Therapeutic Effect Of Superficial Acupuncture In Treating .
HindawiEvidence-Based Complementary and Alternative MedicineVolume 2018, Article ID 9125746, 7 pageshttps://doi.org/10.1155/2018/9125746Research ArticleTherapeutic Effect of Superficial Acupuncture in TreatingMyofascial Pain of the Upper Trapezius Muscle: A RandomizedControlled TrialChao Ching Wang,1 Tse Hung Huang ,1,2,3,4 Kuo Ching Chiou,5 and Zi Yu Chang1,21Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Keelung, TaiwanSchool of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan3School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan4Graduate Institute of Health Industry Technology, Chang Gung University of Science and Technology, Taoyuan, Taiwan5Department of Finance, Chaoyang University of Technology, Taichung, Taiwan2Correspondence should be addressed to Zi Yu Chang; changzhi887@cgmh.org.twReceived 11 August 2018; Revised 23 October 2018; Accepted 14 November 2018; Published 2 December 2018Academic Editor: Nobuo YamaguchiCopyright 2018 Chao Ching Wang et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.The aim of this study was to compare the treatment efficacies of superficial acupuncture and traditional acupuncture on triggerpoints of the upper trapezius muscle. Forty people were recruited and randomly allocated to the traditional and superficialacupuncture groups. Each subject received two treatments per week in a four-week period. Outcomes were measured by visualanalogue scale (VAS), the Northwick Park neck pain questionnaire scores (NPQ), and pressure pain threshold (PPT) assessmentsof trigger points. Data collected before the interventions were considered as baseline. Assessments were performed after the firsttreatment and at the end of the second and fourth weeks of treatment. Patients reported significant (p 0.05) and immediateimprovements in VAS and PPT for both superficial acupuncture and traditional acupuncture after the first treatment and after twoand four weeks. Significant improvements (p 0.05) in NPQ were attained after two weeks of treatments in both groups. Becausesuperficial acupuncture is associated with less pain while producing immediate pain relief, we recommend it for treating myofascialpain syndrome in the upper trapezius muscle.1. IntroductionMyofascial pain syndrome is a common source of musculoskeletal pain in primary care. About 30% of the patientswho visit health care clinics because of pain meet the criteriafor myofascial pain syndrome [1]. Commonly seen at musclesthat are under prolonged eccentric loading [2], myofascialpain syndrome is characterized by trigger points, whichare focal, discrete, and hyperirritable areas in taut bandsof muscle fibers, are associated with typical pain referralpatterns, and give rise to motor dysfunction and autonomicphenomena [3]. Because of its high prevalence and ease-ofaccess, the most commonly tested muscle is the upper trapezius muscle, which is implicated in neck and shoulder pain [4].The formation of trigger points remains elusive. Onehypothesis suggests that when excessive acetylcholine isreleased at the motor end plates, the calcium pump mechanism is disturbed, causing the sustained contraction ofsarcomeres in the myofascial and local hypoxia due to bloodvessel compression. This mechanism of action conforms tothe energy crisis theory [5].A variety of methods may be applied for treating myofascial pain. The noninvasive treatments include physical therapies, such as heat, massage, transcutaneous electrical nervestimulations, stretching, and mud baths, or magnetic fieldapplication [6, 7]. The invasive methods include intramuscular electrical stimulation, injection therapy, and dry needling.Intramuscular electrical stimulation, or electroacupuncture,is usually performed with acupuncture needles as electrodes,the use of which provides more pain relief and improvedfunctionality than traditional transcutaneous nerve stimulation [8]. Myofascial pain injections are performed with a
2Evidence-Based Complementary and Alternative MedicineTable 1: Inclusion and exclusion criteria of the patients.Inclusion criteria(1) One or more tender spots within palpable taut bands over upper trapezius muscle(2) Referred pain pattern is shown when a pressure of 2.5 kgf/cm2 was applied on the taut bands(3) VAS of upper trapezius region within two to sevenExclusion criteria(1) Fibromyalgia, cervical radiculopathy, myeloid type cervical spondylopathy, and those who have had cervical spine operation(2) A systematic disease such as rheumatoid arthritis, multiple sclerosis, or tuberculosis(3) Therapy for myofascial pain in the upper trapezius muscle within the past one month before the evaluation(4) Contraindication to undergoing acupuncture treatments, such as being pregnant, local infection, anticoagulant therapy, and allergy toalcohol or stainless steelvariety of injectable drugs, such as procaine, lidocaine, isotonic saline solution, nonsteroidal anti-inflammatory drugs,corticosteroids, bee venom, botulinum toxin, or serotoninantagonists. However, Cummings and White concluded, “thenature of the injected substance makes no difference to theoutcome, and wet needling is not therapeutically superior todry needling.” [9, 10] Dry needling is an invasive techniquein which needles are inserted into the skin and muscles, atthe myofascial trigger points. The inserting and pistoning ofthe needles may elicit localized twitch responses, which mayinterrupt motor end-plate noise and reduce the pain [10].The procedure of palpating the tender spots and insertingneedles into them is similar to the traditional acupuncturetechnique of treating “Ah shi” points. The appearance of alocalized twitch response is similar to the “de qi” sensation.Hong agreed that, with the way acupuncturists treat Ahshi points, they might well be treating myofascial triggerpoints [11]. Superficial acupuncture was first documentedin “Huangdi Neijing” and was performed to treat nobleswith good nutritional support who were characterized ashaving tender bodies by inserting small needles shallowlyand leaving them inserted for a little time. Advocated byBaldry, superficial dry needling is a technique in whichthe therapist inserts an acupuncture needle into the tissuesoverlying each trigger point to a depth of 5-10 mm for 30seconds. Practitioners claimed to have a successful practice,with minimal patient discomfort [12].In this randomized controlled trial, we evaluated andcompared the efficacies and adverse events of superficial acupuncture and traditional acupuncture for treatingmyofascial pain of upper trapezius muscle.2. Materials and Methods2.1. Design. This study is a parallel designed randomized controlled trial with the allocation ratio of 1:1, conducted at theKeelung branch of Chang Gung Memorial Hospital, KeelungCity, Taiwan. It was approved by the Chang Gung MedicalFoundation Institutional Review Board (IRB number 1061472C1).2.2. Subjects. Sample size calculation was based on a previousstudy testing the effect of dry needling on upper trapeziusmuscle [13]. Patients with neck and shoulder pain with VASscores of two to seven, who were referred for evaluation andtreatment from August 2016 to October 2017, were included.Physical examination revealed tender spots within palpabletaut bands in the upper trapezius muscle, which showed areferred pain pattern when a pressure of 2.5 kgf/cm2 wasapplied to the taut bands [13].Participants were excluded if they experienced any of thefollowing criteria: (a) fibromyalgia, whiplash injury, cervicalspine fracture, cervical radiculopathy, myeloid type cervicalspondylopathy, and cervical spine surgery; (b) systematicdisease such as rheumatoid arthritis, multiple sclerosis, ortuberculosis; (c) treatment or therapy for myofascial painin the upper trapezius muscle within the past one monthbefore the evaluation; (d) contraindications to acupuncturetreatments, such as pregnancy, local infection, current anticoagulant therapy, and allergy to alcohol or stainless steel(Tables 1 and 2).All participants were asked to stop any other treatmentor therapy for myofascial pain syndrome while they wereundergoing the acupuncture treatment and to report anyadverse event they experienced. Randomization was performed by lots using opaque envelopes. Investigators ensuredthe envelopes were opaque when held to the light and openedafter the participant’s names were written on the envelopes.2.3. Assessment and Follow-Up. The VAS score, the Northwick Park neck pain questionnaire, and trigger point pressurepain threshold were assessed as outcome measures. Thefirst assessment was performed before treatment at baseline.Assessments were then conducted immediately after the firsttreatment, at the end of the second and fourth weeks aftertreatment (Figure 1).2.4. Measurement Instruments. The visual analogue scale isa psychometric response scale for subjective perception ofcurrent pain intensity, rated from 0 (no pain) to 10 (mostsevere pain ever experienced). The Northwick Park neckpain questionnaire has good short-term repeatability, highinternal consistency, and sensitivity to change; it measuresneck pain and consequent patient disabilities, providing anobjective measure to evaluate the outcome and monitorsymptoms in patients with acute or chronic pain over time[14, 15]. The participants had to fill in the questionnairewhich was divided into nine five-part sections: (1) neck pain
Evidence-Based Complementary and Alternative Medicine3Table 2: Characteristics of study subjects.GroupsSATATotalNumber192039Age mean SD33.37 9.1735.35 10.76Sex M/F5/149/1114/25SA, superficial acupuncture; TA, traditional acupuncture.Recruitment (n 40)RandomizationSuperficialacupuncture group(n 20)Traditionalacupuncture group(n 20)Day 1 (Pre-Tx)assessment1st treatment(n 20)1st treatment(n 20)Day 1 (Post-Tx)assessment4th treatment(n 19)4th treatment(n 20)Day 14assessment8th treatment(n 19)8th treatment(n 20)Day 28assessmentFigure 1: Flowchart of the study.intensity, (2) neck pain and sleeping, (3) pins and needles ornumbness in the arms at night, (4) duration of symptoms,(5) carrying, (6) reading and watching television, (7) workingand/or housework, (8) social activities, and (9) driving.The assessments of pressure pain threshold were performedby the same licensed doctor using an algometer (modelFDX 50 by Wangner Instruments, Greenwich, Connecticut,USA). Participants were asked to sit upright on a chairwithout armrests, with hip and knee joints flexed to 90 ,with bilateral scapulae in a neutral position with both armsdropped naturally next to the trunk. The doctor explainedthe procedure to the participants at first and then markedthe positions of trigger points in upper trapezius muscles. Thealgometer was perpendicularly applied to the skin surface ofthe trigger point, compressing the trigger point with a slowand steady force, which increased to approximately 1 kgf/cm2per second. The participants were instructed to report “pain”once the participant felt any increase in pain intensity ordiscomfort. The doctor stopped applying force on the triggerpoint immediately and recorded the peak pressure showingon the algometer, expressed as kgf/cm2 . Three repetitivemeasurements with an interval of 30 seconds were performedand averaged for pain threshold value [16].2.5. Intervention. Participants were allocated randomly intosuperficial acupuncture or traditional acupuncture groups;they underwent treatment twice weekly for a 4-week period.During treatment, participants were asked to sit with botharms placed naturally alongside the body. A licensed doctorfully instructed the participants on the procedure and thengently wiped the trigger points on upper trapezius musclewith cotton swabs soaked with 75% alcohol.2.5.1. Superficial Acupuncture. Stainless steel ear acupunctureneedles (0.2 mm diameter, 2.5 mm length. “YU KUANG”disposable ear acupuncture needles) were fully insertedperpendicularly into the skin over each trigger point with thedepth of 2.5 mm. All needles were left in place for 20 minutesand then removed.2.5.2. Traditional Acupuncture. Stainless steel acupunctureneedles (0.3 mm diameter, 40 mm length. “YU KUANG”disposable acupuncture needles) were inserted perpendicularly into the skin at each trigger point. The needles wereinserted and withdrawn several times in each taut band usingthe pistoning acupuncture technique. One or more localizedtwitch responses were elicited. Before removal, the needles
4Evidence-Based Complementary and Alternative MedicineTable 3: Baseline and follow-up characteristics by group.Day 1Pre-TxVASPPTNPQ4.737 1.6611.454 0.43823.17 11.016VASPPTNPQ5.40 1.9571.433 0.33623.30 14.020Mean SDDay 1Post-TxSuperficial Acupuncture4.105 1.6291.759 0.48722.88 11.544Traditional Acupuncture4.55 1.9051.854 0.57922.22 13.868Day 14Day 283.632 1.5711.987 0.63415.56 7.5872.474 1.2642.419 0.83910.33 7.8314.20 2.0422.000 0.64616.18 10.1663.00 1.7172.175 0.68511.34 10.760SD, standard deviation; Tx treatment; VAS, visual analogue scale 0-10; PPT, pressure pain threshold kgf/cm2 ; NPQ, the Northwick Park neck pain questionnaire,%.VASwere inserted in the taut bands with an approximate depthof 1 cm for 20 minutes.SCORE2.6. Statistical Analysis. Measurements of VAS, NPQ, andpressure pain threshold were calculated and presented asmeans standard deviations. The repeated measure ANOVAwas used to assess the differences between the data beforeand after treatments in each group, and post hoc comparisonswere performed using Fisher's least significant difference(LSD). Effect sizes were calculated and reported as eta square(𝜂2 ). The statistical significance was established at p 0.05(two-sided). SPSS version 22.0 for Windows was used foranalyzing all data.8.00 6.00 #§4.002.000.00DAY 1(PRE)DAY 1(POST)3.2. Increased Pressure Pain Threshold of Trigger Points. Thechanges the in pressure pain threshold of trigger pointsrevealed a significant objective relief of the myofascialpain syndrome after superficial acupuncture and traditionalacupuncture treatments. A large main effect of time onpressure pain threshold of trigger points (p 0.001, 𝜂2 0.577)was observed. Pressure pain threshold increased as moretreatments were applied to the participants in each group(Figure 3). No significant time group interaction (p 0.136,𝜂2 0.053) was shown.DAY 28Figure 2: Serial changes in visual analogue score VAS. 𝑃 0.05versus DAY 1 (PRE); # P 0.05 versus DAY 1 (POST); § P 0.05 versusDAY 14. Error bars represent standard deviations.PPT (KGF/C－2 )3.1. Reduced Pain Intensity. According to the changes in VAS,all participants had reduced pain sensation in the uppertrapezius muscle. Compared to the data collected at baseline,VAS scores after the first treatment and at the 2 and 4-weekfollow-up assessments showed significant improvements. Alarge main effect of time on pain intensity (p 0.001, 𝜂2 0.545) was observed. The results of both groups revealed thatthe pain intensity decreased as more treatments were applied(Figure 2). There was no significant time group interaction(p 0.919, 𝜂2 0.003).DAY 14TASA3. ResultsThe changes in parameters are listed in Table 3. No adverseevent was reported by participants. #PPT4.03.0 # #§DAY 1(POST)DAY 14DAY 282.01.00.0DAY 1(PRE)TASAFigure 3: Serial changes in pressure pain threshold PPT, kgf/cm2 . 𝑃 0.05 versus DAY 1 (PRE); # P 0.05 versus DAY 1 (POST); § P 0.05versus DAY 14. Error bars represent standard deviations.3.3. Improvements in Neck Pain and Consequent Disability.The Northwick Park neck pain questionnaire is designedto show how patients’ neck pain affects their ability tomanage tasks in daily life. The NPQ score did not differsignificantly before and after the first treatment in eithergroup. However, at the 2- and 4-week follow-up assessments,significant improvements (p 0.01, 𝜂2 0.412) in NPQ scoresoccurred in both groups. The time group interaction wasnot significant (p 0.852, 𝜂2 0.003).
%Evidence-Based Complementary and Alternative Medicine25.0020.0015.0010.005.000.00NPQ #DAY 1(PRE)DAY 1(POST)DAY 14 #§DAY 28TASAFigure 4: Serial changes of the Northwick Park neck pain questionnaire, NPQ. 𝑃 0.05 versus DAY 1 (PRE); # P 0.05 versus DAY1 (POST); § P 0.05 versus DAY 14. Error bars represent standarddeviations.The data indicate that the superficial and traditionalacupuncture treatments improved the consequent disabilitydue to neck pain after a series of treatments, but the treatments were not immediately effective (Figure 4).4. DiscussionThe aim of this randomized controlled trial was to evaluatethe therapeutic effect of superficial acupuncture for treatingmyofascial pain syndrome in the upper trapezius muscle.Direct needling in the trigger point, as in Ah shi pointacupuncture in Eastern medicine or dry needling in Westernmedicine, has been proven as an effective therapy for myofascial pain [9, 17–20]. In many cases, superficial acupuncturehas been used as a sham control [21, 22]. However, manyof the clinical trials could not differentiate the therapeuticeffect of true acupuncture and superficial acupuncture. Asystematic review of Moffet concluded that sham acupuncture could be as efficacious as true acupuncture [23], whichimplies a therapeutic effect for superficial acupuncture. In theearly 1980s, Baldry suggested the technique “superficial dryneedling” for treating myofascial pain syndrome by insertingthe needle superficially into the skin and subcutaneous tissuesoverlying the trigger points [12, 24]. In contrast to deepdry needling, the advantages of superficial dry needling arerelative painlessness, less risk of damage to nerves and bloodvessels, minimal bleeding, and a low incidence of posttreatment soreness. Baldry advocated the use of superficial dryneedling for treating primary nociceptive myofascial triggerpoint pain [25]. A review by Kalichman et al. suggestedusing the superficial needling technique over areas withpotential risk of significant adverse events, such as lungs andlarge blood vessels [26]. Triggered by hyperglycemia, chronicinflammation, micro- and macrocirculatory dysfunction,hypoxia, autonomic and sensory neuropathy, and impairedneuropeptide signaling, diabetes can lead to a slowed healingresponse [27]. Acupuncture is contraindicated if the diabetesis unstable. With the advantages of less risk of damage tonerves and blood vessels, superficial acupuncture should be afeasible treatment option.The exact mechanisms of action of trigger point dryneedling remain elusive. Improving blood perfusion may5ease the local hypoxia due to blood vessel compression,according to the energy crisis theory. Antidromic vasodilation is seen when unmyelinated C-fibers are stimulated. Theneuropeptides released from peripheral terminals induce theneurogenic inflammation and increase the blood flow in skinand muscle [28, 29]. Sato et al. suggested the contributionof calcitonin gene-related peptide to antidromic vasodilation of skeletal muscle blood flow produced by acupuncture [30]. However, several reports have demonstrated theacupuncture-induced nitric oxide generation and increasedlocal circulation [31–34]. Furthermore, Kimura et al. suggested that nitric oxide contributes to cutaneous vasodilationinduced by acupuncture stimulation, whereas the antidromicvasodilation mediated by calcitonin gene-related peptide isless important [35]. A randomized, crossover experiment byZhang et al. investigated the impact of acupuncture needlesize and needling depth on microperfusion [36]. Superficial needling with thick needle (0.4
shi points, they might well be treating myofascial trigger points []. Supercial acupuncture was rst documented in “Huangdi Neijing” and was performed to treat nobles with good nutritional support who were characterized as having tender bodies by inserting small needles shallowly and leaving them inserted for a little time. Advocated by Baldry, supercial dry needling is a technique in which .
1. Acupuncture treatment: Boby acupuncture Ear acupuncture Scalp acupuncture Facial acupuncture Hand and Foot acupuncture Electro-acupuncture 2. Chinese herbal medicine 3. Cupping 4. Moxibustion 5. Chinese Tui Na ( massage) and acupressure 6. Foot therapy 7. Exercise
Teaching acupuncture 53 Acupuncture organisations 57 National guidelines for acupuncture training 60 Summary 61 5 Acupuncture in primary care 63 Introduction 63 Provision of CAM by general practitioners 64 GPs' knowledge about acupuncture 65 BMA survey—The use of acupuncture in primary care services 67 Discussion 77 6 Future developments 83
the Acupuncture Licensure Act. Additional copies of this publication are available from Department of Consumer Affairs CALIFORNIA ACUPUNCTURE BOARD 444 North 3rd Street, Suite 260 Sacramento, CA 95811. For more information call 916/445-3021, or visit the California Acupuncture Board Web site at www.acupuncture.ca.gov. 07-043 (04/08)
strated that acupuncture is beneficial for relieving dyspep-sia symptoms and associated negative emotions, thus improving patient quality of life [4–6]. The acupoints and acupuncture stimulus such as manual acupuncture (MA) manipulations are the key elements inducing the effect. Related research studies on treating FD with acupuncture
Acupuncture: review and analysis of controlled clinical trials 4 controlled clinical trials have been undertaken in countries where there is scepticism about acupuncture, as well as considerable interest. A more practical way to evaluate the therapeutic effect of acupuncture is to compare it with the effect of conventional therapy through .
Page 1 of 5 The NCCAOM Certification in Acupuncture About Acupuncture The practice of acupuncture in the United States incorporates medical traditions from China, Japan, Korea, and other countries.1 Acupuncture is one of the essential elements of Oriental medicine and the o
THE THREE-LEVEL ACUPUNCTURE BALANCE Integrating Japanese Acupuncture with AcuGraph Computer Diagnosis Jake Paul Fratkin, OMD, L.c. PART 1 ANTECEDENTS TO 3-LEVEL PROTOCOL A. Overview and Introduction p. 2 B. Schools of Acupuncture Practiced in the West 5 C. Acupuncture: General Considerations 6 D. Level One: The Primary Channels 8
Acupuncture involves the puncturing of the skin with thin sterile needles, at defined acupuncture points, that are then stimulated either manually or electrically. In manual acupuncture (MA) the needles are twisted back and forth by hand until a sensation of DeQi is achieved. In electro-acupuncture the needles are connected to a
