture for the alleviation of lateral epicondyle
pain: a systematic review. Rheumatology 43, 1085–1090.
Walrod B. J. (2017) Lateral Epicondylitis. Medscape Aug,
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Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 69–79

case report

Whiplash associated disorder

Z. Krejcova
Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK

Abstract
Whiplash is a relatively common injury that is usually a result of sudden acceleration-­
deceleration force, most commonly from motor vehicle accidents. Whiplash is often ignored
or mistreated due to lack of understanding of the condition, but fortunately it is not a
life-­threatening injury. This injury can lead to a more severe chronic condition associated
with psychosocial symptoms, therefore it is important to facilitate the patient’s recovery at
the early stage.
This study discusses the use of acupuncture for the pain in 32-year-old female patient
with four weeks history of whiplash injury, which affected her physical and psychosocial
wellbeing as a result of the car accident.
The patient was treated with five sessions of acupuncture and manual therapy with the
goal to reduce pain, improve mobility of cervical spine and facilitate her return back to all
activities of daily living. Following the acupuncture treatment the patient noticed significant
improvement in her symptoms, reduced pain and enhanced functional levels to the ability of
living her life comfortably again.
Keywords: acupuncture, needling, physiotherapy, whiplash associated disorder.

Introduction work productivity, as well as personal cost, is

Whiplash Associated Disorder (WAD) is a com-
mon, potentially disabling and costly condition,
that usually occurs as a consequence of a motor
vehicle accident. Recent data indicates that rapid
improvement in symptoms occurs in the first
3 months post injury, with a little if any change
after this period, that up to 50% of injured
people will not fully recover (Carroll et al. 2008),
and the associated secondary cost of whiplash
injury, including medical care, disability, lack of
Correspondence: Zuzana Krejcova, Northamptonshire
Healthcare NHS Foundation Trust, Highfield Clinical
Care Centre, MSK Physiotherapy Department,
Cliftonville Road, Northampton, Northamptonshire,
NN1 5BD (email: krejcova.zuzana@mail.com)
substantial (Crouch et al. 2006).
Motor vehicle crashes can lead to bony or
soft tissue damage, which in turn may result in
a variety of clinical manifestations. The primary
symptom is neck pain, but frequently reported
can be headache, arm pain, paraesthesia, diz-
ziness and cognitive difficulties (Spitzer et al.
1995).
Bioengineering studies have demonstrated
perturbations in segmental movement, includ-
ing intersegmental hyperextension, S-­ curve
formation and differential acceleration of the
upper cervical spine after rear-­ end crashes,
therefore any cervical spine structure may
sustain injury following whiplash (Cusick et al.
2001).

© 2019 Acupuncture Association of Chartered Physiotherapists 69

Whiplash Associated Disorder
Table 1. Quebec Task Force
WAD I Neck complaint without musculoskeletal signs.
WAD II Neck complaint with musculoskeletal signs.
WAD III Neck complaint with musculoskeletal signs and
neurological deficit.
WAD IV Neck complaint with musculoskeletal signs,
neurological deficit, fracture or dislocation.
Classification systems of whiplash injury
have been proposed in order to assist in the
early assessment, prognosis and management.
Quebec Task Force (QTF) is the most com-
monly used classification system (Spitzer et al.
1995). The condition is defined into four groups
(see Table 1).
One of the most common clinical character-
istics of patients with WAD is either movement
loss or decreased cervical range of movement
(Dall’Alba et al. 2001). The most prospective
studies have shown that all whiplash-­ injured
patients have a loss of cervical active range of
movement from soon after injury, that persists
in those who do recover (Sterling et al. 2003b).
Altered patterns of muscle recruitment in
both the cervical spine and the shoulder girdle
regions have been shown to be features of
chronic WAD (Nederhand et al. 2002; Jull et al.
2004). These findings suggest that the driver of
such motor changes may be more the nocicep-
tive input rather than injury mechanism itself
(Fernàndez-­de-­las-­Peñas et al. 2016).
Morphological changes to cervical spine
muscles have also been demonstrated in people
with chronic whiplash using magnetic resonance
imaging (MRI) which showed presence of fatty
infiltrate in both deep and superficial cervi-
cal extensors and flexor muscles in WAD, the
highest in deeper muscles, the rectus capitis
posterior minor, major and multifidi (Elliot et al.
2006).
Dysfunction of sensorimotor control is also
a feature of both acute and chronic WAD
(Fernàndez-­de-­las-­Peñas et al. 2016). Loss of
balance and disturbed neck influenced eye move-
ment control are present in patients with chronic
WAD, therefore individuals with sensorimotor
disturbances report dizziness in association with
neck pain (Treleaven et al. 2005a, 2005b).
Psychosocial distress – anxiety, depression
and behavioural abnormalities such as fear of
70
movement – is often present in acute or chronic
WAD cases, with most people showing some
distress regardless of pain and disability levels
(Sterling et al. 2003c). Some studies indicate
association of psychological distress with non-­
resolving pain and disability (Fernàndez-­de-­las-­
Peñas et al. 2016).
In traditional Chinese medicine (TCM),
whiplash encompasses pain and discomfort or
weakness in one or both sides of the head, cer-
vical and upper thoracic region, and the nature
of pain can lead to acute stagnation of Qi and
blood in the local channels and collaterals of
the above areas (ITCM 2012).
According to White et al. (2008), acupuncture
is known for several effects:
• Local effects to promote healing in the area
where the needle is inserted;
• Segmental effects by stimulating Aö fibres
in skin, when the action potentials travel up
the nerve directly to its particular segment in
the spinal cord, where they tend to depress
the activity of the dorsal horn and reduce its
response to painful stimuli;
• Extrasegmental effects, when the action
potentials produced by the acupuncture
needle then travel from the dorsal horn up
to the brainstem, where they stimulate the
body’s own pain-­ suppressing mechanism.
The brain can inhibit pain by descending
nerves, which release some neurotransmitters
at every segment of the spinal cord;
• Central regulatory effects;
• lnactivating myofascial trigger points.
Carlsson (2002) reviewed several mechanisms
of therapeutic acupuncture:
• Peripheral events that might improve tissue
healing and give rise to local pain relief
through axon reflexes, the release of neuro-
peptides with trophic effects, dichotomizing
nerve fibres and local endorphins;
• Spinal mechanisms, for example gate-­control,
long-­
term depression, propriospinal inhibi-
tion and the balance between long-­ term
depression and long-­term potentiation;
• Supraspinal mechanisms through the
descending pain inhibitory system, diffuse
noxious inhibitory control (DNIC), the
© 2019 Acupuncture Association of Chartered Physiotherapists

sympathetic nervous system and the hypo-
thalamic pituitary adrenal axis;
• Cortical, psychological, “placebo” mecha-
nisms from counselling, reassurance and
anxiety reduction.
Therefore, acupuncture helps to reduce neck
pain by stimulating nerves located in muscles
and other tissues, which leads to release of
endorphins and other neurohumoral factors and
changes the processing of pain in the brain and
spinal cord (Pomeranz 1987; Zhao 2008).
Needles activate Ab and C-­ afferent nerve
fibres in muscle, and sends signals to the spinal
cord, where dynorphin and enkephalins are
released. Afferent pathways continue to the
midbrain, triggering excitatory and inhibitory
mediators in the spinal cord. These ensure
release of serotonin and norepinephrine onto
the spinal cord, which leads to pain transmis-
sion being inhibited both pre and postsynapti-
cally in the spinothalamic tract. These signals
reach the hypothalamus and pituitary, triggering
release of adrenocorticotropic hormones and
beta-­endorphin (Pomeranz 1987).
The anti-­inflammatory effect of acupuncture
is enhanced by promoting release of vascular
and immunomodulatory factors. The inser-
tion of acupuncture needles initially stimulates
production of beta-­ endorphins, calcitonin
gene related peptide (CGRP) and substance
P, leading to further stimulation of cytokines.
Frequently applied low dose treatment of acu-
puncture could provoke a sustained release of
CGRP with anti-­inflammatory activity, without
stimulation of pro-­inflammatory cells (Kavoussi
& Ross 2007; Zijlstra 2003). There is evidence
from an experimental study on rabbits in which
acupuncture stimulation was directly observed
to increase diameter and blood flow velocity
of peripheral arterioles, enhancing local micro-
circulation, which improved stiffness and joint
mobility (Komori et at. 2009).
Patient Profile
32-year-old female patient, stay-­
home mother,
normally very active with daily activities and
sport. Four weeks ago, she was involved in a car
© 2019 Acupuncture Association of Chartered Physiotherapists
Z. Krejcova
accident while waiting stationary for upcoming
traffic, she was hit by another vehicle from the
rear.
History of present condition
History of four weeks persistent pain and
ache across cervical spine, more prominent on
right side with radiation of the pain into right
shoulder blade, restricting cervical range of
movement, disturbing sleeping and limiting daily
activities. Aggravating factors: carrying children,
heavy lifting, maximal movements in cervical
spine, leaning on right side and driving. Eases:
rest, heat, painkillers.
Past medical History
Hypothyroidism.
Drug history
Levothyroxine, Naproxen, Paracetamol.
Social history
Stay at home mother looking after 3 children
aged 2, 5 and 8. Regularly attends exercise classes
and does many sport activities with family.
Patient expects overall improvement in her
symptoms within next five to six weeks in
reducing pain level, improving range of move-
ment in cervical spine, improving ADL, sleep-
ing and feeling comfortable during all free time
activities.
Clinical diagnosis
Whiplash Associated Disorder Grade II.
Treatment
Prior to acupuncture treatment the patient
had completed an acupuncture pre-­ treatment
checklist which indicated no contraindication or
precaution to treatment. Patient gave verbal and
written consent for treatment and was informed
about all natural side effects and adverse reac-
tions of acupuncture.
The goal of the treatment was to reduce
the patient’s pain, improve mobility in cervical
spine and to feel comfortable during all daily
activities including sleeping. For treatment of
acute neck pain, the patient received five weekly
71
Whiplash Associated Disorder
Table 2. Subjective markers.
Pain and VAS scale
Headache
Sleeping
Driving
Lifting/carrying
Painkillers dosage
8/10 when aggravated, sharp and shooting pain radiating into right shoulder blade.
6/10 constant dull ache.
Intermittent suboccipital, temporal and frontal, every 2 to 3 h, always appears when symptoms are
aggravated.
Unable to get comfortable.
Disturbed four to five times during night.
Only necessary short distances. Uncomfortable due to pain and restricted movements. Anxiety and
stress reported.
Difficult carrying 2-­year-old son. Unable to do household chores involving lifting.
Naproxen taken every 6 h.
Paracetamol taken as needed when headache occurs.

Table 3. Objective markers.

Observation Patient is sitting with head in anteflexion, and shoulders elevated, tensed posture due to pain.
Visible hypertonus in upper trapezius bilaterally and prominent C7.
Scapula alatae, mild thoracic hyperkyphosis.
Range of movement Cervical flexion 75%, extension full, side flexion left
50°/», right 60%, rotation left 60%, right 70%. Movements more painful towards right side, pulling
sensations when moving left.
Palpation Tenderness over right trapezium more than left, right cervical paraspinals, suboccipital extensors,
levator scapulae right and rhomboidei bilaterally.
Special tests Spurting, dermatomes/myotomes negative.
Full muscles strength. No red flags.

Table 4. Point selection summary.

Treatment session 1 2 3 4 5
Position of patient Supine Prone Side lying Side lying Prone
unaffected side affected side
Selected points LI 4 LI 4 LI 4 LI 4 BL 10
LR 3 BL 10 SI 9 HT 7 BL 11
HT 7 BL 11 SI 10 HT 3 GV 14
LU 7 GV 14 SI 11 PC 6 GB 21
SP 6 GB 20 SI 12 GV 14 SI 15
GB 21 SI 13 GB 20 SI 14
SI 14
SI 15
Targets Analgesia Analgesia Analgesia –­ Analgesia Analgesia
Neck stiffness Neck stiffness scapula/shoulder/arm/ Anxiety Neck stiffness
Headache UFT neck/upper back Depression Headache
Dizziness Hypertonus Weakness Stress Dizziness
Insomnia Headache Neck stiffness Insomnia
Stress Anxiety Headache
Anxiety Sleeping

sessions of acupuncture in duration from 15
to 20 min, as at least 10 min is required for
endorphins production, with maximal release
after 20 min (Wilkinson & Faleiro 2007).
Acupuncture treatment was combined with
deep soft tissue massage (DSTM), mobilisation
techniques, home exercises and advices on pain
management and lifestyle activities.
For treatment, single use needles sizes from
13 mm × 0.22 to 40 mm × 0.22 were used, with
needle stimulation carried out two or three times
per session in five min intervals to achieve De
Qi.
Acupuncture points selection
and rationale
The first treatment goal was to reduce pain and
inflammation through strong distal acupuncture
points. Large Intestine (LI) 4 acupuncture point
is known for its strong analgesic effect, master
point of pain and relaxation (AACP 2018), and

72 © 2019 Acupuncture Association of Chartered Physiotherapists


therefore was used bilaterally to impact on neck
pain. From traditional Chinese acupuncture
(TCA), LI 4 and Liver (LR) 3 bilaterally are cre-
ating ‘four gates’ to stimulate the higher centres
of the brain to achieve a pain-­relieving response
(Kaptchuk 2002). Heart (HT) 7 was selected to
help the patient with her anxiety and stress, in
TCA used also for insomnia (AACP 2018). Lung
(LU) 7 is indicated for stiffness of the neck
and headache, and during first treatment was
needled on right side, where the pain was more
intense. Treatment with this acupuncture point
is supposed to help the lungs to receive more
air, thus ‘breathe easy’ and have the strength
to move on to new experiences, therefore was
found very useful for patient after traumatic
experience such as car accident. Spleen (SP) 6
was used bilaterally for its strong central effect.
Prior to first acupuncture treatment, DSTM
was carried out for 10 min to right paraspinal
muscles of cervical spine and upper trapezius.
Patient was provided with a program of home
exercises, self-­management techniques and pos-
tural advices.
Distal drainage point LI 4 was used bilater-
ally to support analgesic effect and to reduce
inflammation during second treatment. To
achieve positive local effects of acupuncture by
promoting healing in the area where the needle
is inserted (White et al. 2008), further points
during second session were selected in the
places where patient reported most of the pain.
Bladder (BL) 10 and BL 11 were needled bilater-
ally to alleviate patient’s suboccipital headaches
and migraines, alongside with Governor Vessel
(GV) 14, which supports analgesic effect in cer-
vicothoracic junction (AACP 2018). Gallbladder
(GB) 20 and GB 21 were used bilaterally to
support analgesic effect, to reduce neck stiff-
ness, anxiety and to improve sleeping (AACP
2018).
For the third treatment session, one distal
point (LI 4) was selected to support analgesic
effect and more local acupuncture points were
chosen to impact on right sided neck, shoulder
and shoulder blade pain. Local points were cho-
sen to follow Small Intestine (SI) yang meridian,
which is known for its effect for upper limb
pain conditions, posterior shoulder pain and
© 2019 Acupuncture Association of Chartered Physiotherapists
Z. Krejcova
cervical referrals (AACP 2018). These points
were selected as they most closely reflected the
patient’s region of pain. Prior to acupuncture,
DSTM and mobilisation techniques were car-
ried out for 10 min to reduce muscle tension,
help to relieve pain and restore joints mobility
in the affected area.
The goal of the fourth treatment was to
impact on patient’s stress, anxiety and disturbed
sleeping by using acupuncture points from the
Heart meridian. In TCA HT 3 together with
HT 7 relieve anxiety, depression and stress
(AACP 2018), therefore these points were used
on affected sided as well as Pericardium (PC)
6 known for its positive effect for insomnia
(AACP 2018). Local points GV 14 and GB 20
were used to support analgesic effect around
the needle insertion.
Finally, during the fifth treatment session, the
combination of local points in the main area of
complaints was used. Due to patient’s positive
response on acupuncture, points were needled
bilaterally and treatment was carried out for
20 min with sufficient time for patient to rest
following the acupuncture. Prior to the last
treatment session, manual treatment was carried
out for 10 min to upper trapezius bilaterally.
Treatment outcome
After five sessions within five weeks, the patient
showed positive effects of acupuncture in
combination with manual treatment and self-­
management techniques (cold/heat, postural
advices). Treatment was set up in such a way,
that every session was slightly different in terms
of desirable treatment effect, positioning of
patient and selection of acupuncture points.
There were positive effects not only on physical
symptoms but on psychosocial factors following
the traumatic event. Patient reported improved
sleeping, reduced anxiety and stress. Symptoms
haven’t changed immediately after treatment ses-
sions, but towards the end of the sessions these
changes were more significant. Due to the use
of manual therapy, it is difficult to determine
whether acupuncture itself had the effect on
patient’s symptoms, but certainly the treatment
combination was beneficial. Subjective and
73
 Table 5. Details of treatment sessions.

Selected points Needling technique Dose Rx response/Adverse effects

74
Treatment 1
LI 4 Perpendicular, 1 cm depth, B/L, Time: 20 min, Needle De Qi elicited in all points, the most intense from needle insertion and from subsequent
Lift and thrust, twist and turn, stimulated 3 ×. stimulation of LI 4 B/L.
25  mm × 0.22 needle. LI 4 left sharp on twisting stimulation – needle slightly withdrew and sensation settled down.
LR 3 Perpendicular, Time: 20 min, Dull ache on LR 3 stimulation, settled down after a while.
1 cm depth, B/L, Needle stimulated 2 ×. HT 7 very shallow insertion due to positioning of the hand (on ulnar side to maintain safe
Lift and thrust, twist and turn, needling technique of LI 4 and to allow hand to relax).
25  mm × 0.22 needle. LU 7 very mild ache on stimulation.
HT 7 Perpendicular, Time: 20 min, SP 6 tingling sensation on stimulation.
Whiplash Associated Disorder

Shallow 0.5 cm depth, B/L, Needle stimulated 3 ×. Small amount of bleeding on LI 4 left removal.
Lift and thrust, twist and turn, Patient felt very relaxed post treatment.
13  mm × 0.22 needle. No immediate response.
LU 7 Obliquely, Time: 20 min, No adverse reactions observed or reported.
0.5 – 1 cm depth, right, Needle stimulated 2 ×.
Twist and turn, free needling.
13  mm × 0.22 needle.
SP 6 Perpendicular, Time: 20 min,
1 – 2.5 cm depth, B/L, Needle stimulated 3 ×.
Lift and thrust, twist and turn.
25  mm × 0.22 needle.
Treatment 2
LI 4 Perpendicular, Time: 20 min, Second session – patient reported
1 cm depth, B/L, Needle stimulated 3 ×. slightly reduced pain level and headaches. Better sleep after first treatment.
Lift and thrust, twist and turn, De Qi elicited in all levels, strongest on BL 11 and GB 21 on the right side and bilaterally on
25  mm × 0.22 needle. LI 4 around the needle.
BL 10 Oblique, Time: 20 min, Sharp sensations on BL 11 insertion, right more than left, settled down after a while.
0.5 – 1 cm depth, B/L, Needle stimulated 3 × Tingling around GV 14 radiating towards suboccipital area.
Lift and thrust, twist and turn, GB 20 and BL 10 mild dull feeling on stimulation, no response after a while.
25  mm × 0.22 needle. GB 21 and BL 11 stronger dull ache on stimulation.
BL 11 Oblique, Time: 20 min, Redness around GV 14, also BL 11 and GB 21 B/L.
0.5 – 1 cm depth, B/L Needle stimulated 3 ×. Immediate response: patient reported reduction of pain and tension in upper trapezius
Lift and thrust, twist and turn, bilaterally. Relaxed post treatment, slightly light headed.
25  mm × 0.22 needle. No adverse reactions observed
GV 14 Perpendicular, Time: 20 min, or reported.
1 cm depth, B/L, Needle stimulated 2 ×.
Twist and turn,
25  mm × 0.22 needle
GB 20 Oblique, Time: 20 min,
1 cm depth, B/L, Needle stimulated 3 ×
Lift and thrust, twist and turn,
25  mm × 0.22 needle.
GB 21 Perpendicular, Time: 20 min,
1 cm depth, B/L Needle stimulated 3 ×.

© 2019 Acupuncture Association of Chartered Physiotherapists

Lift and thrust, twist and turn.
25  mm × 0.22 needle. Continued/
 Table 5. (Continued)

Selected points Needling technique Dose Rx response/Adverse effects

Treatment 3
LI 4 Perpendicular, Time: 15 min, Needle Patient reported reduced neck pain since second treatment
1 cm depth, B/L, stimulated 3 ×. a week ago, but residual dull ache in right shoulder and shoulder blade.
Lift and thrust, Continued improvement in symptoms overall, improved range of movement in cervical spine,
25  mm × 0.22 needle. only restricted maximal left side flexion and right rotation – 90% of full range of movement.
SI 9 Perpendicular, Time: 15 min, Needle Reported reduced use of painkillers and improved sleeping following two previous sessions.
2 cm depth, right, stimulated 3 ×. De Qi elicited in all levels, mainly SI 13, SI 14 and SI 15.
Lift and thrust, twist and turn, No response on SI 9 after a minute, mild tingling on stimulation.
25  mm × 0.22 needle. Redness around SI 12 and SI 13.
SI 10 Perpendicular, Time: 15 min, Small amount of bleeding on SI 12 removal.
1 – 2.5 cm depth, right, Needle stimulated 3 ×. LI 4 on right side with tingling sensations all through the sessions.
Lift and thrust, twist and turn, No adverse reactions observed or reported.
25  mm × 0.22 needle. Immediate response: slightly reduced pain, patient felt energized rather than relaxed.
SI 11 Perpendicular, Time: 15 min,
1 – 1.5 cm depth, right, Needle stimulated 3 ×.
Lift and thrust, twist and turn,
25  mm × 0.22 needle.
SI 12 Oblique, Time: 15 min,
1 – 2 cm depth, right, Needle stimulated 3 ×.
Lift and thrust, twist and turn,

© 2019 Acupuncture Association of Chartered Physiotherapists

25  mm × 0.22 needle.
SI 13 Oblique, Time: 15 min,
1 – 2 cm depth, right, Needle stimulated 3 ×.
Lift and thrust, twist and turn,
25  mm × 0.22 needle.
SI 14 Oblique, Time: 15 min,
1 – 2 cm depth, right, Needle stimulated 3 ×.
Lift and thrust, twist and turn,
25  mm × 0.22 needle.
SI 15 Oblique, Time: 15 min,
1 – 2 cm depth, right, Needle stimulated 3 ×.
Lift and thrust,
25  mm × 0.22 needle.
Treatment 4
LI 4 Perpendicular, Time: 20 min, Needle Forth session – patient reported
1 cm depth, left, stimulated 3 × relief from shoulder/shoulder blade pain. Continued improvement in symptoms – only
Lift and thrust, twist and turn, minimal restriction in ROM to left side flexion in cervical spine. Residual but intermittent
25  mm × 0.22 needle. headaches.
HT 7 Perpendicular, Time: 20 min, De Qi elicited in all levels from subsequent stimulation, the most intense on LI 4 and HT 7.
Shallow 0.5 cm depth, right, Needle stimulated 2 × HT 3 without response after a minute, very mild dull ache on stimulation.
Lift and thrust, twist and turn,

75
Z. Krejcova

13  mm × 0.22 needle. Continued/

 Table 5. (Continued)

76
Selected points Needling technique Dose Rx response/Adverse effects

HT 3 Perpendicular,
1 – 2 cm depth, right,
Lift and thrust, twist and turn,
25  mm × 0.22 needle.
PC 6 Perpendicular,
1 – 2 cm depth, right,
Lift and thrust, twist and turn,
13  mm × 0.22 needle.
Time: 20 min, PC 6 sharp on insertion, tingling on stimulation, settled down after a while.
Needle stimulated 2 ×. GV 14 mild tingling radiating into suboccipital area.
GB 21 needled on contralateral side with mild numbness response initially, withdrew and
stimulated with tingling sensations, settled down after a while.
Time: 20 min, Redness around HT 3, GV 14.
Needle stimulated 3 × No adverse reactions observed or reported.
No immediate response. Patient felt relaxed.
Whiplash Associated Disorder

GV 14 Perpendicular, Time: 20 min,

1 cm depth, B/L, Needle stimulated 3 ×.
Twist and turn,
25  mm × 0.22 needle.
GB 21 Perpendicular, Time: 20 min,
1 cm depth, left, Needle stimulated 3 ×
Lift and thrust, twist and turn.
25 mm × 0.22 needle.
Treatment 5
BL 10 Oblique, Time: 20 min, A week after treatment four – patient reported only intermittent pain, improved sleeping,
0.5 – 1 cm depth, B/L, Needle stimulated 3 ×. reduced headaches and no restrictions in range of movement. Some improvement in
Lift and thrust, twist and turn, psychological symptoms – reduced anxiety when driving.
25  mm × 0.22 needle. De Qi was elicited in all levels. Redness around GV 14. BL 11, GB 21 and SI 15.
BL 11 Oblique, Time: 20 min, Tingling to suboccipital region from BL 10.
0.5 – 1 cm depth, B/L Needle stimulated 3 ×. SI 14 sharp on insertion on right side, settled down after a while.
Lift and thrust, twist and turn, Patient felt very relaxed during treatment, comfortable lying prone, feeling sleepy.
25  mm × 0.22 needle. No adverse reaction observed or reported.
GV 14 Perpendicular, Time: 20 min, Immediate effect: no pain reported post treatment. Reduced tension in upper trapezius. Easier
1 cm depth, B/L, Needle stimulated 3 ×. ROM in cervical spine post manual therapy.
Twist and turn,
25  mm × 0.22 needle
GB 21 Perpendicular, Time: 20 min,
1 cm depth, B/L, Needle stimulated 3 ×.
Lift and thrust, twist and turn
25  mm × 0.22 needle
SI 15 Oblique, Time: 20 min,
1 – 2 cm depth, right, Needle stimulated 3 ×.
Lift and thrust, twist and turn
25  mm × 0.22 needle
SI 14 Oblique, Time: 20 min,
1 – 2 cm depth, right, Needle stimulated 3 ×
Lift and thrust, twist and turn,
25  mm × 0.22 needle

© 2019 Acupuncture Association of Chartered Physiotherapists


Table 6. Subjective markers.
Pain and VAS scale
Headache
Sleeping
Driving
Lifting/carrying
Painkillers dosage
Z. Krejcova
3–4/10 intermittent dull ache mainly when lifting/carrying a child and/or lying on right side for
long period of time, no radiation of the pain.
None.
Comfortable, occasionally stiff in the morning.
Able to drive all usual distances. Hasn’t tried long distance driving yet.
Able to lift and carry, aware of very heavy lifting as this could aggravate her symptoms.
No medications taken.

Table 7. Objective markers.

Observation Visibly improved posture comparing to first treatment session. Head is slightly in anteflexion
which could be normal for patient due to present thoracic hyperkyphosis and slight scapula alatae,
shoulders are not elevated, more relaxed.
Range of movement Full, pulling sensations on maximal left side flexion.
Palpation Mild tenderness over right trapezius.
Special tests Spurting, dermatomes/myotomes negative. Full muscles strength.

objective markers after five treatment sessions
changed (see Tables 6 and 7.)
Conclusion and discussion
This case study presents successful use of acu-
puncture following whiplash injury to cervical
spine. The use of acupuncture in combination
with manual therapy and self-management
techniques for neck pain, facilitated the patient’s
recovery, helping to improve pain level, range
of movement and psychological symptoms,
which are common after trauma caused by
the car accident. The patient was very anxious
about her persistent pain, unable to do her daily
activity, struggling to get comfortable in bed,
therefore was happy to receive acupuncture and
manual treatment to return to her day to day life
as soon as possible. However, due to the use of
manual therapy alongside the acupuncture, it is
impossible to determine whether the achieved
effect was down to the one treatment modality
itself.
Following the first treatment session, the
patient reported positive impact on her sleep-
ing, slightly reduced pain level and improved
range of movement in cervical spine due to
advised home exercises. At the beginning of
the third treatment session, the patient reported
reduced headache and continued improvement
in her symptoms in terms of ability to do more
activities less uncomfortably, and reduced use
of painkillers. During the third session, the
main concern was residual pain in right shoul-
der and shoulder blade, therefore the selection
of acupuncture points from SI meridian was
chosen. By the fourth session, the difference in
pain level was more significant, range of move-
ment wasn’t restricted in any planes, but the
patient still reported residual anxiousness and
disturbed sleeping. The effect of acupuncture
was the most notable on the fifth session with
reduction in pain level from initial 6–8/10 to
3–4/10 on VAS scale. The patient returned to
all her daily activities without any significant
limitation, without any further use of painkillers,
but with residual, very intermittent, dull ache
in right upper trapezius mainly after carrying/
lifting her two year old son and/or after pro-
longed lying on the right side.
It is difficult to determine whether the symp-
toms have improved due to several factors; heal-
ing time after soft tissue injuries, use of manual
treatment and self-­ management. There is the
need for further research not only for the effect
of Acupuncture on WAD, but for the research
of understanding whiplash injury itself. It is
unknown how big the impact is on symptoms
from the psychological side. Symptoms of post-­
traumatic stress have been shown to be present
in people following a whiplash injury due to
a car accident (Sterling et al. 2010). Foa et al.
(1997) demonstrated that 22% of a prospective
sample of 155 whiplash-­injured patients had a
probable diagnosis of post-­traumatic stress dis-
order at 3 months post car accident, and 17%
by 12 months post injury (Sterling et al. 2010),
which indicates the need for further psychologi-
cal evaluation of these patients.

© 2019 Acupuncture Association of Chartered Physiotherapists 77

Whiplash Associated Disorder
The limitations of this study are numerous
due to a lack of control over modalities of the
treatment, due to lack of supported evidence of
acupuncture use for whiplash treatment, due to
physiotherapist’s lack of experience in acupunc-
ture treatment, difficulties in positioning patient
to needle exact points (LU 7, LI 4, HT 7 in this
case study), and due to ‘normal’ healing time
for acute injuries. Despite all the limitations, the
patient achieved very good improvement and
found whole treatment very beneficial.
Although this case study doesn’t show the
long-­term effect of the treatment, full recovery
is expected for this patient with continued self-­
management program, as she was exceptionally
compliant with all advices given on treatment
sessions and understood the importance of
exercises and rest from aggravation for her
quickest recovery.
Acknowledgement
I would like to thank both the patient for agree-
ing to take a part as a subject in this case study,
and my AACP tutor, John Wood, for great
support and instruction throughout the AACP
acupuncture course.
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© 2019 Acupuncture Association of Chartered Physiotherapists
Z. Krejcova
Zuzana Krejcova qualified as a physiotherapist in
Slovakia in 2013 and has worked in Czech Republic
in hospital and ambulance settings. She has developed an
interest in musculoskeletal physiotherapy which led her
to move to UK at the end of 2015. Since then she has
worked in private MSK services until moving to work
for Northamptonshire Healthcare NHS Foundation
Trust in MSK Outpatients Department.
79
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 81–89

case report

The use of acupuncture for the treatment of

supraspinatus tendinopathy
W. Lu
Private Practice, Queensland, Australia

Abstract
This case study outlines four sessions of acupuncture treatment for a 45-year-old gentleman
with five to seven years history of supraspinatus tendinopathy. The clinical assessment and
examination findings that lead to the decision to combine acupuncture with the conventional
physiotherapy intervention are supported by Cochrane database and research studies. Both
the Patient Specific Functional Scale (PSFS) and Visual Analogue Scale (VAS) are reliable
and valid instruments for measuring patient’s clinical progress. They demonstrate concur-
rently with the available literature that acupuncture can reduce pain severity and improve
quality of life in individuals with supraspinatus tendinopathy. However, since the clinical
presentation of supraspinatus tendinopathy can differ greatly from patient to patient, a treat-
ment should be tailor-­made to a patient’s problems.
Keywords: acupuncture, shoulder, subacromial pain syndrome, supraspinatus, tendinopathy.

Introduction subdeltoid bursitis, supraspinatus tendinopathy,

Shoulder problems affect 7% to 26% of the
UK population each year (Urwin 1998; Chard
et al. 1991). It is the third most common mus-
culoskeletal presentation to general practice
(McCormick et al. 1996). Subacromial pain
syndrome (SAPS) is one of the leading causes
of shoulder disorders and it is defined as a
non-­ traumatic, unilateral, shoulder pain local-
ized around the acromion during or subsequent
to lifting of the arm (Diercks et al. 2014). The
term has been recently updated from Neer’s
(1983) original concept of impingement
syndrome to better describe the relationship
between shoulder anatomical structure, func-
tional load and pain. The different clinical and/
or imaging diagnosis such as subacromial/
Correspondence: Winnie Lu, Spine and Reconditioning
Clinic, 119 Nursery Avenue, Runcorn, Queensland
4113, Australia (email: winnielu321@gmail.com)
tear of the rotator cuff, or tendinosis calcarea
of the bicep, all fall under the umbrella of
SAPS. This case study report will examine the
effect of acupuncture as an adjunct to the con-
ventional physiotherapy intervention in treating
supra­spinatus tendinopathy.
Supraspinatus tendinopathy is an overuse
tendon injury most often as a result of repeti-
tive stresses and overloading during sports or
occupational activities (Starr & Kang 2001;
Sommerich et al. 1993). It is a debilitating con-
dition that affects people across different age
groups with varying degrees of pain, irritabil-
ity, decreased exercise tolerance and capacity
to function. Pathophysiological changes such
as hypovascularity, decrease in oxygen sup-
ply and neovascularisation in the structure
of supra­ spinatus tendon and its entheses
weaken its capability to sustain repeated tensile
load.

© 2019 Acupuncture Association of Chartered Physiotherapists 81

Acupuncture for the treatment of supraspinatus tendinopathy
Cook and Purdam’s (2009) model describes
three stages of continual tendon pathology:
reactive tendinopathy, tendon dysrepair (failed
healing) and degenerative tendinopathy. Unlike
normal tendon adaptation that occurs through
tendon stiffening with minimal increase in
thickness, reactive tendinopathy induces tempo-
rary noninflammatory homogeneous thickening
of the tendon to reduce stress by increasing
cross-­sectional area (Magnusson et al. 2008). In
the early stage, the tendon has the potential
for reversibility if the overload is sufficiently
reduced. Tendon dysrepair is the next stage
with greater extent of matrix breakdown. There
is a marked increase in protein production as a
result of the proliferation of myofibroblasts and
chondrocytic cells. The proteoglycans separate
the collagen leading to disorganisation of the
matrix in the tendon. Imaging may also show
swelling and increase in vascularity. The tendon
still has the potential for some reversibility
with load management and exercise (Ohberg
et al. 2004). However, there is little capacity
left for reversibility of pathological changes
once tendon has progressed to the last stage.
Considerable heterogeneity and breakdown of
the matrix due to large areas of cell apoptosis,
trauma, acellularity and vascularity are observed
in degenerative tendinopathy (Lian et al.
2007).
Studies have shown that acupuncture induces
blood flow to promote healing to the area
(Sandberg et al. 2003) and confers an analgesic
effect by stimulating the release of endorphin,
serotonin and enkephalin at local spinal level
(Carlsson 2002) and noradrenaline through-
out all levels (White et al., 2008) respectively.
Therefore, it is acceptable to reason that acu-
puncture may provide valuable outcomes when
treating patients with supraspinatus tendinopa-
thy. However, there is little evidence to support
or refute the use of acupuncture in this patient
population.
Cochrane database (2005) has conducted a
systemic review on the effect of acupuncture in
the intervention of individuals suffering from
shoulder disorders including adhesive capsulitis,
rotator cuff disease and osteoarthritis. Nine
trials of varying methodological quality that
82
met the inclusion criteria were analysed. In
these trials, participants had acupuncture, sham
acupuncture, ultrasound, gentle movement or
exercises for 20–30 min, two to three times a
week for three to six weeks. Although two tri-
als assessed short-­term success of acupuncture
for rotator cuff disease found no significant
difference in short-­ term improvement when
compared to sham acupuncture, due to small
sample sizes this may be explained by Type II
error. Acupuncture was beneficial over sham
acupuncture in improving shoulder function
at four weeks. However, by four months, the
difference between the acupuncture and sham
acupuncture groups, whilst still statistically
significant, was no longer likely to be clinically
significant. There were some benefits of both
traditional and ear acupuncture plus mobiliza-
tion over mobilization alone. Acupuncture
combined with exercise was proven to be more
effective than exercise alone for improving pain,
range of motion and function for up to five
months. Another trial indicated there was no
difference in adverse events between acupunc-
ture and sham acupuncture.
One prospective, randomized controlled
trial was conducted to compare the efficacy of
electro-­acupuncture with placebo-­acupuncture
for the treatment of shoulder pain for patients
aged from 25 to 83 years (Hoyos et al. 2004).
At six month follow-­ up after treatment the
acupuncture group showed a significantly
greater improvement in pain intensity compared
with the control group and had consistently
better results in range of motion (goniom-
eter), functional ability (SPADI), quality of
life (COOP-­WONCA charts), NSAIDS intake
and global satisfaction (10 points analogue
scale).
Overall, although little can be concluded due
to a small number of clinical and methodologi-
cally diverse trials, the available evidence sug-
gests that acupuncture can provide beneficial
outcomes in the treatment of supraspinatus
tendinopathy. The case study below further
supports acupuncture as a useful adjunct when
combined with conventional physiotherapy
intervention for a patient with supraspinatus
tendinopathy.
© 2019 Acupuncture Association of Chartered Physiotherapists

Description of the case
This case study outlines the treatment of a
45-­year-­old gentleman with supraspinatus tendi-
nopathy in his left shoulder.
Medical screening for acupuncture and
consent
Following subjective and objective examina-
tions, I had provided education, discussed his
diagnosis with the patient, and the possibility of
combining both acupuncture and physiotherapy
treatment together. He was informed of the
chemical effects of acupuncture on his body
and its possible associated risks and side-­effects.
In date, sterile and single-­use acupuncture nee-
dles would be administered under a safe work-
ing practice and disposed in sharps and clinical
waste containers after each use. Anti-­ bacteria
dry hand wash and clinical wipes would also be
applied throughout all treatment sessions. The
patient did not have any contraindications or
W. Lu
precautions towards receiving acupuncture. His
informed consent to the agreed treatment plan,
was obtained.
The patient had given verbal and written
consent to the clinic’s policy and to details high-
lighted within the information sheet outlining
risks and possible side effects for acupuncture.
The patient was encouraged to list all physical
contributing factors that would aggravate his
pain in his activities/daily life and was advised
to avoid these movements as much as possible
as per NICE guidelines (2017). The importance
of maintaining a good posture and performing
home exercise program on a daily basis was
reinforced. A set of shoulder mobilising exer-
cises and rotator cuff strengthening exercises
was included in his home exercise program. The
goals of applying acupuncture as an adjunct to
the management of patient’s condition focussed
on pain relief, decreased interference with sleep
and improved mood and functions in ADLs.

Table 1. Patient Profile

History of present This right-­handed 45-­year-­old gentleman presented to physiotherapy on the 16th of June 2017 with
condition a five to seven years history of left shoulder pain. He reported insidious onset of constant dull ache
6/10 VAS across anterosuperior and lateral aspect of his left shoulder. He had had two corticosteroid
injections three years ago with no benefit. He had also attended the physiotherapy department in the
Memorial Hospital twice, three to four years ago, and received conventional physiotherapy treatment i.e.
soft tissue massage, trigger point release and home exercise program with temporary and minimal effect.
He experienced an acute episode of flare-­up with 9/10 VAS pain three weeks ago, which had gradually
improved after taking one week off work. However, he had another episode again six days ago. He
expressed that he had become increasingly frustrated and was considering having surgery but decided
to try physiotherapy once more. Aggravating factors were reaching out and lifting his arms especially
in sideway direction. Applying ice, taking naproxen and paracetamol as required helped to ease his pain
temporarily. He exhibited no particular 24-­hour pattern, but his sleep was disturbed every night when he
had acute recurrence. Otherwise, he wakes up at night only if he lies on his left.
Investigation Recent ultrasound shows mild tendinosis and calcification of long head of biceps and supraspinatus
muscles.
Past medical condition No significant medical condition reported. He is generally fit and well.
Drug history He takes paracetamol and naproxen PRN according to the state of his left shoulder.
Social history He has been working in a heavy industrial plastic pipe manufacturing factory for the past 23 years. His
job involves many manual labour tasks, one of which requires him to lift one end of 6-­10 kg pipes and
throw them into scrap briquetting machinery. He lives with his family and enjoys spending time with his
four-­year-­old daughter.
Patient expectation Patient wished to prevent any further episode of recurrence, decrease his shoulder pain and be able to
and concern do at least most of the lighter manual tasks at work.
Clinical assessment & On initial examination, this gentleman showed slightly elevated BMI with a slouching forward headed
examination findings position. His active shoulder range of motion was approximately full in all planes with constant 6/10
VAS dull ache throughout range. Whilst his Hawkins-­Kennedy test was negative, pain was provoked
in both Empty Can and Neer’s impingement tests. Manual muscle testing of his external rotators and
deltoid were weak 4-­/5 and painful. There was point tenderness over the fibres of upper trapezius,
levator scapulae, deltoid and supraspinatus muscles. Apley’s scarf test and Speed’s test were unremarkable
and his cervical spine was cleared. His presentation on examination showed that his pain had settled,
and his shoulder was no longer irritable since the acute episode six days ago. His total score for patient
specific functional scale (PSFS) was 1.3 when there was a flare-­up (see Fig. 1).

© 2019 Acupuncture Association of Chartered Physiotherapists 83

Acupuncture for the treatment of supraspinatus tendinopathy

Figure 1. Additional questionnaire information

84 © 2019 Acupuncture Association of Chartered Physiotherapists

 W. Lu
Table 2. Consultation and Treatment: Session One
Outcome measure pre-­Rx: Constant 6/10 VAS dull ache throughout all shoulder AROM. Positive Empty Can and Neer’s impingement
tests. PSFS average score 1.3.
MMT of deltoid and external rotators 4-­/5.

Date of Acupuncture Angle of Depth of

treatment point Needle size needle needle Time De Qi

16/06/17 (L) LI 14 40  mm × 0.25 P 2 cm 10 min Strong De Qi

(L) LI 15 40  mm × 0.25 O 2 cm no stim achieved all points
(L) LI 16 40  mm × 0.25 P 0.5 cm
(L) TE 14 40  mm × 0.25 O 1.5 cm
(L) SI 10 40  mm × 0.25 P 1 cm
(L) SI 14 40  mm × 0.25 O 1 cm
Rx position: Upright sitting, arm supported by pillow with upper body exposed.
Post treatment: Patient was slightly fearful when the needles were inserted. Reassurance was provided constantly throughout the whole
treatment session. Good erythema response was observed. Patient felt mildly fatigued after needles were removed. A cup of cold water
was prepared for him while he rested in the reception area until he felt ready to leave.
Considerations for next Rx: If patient experienced a positive response then increased time of treatment and/or depth of needle
insertion and/or number of points used and/or stimulation. Consider Gall Bladder (GB) 21 for dermatomal overlap, and Bladder (BL)
17 as an influential point for blood.
Limitation: 30 mm needle was not available in the clinic.

Abbreviations: P = perpendicular, O = oblique, L = Left, R = Right, Stim = stimulation, Rx = treatment

Table 3. Consultation and Treatment: Session Two

Patient was pleased and surprised at the same time that his symptoms had significantly improved three days after the first acupuncture
treatment. His pain had reduced from 6/10 VAS to 3/10 VAS with all planes of active shoulder movement and he was able to work (PSFS
2/10 to 6/10), dress himself (PSFS 2/10 to 8/10) and sleep at night (PSFS 0/10 to 8/10) a lot better. His Neer’s impingement test was
now negative. He had not needed to take naproxen or paracetamol since last treatment. He had been compliant with his Home Exercise
Programme (HEP) and managed to discuss with his superior at work to allow him to rest from lifting heavy pipes. He reported this was
the best he had felt in five years since the onset of shoulder pain. GB 21 and BL 17 were added, depth of needles, treatment time and
stimulation were increased.

Date of Acupuncture Angle of Depth of

treatment point Needle size needle needle Time De Qi

29/06/17 (L) LI 14 40  mm × 0.25 P 3 cm 15 min Strong De Qi

(L) LI 15 40  mm × 0.25 O 3 cm moderate stim achieved all points
(L) LI 16 40  mm × 0.25 P 1 cm
(L) TE 14 40  mm × 0.25 O 2 cm
(L) SI 10 40  mm × 0.25 P 2.5 cm
(L) SI 14 40  mm × 0.25 O 2 cm
(L) GB 21 40  mm × 0.25 P 2.5 cm
(L) BL 17 40  mm × 0.25 O 2 cm
Rx position: Upright sitting, arm supported by pillow with upper body exposed.
Post treatment: No adverse effects, patient felt comfortable.
Considerations for next Rx: If patient experienced a positive response then increased time of treatment and/or number of points used
and/or stimulation. Consider HTJ T5 and SI 11 to enhance UL sympathetic outflow and C5/ C6 segmental myotomal effect.

Abbreviations: P = perpendicular, O = oblique, L = Left, Stim = stimulation, Rx = treatment, HEP = ?

Treatment on a weekly basis was ideal, however;
changes had to be made according to patient
and therapist’s availability.
Rationale for acupuncture point selection
and treatment dose
As patient had constant dull ache along the
anterosuperior and lateral aspect of his left
shoulder, Large Intestine (LI) 14, LI 16 and the
eyes of the shoulder LI 15 and Triple Energizer
(TE) 14 were chosen to provide a direct pain
relief peripherally at this area. Simultaneously,
neuropeptides from sensory nerve endings such
as calcitonin gene-­related peptide was released
at the location of needle insertion causing
vasodilation thereby increasing blood flow
(Sandberg 2003). This effect could help the
patient’s body to possibly reabsorb the calcium

© 2019 Acupuncture Association of Chartered Physiotherapists 85

Acupuncture for the treatment of supraspinatus tendinopathy
Table 4. Consultation and Treatment: Session Three
Patient continued to make good progress. His pain had remained at minimal 3/10 VAS with all planes of active shoulder movement and
his ability to work continued to improve (PSFS 6/10 to 8/10). He now had no problem dressing himself (PSFS 10/10 to 10/10) and
his sleep was no longer disturbed (PSFS 10/10 to 10/10). His external rotators and deltoid MMT had improved from 4-­/5 to 4/5 with
minimal pain. His Empty Can test now was negative. HTJ T5 and SI 11 were added, depth of needles and treatment time were increased.

Date of Acupuncture Angle of Depth of

treatment point Needle size needle needle Time De Qi

07/07/17 (L) LI 14 40  mm × 0.25 P 3 cm 20 min Strong De Qi

(L) LI 15 40  mm × 0.25 O 3 cm moderate stim achieved all points
(L) LI 16 40  mm × 0.25 P 1 cm
(L) TE 14 40  mm × 0.25 O 2 cm
(L) SI 10 40  mm × 0.25 P 2.5 cm
(L) SI 14 40  mm × 0.25 O 2 cm
(L) GB 21 40  mm × 0.25 P 2.5 cm
(L) BL 17 40  mm × 0.25 O 2 cm
(L) HTJ T5 40  mm × 0.25 O 1 cm
(L) SI 11 40  mm × 0.25 P 1 cm
Rx position: Upright sitting, arm supported by pillow with upper body exposed.
Post treatment: No adverse effects, patient felt comfortable.
Considerations for next Rx: If patient experienced a positive response then increased stimulation. Continued to avoid aggravating factors
and focus on strengthening exercises.

Abbreviations: P = perpendicular, O = oblique, L = Left, Stim = stimulation, Rx = treatment

Table 5. Consultation and Treatment: Session Four

Patient’s pain had further decreased to 2/10 VAS with all planes of shoulder movement. However, he admitted he had been doing more
manual work before today’s consultation and thus his shoulder was more achy. He felt some tension across his chest and shoulder after
work. Having realistic expectations and respecting the healing process were emphasized during our last consultation. His usual exercises
were reviewed and deltoid, pectorals and upper trapezius stretches added into his HEP.

Date of Acupuncture Angle of Depth of

treatment point Needle size needle needle Time De Qi

14/07/17 (L) LI 14 40  mm × 0.25 P 3 cm 20 min Strong De Qi

(L) LI 15 40  mm × 0.25 O 3 cm strong stim achieved all points
(L) LI 16 40  mm × 0.25 P 1 cm
(L) TE 14 40  mm × 0.25 O 2 cm
(L) SI 10 40  mm × 0.25 P 2.5 cm
(L) SI 14 40  mm × 0.25 O 2 cm
(L) GB 21 40  mm × 0.25 P 2.5 cm
(L) BL 17 40  mm × 0.25 O 2 cm
(L) HTJ T5 40  mm × 0.25 O 1 cm
(L) SI 11 40  mm × 0.25 P 1 cm
Rx position: Upright sitting, arm supported by pillow with upper body exposed.
Post treatment: No adverse effects, patient felt comfortable.
Plan: Patient was happy to be discharged with the given direction and independent HEP.

Abbreviations: P = perpendicular, O = oblique, L = Left, Stim = stimulation, Rx = treatment, HEP = ?

deposit in the long head of bicep and supraspi-
natus tendons shown on the ultrasound results.
By using points LI 14, LI 15 and LI 16 along
the same meridian i.e. large intestine meridian in
this case would help to correct patient’s flow of
chi, our body energy. According to traditional
Chinese medicine, a balanced flow of chi along
all major meridians is vital in reducing tension
and improving a person’s health and general
wellbeing (NCCIH 2013). Small Intestine (SI)
10 was added as it is inserted into infraspinatus
which shares the same C5 and C6 myotomes as
supraspinatus muscle. They are both innervated
by the suprascapular nerve. The two rotator
cuff muscles work in synergy to externally
rotate the humerus and stabilise the shoulder
joint. Furthermore, as the deltoid muscle is
also innervated by the anterior rami of C5 and
C6, this point could improve the strength of
the muscle. The location of SI 14 exploits the

86 © 2019 Acupuncture Association of Chartered Physiotherapists


“layering technique” by overlapping the sensory
tissues supplied by C5 nerve root, which is
effective in treating chronic nociceptive pain
(Bradnam 2003). No stimulation was applied
and reassurance was constantly given to address
patient’s fear towards receiving acupuncture for
the first time. In order to avoid risk of exac-
erbation, the treatment duration was limited
to 10 min, which is also the timeline dose to
increase vascular permeability (Pearce 2006).
At second consultation, the patient’s shoulder
pain and function had significantly improved.
GB 21 was added as it further enhanced the
C6 dermatomal segmental analgesia. This
was achieved through the axon reflex of fast
myelinated Aδ fibers, which inhibits nociceptive
input produced in substantia gelaotinosa stimu-
lated by slower unmyelinated C fibers in the
upper segment of spinal cord (White 2008). As
there would likely appear to be a certain degree
of hypovascularity and neovascularisation due
to the chronic nature of his tendinopathy, the
influential point for Blood Bladder (BL) 17 was
also added. Depth of needle insertion, treat-
ment time and stimulation were increased since
patient had responded reassuringly to the initial
acupuncture treatment.
At the third and last consultations, HTJ T5
and SI 11 were added as the patient continued
to show functional progress in his activities/
daily life. The spinal HTJ T5 point is considered
to influence patient’s upper limb sympathetic
outflow and activate descending inhibitory sys-
tems from the hypothalamus (Bradnam 2003).
SI 11 further enhances the C5/C6 segmental
myotomal effect removing pain inhibition and
thus improving infraspinatus, supraspintus and
deltoid muscles activation. Strong De Qi sensa-
tion was achieved throughout all treatment ses-
sions to stimulate type II and III fibers in the
muscle layer (Pomeranz 1997).
Discussion
As the patient already received two corticos-
teroid injections into his shoulder along with
the conventional physiotherapy treatment with
minimal and temporary effect, the available
evidence suggests that acupuncture can be an
effective alternative analgesia option for pain
© 2019 Acupuncture Association of Chartered Physiotherapists
W. Lu
control and progressive rehabilitation. The
PSFS and VAS were completed at the beginning
of each treatment session as outcome measures
for the patient’s clinical progress. The PSFS
is shown in Fig. 1 while VAS was recorded in
tables 2 to 5. Studies have shown that the PSFS
is a reliable, valid and responsive instrument
for determining treatment goals and evaluating
treatment in patients with a primary shoulder
complaint (Koehorst et al. 2014). VAS assesses
variation in patient’s intensity of pain and has
been established as a valid and reliable method
in a range of clinical and research applications
(McCormack 2009). In this case study, both the
PSFS and VAS demonstrate that acupuncture
can reduce pain severity and improve quality
of life in individuals with supraspinatus tendi-
nopathy. However, lack of long-­term follow-­up
of the patient’s progress and the unlikelihood
of acupuncture to remain clinically significant
by four months suggested by research, are the
limitations present in this case study.
Segmental, extrasegmental and homonculous
points away from head of humerus and acro-
mion region could be used instead of the local
points if the patient was in acute pain upon his
presentation (Bradnam 2003). This would stimu-
late both segmental pain relief and supraspinal
analgesic mechanism without exacerbating his
acute symptoms. While crucial patient education
and advice in regards to avoidance of aggravat-
ing activities were given as per NICE guidelines
(2017), the importance of allowing sufficient
time between loadings to assist tendon recovery
and improve strength could also be mentioned.
As tendons can respond to load both ana-
bolically and catabolically, an imbalance between
repetitive energy storage and release and exces-
sive compressive force appear to be key factors
in the onset of tendinopathy (Andres & Murrell
2008).
As the patient also presented with latent
myofascial trigger point pains (MTPs) in upper
trapezius, levator scapulae and deltoid muscles,
dry needling could have been used as an alter-
native treatment method to using acupuncture
meridian points. When the MTPs are pressed,
they may elicit referred pain characteristic of
that muscle (Simons 2008). This is explained by
87
Acupuncture for the treatment of supraspinatus tendinopathy
the increased amount of local noxious chemicals
such as bradykinin, substance P and calcitonin
gene-­related peptide stimulating the surround-
ing nociceptors. There is severe hypoxia in the
area of an MTP that would result from the
ischemia and increased energy demand from the
sarcomere shortening of taut bands causing a
local energy crisis (Simons 2008). Unlike active
MTPs, which elicit pain pattern that the patient
recognises as familiar when pressed, latent MTPs
are tender but cause no clinical pain compliant.
Latent MTPs can significantly disturb normal
motor function not only in the same muscle
but also in functionally related muscles. Dry
needling into MTPs attempts to elicit a local
twitch response to restore the energy deficit.
In conclusion, this case study concurs with
the available literature to suggest that acupunc-
ture can provide beneficial outcomes in the
treatment of supraspinatus tendinopathy. It also
further supports the findings that acupuncture
combined with exercise is more effective than
exercise alone for improving pain, range of
motion and function for up to five months.
However, more long-­ term future studies will
need to be conducted in order to consolidate
these theories. It is worth noting that individu-
als with supraspinatus tendinopathy will present
with varying degrees of pain, irritability and
functional capacity. Therefore, treatment should
aim to tailor to each patients’ needs as opposed
to using a generic ‘one size fits all’ approach.
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investigations in the literature. Ergonomics 36, 697–717.
Starr M. & Kang H. (2001) Recognition and management
of common forms tendinitis and bursitis. The Canadian
Journal of CME, 155–163.
© 2019 Acupuncture Association of Chartered Physiotherapists

Urwin M., Symmons D., Allison T. et al. (1998) Estimating
the burden of musculoskeletal disorders in the com-
munity: the comparative prevalence of symptoms at
different anatomical sites, and the relation to social
deprivation. Annals of the Rheumatic Diseases 57 (11),
649–655.
White A., Cumming M. and Filshie J. (2008) An Introduction
to Western Medical Acupuncture. Chapter 5. Churchill
Livingstone Elsevier, Edinburgh.
Winnie graduated with a Bachelor of Physiotherapy
degree from the University of Queensland, Australia
© 2019 Acupuncture Association of Chartered Physiotherapists
W. Lu
in 2012. Since graduation, she has worked across
different areas from community to intensive care unit
and acute inpatient neurosurgical ward. Winnie spent
18 months working in the UK within the NHS and
with sports athletes and amateur riders in the British
Transplant Games and Haute Route racing through
the Alps of France and Switzerland. She is now the
director of Spine and Reconditioning Clinic in Brisbane,
Australia.
89
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 91–97

case report

Is electroacupuncture effective in the treatment

of gluteal tendinopathy?
J. Breese
Liskeard Hospital, Cornwall, UK

Abstract
A 35-year-old male estate agent with an ongoing 3 month history of right sided lateral hip
pain self-­referred into physiotherapy. The pain was of insidious onset, and was causing him
problems at work, climbing stairs and partaking in hobbies such as mid-distance running
and surfing. The lower back and sacroiliac joint (SIJ) were cleared for pathology and internal
structural hip tests were negative. Clinical testing, giving consideration to the diagnostic utility
of a specific combination of tests, led a working diagnosis of gluteal tendinopathy. The client
was treated with electroacupuncture (EA) over 5 sessions, with the aim of stimulating tissue
healing and providing analgesia to facilitate subsequent progression into a phased loading
programme. The client reported almost 100% resolution in symptoms, using a self-­reported
pain numeric rating scale (NRS), along with significant improvements in scores using the
MSK-­HQ health questionnaire post-treatment. Objectively, improvements in strength were
also observed. Electroacupuncture was deemed very effective in the management of gluteal
tendinopathy, in order to facilitate subsequent re-­loading of the painful tendon/s. For the
purpose of this case report, only the EA therapy phase will be presented.
Keywords: electroacupuncture, gluteal tendinopathy, lateral hip pain.

Introduction weight-­bearing tasks, which makes it a debili-

Tendinopathy of the gluteus minimus (G-­min)
and gluteus medius (G-­ med) tendons is now
recognised as a primary local source of lateral
hip pain (Grimaldi et al. 2015). The prevalence
of the pathology is high in recreational and
elite athletes, and typically affects females more
than males. Sedentary individuals can also be
at increased risk, particularly with reference
to recent studies surrounding systemic risk
factors, such as central adiposity (Gaida et al.
2008). The pathology interferes with common
Correspondence: Jordan Breese BSc MCSP, Physio­
therapy Out­patients, Liskeard Hospital, Clemo Road,
Liskeard, Cornwall, PL14 3XD, UK (email: Jordan.
breese@nhs.net)
tating musculoskeletal condition. Mechanical
loading drives the biological processes within
a tendon and determines its structural form
and capacity to tolerate load (Cook et al. 2016).
The combination of excessive compression and
high tensile stresses within tendons are thought
to be most damaging. As a result, macroscopic
damage to collagen myofibrils occurs, and insuf-
ficient repair can lead to a cycle of microtrauma
and tendon degeneration (Langberg et al. 2007).
Cook and Purdam (2009) first described the
“degenerative tendinopathy” as a degrada-
tion of extracellular matrix (ECM) in patho-
logical tendons, alongside dispersed neovascular
ingrowth, disorganised collagen myofibrils and
a cycle of tenocyte apoptosis. Through the use

© 2019 Acupuncture Association of Chartered Physiotherapists 91

Electroacupuncture in the treatment of gluteal tendinopathy
of microscopy, these events have since been
observed (Malliaras et al. 2013). Although cur-
rent evidence shows a general trend towards
converged ideas of tendon pathophysiology,
there still remains conflicting opinion as to the
mechanisms that drive tendon pain. A body
of evidence exists arguing that tendon pain is
driven by interplay between corticospinal exci-
tation and inhibition (Rio et al. 2015), whereas
conflicting evidence leans towards ingrowth of
sensory and sympathetic nerves from the para-
tenon, directly delivering nociceptive substances
to the local level (van Sterkenburg & van Dijk
2011). The complexity of normal tendon struc-
ture and the multifaceted nature of the tendon’s
response to injury and load makes it difficult
to develop a model that mimics load-­ related
tendon pathology in humans (Cook et al. 2016).
The result however is difficulty pinpointing
which treatments are the most effective for
patients presenting with gluteal tendinopathy.
In musculoskeletal medicine, EA has been
shown to be an effective treatment in chronic
pain conditions, varying from myofascial pain
syndromes to chronic severe osteoarthritis
(Leung 2012). The principle of acupuncture
analgesia has been described as the manifesta-
tion of the integrative neurophysiological mech-
anisms at different levels of the central nervous
system (CNS) that respond to the stimulation
of A-­beta, A-­delta and, often, C afferent fib-
ers, located at varying neuroanatomical points
around the body (Zhao 2008). The introduction
of an acupuncture needle stimulates nociceptive
afferents, which in turn release vasodilatory
neuropeptides into the muscle and skin which
they innervate, forming the key principle of
local or peripheral effects of acupuncture
(Sato et al. 2000). This stimulates a vasodila-
tory response, and an increase in inflammatory
exudate including bradykinin and serotonin,
encouraging healing factors acting as local anal-
gesia. Acupuncture also acts at a spinal cord
level, known as a segmental effect. Inserting
a needle directly into the tissues that share an
innervation with the appropriate spinal level
(myotomes/dermatomes/sclerotomes) inhibits
dorsal horn neurons via the gate control theory
of pain, producing spinal cord level analgesia
92
(Longbottom 2010). Studies have also shown
that acupuncture influences neuronal structures
within the brain. Analgesic pathways such as
diffuse noxious inhibitory controls (DNIC)
and beta-­ endorphin mediated descending pain
inhibitory pathways from the hypothalamus,
are activated with the introduction of a mildly
painful stimulus (Stener-­ Victorin et al. 2002).
These are termed supraspinal effects, acting as a
third analgesic pathway. Needling points rich in
cutaneous receptors (e.g. hands/feet/face) can
enhance this response.
There has been a shift towards more focused
research into the effects of EA on the organisa-
tion of ECM in painful tendons. De Almeida
et al. (2014) concluded that when an acupunc-
ture needle is inserted in the proximity of the
pathological tendon, electrical stimulation of
that point leads to upregulation of the cell,
which is reported to trigger events such as Type
1 collagen synthesis as a means of repair. This
is to name just one of many cellular responses
achieved through increased tendon microcircu-
lation, and the augmentation of angiogenesis to
provide the optimum environment for tendon
healing and repair (Longbottom 2010).
Background
The client was a 35-year-old male with a 3 month
history of right lateral hip pain. This came on
fairly insidiously and was affecting simple tasks
and hobbies, such as climbing a flight of stairs,
recreational mid-­distance running and surfing.
Subjective assessment
Verbal and written consent was obtained for
physiotherapy assessment. The client reported
an insidious onset of fairly localised right sided
lateral hip pain, with intermittent referral pain
felt in the right postero-­lateral thigh. The onset
was 3 months ago, and with no obvious history
of trauma. On further probing, the only ration-
alization for the onset of pain was an increased
amount of surfing and running at the time, due
to a recent bout of particularly good weather.
There was no paraesthesia or anaesthesia.
Aggravating factors included right side lying and
ascending stairs. Easing factors included self-­
massage, heat and avoiding prolonged postures
© 2019 Acupuncture Association of Chartered Physiotherapists

(standing/sitting). Subjective pain levels on a
NRS were 7–8/10 at worst, and were reported
to be moderately irritable. The client scored
30/56 on the MSK-­HQ self-­reported question-
naire. Past medical history was unremarkable,
and drug history included paracetamol and
ibuprofen p.r.n.
Objective assessment
On observation the client had a decreased time
weight bearing during stance on the affected
(right) side, with noticeably decreased hip exten-
sion during mid to terminal stance. There was
slight atrophy of the Gluteus maximus (G-­max)
on the right side. There was no obvious pelvic
mal-­alignment. Lumbar active range of move-
ment was full and free, and did not reproduce
the client’s symptoms. The alignment of the
posterior superior iliac spine was equal, and the
stork test for iliac dyskinesia/dysfunction was
negative. A neurological screen was deemed
unnecessary, as too was further probing for SIJ
pain. The right sided single leg stance test for
up to 30 s replicated the client’s pain late into
the count, at 16–30 s. Right hip active range
of motion (AROM) in supine and with the hip
at 90 degrees flexion, was limited into internal
rotation and abduction by pain. Passively exter-
nal rotation in 90 degrees hip flexion replicated
the client’s pain on the right side. Muscle power
on the right side was reduced to 4-­ /5 on
resisted abduction (in side lying) and external
de-­rotation, using the Oxford scale, and very
slightly reduced to 4+/5 on prone hip exten-
sion. Muscle testing replicated the client’s pain.
Palpation revealed positive pain replication and
palpable spasm deep into piriformis, with pain
extending more superficially towards the greater
trochanter of the femur. The client’s left hip
was in status quo for all objective tests.
Working diagnosis
The working diagnosis centred on gluteal
tendinopathy, informed clinically primarily by
deep palpation into gluteal zones, the resisted
external de-­rotation test, and the 30 s single leg
stance test. Lequesne et al. (2008) showed that
the Sensitivity and specificity were 100% and
97.3%, respectively, for the single-­ leg stance
© 2019 Acupuncture Association of Chartered Physiotherapists
J. Breese
test and 88% and 97.3%, respectively, for the
resisted external de-­rotation test in the supine
position (n = 17). Clinically it was hypothesized
that the client had overloaded the gluteal tissues
beyond their maximum tissue capacity 3 months
previously, during his bout of increased levels
of surfing and running. This was theorized in
conjunction with Cook et al.’s (2016) tendon
pathology continuum, whereby the client’s
gluteal tendinopathy had now become, and
would be treated as, a chronic degenerative
tendinopathy.
Treatment
Verbal and written consent was obtained to
commence physiotherapy treatment. This began
with advice and education about the client’s
condition, including self-­directed strategies and
adaptations to lifestyle during treatment. Tissue
loading at this early stage was deemed inap-
propriate as pain was the key feature limiting
ability to begin challenging and improving the
tissues capacity to tolerate load. Therefore, five
weekly sessions of EA treatment (following
the treatment schedule shown in Table 1) were
provided, the outcomes of which are displayed
in Table 2. The client was provided with an
information sheet, detailing the procedure, risks
and benefits of EA and contraindications were
ruled out using an acupuncture record sheet.
The client was positioned in left side lying, with
the hips and knees flexed as comfortable. Two
pillows were used under the head to maintain
a comfortable and neutral vertebral alignment,
and two pillows were placed between the knees
to avoid hip adduction and internal rotation. A
wider bariatric plinth was utilized to provide
comfort for the resting upper limbs, and in the
event of a vasovagal response. In the gluteal
region the following soft tissues were the target
areas of treatment: G-­ med, G-­ min, and the
lateral piriformis. Pre-­sterilised single use Classic
Plus acupuncture needles (HMD Europe Ltd,
Chipping Norton, Oxfordshire, UK) were used.
Two, 0.25 × 70 mm needles were inserted into
the following acupoints: Gall Bladder (GB) 30
and Bladder (BL) 54. GB 30 targeted the lateral
piriformis musculo-tendinous junction and was
located in posterolateral hip, one third of the
93
Electroacupuncture in the treatment of gluteal tendinopathy
Table 1. EA treatment schedule
Acupuncture Frequency Pulse Duration
Session Points (Hz) (µs)
Session 1 GB 30 33–100 150
BL 54
Session 2 GB 30 33–100 150
BL 54
Session 3 GB 30 33–100 150
BL 54
Session 4 GB 30 33–100 150
BL 54
Session 5 GB 30 33–100 150
BL 54
BL = Bladder, GB = Gall Bladder
distance between the greater trochanter of the
femur and the sacral hiatus. The needle was
inserted perpendicularly through the muscle
belly angled slightly cephalad and towards the
symphysis pubis, at a depth of around 60 mm.
BL 54 targeted the G-­max and G-­med muscle
bellies, and was located on the buttock in the
depression three fingerbreadths lateral to the
sacro-­coccygeal hiatus. The needle was inserted
perpendicularly-­ obliquely towards the anterior
inferior iliac pine, at a depth of around 60 mm.
The location of each needle would allow electric
current to flow between the sites. The EA cur-
rent was supplied by an ITO ES-­160 6-­channel
programmable EA unit (ITO Co. Ltd, Tokyo,
Japan). The programme selected was a sweeping
programme, which offered varying frequencies
and a static pulse width throughout the duration
of the treatment session. The frequency was
from 33-­100Hz, and the pulse width remained
constant at 150 µs. Amplitude (mA) was set to
the client’s maximum tolerable level, to ensure
a good sensation of De Qi, and was revised
throughout the treatment session.
Discussion
The rationale for the treatment of this client
utilising EA was informed primarily by evidence
which supports the use of EA to promote tis-
sue healing in, and provide analgesia for, tendon
pain (Longbottom 2010; Silvério-­Lopes 2011).
Previous literature has shown EA to be far supe-
rior to standard acupuncture in the treatment
of musculoskeletal pain (Silvério-­Lopes 2011).
Further literature detailing frequency-­dependant
94
Tolerated
Amplitude Treatment Needle size Approx. Depth
(mA) time (mins) (mm) of needle (cm) De Qi sensation
3 10 0.25 × 70 6 mild
4 15 0.25 × 70 6 moderate
4.5 15 0.25 × 70 6 moderate-­strong
5 20 0.25 × 70 6 strong
5.5 25 0.25 × 70 6 strong
opioid release from the CNS, in greater quan-
tities in response to a peripheral electrical
stimulation, adds body to this (Zhang et al.
2014).
EA parameters were set to a constant re-­
settable programme in order to maintain an
objective and replicable treatment between
sessions and, if changes were to occur in
the client’s pain, allow better control of the
variables that might have accounted for this.
Previous research into spontaneous release of
neurotransmitters which differed depending on
the EA parameters that were applied, suggested
that low-­frequency EA (2-­15Hz) is superior at
inhibiting noxious stimuli to high frequency
EA, whereas high frequency EA (80-­ 100Hz)
was superior for greater opioid secretion in the
CNS (Kuo et al. 2013). Silvério-­ Lopes, (2011)
reported similar findings, but also advised that
client comfort during each session could be
more easily achieved through higher frequen-
cies. The EA programme in this case was set
to a ‘sweeping’ programme, meaning that EA
parameters were set to a frequency between 33-­
100Hz, and a pulse duration of 150µs. Drawing
on the above literature it was therefore reasoned
that these parameters would provide a good
trade-­off between strong noxious inhibition
and opioid secretion, along with consideration
for client comfort throughout treatment. As
with many practices within musculoskeletal
medicine, current literature has not yet identi-
fied a ‘one size fits all’ model for provision of
EA, and therefore an argument could be made
for utilising the entire frequency spectrum for
© 2019 Acupuncture Association of Chartered Physiotherapists
 J. Breese
Table 2. Details of treatment sessions
Pain through hip PROM
Treatment report MSK-­HQ Score post-­treatment Hip Strength post-­treatment

Session 1 30/56 (Pre) NRS – 7/10 Abd (side lying): 4-­/5

The client was treated with 10 min of EA at a IR (at 90 hip flex): 4-­/5
comfortable tolerance in the first session, to assess
his response. No adverse effects took place and the
therapist was outside of the cubicle during treatment.
The client exhibited a sharp jerking motion upon
introduction of the first needle, which he later described
as a “heavy pulsing ache”. Reported De Qi was mild.
Session 2 Not tested NRS – 5/10 Abd (side lying): 4-­/5
The client reported a significant decrease in pain IR (at 90 hip flex): 4/5
intensity following the previous session, however pain
frequency was fairly unchanged. The client was treated
with EA for 15 min, and with the client’s tolerance
previously assessed, stimulation amplitude was increased
to 4. There were no adverse events. Reported De Qi was
moderate.
Session 3 Not tested NRS – 4/10 Abd (side lying): 4/5
The client reported a further decrease in pain intensity IR (at 90 hip flex): 4/5
and now frequency also, following the previous session.
Pain no longer as prevalent throughout a normal day,
with activities such as ascending stairs. Therapist running
slightly behind with diary, therefore treatment time
allowed was repeated at 15 min EA. There were no
adverse events. De Qi reported to be moderate to strong
this session.
Session 4 Not tested NRS – 2/10 Abd (side lying): 4+/5
The client reported a significant decrease in pain levels IR (at 90 hip flex): – 4/5
and increase in functional activities following the previous
session. Surfed for 2 h on the weekend. Pain no
longer noticeable at work. EA treatment given for
20 min. No adverse events. Strong reported De Qi.
Session 5 53/56 (Post) NRS – 0–1/10 Abd (side lying): 4-­/5
Client reports a “small niggling” pain now, otherwise IR (at 90 hip flex): 4-­/5
not bothering him and no longer feels pain at work,
doing stairs or when surfing. Pain still occasional after
around 30–45 min of steady state running. EA
treatment given for 25 min. No adverse events.
Strong De Qi reported.

individualised treatment, and greater outcomes
in pain inhibition.
The Acupoints selected in this case report,
GB 30 and BL 54, were selected primarily due
to their anatomical position to the tissues that
were theorised to be at fault (i.e. G-­med, G-­min,
piriformis). The relative distance between these
points would also allow for good electrical flow
between the sites. Pearce (2006) suggests that
the therapist should always question exactly
what they require of the needle during treat-
ment. Given that the treatment was aimed at
not only reducing pain but also to facilitate a
structural change in the pathological ECM of
the tendon, the location of the acupoints was
particularly relevant. When needling the gluteal
zone needle depth was achieved by measuring
the length of needle left outside of the skin
subtracted from the total length of the needle.
It was theorised that the tissue that would be
penetrated at each point were G-­max, G-­med,
G-­min and piriformis. Anatomically G-­max is
the most superficial of the gluteal muscles, and
this was used a guideline to hypothesized tissue
penetration. Cadaver studies have previously
reported the depth of G-­ max to be 2.5 cm

© 2019 Acupuncture Association of Chartered Physiotherapists 95

Electroacupuncture in the treatment of gluteal tendinopathy
+/-­2.9 mm below surface level (Fukumoto et al.
2012). Contrastingly one of the deepest gluteal
muscles is piriformis, and further cadaver stud-
ies utilising fluoroscopic guidance have reported
that its location can lie at a depth of up to
9 cm (Gonzalez et al. 2008). This highlights
one drawback of this case report, whereby
needling was deemed adequate at 6 cm depth.
Therefore, given the above literature, it could be
argued that the likelihood of penetrating both
G-­ min and Piriformis is significantly reduced
or even absent. To challenge this, anatomical
heterogeneity between individuals, a relative
lack of literature to justify choice of needling
depths, combined with an end result of signifi-
cant reduction in the client’s symptoms, it might
be argued that such a detail does not hold
much clinical value, but rather a methodological
flaw.
It should be noted that many of the leading
studies investigating the effects of EA have
been conducted on rats and mice. Whilst these
cannot be truly representative of a human
population, these studies are still important
because they are based on the analgesic effects
of neurotransmitter release. Animal models
allow evaluations that cannot easily be studied
in humans, and for these to be useful, it is
important to use those that represent valid
models of the human tendon pathologies which
are commonly confronted in clinical practice
(Speed 2015). This is challenging, but rat mod-
els of tendinosis in patellar and supraspinatus
tendons do exist (Wardle 2007). In contrast they
do not take into account emotional, cultural and
biomechanical variables experienced in human
pain, and whilst authors have reported findings
(White et al. 2008) EA studies in humans are
still scarce, particularly those comparing EA
parameters.
This case report highlights that EA can be
a very useful tool for facilitating a reduction
in pain to allow re-­ ablement and subsequent
return to more functional loading of the pain-
ful tendon/s. This case study also brings to the
forefront the relative scarceness of EA studies
in the treatment of human populations with
musculoskeletal pathologies, and encourages
future literature into such a field.
96
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Jordan Breese is a musculoskeletal physiotherapist work-
ing in an outpatient setting within the NHS in Devon
and Cornwall. He graduated from Plymouth University
in 2016 with a BSc (Hons) in Physiotherapy, and has
gone on to develop a special interest in the cervical spine
and lower limb. In the future Jordan hopes to undertake
his MSc in sports medicine. Jordan undertook his acu-
puncture training in 2017, and finds it as a useful tool
to facilitate more conventional methods of rehabilitation
in the management of musculoskeletal pain within the
health service.
97
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 99–106

case report

The use of acupuncture for the conservative

management of lateral epicondylalgia
H. Sandelands
Private Practice, London, UK

Abstract
This case study outlines a 41-­ year-­
old male with a three-­ month history of Lateral
Epicondylalgia (LE) treated conservatively with acupuncture, other manual therapy tech-
niques, and exercise. He was treated for a total of four sessions at two-­week intervals and
showed improvements in pain and function. At the initial assessment, the patient reported
his Visual Analog Scale (VAS) was 9/10, Patient Specific Functional Scale (PFPS) was 3, and
he had a positive Cozen’s, Maudsley’s and Mill’s Tests. By his fourth and last treatment ses-
sion, patient reported VAS was 0/10, PFPS was 10, and had a negative Cozen’s, Maudsley’s
and Mill’s Tests. Therefore, it was concluded that acupuncture can effectively be used in the
conservative management of LE.
Keywords: Active Range of Motion (AROM), Large Intestine Meridian (LI), Lateral
Epicondylalgia (LE), Passive Range of Motion (PROM), Patient Specific Functional Scale
(PFPS).

Introduction can directly correlate their symptoms to playing

Lateral epicondylalgia (LE), or tennis elbow, is
a common overuse injury presenting as lateral
elbow pain caused by repetitive activity leading
to micro traumatic tissue failure of the forearm
extensor muscles (Bisset et al. 2011; Chourasia
et al. 2013; Coombes 2015; Dutton 2017). The
incidence of lateral elbow pain in general prac-
tice is found to be between 4–7/1000 people a
year in the UK (Bisset et al. 2011). LE is most
prevalent in individuals between the years of
40 to 50, with a higher incidence in women
than men (Bisset et al. 2011; Wong et al. 2017).
Although often referred to as tennis elbow,
only about 5% of people diagnosed with LE
Correspondence: Holly Sandelands, Complete Physio
and Complete Pilates, The Bankside Health Club,
Blue Fin Building, 110 Southwark St, London
SE1 0SU (email: Holly@complete-­physio.co.uk)
tennis (Bisset et al. 2011). Rather, the diagnosis
is often found amongst those with professions
whose job requires repetitive and forceful
manual tasks in nonneutral wrist postures and
repetitive gripping (Dutton 2017).
Symptoms of LE can affect individuals for
anywhere from six months to two years, causing
self-­limiting impairments in function (Dimitrios
2016, Wong et al. 2017). Only about 20% of
people report symptoms persisting over a year
(Bisset et al. 2011). Upon objective assessment,
patients will present with lateral elbow pain,
palpable tenderness over extensor capri radialis
brevis, extensor carpi radialis longus, and the
lateral epicondyle (Dutton 2017; Scott 2015;
Waugh et al. 2005). Pain is reproduced with
resisted wrist extension and radial deviation
when the elbow is extended and with gripping
activities (Dutton 2017; Dimitrios 2016). Diffuse

© 2019 Acupuncture Association of Chartered Physiotherapists 99

Acupuncture for the conservative management of Lateral Epicondylalgia
achiness over the lateral elbow, morning stiff-
ness, and pain at night can also be experienced
(Dutton 2017; Scott 2015).
Physiotherapy is recommended for the man-
agement of LE, however there is no defined
standard of treatment. Physiotherapists often
employ a vast array of treatment techniques
with the overarching goal of reducing pain and
improving function (Dimitrios 2016; Gonzalez-­
Iglesias et al. 2011). Commonly used treatment
techniques include: extracorporeal shock wave
therapy, manipulation, Mulligan mobilization
with movement, massage, ultrasound, acupunc-
ture, corticosteroid injections, iontophoresis,
laser therapy, and eccentric based exercises
(Bisset et al. 2011; Coombes 2015; Dimitrios
2016; Gonzalez-­Iglesias et al. 2011).
Acupuncture is increasingly being employed
by physiotherapists on patients with LE to
alleviate pain (Zaslawski et al. 2016). The United
States National Institutes of Health recognizes
that acupuncture may be a useful alternative
treatment for patients with LE (NIH 1998).
Low-­ quality research of LE shows that acu-
puncture promotes short-­ term improvements
in pain and function compared to sham-­ laser
treatment (Liu et al. 2016). Another study shows
that needle acupuncture versus sham acupunc-
ture may be more effective for pain relief and
improving functional impairments in the short-­
term (Bisset et al. 2011). A systematic review by
Gadau et al. (2014) concluded that acupuncture
has the potential to alleviate pain in patients for
up to six months. However, another systematic
review by Tang et al. (2015) concluded that no
firm conclusions could be made regarding the
role acupuncture has on LE rehabilitation. With
a limited number of high quality randomized
controlled trials available, firm conclusions cor-
relating acupuncture and improvements in pain
and function cannot be drawn.
Despite the lack of agreement in the literature
for the use of acupuncture with a diagnosis of
LE, the beneficial effects of acupuncture can-
not be denied. Acupuncture has been validated
as a good treatment option for several other
pain conditions (headaches, osteoarthritis, neck
pain, etc.) secondary to its analgesic effects, not
just at the local level, but also at the segmental
100
and supraspinal levels (Kim et al. 2016). Locally,
acupuncture causes molecular and cellar
changes at and around the location of the nee-
dled acupoint, which precipitates the release of
local endorphins and receptors that reduce pain
through the pain gate (Kim et al. 2016; Srbely
et al. 2010; Stein et al. 2001; White et al. 2008).
Additionally, acupuncture enhances soft tissue
repair after injury, increases local blood flow to
the skin and muscle via local vasodilation, and
increases collagen proliferation (Kim et al. 2016;
Neal & Longbottom 2012; Speed 2015). On the
segmental level, acupuncture stimulates both
alpha delta fibers in the skin and type II and
III muscle nerve fibers to induce the release of
encephalin to block the influx of nociceptive
input from C-­fibers at the level of the dorsal
horn (White et al. 2008). On the supraspinal
level, acupuncture inhibits the descending
pathways from the higher orders of the brain
through the release of opioid peptides (White
et al. 2008).
Although there is still conflicting evidence
regarding the use of acupuncture with LE,
we cannot deny the short-­term benefits found
among low quality studies and the benefits acu-
puncture has on other chronic pain conditions.
Therefore, this case study dived further into
investigating acupuncture’s potential role in LE
rehabilitation.
Description of the case
This case study describes the care of a
41-­
year-­
old male with LE, treated every two
weeks for a total of four treatment sessions
plus an initial assessment. Table 1 summarizes
the patient’s history and clinical presentation.
Initial objective assessment
On clinical assessment, the patient demon-
strated a forward head, rounded shoulders, and
protracted/abducted/anteriorly tilted bilateral
scapulae. Palpable tenderness was found over
his right extensor carpi radialis longus, extensor
carpi radialis brevis, common extensor tendon,
common flexor tendon, lateral epicondyle, distal
biceps, and distal biceps tendon insertion. He
demonstrated full elbow and wrist active range
© 2019 Acupuncture Association of Chartered Physiotherapists

Table 1. Patient profile
Age
Gender
Occupation
History of Present Condition
(include investigation)
Past Medial History
Drug History
Social History
Patient main concern of problem
Patient’s expectation with PT
Medical Screening and Informed
consent?
H. Sandelands
41
Male
Works in IT for fashion brand in central London.
Patient reports onset of right lower biceps and lateral elbow pain that began about three months
ago. He reports that three months ago he returned to playing squash after a 10-­year hiatus. He
began experiencing acute lower biceps and lateral elbow pain within 10 minutes of his second
45-­minute squash game in a one-­week time period. He reports that since then his right lateral
elbow and biceps have been persistently aggravating him and the pain has slowly been getting
worse. He complains of a numbness feeling over his lateral elbow and constant pain that gets
worse with elbow/wrist extension and forearm pronation, wrist extension, and prolonged grip
squeeze. He complains that the pain can be sharp and sometimes wakes him up in the middle of
the night. Additionally, he reports achiness and stiffness of the right elbow upon waking in the
morning. He complains of pain with all activities of daily living, when swinging a racket, typing
on his computer at work, carrying objects greater than 5lbs in his right hand for prolonged
periods of time, lifting objects greater than 5lbs in his right hand, and turning a doorknob. He
reports that rest and gentle massage slightly eases his pain. He denies any recent imaging of his
of right elbow/forearm/wrist.
Denies any past medical or surgical history. Reports that he is in good health and denies any
previous injuries to his right upper extremity.
Occasionally takes aspirin for pain.
Lives alone in central London and inconsistently goes to the gym 2–3 times a week.
Concerned about the constant pain, especially with all day to day activities.
Patient believes that physiotherapy should help to relieve his pain and improve his function day
to day. He has hopes that physiotherapy will allow him to return to sports.
Informed consent for treatment and acupuncture.

of motion (AROM), however demonstrated Acupuncture treatment rationale

right elbow pain with elbow extension plus
wrist flexion/extension and forearm pronation/
supination passive range of motion (PROM).
Isometric manual muscle testing reproduced
right lateral elbow pain with right shoulder
flexion/abduction, wrist extension/flexion/
radial deviation, forearm pronation/supination,
and grip squeeze. Right shoulder flexion/abduc-
tion/external rotation, wrist flexion/extension/
radial deviation, and forearm pronation/supina-
tion were all deemed 4+/5. Right grip strength
was weaker than left grip strength. Dermatomal
testing was symmetrical and equal throughout
C3-­T1. He had positive Cozen’s, Maudsley’s and
Mill’s Tests.
The AACP Manual checklist was used to
ensure all acupuncture related criteria had
been checked and assessed prior to all treat-
ment. This ensured that the patient had no
contraindications or precautions deemed by
the AACP. Before the patient’s initial evalua-
tion and every subsequent treatment session,
patient consent was received for both physio­
therapy and acupuncture both verbally and
written.
Seven acupoints along the Large Intestine (LI)
meridian were used in the four treatment ses-
sions. Since good improvements in pain and
function were found after the first treatment
session using the LI acupoints, the same points
were used for the rest of the three sessions.
The LI meridian was chosen based upon the
meridian’s close correspondence to the patient’s
area of pain. The ultimate goal for use of the
seven acupoints was for local and segmental
analgesia, vasodilation, promotion of soft tissue
repair, promotion of collagen proliferation, and
relaxation of both mind and body (Bradnam
2003; Deadman 2008; Kim et al. 2016; Sandberg
et al. 2003; Stein et al. 2001; White et al. 2008).
More specifically, points were selected along the
C6 and C7 dermatomes and myotomes, as these
correlated with the myotomal and dermatomal
innervations of the patient’s painful presenta-
tion. Since the patient presented with chronic
pain, acupoints were chosen closer to the
patient’s affected area as this would generate a
“strong pain inhibitory effect” (Bradnam 2003;
Srbely et al. 2010). More distant points were also
implemented to apply Bradnam’s (2003) layering

© 2019 Acupuncture Association of Chartered Physiotherapists 101

Acupuncture for the conservative management of Lateral Epicondylalgia
Table 2. Point selection and rationale

Point Reasoning

Large Intestine LI 4 is described as the ‘master point’ for pain and relaxation (AACP 2018). It provided a peripheral
(LI) 4 (Hegu) segmental analgesic effect along the C6 and C7 dermatome (AACP 2018). Additionally, it is considered
a good point to “relieve pain and spasm and promote smooth flow of qi and blood in the whole arm”
(Deadman et al. 2008). Segmental points were used to stimulate both alpha delta fibers in the skin and type
II and III muscle nerve fibers to promote the release of encephalin to block the influx of nociceptive input
from C-­fibers at the level of the dorsal horn (White et al. 2008).
LI 5 (Yangxi) LI 5 provided a peripheral segmental analgesic effect along the C6 and C7 dermatomes (AACP 2018).
LI 10 (Shousanli) LI 10 was a local point for the patient’s lateral elbow pain and allowed direct needle stimulation of the
patient’s tender extensor carpi radialis longus (AACP 2018). The point is considered an important point for
arm disorders and applied in cases with forearm and elbow pain and soreness (Deadman et al. 2008). Local
points were used to allow the release of local endorphins and receptors at the needle sight which reduces
pain locally through the pain gate (Kim et al. 2016; White et al. 2008). Additionally, they were used to enhance
soft tissue repair, increase local blood flow in the skin and/or muscle via local vasodilation, and increase
collagen proliferation (Kim et al. 2016; Speed 2015; Neal & Longbottom 2012).
LI 11 (Quchi) LI 11 was a local point for the patient’s lateral elbow pain and allowed direct needle stimulation of the
patient’s tender extensor carpi radialis longus (AACP 2018). The point is also commonly used for pain located
in the forearm, elbow, and shoulder (Deadman et al. 2008).
LI 12 (Zhouliao) LI 12 was used as a local point for the patient’s lateral elbow pain and is commonly used as a local point for
elbow pain (Deadman et al. 2008).
LI 13 (Shouwuli) LI 13 was used as a local point for the patient’s lateral elbow pain and long head of biceps brachii pain. The
point was also used as a segmental point for the C6 and C7 dermatome and myotome. Lastly, it is also often
used for “pain, numbness, and contraction of the elbow and upper arm” (Deadman et al. 2008).
LI 14 (Binao) LI 14 was used as a local point for the patient’s long head of biceps brachii pain, since oblique/medial
insertion of the needle pierces the long head of biceps brachii (AACP 2018). The point was also used as a
segmental point for the C6 and C7 dermatome and myotome (AACP 2018). Lastly, it is often used for pain
of the upper arm and shoulder (Deadman et al. 2008).

effect. See Table 2 for further discussion on
acupuncture point selection.
Treatment dose was determined based upon
the patient’s chronic presentation. Pearce (2006)
suggests that for chronic conditions optimal treat-
ment dose period should be between 15–40 min,
as longer needling times “activate” the Central
Nervous System structures, which result in a
global release of neurochemicals such as sero­
tonin [and] endorphin;” therefore affecting the
Autonomic Nervous System and higher centers
of the Central Nervous System. Furthermore,
needle stimulation halfway through the treatment
dosage enhanced greater sensory input.
Attainment of De Qi determined accuracy
of needle point location along the meridian. De
Qi, or the energy, describes the sensation expe-
rienced upon needle insertion (Lundeberg 2013;
Vickers et al. 2002; Wang et al. 1985). Upon
stimulation of type II afferent fibers, patients
report a numbness/tingling/soreness sensa-
tion; while a heaviness/mild ache/distention
sensation is reported with stimulation of type
III afferent fibers (Lundeberg 2013; Pomeranz
1997; Wang et al. 1985).
Based upon the patient’s availability, he
attended physiotherapy sessions every two
weeks. The patient attended four treatment ses-
sions plus his initial evaluation, following which
he decided he no longer felt that additional
sessions were necessary.
Treatment overview
For each of the four treatment sessions, the
patient was placed in a seated position on a
plinth with a pillow placed parallel along his
spine and a second pillow on his lap supporting
his right arm. Before each session, the acupunc-
ture needles, yellow sharps container, and cot-
ton buds were placed on the counter adjacent
to the plinth. The physiotherapist’s hands were
washed before handling needles and expiration
date of each needle was checked. After each
session, all needles were properly disposed of
in the yellow sharps container and cotton buds
were used for any bleeding upon removal and
disposal of needles. See Table 3 for the patient’s
acupuncture treatment overview.
Before each treatment session, the benefits
and risks of acupuncture were explained, and

102 © 2019 Acupuncture Association of Chartered Physiotherapists

 H. Sandelands
Table 3. Acupuncture treatment overview
Treatment Dose (time, Acupuncture Point Depth of Treatment Response/ Adverse
Session stimulation) *Right side only Needle Size Angle of Needle Needle Effects

Session 1 15 min – gentle LI 4 0.20 × 25mm Perpendicular 1cm Strong De Qi. Slight bleeding
stimulate half upon needle removal.
way through No Adverse effects reported
dosage or observed for all points.
LI 5 0.20 × 25mm Perpendicular 0.5cm Strong De Qi.
LI 10 0.25 × 40mm Perpendicular 2cm Moderate De Qi. Redness
around needle application.
Slight bleeding upon needle
removal.
LI 11 0.25 × 40mm Perpendicular 2cm Strong De Qi. Redness around
needle application. Slight
bleeding upon needle removal.
LI 12 0.25 × 40mm Perpendicular 1cm Strong De Qi. Slight bleeding
upon needle removal.
LI 13 0.25 × 40mm Perpendicular 2cm Strong De Qi.
LI 14 0.25 × 40mm Oblique – Medial 2cm Minimal De Qi.
towards LHB

Session 2 15 min – gentle LI 4 0.20 × 25mm Perpendicular 1cm Moderate De Qi.

stimulate half No Adverse effects reported
way through or observed for all points.
dosage LI 5 0.20 × 25mm Perpendicular 0.5cm Minimal De Qi.
LI 10 0.25 × 40mm Perpendicular 2cm Strong De Qi. Redness around
needle application. Slight
bleeding upon needle removal.
LI 11 0.25 × 40mm Perpendicular 2cm Strong De Qi. Redness around
needle application. Slight
bleeding upon needle removal.
LI 12 0.25 × 40mm Perpendicular 1cm Strong De Qi. Slight bleeding
upon needle removal.
LI 13 0.25 × 40mm Perpendicular 2cm Strong De Qi.
LI 14 0.25 × 40mm Oblique – Medial 2cm Minimal De Qi. Slight
towards LHB bleeding upon needle removal.

Session 3 15 min – gentle LI 4 0.20 × 25mm Perpendicular 1cm Moderate De Qi.

stimulate half No Adverse effects reported
way through or observed for all points.
dosage LI 5 0.20 × 25mm Perpendicular 0.5cm Minimal De Qi.
LI 10 0.25 × 40mm Perpendicular 2cm Strong De Qi. Redness
around needle application.
Slight bleeding upon needle
removal.
LI 11 0.25 × 40mm Perpendicular 2cm Strong De Qi. Redness
around needle application.
Slight bleeding upon needle
removal.
LI 12 0.25 × 40mm Perpendicular 1cm Strong De Qi. Redness
around needle application.
Slight bleeding upon needle
removal.
LI 13 0.25 × 40mm Perpendicular 2cm Moderate De Qi. Slight
bleeding upon needle
removal.
LI 14 0.25 × 40mm Oblique – Medial 2cm Minimal De Qi.
towards LHB

Key: LHB – Long Head of Biceps; LI – Large Intestine Meridian

© 2019 Acupuncture Association of Chartered Physiotherapists 103

Acupuncture for the conservative management of Lateral Epicondylalgia
Table 4. Outcome measures pre-­and post-­treatment
Session 1 Session 2
Initial Assessment Pre Post Pre
VAS 9/10 8/10 5/10 3/10
PSFS Score 3 10
Mill’s Test + + + -­
Maudsley’s Test + + + -­
Cozen’s Test + + + -­
the patient was made aware of the transient
symptoms that could be experienced during
and after acupuncture. Following the first ses-
sion, the patient received an AACP acupuncture
information pack.
Following a 15-­min acupuncture session, the
patient received 10–15 min of manual therapy
including: soft tissue mobilization of right
forearm flexors and extensors and active release
technique to right biceps, forearm flexors and
extensors.
The patient was provided with therapeutic
exercises, to be completed a minimum of three
or four times a week. At his initial assessment,
the patient was given eccentric wrist extension
and isotonic wrist flexion, ulnar deviation,
and radial deviation with a yellow Theraband.
At his first treatment session, the patient was
given palm slides, resisted forearm pronation
and supination with hammer, bilateral shoulder
external rotation with green Theraband, and
cervical retraction with red Theraband. At his
second treatment session, his wrist isotonics and
eccentrics were progressed to a red Theraband.
At his third treatment session, he was given
prone T’s, prone Y’s, and wall angels.
After his first treatment session, the patient
reported mild improvements in pain (5/10
VAS). However, by his second treatment ses-
sion, the patient reported moderate improve-
ments in pain (3/10 VAS) and function. He
complained of mild pain with all activities of
daily living and with therapeutic exercises. By
his third treatment session, the patient reported
further improvements in pain, inconsistent
reproduction of minimal pain with activities of
daily living (2/10 VAS), denied any reproduc-
tion of pain while at work, and reported that he
frequently forgot about his injury altogether. By
his fourth treatment session, the patient denied
104 © 2019 Acupuncture Association of Chartered Physiotherapists
Session 3 Session 4
Post Pre Post Pre Post
1/10 2/10 0/10 1/10 0/10
-­ -­ -­ -­ -­
-­ -­ -­ -­ -­
-­ -­ -­ -­ -­
any reproduction of symptoms with all activi-
ties of daily living and reported that he was able
to play a round of golf pain-­free. He reported
consistency of his therapeutic exercises since
beginning physiotherapy.
Outcome Measures
See Table 4 for the patient’s outcome measure
assessment throughout the course of treatment.
The PSFS (Patient Specific Functional Scale)
asks patients to rate their functional status of
“3–5 activities on an 11-­point scale, 0 is unable
to perform activity and 10 is able to perform
the activity at preinjury level” (Hefford et al.
2012). It is a “valid, reliable, and responsive out-
come measure in patients with upper extremity
musculoskeletal problems” (Hefford et al. 2012).
The Mill’s test, Maudsley’s Test and Cozen’s
Test are three special tests used by clinicians to
determine the existence of LE and reproduce
pain (Dutton 2017; Luk et al. 2014; Waseem
et al. 2012). However, at this time no formal
diagnostic accuracy studies have been completed
to assess the specificity and sensitivity of these
tests (Dutton 2017).
Discussion
The patient in this case study demonstrated
progressively improving VAS scores and cor-
relating improvements in function with each
treatment session. Four treatment sessions, at
two week intervals, that used a combination
of acupuncture, soft tissue mobilization, active
release techniques, and an exercise program,
were enough to successfully conservatively
manage a patient with chronic LE. The use
of acupuncture for this given case study was
influenced by the validated use of acupuncture
with other chronic pain diagnoses (neck pain,

headaches, osteoarthritis, etc.) (Kim et al. 2016,
Wong et al. 2017). This case study supports
acupuncture as an effective local and segmental
analgesic treatment for LE.
While this case study shows that acupuncture
can be successfully implemented within the
rehabilitation of LE to produce improvements
in pain and function; similar conclusions cannot
be drawn from other research with LE. At this
time, there is too much inconsistency in the
results from poor-­quality high biased research
to support the effectiveness of acupuncture
for LE (Wong et al. 2017). Several systematic
reviews agree that there is too much inconsistent
evidence, which prevents defined conclusions to
be made regarding the effect acupuncture has
on LE (Bisset et al. 2011; Gadau et al. 2014;
Tang et al. 2015). Even though countless low-­
quality studies have demonstrated that acupunc-
ture has a short-­term effect in improving pain
and function in patients with LE; until higher
quality randomized controlled trials directly cor-
relate acupuncture with improvements in pain
and function, scepticism will persist (Bisset et al.
2011; Liu et al. 2016; Shin et al. 2013; Tang et al.
2015; Wong et al. 2017). Future randomized
controlled trials with higher quality evidence and
low bias are required to remove the scepticism
and validate acupuncture use in the conservative
management of LE.
A limitation of this study was that there was
more than one treatment technique used dur-
ing treatment sessions, therefore it was unclear
whether acupuncture alone promoted the
significant improvements in pain and function
found, or if it was from the combination of
treatment techniques – acupuncture, soft tissue
mobilization, active release technique, and an
exercise program with eccentric bias. Therefore,
it is difficult to draw conclusions from this case
and apply to future cases as it is difficult to
determine the isolated effect acupuncture had
on the patient’s presentation.
Another limitation of this case study was the
fact that the same acupoints were used at each
treatment session, when additional points could
have been implemented. Since LE is an overuse
injury of muscles and tendons, acupoint Gall
Bladder (GB) 34 (Yanglingquan) could have been
© 2019 Acupuncture Association of Chartered Physiotherapists
H. Sandelands
used, as this point is considered an influential
point for muscles and tendons (AACP 2018).
Additionally, acupoints on the contralateral
arm could have been used to reduce pain and
improve function in this patient case. The use
of acupoints on the contralateral arm have been
successfully used to decrease pain and improve
mobility in patients with chronic shoulder pain
(Zhang 2016).
In conclusion, this case study shows the
potential benefit acupuncture has on patients
with LE in adjunct with exercise and other
manual therapy techniques to reduce pain and
restore function. Acupuncture is a cost-­effective
treatment and future research has the opportu-
nity to uncover the superiority it has over other
more expensive treatments.
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on the receptive field of acupoints and the relation-
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epicondylitis: A review of the literature. J Back
Musculoskelet Rehabil. 25, 131–42.
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What’s in a name? J Orthop Sports Phys Ther 35 (4),
200–2.
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of Western Medical Acupuncture. Churchill Livingstone,
Edinburgh.
Wong C. W., Ng E. Y., Fung P. W., et al. (2017) Comparison
of treatment effects on lateral epicondylitis between
acupuncture and extracorporeal shockwave therapy.
Asia Pac J Sports Med Arthrosc Rehabil Technol 24(7), 21–6.
Zaslawski C., Berle C., Gadau M., et al. (2016) Protocol
for acupuncture treatment of lateral elbow pain: A
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Holly Sandelands received her Doctor of Physical
Therapy from Columbia University in New York,
USA and has been working in the UK for the past
2 years. She currently works as a chartered physiothera-
pist for Complete Physio in London, UK. Holly is also
a trained Polestar Pilates Rehabilitation provider and
works as a chartered physiotherapist teaching clinical
Pilates for Complete Pilates in London, UK. Holly is
a member of the Chartered Society of Physiotherapy,
Health and Care Professions Council, Acupuncture
Association of Chartered Physiotherapists, and the
American Physical Therapy Association.
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 107–115

case report

Treatment of non-­union fracture of the fifth

metatarsal with electroacupuncture and manual
acupuncture
S. Bailey
Private Practice, Nottingham, UK

Abstract
Fracture of the fifth metatarsal occur more frequently than any other metatarsal fracture
and is the most common fracture of the foot. Fracture of the fifth metatarsal are frequently
seen in athletes however, it also affects the general population. A 36-­year-­old Eastern male
taxi driver presented in clinic with a non-­union stress fracture to the right fifth metatarsal
following twisting the foot in a car park while shopping with family. The patient received a
total of 12 treatment sessions over seven weeks and demonstrated significant improvement
in symptoms to enable him to return to work within two weeks of treatment and to go on
holiday and walk without crutches. The use of the cathode (+) over the fracture site and an
optimum EA frequency of 10Hz as suggested by Yasuda (1974) proved to be effective in
the management of non-­union fifth metatarsal fracture.
Keywords: electroacupuncture, manual acupuncture, non-­union fracture.

Introduction classified as zone 1, 2 or 3 by Lawrence & Botte

It is suggested that fracture of the fifth meta-
tarsal occurs more frequently than any other
metatarsal fracture (Armagan & Shereff 2001;
Cakir et al. 2011; Ding et al. 2012; Owen et al.
1995; Petrisor et al. 2006) and is the most
common fracture of the foot (Metcalfe 2001).
Fracture of the fifth metatarsal are frequently
seen in athletes however it also affects the gen-
eral population (DeLee et al. 1983; Zwitser &
Breederveld 2010; Nielsen et al. 1998).
Fracture of the fifth metatarsal occur in
three key areas of the bone (see Fig. 1).
The shaft (diaphyseal) metaphyseal and the
tuberosity and can be classified depending on
their location. Fracture of the base (tuberos-
ity) of the fifth metatarsal was first described
by Sir Robert Jones in 1902 and have been
Correspondence: Steve Bailey, Foot Knee and Back
Clinic, Long Eaton, Nottingham, NG10 4LB, UK.
Email: info@stevebaileyacupuncture.com
(1993).
Shaft fractures which occur in the diaphysis
can be oblique or transverse. Fractures occur-
ring in the proximal diaphysis (up to 1.5 cm
distal to the tuberosity) have a significantly
increased risk for delayed union or non-­union
(Smith et al. 1992). Dancers’ fractures occur
in the diaphysis; however, they are long spiral
fractures that extend in to the metaphyseal
region.
Kane et al. (2015) assessed 1275 fifth metatar-
sal fractures and found that the most frequent
occurring site of fracture was in zone 1 (tuber-
osity) followed by the shaft and then zone 2 of
the metatarsal head. The main mechanism of all
injury location was due to twisting followed by
a fall. Males in their third decade of life were
found to be at greatest risk of sustaining a frac-
ture of the fifth metatarsal. While females in the
seventh decade of life were at the greatest risk
of sustaining a zone 1 fracture from twisting

© 2019 Acupuncture Association of Chartered Physiotherapists 107

Treatment of non-­union fracture of the fifth metatarsal
Figure 1. Illustration to show the location of stress fracture to the fifth metatarsal.
the foot (Kane et al. 2015). Studies have demon-
strated that the increase in fractures in women
with age is due to a postmenopausal decrease
in oestrogen leading to the development of
osteoporosis and increased risk for fractures in
general (Kanis et al. 2008; Singer et al. 1998; Siris
et al. 2006).
Case Report
A 36-­year-­old Eastern male taxi driver presented
in clinic with a non-­union stress fracture to the
right fifth metatarsal following twisting the foot
in a car park while shopping with family. His
main concern was that the foot was not heal-
ing and was progressively getting worse and
he was unable to put the foot to the ground.
Furthermore, he was due to go on holiday in
seven weeks to Greece and he may not be able
to go sightseeing. The patient was in good health
but slightly over-­weight and taking co-­codamol
to manage his pain.
Assessment
• Moderate-­ severe non-­ pitting swelling, and
tenderness noted over the right fifth meta-
tarsal shaft with discolouration and bruising
• The area was very sensitive to touch
• Cool to the touch
• There was no muscle deficit on active ever-
sion of the foot which indicates that the
peroneus brevis was not involved and that
108
the tuberosity (avulsion fracture) was not the
cause
• A non-­union stress fracture along the distal
shaft of the fifth metatarsal was confirmed
following an x-­ray in accident and emergency
at the hospital three weeks prior to attending
clinic
• A pair of crutches and an air cast boot had
been fitted, which he removed each evening
before going to bed
• During gait, the patient was unable to put the
foot to the ground and was totally dependent
on crutches
• Tightness and muscle spasm were present in
the right calf and peroneal muscles
Measurement
The patient completed two Manchester-­Oxford
Foot Questionnaires (MOXFQ), one at initial
assessment and one at four weeks following
initial treatment. Unfortunately, we were unable
to obtain a final assessment as the patient did
not attend his final appointment.
The MOXFQ is a 16-­item patient reported
outcome measure that was initially developed
and validated for use in clinical trials involv-
ing bunion corrective surgery (Morley et al.
2013). It has since been modified and validated
for use among patient with a variety of foot
and ankle disorders. The MOXFQ is a five-­
point Likert scale that assess three domains:
© 2019 Acupuncture Association of Chartered Physiotherapists

walking/standing problems (seven items), foot
pain (five items), and issues related to social
interaction (four items). All domains relate to
symptoms the patients have experienced over
the past four weeks and have been shown to
have excellent psychometric properties with
regards to reliability, validity and responsive-
ness (Dawson et al. 2006; Dawson et al. 2007;
Dawson et al. 2011; Dawson et al. 2012). Each
item is scored from 0–4, with 4 representing
the most severe state. The scale scores are then
converted in to metric from 0–100, where 100
denotes the most severe.
Patients concerns
• The foot is not healing and is progressively
getting worse
• Unable to work because he cannot drive due
to pain and swelling in the foot therefore
losing money
• Unable to wear shoes due to pain and
swelling
• Going on holiday in seven weeks and wants
to be able to walk without crutches
Aim of treatment
• To reduce swelling which will in turn reduce
pain and initiate the healing process
• Initiate healing of bone through the selection
of distal classical acupuncture points and the
physiological effect of electroacupuncture
locally
• Improve muscle strength to allow early
ambulation
A combined approach of western and traditional
Chinese medicine (TCM) was used to obtain the
best treatment outcome for the patient. Western
medical acupuncture generally focusses on the
management of pain (symptom) and the physio­
logical effect of acupuncture, however TCM
focus on the underlying cause and the effect
of acupuncture by invigorating Qi and Blood.
In this case report, pain was not the primary
focus of treatment as pain is a symptom that
arises from swelling due to pro-­ inflammatory
chemical mediators such as prostaglandin E2,
substance P, and calcitonin gene related peptide
(CGRP) that are released from damaged tissue
following trauma. Substance P is a vasodilator
© 2019 Acupuncture Association of Chartered Physiotherapists
S. Bailey
and is responsible for the transmission of
information about damaged tissue from periph-
eral receptors to the central nervous system to
be converted to the sensation of pain (Bailey
2018). Prostaglandin E2 is a strong vasodila-
tor and is the best-­known lipid mediator that
contributes to inflammatory pain (Kawabata
2011) and CGRP is a potent peptide vasodilator
and can function in the transmission of pain.
In addition to chemical mediators there will be
pressure on nerve endings causing further pain
and stiffness in the region. Initially in this case
report the main aim of treatment was to reduce
swelling by ending the inflammatory phase and
initiating the proliferative phase of healing,
which would in turn reduce swelling, stiffness
and pain and allow healing to take place.
Treatment
Non-­ invasive bone growth stimulators using
pulsed electromagnetic field (PEMF) technology
are currently in widespread use by patients with
impaired fracture healing. Murray & Pethica
(2016) assessed the effects of 15Hz, 225 ms
pulse PEMF on 1382 patients with non-­union
fractures, and found an overall success rate of
89.6%. In support of these findings Holmes
(1994) demonstrated the effect of pulse electro-
magnetic fields on non-­union of fifth metatarsal
fractures of nine subjects combined with non-­
weightbearing cast. He found that they healed
within a mean time of three months (two to
four months) and presented with no refracture
after a mean time of 39 months. Therefore,
to achieve similar treatment outcome low fre-
quency (10Hz) electroacupuncture will form the
primary treatment modality in this case report
to enhance the healing process of bone.
Since the 1800s there have been significant
advancements in the understanding of the
physiology of acupuncture that have led to a
wider acceptance by healthcare professionals
throughout the world, thus allowing acupunc-
ture to be integrated into western medical prac-
tice. There is now a considerable growth in the
number of healthcare professionals undertaking
acupuncture training and these professionals
view acupuncture from a scientific perspective
(Bailey 2018). Through research there is now
109
Treatment of non-­union fracture of the fifth metatarsal
a growing body of evidence that explains the
function of commonly used classical acupunc-
ture points. Many of these studies have dem-
onstrated the physiological effect of manual
and electroacupuncture on the healing process
of bone (Shakya et al. 2014; Zhang 2004; Wie
et al. 2010; Shen et al. 1999; Yeom et al. 2013;
Sharifi et al. 2003; Ganne 1988; Yasuda 1974)
soft tissue (Kjartansson et al. 1988; Jansen et al.
1989a; Lundeberg et al. 1988; Parmen et al. 2014;
Uema et al. 2008; Machado et al. 2012), and ten-
dons (Kubo et al. 2010; Kishmishian et al. 2012;
Zhang et al. 2013; Langevin et al. 2007; Almeida
et al. 2015) in both animal and human.
From clinical experience of treating non-­
union of the fifth metatarsal and the short time
scale in which to get the patient walking crutch
free, acupuncture was discussed with regards to
its benefits, physiological effects on healing and
possible adverse effects and contraindications.
The patient gave verbal consent as well as com-
pleting and signing an acupuncture health and
consent form.
Initial treatment session
Soft tissue massage was applied to the calf and
peroneal muscles and very lightly over the foot
to stimulate general circulation in the lower
limb and to ease muscle tension in the calf and
peroneal muscles. This was followed with laser
acupuncture to Gall Bladder (GB) 39, GB 41,
GB 43, Urinary Bladder (UB) 60, UB 63 to UB
66. Laser acupuncture is defined as the stimula-
tion of traditional acupuncture points with low
intensity, non-­thermal laser irradiation, and its
clinical application is widespread. Since the early
1980s, low-­level lasers have been used anecdo-
tally to stimulate acupuncture points (instead of
needles) to help treat pain (Kleinkort & Foley,
1984). In this case report laser acupuncture
was applied using an Omega 820nm 200mW
probe. The probe was fitted with a 0.5 cm
acupuncture attachment and a frequency of
10Hz for 30 s (0048.0 J/cmsq) was applied to
each acupuncture point. Laser acupuncture was
applied on the initial treatment session to local
points in order to desensitize the lateral border
of the foot, to reduce swelling and inflam-
mation in preparation for the application of
110
electroacupuncture. Laser acupuncture does not
generate heat and would not cause vasodilation
as seen with manual acupuncture, which would
lead to further swelling, pain and stiffness when
applied to local acupuncture points.
Second treatment session
This took place 5 days later. The patient re-­
ported significant improvement in pain. The
bruising was more pronounced as it made its
way to the surface of the skin. Swelling was
now mild to moderate along the shaft of the
right fifth metatarsal and extending to the
metatarsophalangeal joint. Manual acupuncture
(MA) and electroacupuncture (EA) was again
discussed with the patient and informed con-
sent was gained.
Phoenix A-­ Type 0.22 mm  × 25 mm needles
were inserted to a depth of 0.5–1 cm depend-
ing on location. The patient was laid supine
and MA was applied to Stomach (ST) 36,
Spleen (SP) 6, UB 63, and GB 39. De Qi was
reported for each point following insertion and
the needles were manually stimulated every 10
min (gently, by rotating the needles clockwise
then anti-­clockwise four to five times) to elicit
a parasympathetic response. 15Hz, continuous,
100ms 30 min EA was applied to GB 41, GB 43
and two needles were inserted into the plantar
surface of the foot in line with GB 41 and GB
43 (see Fig. 2). Electrical stimulation was applied
using an AWQ-­ 104E electroacupuncture unit
with reversible polarity switch for each channel
(see Fig. 3). The AWQ-­104E unit allowed each
individual electrode output to be set to anodal
(-­) or cathodal (+) stimulation. As the primary
aim of treatment was to reduce swelling and the
inflammatory phase and initiate the proliferative
phase of healing, the device was set so that all
the electrodes would stimulate with an anodal (-­)
current. Vaccaria seeds were applied to Kidney
(KI) 7 and SP 9 for the patient to stimulate
daily at home for one min on each point.
Justification for choice of points
ST 36 and SP 6
Several studies have shown that MA, EA and
laser acupuncture at ST 36 and SP 6 increase
© 2019 Acupuncture Association of Chartered Physiotherapists

Figure 2. Illustration to show needle placement for EA
of the fifth metatarsal.
Figure 3. Illustration to show the AWQ-­104E
electroacupuncture unit.
bone mineral density and bone growth (Zhang
et al. 2004; Wie et al. 2010; Yeom et al. 2013).
Shen et al. (1999) and Sharifi et al. (2003) found
acupuncture to be effective in enhancing bone
healing and faster remodeling of callus. Zhang
et al. (2004) compared EA at ST 36 and SP 6
with other acupoints and found that these two
points were more effective than needling UB
20, UB 23 in bone anabolic regulation.
KI 7 and SP 9
KI 7 is an important point for regulating inter-
stitial fluids in the body and water metabolism.
When KI 7 is used in conjunction with SP 9,
it is effective at reducing swelling and oedema
in the lower limb. KI 7 and SP 9 are recom-
mended in case of post-­ surgical swelling, or
excessive swelling and inflammation following
trauma. If the swelling is too extensive in the
limb concerned, needling can be applied to
© 2019 Acupuncture Association of Chartered Physiotherapists
S. Bailey
the contralateral limb with good effect (Bailey
2018).
UB 64 and 65
Chronic sports injuries and acute or chronic
pain along the lateral border of the foot and the
Urinary Bladder meridian (Bailey 2018).
GB 39
GB 39 is an important point for bone pain as it
is the influential point for marrow (Bailey 2018).
The justification for the frequency setting is
that visceral (smooth) muscles supplied by the
autonomic nervous system are stimulated opti-
mally at 10-­15Hz. This frequency will activate
the muscle pump and produce a rhythmic con-
traction of both smooth and skeletal muscles.
This in turn will promote blood flow and the
absorption of exudates, thereby reducing swell-
ing and pressure on nerve endings and pain.
Furthermore, the anode (-­) electrode attract lym-
phocytes, neutrophils and macrophages (Kloth
2005; Talebi et al. 2007) to the site which will
shorten the inflammatory phase and initiate the
proliferative phase. Vaccaria seeds were applied
to KI 7 and SP 9 for the patient to stimulate
daily at home for one min on each point.
Third treatment session
This took place 5 days later. The patient re­ -
ported feeling much better and had experi-
enced no adverse events. On examination, it
was noted that the swelling had subsided and
tenderness on palpation was localized to the
distal metatarsal shaft of the right fifth on the
plantar lateral surface. Now that the swelling
had subsided, treatment was primarily aimed
at stimulating bone repair therefore, the polar-
ity of the electrodes was changed to (+) and
the cathode electrode was attached to needles
placed in GB 41, GB 43, UB 64, UB 65 and
two needles were inserted on the plantar surface
of the foot directly below GB 41 and GB 43. It
was important to ensure that sufficient needles
were placed around and as close to the fracture
site as possible, and to further enhance bone
growth therefore cathode (+) electrodes were
placed around the fracture to allow optimal
healing as suggested by Friedenberg et al. (1971),
111
Treatment of non-­union fracture of the fifth metatarsal
and Nakajima et al. (2010). 10Hz, high intensity
stimulation was applied to the area for 30 min-
utes. MA was applied to ST 36, SP 6, UB 63 and
GB 39. De Qi was reported for each point fol-
lowing insertion and the needles were manually
stimulated every 10 min (gently, by rotating the
needles clockwise then anti-­ clockwise four or
five times to elicit a parasympathetic response).
The justification for the change in frequency
and changing the electrical polarity from
negative to positive is because it is reported
that quicker results are obtained in the healing
of fractures when the cathode (+) electrode
is placed in the fracture site (Friedenberg et al.
1971; Nakajima et al. 2010). Furthermore, from
past clinical experience one has found a quicker
healing of fractures when the cathode (+) is
applied around the fracture site. A frequency
of 10Hz was chosen because Ganne (1988,
1980), demonstrated a frequency of 20Hz to be
significantly more effective than 100Hz in the
management of non-­union of tibial fractures.
The change in frequency from 100hz to 20hz
by Ganne (1988) was based on the findings of
Yasuda (1974), who assessed the effectiveness
of four different frequencies (10, 60, 100 and
250Hz) on leg fractures. Yasuda (1974) found
the greatest callus formation occurred in the
group receiving 10Hz, therefore 10Hz was used
in this case report.
Treatment continued for a further four
sessions over two weeks. During this time a
semi-­weightbearing strengthening program was
implemented for the intrinsic and extrinsic mus-
cles of the right foot.
The sixth treatment session
Moderate pressure was applied on palpation
over the fifth metatarsal shaft and the patient
reported that he is now able to drive and that
there is mild discomfort therefore he was
advised to start to remove the air cast boot and
do short walks around the house. To help with
his gait, a tarsal pad with a cut out under the
fifth metatarsal was applied to his right training
shoe. EA and MA were repeated as before.
The patient returned on the following visit
reporting that his foot was much better how-
ever, his calf muscle had spasmed up and was
112
keeping him awake at night. Before treatment
commenced on the seventh session the patient
completed a second MOXFQ to help determine
his overall progress during the past four weeks
(see table 1). Soft tissue massage along with
local Ah Shi points were applied to the calf
muscle to help reduce muscle spasm in addition
to manual and EA as before.
The muscle spasm settled relatively quickly
over the following couple of treatment ses-
sions as the patient became more mobile over
the following weeks. The patient found that he
was able to comfortably walk short distances
without any aid before he went on holiday.
Unfortunately, he did not attend his follow-­up
session following his holiday. However, follow-
ing a telephone conversation, he reported that
he was very happy with the treatment and was
able to walk a reasonable distance before his
foot started to ache.
Discussion
The patient received a total of 12 treatment
sessions over seven weeks and demonstrated
significant improvement in symptoms to enable
him to return to work within two weeks of
treatment and to go on holiday and walk
without crutches. The use of the cathode (+)
over the fracture site and an optimum EA fre-
quency of 10Hz as suggested by Yasuda (1974)
proved to be effective in the management of
non-­union fifth metatarsal fracture. The score
for the MOXFQ domain walking/standing and
pain at four weeks of treatment showed an
overall reduction of 9% respectively (see Table.
1). These results are not as great as one would
have expected at this stage of treatment as from
past experience of treating this type of condi-
tion the domain scores for walking/standing
and pain would generally be higher.
It is believed the reason for the low domain
score reason is that progress was delayed as
the patient was a little over ambitious as he
became more mobile and sustained a minor tear
in the belly of the gastrocnemius muscle prior
to the completion of the second MOXFQ.
The impact of the tear affected walking/
standing and pain score, however the pain in his
© 2019 Acupuncture Association of Chartered Physiotherapists

Table 1. Summary of the MOXFQ domain scores pre-­treatment and at four weeks treatment.
Domain Pre-­treatment 4wk treatment
Walking/standing 86 78
Pain 55 50
Social interaction 75 56
foot from the stress fracture had significantly
reduced. Therefore, the score for walking/
standing and pain domains was mainly relating
to the symptoms of the tear in the calf muscle
and not the fracture in his foot. Overall there
was a significant improvement in social interac-
tion score (25%) over the four weeks as he felt
less self-­conscious about his foot and the shoes
he had to wear and found he was able to get
more involved in his daily social and recreational
activities. Furthermore, he was able to return to
work as a taxi driver after the first two weeks of
treatment. By the fourth week he was able to
walk around the house and to and from the car
without crutches. By the seventh week he was
able to walk with more confidence, although
there was a slight limp. At this stage I would
have liked the patient to have completed another
MOFXQ, however he did not attend his last
appointment as he was feeling fine. No adverse
event was reported throughout the treatment.
With the result of this single case report, it is
difficult to determine whether the full effects of
the treatment outcome were due to the effects
of electroacupuncture as no control was used
and a greater number of subjects would be
required to make a true representation of the
general population. However, it is promising to
see that treatment outcome in this case report is
similar to that of other studies that used pulsed
electromagnetic fields on nine subjects in the
management of non-­union stress fractures of
the fifth metatarsal (Holmes et al. 1994), and
EA in human studies (Ganne 1988) and animal
studies (Friedenberg et al. 1971; Nakajima et al.
2010).
Limitations
Unfortunately, the patient did not attend the
final treatment session to enable completion of
a final MOXFQ. However, at the end of the
seven weeks treatment, the patient was walking
© 2019 Acupuncture Association of Chartered Physiotherapists
S. Bailey
Score change % decrease
-­8 -­9.3%
-­5 -­9.09%
-­19 -­25.3%
pain free and had returned to his normal daily
activity.
Conclusion
Fifth metatarsal fracture is a common condi-
tion affecting the general population which can
develop complications leading to delayed, non-­
union, refracture and soft tissue complications.
In many cases of non-­ union fifth metatarsal
fractures, surgical intervention is required. Low
frequency (10Hz) electroacupuncture with the
cathode (+) placed around the fracture site
appear to enhance the rate of repair of bone
in non-­ union of the fifth metatarsal. More
rigorous studies are required to confirm the
optimum frequency and the benefit of using the
cathode in the management of fractures.
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(1989). Increased survival of ischaemic musculocutane-
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135, 555–8.
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Kjartansson J., Lundeberg T., Samuelson U. E. &
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Preventative and therapeutic effects of acupuncture on
© 2019 Acupuncture Association of Chartered Physiotherapists
S. Bailey
bone mass in osteopenia ovariectomised rats. American
J Chin Med 32 (3), 427–43.
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the fifth metatarsal; diagnosis and treatment. Injury 41
(6), 555–62.
Steve Bailey is the principal of Steve Bailey Acupuncture
CPD Training and the managing director of BP
Orthotics Ltd. He is an active sportsman, and practicing
Podiatrist, Sports Therapist, Acupuncture Practitioner
and Physiotherapist with two successful clinics. Steve
started his career in the armed forces as a physical train-
ing instructor before training as a physiotherapist. Over
the past 20 years he has treated, coached and trained
various teams and individual athletes up to national
and international standards, which includes members of
the British Judo Squad, Nottingham Forest Football
Club, Coventry City Football Club, Sheffield United
Steve has completed an MSc in lower limb biomechanics
and an MSc in acupuncture and has been practicing
both Western and Traditional Chinese acupuncture
for over 10 years. He specializes in the treatment of
sports injuries and utilizes acupuncture to enhance sports
performance in many of his athletes. Steve has published
a number of research articles concerning acupuncture in
sports medicine and the management of musculoskeletal
disorders and has spoken at several conferences. He
lectures nationally and internationally in acupuncture
and has published his first book ‘Dry needling and
Traditional Chinese Acupuncture: A manual
of acupuncture points, trigger points and
auricular points for the management of mus-
culoskeletal and associated disorder’ in August
2018.
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Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 117–118
event report
2nd International Symposium on Research in Acupuncture
Organised by A.M.A.B. (Associatiazione Medici Agopuntori Bolognesi) and
SAR (Society for Acupuncture Research)
October 20–21, 2018, Bologna, Italy
I was fortunate to be able to attend the AMAB
Symposium last October and found myself in
an impressive gathering of acupuncture lumi-
naries. The proceedings were in English and
Italian with simultaneous translation available.
At least 12 speakers were available to offer
their views on the general state of acupuncture
research, with an emphasis on how to select the
best way forward. There was wide agreement
that, although those of us involved in research
were well aware of the amount and quality of
the published work, publication still remained
difficult.
The symposium focussed on this situation
with many suggestions as to how the message
could be spread. Naturally there were some
perceived enemies, well known for their publi-
cations in popular newspapers. Well-­supported,
good, science has never been more needed.
The presentations were offered by 15 speak-
ers, some very well known to the AACP;
Hugh MacPherson, Thomas Lundeberg,
Vitaly Napodow, Richard Harris, Myeong Soo
Lee, Remy Coeytaux, Stephen Birch, Claudia
Witt and Rosa Schnyer. Others were less well
known in the UK but busy in Europe and the
States.
There were many discussions during the con-
ference; comment was free and ideas, although
not always original, kept returning to the prob-
lem of not enough really good research. We
have always been faced with some seemingly
insurmountable issues.
• Research funding is often confined to main-
stream medicine, acupuncture being either
ignored or, worse, rejected, usually as a
placebo.
© 2019 Acupuncture Association of Chartered Physiotherapists
• Acupuncture is still seen as something very
old-­fashioned, the fact that it has survived
pretty successfully for hundreds of years is
seen either as a testimony to its efficacy, or,
less encouraging, it’s value as a placebo.
• The pharmaceutical industry has offered
very effective counter-­ publicity for many
years now.
It is not really possible to summarize the discus-
sions; several books could easily have been writ-
ten! The following offers an idea of the topics:
• Achieving an emphasis on confidence in
scientific proof.
• Seeking to optimise both specific and non-­
specific effects in directed “Real World”
research.
• Observing reward circuit plasticity in the
perception of pain following acupuncture
and the role of neuroimaging
• Current methodological issues in acupunc-
ture researches.
• Cost-­effectiveness of acupuncture and inte-
gration into healthcare, particularly conven-
tional academic and military centres in the
USA.
• Self-­pressure for chronic pain and fatigue.
• Role of neuroimaging to assess acupuncture-­
induced neuroplasticity in pain relief.
• Beyond efficacy: conducting and translating
research for policy-­makers considering acu-
puncture reimbursement in a small, rural US
state.
• Acupuncture in migraine: from research to
clinical management.
• Towards a better understanding of why so
many acupuncture trials are ‘negative’ in
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2nd International symposium on research in acupuncture
contrast to the good results seen in clinical
practice.
• Distant effects of acupuncture on connec-
tive tissue.
• Recommendations for the use of acupuncture
in clinical practice and treatment guidelines.
• Evidence-­informed integration of acupunc-
ture into cancer care.
• Acupuncture in the treatment of Gulf/war
illness among veterans.
So many useful suggestions. All we have to do
now is to follow them up and, once we have the
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new proofs, make sure that the medical com-
munity can’t overlook it.
Those who know me will know that I have
been anxious to encourage more excellent
research for quite some time now. It was good
to meet an inspiring international group of
acupuncturists who feel the same.
Dr Val Hopwood.
Clinical Editor, Acupuncture in Physiotherapy
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 119–120
event report
AACP Scotland Study Day
Queen Margaret University in Musselburgh was
the venue for the 2018 Scotland Study Day.
First up was Lynn Pearce whose presentation
looked at the merging worlds of art, anatomy
and the science of biological exploration into
the communication networks of the human
body. Her challenge was to present enough
evidence and ideas to enable delegates to think
about what the meridian systems may be to us
in the West, in a new and connected way. The
anatomy of fascial trains and their pathways was
reviewed and the link with myofascial release in
clinical practice, discussed.
The Jing-­ River points and key acupuncture
points were used to demonstrate, on volunteer
delegates, the systematic process of assessment
which shows where tension lies within the
meridial network/fascial system from head to
toe. From the assessment, it was possible to
ascertain the best areas to treat with acupuncture
for conditions involving pain from tightness and
lack of movement in the tissues. Skilful palpa-
tion was advocated as key to determining the
condition of the tissues and to giving essential
information for an effective assessment.
Lynn suggested that appreciating the com-
plexities of internal body-­wide communication
and what drives that, is fundemental.to appre-
ciating how acupuncture might work. Fascial
tissues are seen as an interconnecting tensional
network which has not just a mechanical com-
ponent, but also an electrical component. This
electrical component relies on fluid and bathes
every cell and our treatments all involve improv-
ing the movement of fluid to differing degrees.
Lynn was, as ever, highly entertaining whilst
delivering an informative and thought-­provoking
lecture.
Johnny Wilson, an Irish physiotherapist with
a special interest in the role of acupuncture
in sport, was the second speaker. He works
© 2019 Acupuncture Association of Chartered Physiotherapists
with elite athletes (in particular professional
footballers), integrating science and innovation
to design and implement performance enhance-
ment conditioning sessions for them.
In his presentation, Johnny discussed how
he uses acupuncture as part of a multi-­modal
player performance approach for the assess-
ment, treatment, recovery and enhancement
of performance in professional footballers.
He illustrated with video clips the demands of
professional football on the athletes and how
he integrates acupuncture within professional
sport.
The presentation covered rehabilitation of
elite athletes, developing speed and power
profiles for professional athletes and the use of
acupuncture when travelling with elite athletes.
A video interview with an injured footballer
gave insight into the mindset of these athletes
for whom injury can become all-­encompassing
and pain a fixation. The footballer’s testimonial
for the acupuncture he received, and how it
helped to overcome his fears and injury, was
heartening.
Johnny delivered his talk with gentle humour
and obvious enthusiasm for his subject which
evoked some excellent debate.
John Wood’s presentation was intriguingly
entitled “Acupuncture, Pain and the Emotional
Mind”. His objective was to give an overview
of the Heart organ/meridian and its relation-
ship to emotions from a traditional Chinese
medicine (TCM) perspective.
He taught how emotional pain might be
less tangible in some respects than a physical
sensation of pain, but that its significant impact
on the human condition is attested to by the
numerous plays, songs and poems which draw
upon emotional suffering for inspiration.
How and why we feel emotion was identified
by its generation from within the limbic system
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Scotland study day
of the brain. Understanding this system is key to
activating or inhibiting activity within the sym-
pathetic and parasympathetic systems, and the
body sensations which acupuncture stimulates
from deep within its connective tissue matrix.
John delighted his audience with the infor-
mation that a cup of hot tea in the hands is
likely to make us feel an interpersonal warmth
towards others so that we will interpret their
intentions as friendlier and kinder. This, he
explained, is due to the warmth of the drink in
the hands and the body causing activation of
the left insula (associated with happy thoughts)
and therefore causing a positive feedback loop
via activation of the parasympathetic nervous
system. Never would I have imagined that a cup
of tea could have such a profound emotional
effect!
The Heart organ and meridian were
described as playing a pivotal role in regulating
the functional activities of the internal organs.
At the core of TCM is the concept that for any
organ or part of the body to function optimally
and resist degeneration and disease processes,
then it must receive a generous flow of well-­
oxygenated blood. Acupuncture may be a man-
ner in which we generate the sensations, feelings
and emotions in the body which are associated
with the health of these tissues. Once initiated,
these sensations seem to reverberate in a self-­
sustaining manner and may, in fact, be at the
very heart of how acupuncture affects the body.
This was a mind-­ blowing lecture which
explored the effects of acupuncture from an
unusual and original perspective.
The final lecture of the day was given by
Caroline McGuire. This was an inspirational
talk with the title “Acupuncture in Neurology”.
The role of acupuncture in this area is not yet
widely regarded and there is limited research,
120
but through clinical practice it has been shown
to positively influence a patient’s condition and
ultimately their quality of life.
Caroline described how she has spent many
years using acupuncture to help ease the symp-
toms of neurological conditions such as fatigue,
pain and motor symptoms. She used clinical
cases to illustrate how our existing knowledge
of acupuncture can be effectively applied to
patients with neurological conditions.
She discussed different acupuncture tech-
niques along with specific protocols which have
been found to be of clinical benefit, and also
described approaches to acupuncture needling
such as muscle lengthening, trigger point release
and central nervous system modulation, in rela-
tion to the neurological patient.
In a most uplifting touch, she interviewed
one of her patients who has multiple sclerosis,
and who eloquently discussed her condition and
the hugely positive effect that acupuncture has
had on her symptoms and quality of life.
The feedback from this lady highlighted the
outcomes from the patient’s perspective and
provided motivation for acupuncture to be more
widely used within the neurological field. There
was also anecdotal evidence from patients with
Parkinson’s disease who stated that acupuncture
settled their tremor, improved gait, decreased
stiffness, increased energy levels, eliminated
pain and improved mood. Furthermore,
as a result of these effects, the amount of
medication required by these patients may be
reduced.
Caroline delivered her lecture with a lovely
easy style and this was a most satisfying way to
end an excellent study day.
Wendy Rarity
AACP Board Director
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 121–122
Book reviews
Electro Acupuncture Handbook for
musculoskeletal problems
By Stephen Lee
Acuman Books, 2018, 136 pages, paperback,
£17.50.
ISBN 978-1-­9996152-­0-­8
Stephen Lee is a practising Acupuncturist and
Herbalist, a member of BAcC and RCHM.
He studied at the College of Traditional
Acupuncture in Leamington in the 1980s and
teaches workshops on electroacupuncture
(EA) for musculoskeletal (MSK) conditions.
The author states his interest in EA is simply
the result of a real desire to treat patients suc-
cessfully; his practical experience over the last
30 years has led him to believe that generally
EA is much more effective for MSK problems
than manual acupuncture.
It makes me sit up and take notice when
someone has a wealth of practice-­based expe-
rience like this author. Although I have rarely
used EA – I was put off years ago on a course
when the intensity was whacked up – I was
keen to read on. The author’s techniques in EA
have been developed over a considerable period
of time studying and listening to feedback from
patients. This book provides a concise and clear
introduction to the practical use of EA, I can
discern that the author has experience in the
day to day treating of patients. He doesn’t seem
rigid in traditional Chinese medicine (TCM) or
Western acupuncture principles and willingly
admits EA doesn’t work for all MSK conditions.
He questions some well used techniques and
methods and attempts to dispel some perpetu-
ated myths. It leaves you thinking.
The initial chapters are informative, a clear
review of the basics of electricity and its effects
on tissues. The next two chapters explain the
EA machine types, include the kind of practi-
cal questions that are not in the manuals and
make good sense. For example, it is suggested
that smaller machines can sit beside the patient
© 2019 Acupuncture Association of Chartered Physiotherapists
on the plinth rather than on a separate table.
Common sense when buying a machine but not
one I might consider when being bamboozled
by frequency and settings.
The chapter on treatment principles is clear
and yet allows room for clinical decision making
without prescription. The practical advice on
‘winding the leads’ is simple but being a winder
of leads, I needed reminding of this!
The main body of the book is split into ana-
tomical areas: neck, hip, low back pain. Some
chapters detail specific conditions such as carpal
tunnel and tennis elbow but they still follow the
anatomical progression so you don’t get lost.
In other words, it should be easy to delve into
this book in a busy clinic. I am not sure why
exercises and ball massage are added to certain
chapters but there is nothing in these sections
that would make a Physio wince or do anything
but nod in approval. There are numerous
case studies in each of these chapters where
Stephen Lee presents clinical reasoning in TCM
and Western acupuncture and is, I think, hon-
est about outcomes without making any wild
claims. I like his honesty about the limitations
of treating frozen shoulders with EA, like many
other points in the book it has me nodding in
agreement.
This is a useful introduction and reference
book for EA and reading it has helped boost my
confidence and whet my appetite for EA again.
So much so, I have been looking at machines.
Mairi Menzies
Callander, Scotland
Dry Needling and Traditional Chinese
Acupuncture
By Steve D Bailey
Steve Bailey Acupuncture, 2018, 365 pages,
paperback, £65.00
ISBN 978-1-­9168303-­0-­3
Steve Bailey’s C. V. makes for dynamic reading,
I’m exhausted just thinking about all he has
121
Book reviews
accomplished and continues to achieve. He is
a Physiotherapist, Podiatrist and sportsman.
He has an MSc in lower limb biomechanics, an
MSc in Acupuncture, runs Acupuncture CPD
courses and specialises in treating sports inju-
ries in his private practice. He also publishes
research articles and presents at conferences.
This is the first of three planned volumes,
phew, one so accomplished certainly commands
respect.
The author believed there was a demand
for a book with straightforward explanations
of common acupuncture points used in mus-
culoskeletal (MSK) conditions, from a Western
medicine perspective. Traditional Chinese medi-
cine (TCM) is not left out however, as Chapter 3
discusses the main point classifications and their
use in MSK conditions from a TCM perspec-
tive. He emphasises the consideration of acute,
sub-­acute and chronic timescales when clinically
reasoning. In subsequent chapters, he explains
individual points with regards to Western and
TCM analysis. Chapter 4 describes classical
acupuncture points and is divided into specific
meridians, a form familiar in other publications.
122
The sections are colour coded on the edge
the of page to indicate subject. I would have
preferred the boxes to have been labelled with
the meridian code rather than the page number
for quick reference. Each meridian is summa-
rised and accompanied by a clear illustration,
clinical uses are discussed and important points
for MSK are listed. The author then goes on to
itemise important points on that meridian, com-
monly used in MSK conditions and describe
each in detail. Indications for use, location,
needling method and segmental relationship
are described with accompanying relevant clear
photographs.
Chapter 5 describes the eight Extraordinary
Vessels in the same format as before and
Chapter 6 details the Extraordinary Points.
Chapter 7 explains Myofascial Trigger Point
physiology, theory and treatment techniques.
We then move on to Chapter 8 where
Myofascial Trigger point location, referred pain
pattern, dysfunction and treatment methods are
described for 72 muscles, with clear diagrams.
The author has added a helpful paragraph
describing the movements that may contrib-
ute to these trigger points. The last chapter,
Auricular Acupuncture, presents the history,
anatomy and point description of this method
of acupuncture. Clear illustrations of points and
uses in a clinical setting are displayed. The evi-
dence is discussed with reference to acute and
chronic pain management which I found useful.
Specific auricular acupuncture points for MSK
conditions are described in a similar format to
previous chapters and I found the suggested
use of this technique in certain MSK conditions
informative. I will make some changes in my
point selection based on what I have learned.
In summary, this is a well referenced book
with a useful index. I think the author has
achieved his goal of a solid reference book for
MSK acupuncture with Western reasoning. This
book would be a good addition to any clinic
library shelf.
Mairi Menzies
Callander, Scotland
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 123–124
News, views and interviews
Mist S. D. & Jones K. D. (2018)
Randomized controlled trial
of acupuncture for women
with fibromyalgia: group
acupuncture with traditional
Chinese medicine diagnosis-­
based point selection. Pain Med
19 (9), 1862–1871
Around 1 in 25 of the UK population has
fibromyalgia – a chronic debilitating condition
involving widespread musculoskeletal pain and
tenderness, fatigue, sleep disturbance, and func-
tional impairment. As yet, there is no known
structural or inflammatory cause (Annemans
et al. 2008).
In fibromyalgia, abnormalities in central pain-­
processing and the release of neurotransmitters
including serotonin and noradrenaline lead to
lower pain thresholds. Predisposing factors for
the condition include female gender, anxiety,
trauma and viral infection (Clauw 2009).
Previous research articles have indicated that
group acupuncture is an effective and economi-
cal delivery method (Kliger et al. 2018), but at
the time of this article being published, had not
been tested in a research setting.
This study looked at 30 female subjects who
received either group acupuncture or group
education over a 10 week period. Acupuncture
subjects received twice weekly sessions using
individualised treatment based on traditional
Chinese medicine diagnosis. Using a revised
Fibromyalgia Impact Questionnaire and the
Global Fatigue Index, acupuncture subjects
reported an initial 25% improvement in fatigue
at the end of treatment and a 33% improve-
ment four weeks post treatment. They also
reported an initial reduction from baseline of
2.8 points on a 10 point scale, and a further
reduction to 3.5 at four weeks post treatment.
Acupuncture was found to be a safe and well
tolerated treatment, and many subjects also
© 2019 Acupuncture Association of Chartered Physiotherapists
reported functional improvements in activities
of daily living.
Although this trial can be criticized for the
small number of subjects, the results are statisti-
cally significant, and an indication that acupunc-
ture could be a valuable tool in treating patients
with fibromyalgia.
References
Annemans L. et al. (2008) Health economic consequences
related to the diagnosis of fibromyalgia syndrome.
Arthritis Rheum 58, 895–902.
Clauw D. J. (2009) Fibromyalgia: an overview. Am J Med
122 (12 suppl), S3-­13.
Kliger B., Nielsen A., Kohrherr C., et al. (2018)
Acupuncture Therapy in a Group Setting for Chronic
Pain. Pain Medicine 19 (2), 393–403.
Rosemary Lillie
News Editor
Schwehr N. I., Shippee N. D.
& Johnson P. J. (2018)
Acupuncture ‘dose’ (number
of treatments) and insurance
benefits in the USA.
Acupuncture in Medicine 36 (2),
88–95.
Clinical effectiveness of acupuncture is depend-
ent upon an adequate treatment dose. This
includes a sufficient number of treatments. The
aim of this study was to examine the character-
istics of adults who used either a full course of
acupuncture (six or more treatments), a short
course (one-­to-­five treatments) or no acupunc-
ture. They also looked at the use of insurance
benefits for acupuncture among the users. The
source of their data was the 2012 national
Health Interview Survey.
Their results showed that amongst acupuncture
users, 38% completed a full course. Acupuncture
use was low (1.5%), but higher amongst women
123
News, views and interviews
and those with greater education and less pov-
erty. Those who used acupuncture insurance
and had greater education were more likely to
receive a full treatment course.
The authors concluded that most people
who receive acupuncture do not receive a full
treatment course. They suggest that considering
the low risk and relatively low cost of delivery,
acupuncture could play a larger role in non-­
pharmaceutical treatment of common condi-
tions such as pain. They also suggest that policy
makers should consider that without insurance
benefits for acupuncture, people are less likely
to complete a full treatment course.
This article does raise some important issues
to consider. With only 38% of users completing
a course of treatment, it would be interesting
to know the reasons why the course was not
completed, as an assumption could be made
that users of acupuncture would be more likely
to regard acupuncture as an effective treatment
modality. It would be interesting to see if a simi-
lar number of users in the UK do not complete
their treatment, and perhaps remind us all to try
to ensure that our patients do complete their
course of treatment. The debate about what
is the correct number of treatments continues,
124
and also should treatment consist of a course
of treatments, or on a continuing basis.
With the UK population of 67.064 million
(ukpopulation2018.com), and an estimated
3 million undergoing acupuncture (Nursing
Times), this equates to approximately 1.9% of
the population using acupuncture. Dr David
Carr was quoted in the Guardian (Pugh 2015)
as saying that the focus of his work is for
acupuncture to become a standard part of
midwifery training, and at the same time change
perceptions among clinicians about its appropri-
ate use for a whole range of other conditions.
References
ukpopulation2018.com [WWW document] (Accessed 30
January 2019).
Nursing Times (2009) Acupuncture [WWW document] URL
www.nursingtimes.net/acupuncture/1994678.article
(Accessed 30 January 2019).
Pugh R. (2015) ‘Should acupuncture be used more
widely in the NHS?’, The Guardian, 13 October.
Available at: https://www.theguardian.com/healthcare-­
network/2015/oct/13/acupuncture-­used-­more-­widely-­
nhs (Accessed 30 January 2019).
Rosemary Lillie
News Editor
© 2019 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 31, Number 1, Spring 2019, 125–127
Guidelines for authors
Introduction
Always 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 email 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 clini-
­cal 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 inclu-
sion in the journal. Academic and clinical
­ of five keywords that best represent the contents.
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 FCSP
18 Woodlands Close
Dibden Purlieu
Southampton SO45 4JG
UK
Email: val.hopwood@btinternet.com
© 2019 Acupuncture Association of Chartered Physiotherapists
Preparation of manuscripts
Authors should submit material by email 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:
Title
The 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
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 dia-
­grams 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.
125
Guidelines for authors
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 writ-
­ing 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:
126
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 reports
The journal welcomes case reports of up to
3000 words. These should be structured as
follows: title, abstract and keywords, a brief
© 2019 Acupuncture Association of Chartered Physiotherapists

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 reviews
At 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
© 2019 Acupuncture Association of Chartered Physiotherapists
Guidelines for authors
no more than 500 words in length; query for
longer.
Please contact the book review editor before
writing a review.
General points to note
Please enclose your home, work and email
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.
127
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Acupuncture in PhysiotherapyTM
Acupuncture in Physiotherapy TM

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Spring 2019
Volume 31, Number 1

Volume 31, Number 1, Spring 2019

ISSN 2058-3281