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Contents
Spring 2010
Journal of the
of Chartered
Physiotherapists
www.aacp.org.uk
The Journal is printed for the membership twice a
year. 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 Editor at
the address below or by e-mail. All articles are
reviewed by the Editor, and whilst 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
Mr John Wheeler
Windsor Centre of Traditional Acupuncture
5a St Leonards Road
Windsor
Berkshire SL4 3BN
UK
The Association
The Association (AACP Ltd) is a recognized Clinical
Interest Group of the Chartered Society of
Physiotherapy. It is a voluntary group of
professionals working to promote the safe practice
of acupuncture by chartered physiotherapists. The
AACP 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
Southgate House, Southgate Park, Bakewell Road,
Orton Southgate, Peterborough, Cambridgeshire
PE2 6YS
Tel: 01733 390007
Printed in the UK by Henry Ling Ltd
at the Dorset Press, Dorchester DT1 1HD
2010 Acupuncture Association of Chartered Physiotherapists
Editorial .........................................................5
Chair report ...................................................7
Chief Executive Officer report ......................9
Finance and Secretariat report .....................11
Webmaster report ........................................13
Political Liaison Officer report ....................15
Development Committee report .................17
Clinical Interest Group Liaison Officer report
......................................................................19
Conference Coordinator report ...................21
Regional reports ..........................................23
Regional representatives ..............................29
Literature review
Acupuncture treatment for osteoarthritis of
the knee by C. Markwell ...............................31
Clinical audits
Auricular acupuncture and substance misuse
by P. Blacker .................................................37
Acupuncture in general practice by I. Broad .43
Traditional Chinese medicine
Five-element theory: understanding the basics
by Lynn Pearce ...............................................47
Case reports
Acupuncture and strengthening in the
treatment of knee osteoarthritis by B. Waldock
......................................................................57
Acupuncture treatment for bilateral heel pain
caused by plantar fasciitis by C. C. Santha ...67
Effects of acupuncture as an adjunct to
standard physiotherapy on pain levels and
function in osteoarthritis of the knee by K. C.
Boyle .............................................................75
Efficacy of acupuncture as an adjunctive
physiotherapy treatment in knee arthroscopy
by R. O’Neil .................................................83
Clinical use of long-duration press needles .91
Research abstracts .......................................93
Book reviews ...............................................97
Letters ....................................................... 101
News from the front ................................. 105
Guidelines for authors ............................... 113
3
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Editorial
Journal of the
of Chartered
Physiotherapists
www.aacp.org.uk
Journal Committee
Clinical Editor
John Wheeler
(e-mail: [email protected])
Corporate Editor
Andrew J. Wilson
News Editor
Rosemary Lillie
Marketing Manager
Diane Morgan
Review Team
Dr Val Hopwood
Jennie Longbottom
John Wheeler
AACP Ltd Board Members
AACP Members on the Board of Directors
Chair: Merian Denning
IAAPT Representative: Lesley Pattenden
Educational Liaison: Vivienne Fort
Clinical Interest Group Liaison: Jenny Manners
Board Member: Kim Rowe
Board Member: Debbie Yates
Executive Director, Auditor and Company Secretary
Finance Adviser: Mark Ruffles
Auditor: Rawlinsons, Peterborough
Company Secretary: Michael Tolond
There are a great many knees in this edition of
the Journal, but this particular joint is not a fetish
of mine, I’m happy to say. Knees, along with
lower backs and a small number of other narrowly defined areas, have an acknowledged evidence base. To an extent, a journal that serves a
community of professionals who are interested
in extending the use of acupuncture within their
scope of practice and, at the same time, defending what they have gained needs to provide its
readership with the material that underpins their
arguments.
At the same time, there appears to be a very
keen interest in looking at fresh ways of dealing
with the same health issues as well as looking at
new methods of treating chronic conditions for
which current strategies are not always effective.
In future, I hope to be able to offer more
contributions like Lynn Pearce’s thoughtful and
challenging piece on traditional Chinese medicine (see pp. 47–55), contributions that question
the reliance on single paradigms and offer insights from others that may complement current
treatment strategies.
Indeed, it seems that the whole area of what
constitutes an evidence base is very much up for
grabs at the moment. The reliance on a very
narrow definition has done exactly what many
predicted, i.e. unearthed a very creative backlash
even among the orthodox. This has itself offered
up some novel ways of incorporating more of
the qualitative assessments on which a far wider
range of papers and case studies could be usefully based. This is a theme that I hope to
address in the next edition. Anyone who wants
to whet his or her appetite might like to read
Smith & Pell (2003), who offer one of the best
critiques of current evidence-based medicine
methods.
Within the next few months, there will be a
great deal more material available to you through
the AACP website. We have far more contributions than we can publish in print, and much of
it is, even in its pre-publication state, good
enough to provide valuable background and
insight. This will, of course, also act as an
inducement to log on and use the website more.
5
Editorial
Make sure you enjoy the spring – according to
the Mayans you’ve only got two more to come!
John Wheeler
Clinical Editor
6
Reference
Smith G. C. S. & Pell J. P. (2003) Parachute use to prevent
death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
British Medical Journal 327 (7429), 1459–1461.
Journal of the Acupuncture Association of Chartered Physiotherapists, Spring 2010, 7–8
Chair report
Spring is not too far away, and along with green
shoots and flowers, comes the promise of some
exciting developments in AACP.
Welcome to this edition of the Journal. I hope
you will find the varied contents both interesting
and of value to your practice. I think you will
agree that JAACP offers something for everyone. Our editors, John Wheeler and Andrew
Wilson, work hard to ensure that the contents of
each issue are of a high standard. They can only
do this if they have access to appropriate
material, and therefore, if you have recently
completed your research or treated an interesting
case, please write up your work and submit it for
publication. The editors have assured me that
they can never have too much material! Even
if they are unable to publish your offering in
the Journal, they intend to e-publish suitable
offerings on the AACP website as part of a
project to develop a bank of material that is both
interesting, informative and accessible.
For some time, the Association has been the
largest body providing acupuncture in the UK,
and in November 2009, our membership rose
above 6000! Quite a family! We hope that all
those reading the Journal for the first time will
enjoy its contents and also feel inspired to take
an active part in some of the activities that are
listed within.
There have been some changes in our organization since the last edition. In September 2009,
we welcomed Mr Ian Brooke as Chief Executive
Officer (CEO) (see pp. 9–10). Ian is an accountant by training, but has had a varied and interesting career that includes working in the City, in
local government and, latterly, as CEO of a
Cambridgeshire-based medical charity. He has
been given a crash course in acupuncture by
various Board members, but remains more at
home with spreadsheets and budgets than with
yin and yang!
We also extend a warm welcome Dr Jill
Higgins, currently Allied Health Professions
Adviser to the East of England Strategic Health
Authority, as Chair of the Education, Training
and Research Committee (ETRC). Dr Higgins
succeeds Ann Green, who most of you will now
know has become Chair of the Chartered Society
of Physiotherapy (CSP) Council (see pp. 109–
110). The Board and I are very grateful to Ann
for all her hard work on the ETRC and wish her
well in her new position at Bedford Row.
Other small but significant changes have been
happening in Peterborough during the long winter months. We are working on developing a
range of exciting new courses that will be
focused on integrating acupuncture skills within
other fields of physiotherapy. We hope that
some of these will be accredited to enable
participants to attain some Master’s-level points
on successful completion. Developing these
courses takes time and energy, but as they
gradually come on stream, they will be advertised
on our website. Keep your eyes peeled! The
Development Committee welcome ideas and
feedback from you in order that our efforts are
channelled appropriately. Meanwhile, our most
popular courses are still available. If you are
interested in holding a course within your area,
please contact your regional representative (see
pp. 29–30) or the AACP Office, where the staff
will be more than happy to help you.
The ongoing issue of statutory regulation took
a small step further forward at the end of last
year. The Government began a consultation
exercise in order to ascertain the most appropriate level of regulation that the public perceived
was necessary in order to regulate the delivery of
acupuncture, herbalism and traditional Chinese
medicine. We do not know when the results of
this consultation exercise will be published,
although we have heard that there was a very
strong response that will take the Government
many months to analyse. It is anticipated that
these results will be published in June, but as
soon as we hear, we will post all the information
on the website.
In the tough economic climate, there are some
difficult times ahead for all of us, whether we
work within or outside the National Health
Service (NHS). The Government have projected
an ‘‘extremely challenging financial outlook’’,
7
Chair report
which brings with it a need for all of us to work
more efficiently while the Government strives to
drive up standards of health and well-being
services across the UK in order to achieve a
consistently high quality of care throughout the
NHS. Proving that acupuncture is an effective
adjunct to physiotherapy has become imperative
as belts are tightened and resources more keenly
fought over. We have been in touch with several
NHS trusts who have been asked to justify the
provision of acupuncture within physiotherapy
in terms of efficacy and cost-effectiveness. The
Association is happy to help where it can to
support its members in such situations. The CSP
has urged AACP, along with other clinical interest groups, to become active in supporting members in collecting data to support their use of
specific treatments. It is our intention to set up
templates for data collection that will help us all
to justify the use of acupuncture. Details of these
will emerge within the next few months and I
encourage you all to participate.
We have an exciting programme lined up for
conference in May. This year’s theme, ‘‘Synergy
8
in Practice’’, has a more practical bias than those
of previous years. Places are still available and I
look forward to meeting as many of you as
possible at Wyboston.
Finally, a plea! The Association needs you! We
are currently desperately short of regional representatives and committee members. This puts
undue strain on those who currently serve the
organization. With over 6000 members, there
must be some of you out there who can spare a
little time. You do not need to be an expert, just
interested and willing to help. The more members who involve themselves in AACP, the
lighter the load will be for those currently
involved. Please don’t just read this and think
that someone else will volunteer: if you care
about the Association, then get in touch with the
Office and let them know that you are interested
in helping out either locally or as a committee
member. You will be welcomed with open arms!
Merian Denning
Chair
Chief Executive Officer report
Building for the future
A big hello to all readers of our Journal.
Please let me introduce myself: my name is
Ian Brooke and, as noted in the Chair’s report
(pp. 7–8), I was appointed as the first Chief
Executive Officer (CEO) of the Association in
September 2009. Coming to a new employer,
which is itself an organization that has undergone considerable change, presents an interesting
challenge, but one that I very much look forward
to meeting successfully.
At the time of writing, with only 4 months
exposure to the world of acupuncture within
physiotherapy, my learning curve remains very
steep, but the Board and committee members,
and existing staff have been tremendously
helpful – I have even been able to witness
patient treatment in action and have had a very
interesting personal treatment session!
Of course, my role as CEO is not directly
focused on clinical matters, but I think it is
important that I understand this side of our
activities, and so, even as a layman, I look
forward to reading the articles and case studies in
this edition of the Journal.
I believe that my primary role is to work with the
Board, its associated committees and the membership as a whole to build on the positive development of services to members that has already been
achieved in recent years. A key contributor to
successful delivery of that role is communication
and I shall expand on that in a moment.
At the time of my appointment, AACP had
already mapped out and approved a 3-year plan
(which can be viewed on our website) that
gives a clear direction for development of the
Association and what it wishes to achieve on
behalf of its membership. My initial task has
been to translate that strategy into an integrated
business plan that sets out a range of activities
and projects aimed at delivering the required
improvements and expansion of services. The
detail of what has been agreed thus far is also set
out in more detail on our website and this will be
regularly updated as progress is made.
Generally, however, the essence of the overall
aims can be captured in what we have called our
‘‘STAR’’ business plan, which summarizes the
key future policy and activity areas of AACP as:
(1)
(2)
(3)
(4)
Standard setting and monitoring;
Training and education;
Access to services; and
Research and evaluation.
As stated above, there is much more detail on
the website, but the planned programme of work
includes such things as: maintaining an influential
input to statutory regulation; developing clinical
audits; expanding the provision of Association
training and continuing professional development education; and support for research
projects.
All of this takes time and resources, of course,
but as noted in the following ‘‘Finance and
Secretariat report’’ (pp. 11–12), the financial
changes accepted by members in 2009 have
provided a solid foundation for improvement.
Obviously, we shall continue to look at ways in
which future resources can be enhanced for the
additional benefit of members’ services.
Whilst most successful and efficient organizations work within a structure of a centralized
planning and operational ‘‘core’’, it is vital that
this sits within an overall framework of knowledge and understanding of the needs and
demands of the whole membership. For this to
be achieved, it is crucial that there is effective
two-way communication to create the best
understanding of what the requirements are and
the actual range of services that are, or will be,
available. It would be very useful as a ‘‘starter for
ten’’ to receive member’s comments or even
criticisms of the ‘‘STAR’’ approach and its
components (e-mail: [email protected]).
We already have elements of communication
such as this Journal, our annual Conference, the
network of regional representatives, the Office
services provided by our headquarters and our
website, but improvements can always be made
and there are a number of plans to achieve these
over the next few months. However, it is evident
9
Chief Executive Officer report
that there are many members who seem to have
little or no communication within the Association, either directly through participation or
more indirectly via the website.
Of course, it may be that this is a sign of
satisfaction with the more general benefits of
membership, but it would be useful to be a lot
clearer on this issue as we continue with our
improvement agenda. Therefore, we may conduct a number of mini-surveys to seek out some
better background and I would hope that, if you
are approached, you will be able to spare a few
minutes of your time to assist.
In these first few months with AACP, I have
been hugely impressed with the enthusiasm,
dedication and sheer hard work of a core
number of members who give very many hours
of personal time to Association business. It is
critical to future progress and success that we
widen this involvement, and any ideas or
thoughts on how this can be achieved would be
most welcome – of course, even more welcome
10
is volunteering for direct input into the running
of AACP!
We do get considerable and favourable feedback about the interest and value of the Journal
itself, but this is only published twice a year and
I would encourage all readers to access our
website on a frequent basis as we seek to further
develop this as our main information, education
and research facility.
These first few months have been demanding
but very enjoyable, and I hope for more of the
same throughout 2010. I also look forward to
meeting more of the membership personally at
Conference and any regional events that might
be kind enough to extend an invitation. Looking
forward, I am convinced that the Association
will continue to grow both professionally and in
terms of membership, and that such growth will
deliver increasing value to all our members.
Ian Brooke
CEO AACP Ltd
Journal of the Acupuncture Association of Chartered Physiotherapists, Spring 2010, 11
Finance and Secretariat report
Administration
Personnel changes do have effects on an organization, especially on such a small team as there is
at AACP headquarters, and there has been considerable change within the past 12 months. The
Autumn 2009 edition of the Journal referred to
the transition from Executive Chair to Interim
Chief Executive Officer (CEO), and my appointment in September 2009 completed that process. Shortly prior to this in July, the Business
Manager, Sharon Fox, left and it was decided to
absorb that role within the CEO post, which
currently remains part-time.
Jennie Daies was appointed as part-time
administrator in September to replace Cora
Baker, who had left us in May, and so we now
have a full team once again. It is greatly to the
credit of our continuing administration duo,
Diane Morgan and Gill Beadle, that they maintained the day-to-day service required to meet
members’ needs throughout this period.
Negotiations with the current landlord of
Southgate House have enabled us to secure
favourable fixed 4-year rental rates and ensure
that our Office can remain at Peterborough for
the foreseeable future.
Membership
As I am sure members will be very aware, the
Board reluctantly approved an increase in membership fees in August 2009 to avoid a potential
deficit. This move also enabled us to lay a stable
foundation for AACP finances and provide
resources to develop future member services.
This was the first subscription change in 3 years,
and we hope that it still represents considerable
value for money when compared with other
acupuncture representative organizations such as
the British Medical Acupuncture Society (£115
per annum) and the British Acupuncture Council
(£620 per annum, including medical insurance).
Although, naturally, we have received some
complaints, the reaction of members was very
positive overall and the Association had its
highest-ever rate of growth at 18%, going from
5019 members in 2008 to 6057 by the end of
2009. Current trends show that membership
continues to grow at about 5% per annum
and we are now by far the largest clinical
interest group within the Chartered Society of
Physiotherapy.
Financial
As noted above, there was a detailed review of
AACP finances in 2009, and we now set very
clear and detailed budgets with monthly monitoring against income and expenditure targets.
Subject to annual audit, the 2009 position is very
satisfactory, with an overall surplus of £59 000
based on income of £445 000 and expenditure of
£386 000. Since investment in services, particularly in education, training and research,
is planned to grow in 2010, expenditure will
rise to £455 000, but this will be matched by
income growth, so there will be no need for
further changes in subscription rates and the
medium-term financial position remains stable.
I would like to remind members that there is
provision for research and small project grants,
full details of which are available on our website.
In summary, the past year has been a period of
change and development, but the Association
now has a very solid administrative and financial
platform upon which we can build and develop
services to our members.
Ian Brooke
CEO AACP Ltd
11
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Webmaster report
Introduction
Table 1. Website total visitor count
This report covers the continuing progress of the
AACP website since it was re-launched in its
current format 3 years ago.
You can now find our website at:
Period
Unique visitors per day
Total visitors per day
2007
2008
2009
58
60
71
96
96
126
(1) http://www.aacp.uk.com/
(2) http://www.aacp.org.uk/
(3) http://www.aacp.co.uk/
Website take-up
Developments
The website is monitored in a number of different ways and these are discussed below.
Calendar
At the end of 2009, at the request of the AACP
Chair, a calendar was added to the members’ area
of the website. This allows events to be displayed
as far in advance as required. Initially, the current
month is displayed, but there is an option to
move forward or backwards, and clicking on a
specific day brings up details of any events on
that date. Information is gradually being added: if
a member has an event that they would like to be
listed, please contact the Office.
Website visitors
Statistics maintained by our Internet service provider (ISP) demonstrate that take-up has been as
shown in Table 1.
The figures show a steady rise in the number
of people accessing the website. The total access
count for 2009 was 46 143, of which just 4983
accesses were by members (see below).
Members’ access
The website itself tracks logins by members.
Table 2 shows the numbers of members logging
on against the number of times each has logged
on.
The figures show a gradual improvement in
access by members, but there are still more than
4000 members who have never logged on to the
site. Thus, the general level of website take-up by
members remains relatively disappointing. The
take-up from those who may be regarded as
‘‘senior members’’ (e.g. AACP tutors, regional
representatives and members of the Education,
Training and Research Committee) also remains
disappointing.
Website updates
AACP changes
Last year saw major changes at the top of AACP,
with the Chair standing down, changes to the
Board and the decision to take on a Chief
Executive Officer (CEO). These changes have
caused some difficulty with regard to keeping the
website updated with the latest information, but
in December 2009, the new Chair invited me, as
Webmaster, to join the Board as Communication
Director, which will start to remedy some the
difficulties outlined above.
Table 2. Access to the AACP website by members
Number of member logins
Time period
1–2
3–5
6–10
11–20
21–50
>51
Total
Since 15 February 2007*
2007
2008
2009
1214
718
768
816
642
305
318
342
363
96
152
152
214
35
49
59
76
12
19
15
16
1
1
4
13 311
3569
4759
4983
*Start of website.
13
Webmaster report
Table 3. Website search rankings: (N/R) not ranked
Date of ranking
Search term(s)
June
2007
December
2007
June
2008
December
2008
June
2009
December
2009
Acupuncture
Acupuncture physiotherapy
Acupuncturist
Acupuncture training
Find acupuncturist
9
2
36
8
9
9
1
N/R
9
5
5
1
8
6
6
10
1
N/R
7
6
4
1
1
3
3
7
1
5
4
7
Table 4. Website search results: (CPD) continuing professional
development
Search term
Search rating (2009)
Guidelines for safe practice
Consent
Blood donor
Journal
Contraindications
CPD
Courses
Student membership
4.6%
4.2%
3.8%
2.7%
2.7%
2.1%
1.5%
1.0%
Website visibility
Surveys on Google are carried out using a
number of relevant search terms and the results
are shown in Table 3.
The website is generally very visible in relevant
Google searches. It should be borne in mind that
AACP does not pay or advertise in order to get
a higher listing in search engines. These days,
many of the acupuncture training colleges do
subscribe to Google advertising, for example, in
order to get a prominent listing in Google-based
searches.
Website content
Searches made on the website are tracked so that
it is possible to identify items for which visitors
are searching. The most common searches so far
this year are shown in Table 4.
Reporting
The statistical information system provided by
our ISP allows detailed analysis of traffic to our
14
website. For example, I can advise which of our
pages are most often accessed, what time of day
is most popular, which countries access our site
and much more. As an example, in response to
a question from the CEO, I was able to advise
that the ‘‘Find a Practitioner’’ page was accessed
14 013 times in the 12 months from 1 November
2008 to 31 October 2009 – that’s nearly 40 times
a day, which must be of some benefit to those of
our members who are private practitioners.
If members would like these summary reports
to cover any specific issue, please let me know.
Conclusions
The website, together with the members’ database, allows the Association to offer members
new facilities and gives AACP scope to provide
many more in response to their requirements,
whilst keeping down its administrative costs and,
hence, members’ subscriptions.
Members are encouraged to think about the
Association’s use of the website. Adding new
areas or facilities is simple, and can usually be
done very quickly. The website is one of the
benefits of membership, and the more interest
that there is in its development, the more use it
will be to all members.
Do please send any questions or comments
you may have about the website to the Webmaster ([email protected]).
J. D. Longbottom
Webmaster
January 2010
Political Liaison Officer report
Health Professions Council
registration
Parliamentary reception and
exhibition
All physiotherapists are invited to renew their
registration with the Health Professions Council
(HPC) in June 2010. The renewal form must be
signed and returned to the HPC by 31 August
2010, with a payment (unless a direct debit
instruction is in place).
To ensure that your name stays on the HPC
Register:
The HPC hosted a parliamentary reception on
Thursday 26 March 2009 in the House of
Commons. The event was held to raise awareness of the HPC’s role in enhancing public
protection while recognizing the importance of
appropriate and effective regulation of health
professionals. Kate Hoey MP sponsored the
event, which provided an excellent opportunity
for key stakeholders to meet and discuss the
future of healthcare regulation. Attendees
included members and representatives of both
Houses of Parliament, the Department of
Health, the HPC, practitioners, patient and advocacy groups, professional and regulatory bodies,
and others.
The Minister of State for Health Services, Ben
Bradshaw MP, spoke about how 2009 was an
important year for the HPC, with a newly
restructured Council being created in the summer, which is smaller, more board-like and
independently appointed. The Minister then
highlighted the HPC’s role in taking forward the
reforms proposed in the White Paper Trust,
Assurance and Safety – The Regulation of Health
Professionals in the 21st Century (DH 2007)
No further news on statutory regulation has
been announced.
(1) send your renewal form (and payment) to
the HPC well before the deadline; and
(2) call the HPC Registration Department (tel:
0845 3004 472) now if you have changed
your home address.
The average processing time for renewal applications is approximately 10 working days,
although this time may vary depending on the
volume of forms that they receive.
Continuing professional
development audits
The HPC will select 5% of physiotherapy practitioners, who will be sent a letter informing
them that they have been selected for audit and
must complete a profile that demonstrates the
activities they have undertaken during the past 2
years to meet continuing professional development (CPD) standards. For more information
about this process, including sample profiles and
the CPD standards, please visit the HPC website
(www.hpc-uk.org/cpd). Selected registrants need
to return their completed CPD profile by 31
August 2010.
The registration team can be contacted from
Monday to Friday between 08:00 and 18:00 h on
the lo-call number noted above.
Jennie Longbottom
Reference
Department of Health (DH) (2007) Trust, Assurance
and Safety – The Regulation of Health Professionals in the
21st Century. Cm 7013. The Stationery Office, London.
15
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Development Committee report
Rolling continuous professional
development programme:
integration with other clinical
interest groups
The Development Committee has now met
twice. Our remit is to advance integrated acupuncture in combination with other clinical
interest and occupational groups. We are working a rolling programme of continuing professional development to meet the needs of the
membership with regard to the integration of
acupuncture and physiotherapy.
The first course will be on the use of triggerpoint needling with diagnostic ultrasound scanning techniques, which will be presented by
Mark Maybury from the Dynamic Ultrasound
Group and Jennie Longbottom on Sunday
16 May 2010 at the AACP Conference.
Further courses will be developed and members will be informed about these early this year.
Watch the website for news.
Jennie Longbottom
17
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Clinical Interest Group Liaison Officer report
Last year was an eventful one for me because I
became the new Clinical Interest Group (CIG)
Liaison Officer. As you are aware, Ahmed
Osman and Lesley Pattenden performed this role
earlier in 2009, so I am still establishing myself
and gaining an insight into how the Chartered
Society of Physiotherapy (CSP), and the CIGs
and occupational groups (CIGOGs) work
together.
The CSP are keen to ensure that, in light of the
recent Darzi Report (Darzi 2008) highlighting
the current Government policy to prioritize
children’s health, mental health and long-term
conditions, the physiotherapy profession is in a
position to provide robust evidence to show that
our clinical treatment is effective in these key
areas of health.
In response to this, Supporting Knowledge in
Physiotherapy Practice (SKIPP) (CSP 2009) was
launched in 2009. Its aim is to produce evidence
notes, position statements (to avoid unprepared
reactive responses to the media) and clinical
guidelines. A number of CIGs were involved in
the pilot scheme to establish a framework for
SKIPP. The CSP is keen for our Association,
along with the other CIGs, to continue to
collaborate by sharing our knowledge of effective
practice through data collection, audit and identifying ‘‘gaps’’ in research, and working towards
further research and, ultimately, evidence-based
practice.
Finally, there are to be some structural/
organizational changes between the CSP and
CIGOGs. These modifications are still under
discussion at present, but I will continue to
work with the AACP Board to ensure that the
Association’s voice is heard.
Jenny Howson
References
Chartered Society of Physiotherapy (CSP) (2009) Supporting
Knowledge in Physiotherapy Practice. [WWW document.]
URL
http://www.csp.org.uk/director/members/
practice/clinicalresources/skipp.cfm
Darzi A. (2008) High Quality Care for All – NHS Next Stage
Review Final Report. Cm 7432. The Stationery Office,
London.
19
Conference Coordinator report
We started taking bookings for the 2010 Conference at Wyboston, Bedfordshire, on 12 October
2009, and I’m pleased to say that we have had a
really good response. If you haven’t booked your
place yet, please contact the AACP Office and
we will be happy to advise you of any spaces that
are still available.
The 2009 Conference was a great success and
I would like to thank everyone who was involved
in the organization and delivery of the weekend.
A big thank you also goes to the Robinson
Executive Centre, who provided an excellent
environment for our meeting as always.
This year’s theme is ‘‘Synergy in Practice’’, and
the programme includes an exciting line-up of
both national and international speakers. These
guests will give Conference a wide variety of
seminars, ranging from information on the latest
research through to hands-on workshops. For
the full Conference itinerary, please go to the
AACP website (www.aacp.uk.com).
We have made a few changes to the layout in
the conference lounge to accommodate
additional trade stands, which we’re sure you will
enjoy visiting. A list of the companies attending
is shown in Box 1.
Box 1. Companies represented at Conference 2010
DongBang Acuprime Ltd
Able 2
UK 3B Scientific Ltd
Oxford Medical Ltd
Barrier Healthcare Ltd
Acupuncture Supplies Porthcawl
College of Traditional Acupuncture
British Acupuncture Society
Herbprime Ltd
Noma (Complex Homeopathic) Ltd
Harmony Medical Ltd
Scarboroughs Ltd
Balance Healthcare Ltd
Play Pause Unwind Ltd
If you have any ideas for future conferences,
please contact the Office: we welcome any suggestions.
We hope to see you at Wyboston in May.
Diane Morgan
Conference Coordinator
21
Regional reports
London
Hello, my name is
Justine Munur, and
I have just volunteered to be your
London regional
representative. I
have only just
taken on the role,
so please bear with
me while I find my
feet. I currently work for a National Health
Service trust and have also been a Chartered
Society of Physiotherapy (CSP) steward for the
past 6 years. I would love to hear from you: let
me know if you have any problems or issues that
I can help with, as well as what you would like to
see happening within the region.
My current plans are to facilitate continuing
professional development (CPD) study sessions
to ensure that everyone has access to training in
order to meet the CPD requirements. I will try to
keep everyone informed via the AACP website
(www.aacp.uk.com), but if you would like to
receive e-mails about when and where these
sessions will be held, please contact me through
the website. I will also be looking for locations
across the area to host these events, so please tell
me if you know of a suitable location.
Justine Munur
Midlands East
Hello everyone,
my name is Diana
Lacraru. I am a
physiotherapist
and an advanced
member of AACP.
I graduated in
2002
from
a
physiotherapy university in Romania, and registered with the
Health Professions Council and the CSP the
following year. In 1999, I went on a scholarship
to China to study traditional Chinese medicine
(TCM) and completed the course in 2001. As for
my postgraduate work, I finished my MSc this
year. Hurray!
At present, I am working in a stroke unit in
St Luke’s Hospital, Market Harborough,
Leicestershire. I also do private work for a few
hours on Saturdays in a sports clinic in Leicester.
I would like to thank all of my colleagues who
supported me in my effort to become one of the
regional representatives for Midlands East after I
finished my degree.
As we all know, we all should keep our CPD
up to date and I have started a programme for
acupuncture physiotherapists in my area. The
events consist of a 1–2-h presentation, some
practical work and a quiz, which attendees
receive in advance and complete before the
meeting. We meet every 2–3 months and the
feedback suggests that my colleagues have
enjoyed themselves so far.
I use acupuncture in my clinical practice on
the stroke unit, and recently began a small
research project on scalp acupuncture to investigate whether it can speed up patient recovery
after a stroke in conjunction with physiotherapy.
Val Hopwood, whom I admire very much, is
guiding me through this project.
The Association offers members a variety of
courses that can help us to keep up with what is
new in the field of acupuncture. Please visit the
website (www.aacp.uk.com) to see what is available that may be of interest to you.
I will answer all your questions to the best of
my ability while I get to grips with what the role
of regional representative involves. You can
contact me at St Luke’s Hospital (tel: 01858
438167; e-mail: [email protected]).
Diana Lacraru
Midlands West
I’d like to welcome all new AACP members in
the West Midlands region. Please go to our
website (www.aacp.uk.com) for the latest
23
Regional reports
information
on
guidelines, courses
and conferences.
You can also use
the site to access
research databases
such as MEDLINE
and CINAHL.
In July 2009, I
made a presentation at the National Osteoporosis Society (NOS) Members’ Day in the International Business Centre, Telford (Fig. 1). The
seminar was about the benefits of physiotherapy
and acupuncture for the symptoms of osteoporosis. This was very well received by the NOS
members, many of whom wanted to find out
more about physiotherapy and acupuncture. It
still amazes me that so many people believe that
we physiotherapists are no more than masseurs
with a title! Each of us needs to continue to
promote our profession to the wider public.
We have recently held several courses, including the ‘‘Acupuncture Refresher Course’’ and
‘‘Meridians and Beyond – Extending Foundation
Course Point Combinations’’. These offer existing practitioners the chance to update their
theoretical clinical reasoning and introduce new
point combinations for difficult trigger points.
The journal club held in Birmingham is now
regaining its momentum, and so I’m getting in
touch with previous attendees by letter or e-mail
to organize dates and topics for discussion.
Remember, the journal club – like the Association itself – is only as effective as its members’
support and involvement!
Please don’t hesitate to contact me about any
AACP matters, and what you would like to see,
hear or make happen in your region.
Jamie Holder
North East England
Hello again, I
can’t believe how
quickly time has
passed since my
last report, and as
I looked back over
the past 6 months,
I initially felt that I
had not done a
great deal with regard to arranging acupuncture
CPD in the region. However, on reflection, I
realize that I have made more contacts in the
world of acupuncture, and by the time that this
edition of the Journal is published, I will have
advertised a new course and some further CPD
workshops.
As I write this, two very popular acupuncture
workshops are running in Morpeth over the
weekend. I could have filled the places twice
over, so apologies if you were disappointed, but
do get in touch early about future events and
remember: cheques secure places. I hope to run
a full-day CPD day of acupuncture for low back
pain if there is sufficient interest, and I will be
discussing other possible CPD workshops with
AACP tutors, so keep checking the website
(www.aacp.uk.com) for future courses.
If you have any ideas for future meetings, do
get in touch!
Karen Ogle
North West England
Figure 1. Jamie Holder presents a seminar on the
benefits of physiotherapy and acupuncture for the
symptoms of osteoporosis at the National Osteoporosis
Society Members’ Day in July 2009.
24
I am Devendra Kumar, Janet Wiggins’ replacement as one of the regional representatives for
North West England. My section of the area
includes Liverpool and Manchester.
I work as a Rheumatology Specialist Physiotherapist in Southport and Formby District
General Hospital (SFDGH), Southport. I qualified as a physiotherapist 7 years ago, but took a
Regional reports
one-year
career
break to do an
MBA in Healthcare Management
and now apply
these skills in my
practice.
I would like to
welcome all new
AACP members in
the North West. I am grateful to everyone who
has contacted me with queries and helped me to
break the ice. These enquiries have ranged from
questions about courses to queries regarding the
safe practice of acupuncture in various clinical
settings. Members are given appropriate information by e-mail and are steered in suitable
directions in order to resolve their questions.
After a hiatus in activities, an AACPrecognized course was held at SFDGH on 13
November 2009. This was organized by one of
my work colleagues, Berj Kishmishian, who is
the course coordinator for the Physiotherapy
Department. Well done, Berj! A course on the
treatment of headaches with acupuncture was
also held at Halton General Hospital, Runcorn,
Cheshire. I did try to organize another course at
SFDGH, but we had to reschedule the venue
because of time constraints.
I have a list of AACP members in my area, but
this doesn’t include any e-mail addresses. I am
trying to collect this contact information so that
I can approach you in order to get an idea of
your needs. I hope that members will contact me
over the coming months so that you can share
your views on acupuncture practice, and let me
know which courses and workshops you would
like to attend. We can build a common platform
to progress our clinical interest group (CIG).
After hearing the views of the membership, I can
also present this information at this year’s AACP
Conference in order to gain further support from
the Association.
Please keep checking the AACP website
(www.aacp.uk.com) for information about
future courses and workshops, and do contact
me regarding any issues you have in relation to
acupuncture practice in the North West. I will
keep you all updated with the latest information.
I would also be grateful if you could keep me
posted regarding any acupuncture-related events
being held in your area. My contact details are
available on the website.
Devendra Kumar
South Central England
Hello to you all and a very warm welcome to
new members. As usual, the South Central
region is thriving and there is a lot of CPD
activity. Nevertheless, if you have any queries,
please do not hesitate to contact me or refer to
the AACP website (www.aacp.uk.com) for further details.
Following the last meeting of the regional
representatives, the Association is proactively
urging members to liaise with the AACP Office
if you have a venue and you would like to host
an acupuncture course. The Association has a list
of accredited tutors who are also vastly experienced clinicians.
Please remember, I would like all members
within the South Central region to form a wide
network in order to liaise with each other, and
share information on evidence-based best practice or any ideas that would benefit the region
and the acupuncture CIG.
Ahmed Osman
South East England
I would like to welcome new AACP members in
the South East. I am sure that you will find the
Journal a great resource. The well-researched
papers it publishes are very interesting and the
quality of writing is excellent.
25
Regional reports
I have been
contacted by quite
a few members,
which has resulted
in one invitation
to an acupuncture
CIG in Canterbury,
and another to facilitate CPD in Oxford
and
Tunbridge
Wells. A private clinic in Brighton has also asked
me to do this. I am also looking forward to
meeting more of you at the AACP Conference in
May, which has a very impressive line-up of
speakers, as always!
Congratulations to Carl Clarkson, a fellow
student of the Coventry MSc in Acupuncture,
who I have just heard has been accepted as an
AACP tutor. The depth of knowledge attained
on this course is invaluable, and it has enhanced
my practice substantially and also extended my
social life!
I have been privileged to assist on a CPD
course with Lynn Pearce and hope to develop my
teaching skills further. I would be pleased to share
CPD hours with anyone in my region and look
forward to hearing about any other CIGs. Remember, regional acupuncture courses contribute
to the requirement to update your CPD hours.
If I can be of any help, please contact me (tel:
01892 724377; e-mail: [email protected]).
Moira Tunstall
Wales
It was only during a recent phone call to the
AACP Office that I discovered that I was no
longer an ‘‘alternative rep’’, but had been promoted to regional representative for Wales.
Hello, Wales, or should I say, Helô, Cymru!
I currently work as a senior lecturer at
Glyndŵr University, Wrexham, teaching TCM at
undergraduate level. I also run a private practice
in Ruabon, just outside of Wrexham. In 1997,
after undergoing acupuncture treatment, I
decided that I’d like to study the subject, so I
enrolled on a course whilst running a physiotherapy practice in South Manchester. Three
years later, I graduated from Salford University
with an BSc (Hons) in Traditional Chinese
26
Medicine. Since 2001, I have integrated acupuncture into my practice as well as teaching TCM.
At the moment, I am not aware of any
local CIGs in my area, but I would appreciate
it if members could contact me (e-mail:
[email protected]) if there are any. I
can then advertise them to other readers in this
column and help to spread the word.
We regularly run workshops for our students
and graduates at Glyndŵr that may be of benefit
to AACP members. For example, we held two
really good courses last year; Acurea presented a
2-day workshop on Korean auricular acupuncture. The response was fantastic and all 20 places
were snapped up within the first week of advertising. The second was a tui na and structural
diagnostics course run by Kevin Young. This
workshop was so successful that we have already
booked Kevin to come back again the year!
Three workshops are planned for 2010, the
first two of which should have been held by the
time you read this:
(1) ‘‘Tui Na and Structural Diagnostics’’ by
Kevin Young (16–17 February 2010);
(2) ‘‘Acupuncture for Sports Injuries’’ by Kevin
Young (18–20 February 2010); and
(3) ‘‘Possession and Aggressive Energy Drain’’
by Chris Nortley (13 April 2010).
Can I take this opportunity to remind readers to
check the AACP website (www.aacp.uk.com),
where they will find up-to-date news about
future events and to contact me at the above
e-mail address with news of any further developments so that we can develop a local CIG?
Paul Battersby
Regional reports
Scotland
West
Hello to all members in the West of Scotland and
a warm welcome to any who are reading the
Journal for the first time. Since my last report, the
final part of the 80-Hour Foundation Course at
Inverclyde Royal Hospital, Greenock, has been
completed, so I hope that a few of you are new
members who have joined the Association as a
result of taking this. The 2-day Acupuncture and
Women’s Health Course was held in the Royal
Alexandra Hospital, Paisley, and greatly enjoyed
by everyone who participated (see p. 108).
The Inverclyde Group continues to meet
quarterly and the numbers attending are rising,
which is encouraging. The meetings are informal,
last for an hour, and cover practical and theoretical topics suggested by those attending. If
anyone is interested in attending, please contact
me.
I would be delighted to hear from anyone
organizing events in the West of Scotland so that
I can keep up to date with what is going on.
Otherwise, I look forward to meeting as many of
you as possible at the Conference in May.
Wendy Rarity
27
Regional representatives
The following table details the regional representatives and how to contact them.
Contact details
Name
E-mail
Telephone
East Anglia
Vacant
–
–
[email protected]/
[email protected]
[email protected]/
[email protected]
–
International
Felicity Edwards
Shelley Walls
London
Justine Munur*
Midlands East
Diana Lacraru
Julie Pearce
Midlands West
Jamie Holder*
North East England
Karen Ogle*
North West England
Devendra Kumar
Dianne Allan
Northern Ireland
Vacant
Scotland
Theresa Sheldon
Wendy Rarity
–
[email protected]/
[email protected]
–
[email protected]/
[email protected]
[email protected]/
[email protected]
–
–
[email protected]/
[email protected]
07915 615625
[email protected]/
[email protected]
01670 511930
[email protected]/
[email protected]
[email protected]/
[email protected]
–
01946 820483
–
–
[email protected]/
[email protected]
[email protected]/
[email protected]
01506 834148
–
*Alternate required.
29
Regional representatives
Contact details
Name
South Central England
Ahmed Osman*
South East England
Moira Tunstall
Norah Bessant
South West England
Vacant
Wales
Paul Battersby*
E-mail
Telephone
[email protected]/
[email protected]
–
[email protected]/
[email protected]/
[email protected]/
[email protected]
–
–
–
[email protected]
[email protected]
–
–
*Alternate required.
30
LITERATURE REVIEW
Acupuncture treatment for osteoarthritis of the knee
C. Markwell
Intermediate Care Services, Belfast Health and Social Care Trust, Belfast, Northern Ireland
Abstract
Osteoarthritis (OA) is the most widespread form of joint disease in the UK. It is a major factor
in limitation of activity and consequent use of healthcare, especially among elderly people. The
condition most commonly affects the knee. Patients with chronic pain are increasingly using
acupuncture for pain relief and to increase their functional abilities. The aim of this review was
to evaluate the literature on the effectiveness of acupuncture for knee OA. Three systematic
reviews of randomized controlled trials (RCTs), five RCTs and one prospective randomized
trial were identified by a literature search. Acupuncture was reported to reduce pain and
improve function in subjects with OA of the knee. Trigger point acupuncture and electroacupuncture were both found to be more effective than standard manual acupuncture treatment.
Needling has relatively few adverse events, and therefore, acupuncture is seen as a safe and
effective treatment for reducing pain and improving function in patients with knee OA. It can
be used as an adjunct to conservative treatment, physiotherapy or medication.
Keywords: acupuncture, knee, osteoarthritis.
Introduction
Osteoarthritis (OA) is the most common form
of joint disease in the UK. It is a major factor in
limitation of activity and consequent use of
healthcare, especially among the elderly. The
condition most commonly affects the knee.
The medications used to treat the symptoms
of OA, such as non-steroidal anti-inflammatory
drugs (NSAIDs), are associated with side effects
(Tramèr et al. 2000), and patients who have a
limited response to medication are recommended for joint replacement surgery. Patients
with chronic pain are increasingly using acupuncture for pain relief and to improve function.
The aim of the present literature review was to
collect information about the effectiveness of
acupuncture for knee OA.
The MEDLINE database identified nine relevant articles, including three systematic reviews
of randomized controlled trials (RCTs), five
Correspondence: Catherine Markwell, Intermediate
Care Services, Curran House, Twin Spires, 155
Northumberland Street, Belfast BT13 2JF, Northern
Ireland (e-mail: [email protected]).
RCTs and one prospective randomized trial. The
sample sizes of the five RCTs ranged from 30 to
1007 patients. Four studies compared acupuncture with sham acupuncture, and two studies also
compared acupuncture to education of patients
about OA and conservative therapy. All of the
RCTs used the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) as
an outcome measure; other measures included a
global patient assessment and a Visual Analogue
Scale (VAS).
Literature review
Itoh et al. (2008) found that acupuncture was
more effective than sham acupuncture in reducing pain in a systematic review of seven RCTs. A
blinded, randomized, sham-controlled clinical
trial by Ezzo et al. (2001) was conducted to
determine if acupuncture at trigger points is an
effective treatment for knee OA when compared
with existing widely used acupuncture at standard acupuncture points. The above study had
inclusion and exclusion criteria that were similar
to those of other studies. Subjects were blinded
31
Osteoarthritis of the knee
to the treatment and measurements were performed by an independent investigator. Thirty
patients were randomly allocated to standard
acupuncture, trigger point acupuncture or sham
acupuncture groups. Each of the 30 subjects
received five, 30-min treatments once a week,
and follow-up measurements were taken 10 and
20 weeks after the first treatment.
In the standard acupuncture group, widely
accepted acupuncture points were needled with
the ‘‘sparrow pecking’’ technique and De Qi was
achieved at each point. The trigger point acupuncture group involved precise needling of
active myofascial trigger points with the ‘‘sparrow pecking’’ technique and local twitch
response was elicited by successful treatment.
The sham acupuncture group received treatment
at trigger points with needles that had the tips cut
off and smoothed. The needles did not penetrate
the skin.
Visual Analogue Scale scores were lower at
weeks 1–10 in the trigger point group and at
weeks 2–10 in the standard acupuncture group
when compared to their respective pre-treatment
scores. These improvements persisted until
5 weeks after the cessation of treatment. The
mean WOMAC scores showed a significant
reduction in the trigger point and standard acupuncture groups. A statistically significant difference between the trigger point and sham groups
was found in both the WOMAC and VAS
scores.
The results suggest that trigger point acupuncture may be more effective than other acupuncture treatments for OA of the knee, and
therefore, the site of stimulation may be important. Ezzo et al. (2001) admitted that their study
had some limitations, such as its small sample
size and the choice of control, since other studies
that have used a non-acupuncture control group
have showed more-positive results.
An RCT of 68 subjects with osteoarthritic
knee pain by Jubb et al. (2008) compared the
effect of acupuncture with that of nonpenetrating sham acupuncture. The patients were
randomly allocated to the acupuncture group or
the sham acupuncture group. All subjects continued taking their usual analgesia or NSAIDs.
Acupuncture points for stiffness and pain were
selected according to acupuncture theory for
treating Bi syndrome. Manual and electrical
32
stimulation were used. The outcome measures
were the WOMAC index, EuroQol scores and
plasma -endorphin levels. All patients received
acupuncture to the same acupuncture points, but
the sham needles were secured to the skin with a
plastic ring covered by a sticking plaster, which
was also used for those undergoing genuine
acupuncture. Both groups received treatment
twice weekly for 5 weeks.
There was a statistically significant improvement in favour of the acupuncture group. Within
the acupuncture group, there was a highly significant improvement in the pain score that was not
seen in the sham group. Nine weeks after the
treatment started, there was no longer a significant difference between the groups. However,
a within-group analysis demonstrated that the
acupuncture group still exhibited a significant
change in baseline. The sham group remained
unaffected. The acupuncture group showed significant improvement from baseline in WOMAC
stiffness and function at both weeks 5 and 9. The
sham group showed a borderline significant
change for WOMAC function at week 9 that was
not seen at week 5, but there was no change in
stiffness. Jubb et al.’s (2008) study found that
patients who received acupuncture exhibited significantly greater pain relief, and their findings
support earlier research demonstrating that acupuncture can alleviate the pain and disability of
knee OA. The trial was designed to study the
short-term effects of skin penetration in acupuncture therapy and not the duration of any
effect. Statistically significant improvement
within the acupuncture group was seen in almost
all of the parameters that were measured and the
benefit was predominantly still present after
4 weeks.
Manheimer et al. (2006) studied 570 subjects
with OA of the knee to determine whether
acupuncture provides greater pain relief and
improved function compared with sham acupuncture or education. The patients were randomly assigned to one of the three groups:
acupuncture; sham control; or education control,
where subjects attended six, 2-h group teaching
sessions based on the Arthritis Self-Management
Program. The RCT took place over 26 weeks,
and involved an 8-week period of twice-weekly
treatments followed by 2 weeks of one treatment
per week, 4 weeks of one treatment per fortnight
C. Markwell
and 12 weeks of one treatment per month. All
patients in the acupuncture and sham groups
were blinded to their treatment. Traditional
acupuncture points were selected, De Qi was
achieved and electrical stimulation was applied to
Xiyan knee points for 20 min. In the sham
group, plastic needle guiding tubes were tapped
on the acupuncture points and immediately
affixed with a piece of adhesive tape without
needle insertion. The outcome measures
included the WOMAC pain and function scores,
the Short Form 36 Health Survey Questionnaire,
a global patient assessment and a 6-min walk.
A statistically significant trend for the three
groups as a whole was to improve over time on
all outcomes except the 6-min walk, but of
greater interest were the differences in the
improvements in outcomes between true versus
sham acupuncture groups at the different points
in time. At 8 weeks, subjects in the true acupuncture group experienced a greater improvement in
WOMAC function scores than those in the sham
acupuncture group, but not in the WOMAC pain
scores or the global patient assessment. At 26
weeks, the true acupuncture group experienced
significantly greater improvement than the sham
acupuncture group in the WOMAC function and
pain scores, and the global patient assessment.
Twenty-six adverse events were reported, but
none were interpreted as treatment-related and
the differences among groups did not reach
statistical significance. Manheimer et al. (2006)
found that acupuncture is a safe and effective
treatment for reducing pain and improving function in patients with knee OA, and may have an
important role in adjunctive therapy as part of a
multidisciplinary integrative approach to treating
symptoms related to this condition (Hochberg
2003).
Scharf et al. (2006) conducted an RCT to
assess the efficacy and safety of traditional
Chinese acupuncture (TCA) compared with
sham acupuncture (needling at non-acupuncture
points) and conservative therapy in subjects with
chronic OA of the knee. The authors included
1007 patients in this study. The subjects were
randomly allocated to one of the three groups,
and patients in the acupuncture and sham acupuncture groups were blinded to their treatment.
Each subject had six physiotherapy sessions and
as-needed NSAIDs, plus either 10 sessions of
TCA, 10 sessions of sham acupuncture (which
involved minimal-depth needling without stimulation at defined distances from TCA points) or
10 physician visits within 6 weeks. Success rates
were calculated according to a change of at least
36% from baseline WOMAC scores at 26 weeks.
The success rates were 53.1% for TCA, 51%
for sham acupuncture and 29.1% for conservative therapy. The acupuncture groups had higher
success rates than conservative therapy, but there
was no difference between TCA and sham acupuncture, which could be a result of placebo
effects or the physiological effect of needling,
regardless of whether it is done according to
TCA principles. The numbers of adverse effects
were comparable to the three groups, but haematoma was reported more often in the TCA
and sham acupuncture groups than in the conservative therapy group. Scharf et al. (2006)
found the absence of specific effects of TCA to
be surprising: specificity of needling points,
depth of needling with stimulation and De Qi
sensation do not result in marked effects. These
authors concluded that the addition of TCA
or sham acupuncture to physiotherapy and
NSAIDs leads to a greater improvement in
WOMAC scores at 26 weeks, and therefore,
could be used to improve conservative therapy
and reduce the use of analgesics.
An open RCT by Tukmachi et al. (2004)
examined the effectiveness of manual acupuncture and electroacupuncture (EA) on symptom
relief in 30 subjects with knee OA. The patients
were allocated to one of three groups. Group A
had acupuncture alone, group B had acupuncture
but continued on their symptomatic medication,
and group C used their medication for the first
5 weeks and then had a course of acupuncture
added. Subjects receiving acupuncture were
treated twice-weekly over 5 weeks. Needles were
inserted (with manual and electrical stimulation)
in acupuncture points for pain and stiffness
selected according to acupuncture theory for
treating Bi syndrome. Patients were assessed by a
blinded observer before treatment, after 5 weeks
of treatment and at one month follow-up using
the VAS and WOMAC as outcome measures.
There was a highly significant improvement in
the VAS pain score, and the WOMAC pain and
stiffness scores after the course of acupuncture
in groups A and B. This was not the case in
33
group C at 5 weeks, but these subjects showed a
significant improvement following their course
of acupuncture. The reduction in the WOMAC
stiffness score was less dramatic in group A, but
was still significant. The benefits were maintained during the month following the course of
acupuncture. The patients rated their global
assessment of improvement at the final visit as
61% in group A, 83% in group B and 88% in
group C. Tukmachi et al. (2004) concluded that
manual acupuncture and EA causes significant
improvement in the symptoms of OA of the
knee, either on its own or as an adjunct therapy.
Tillu et al. (2001) conducted a prospective
RCT of acupuncture for 44 subjects with
advanced knee OA who were awaiting total knee
replacement. The aim of the study was to determine if there was any difference between unilateral and bilateral acupuncture for the treatment
of OA of the knee. Acupuncture meridians are
bilateral and it is a common belief that bilateral
acupuncture is more effective than unilateral
treatment (Tillu et al. 2001). The patients were
randomly allocated to two groups: group A
received acupuncture to the most affected knee
and group B received acupuncture to both knees.
Acupuncture was given to four local points and
one distal point. Each session lasted 15 min and
all subjects received six acupuncture treatments
at weekly intervals. A blinded observer assessed
knee function before treatment, and at the end
of 2 and 6 months. This study showed that there
was a significant reduction in symptoms in both
groups that was sustained for 6 months. There
was no statistically significant difference between
the two groups. The authors concluded that
unilateral acupuncture is as effective as bilateral
acupuncture in increasing function and reducing
pain associated with knee OA.
White et al. (2006) conducted a systematic review of the effectiveness of acupuncture for OA
of the knee. Systematic reviews assess the validity
of relevant research, and provide a valid and
reliable method of combining the results of these
studies in a meta-analysis. This review evaluated
the effectiveness of acupuncture in treating pain
and improving function in patients with OA of
the knee. The authors planned to include only
RCTs that compared acupuncture with sham acupuncture, other sham treatments or other forms
of care, including waiting lists or standardized
34
care with analgesic drug treatment. ‘‘Sham’’
means any intervention that is intended to appear
the same to the patients, but has a very small
physiological effect. White et al. (2006) searched
six databases for literature. Multiple comparisons
were made between studies, first for pain and
then for function, both for the short term (up to
6 months) and the long term (6 months to one
year). Thirteen studies were found.
Five studies with short-term outcomes and
three with long-term outcomes showed that
acupuncture was significantly superior to sham
acupuncture for pain reduction. The results for
improvement in function were similar to those
for pain in both the short and long term.
Acupuncture demonstrated a small but statistically significant superiority to sham acupuncture
in both time periods. Two other studies that
compared acupuncture with sham transcutaneous electrical nerve stimulation showed that
acupuncture was either significantly superior, or
showed a strong trend for pain and function.
Four studies compared acupuncture with no
additional treatment for pain and three did so for
function. In three studies, current medication,
including NSAIDs, was permitted, and in the
fourth study, diclofenac was prescribed. Acupuncture was significantly superior for pain and
improvement in function. Only one study
assessed in this review compared acupuncture
with an education programme; it found that true
acupuncture was significantly better for reducing
pain and improving function in both the short
and long term. White et al.’s (2006) review shows
that acupuncture is significantly superior to placebo (sham acupuncture) and to no additional
treatment for knee OA in both reducing pain
and improving function. The overall result of
these studies is positive and this review shows
that acupuncture seems to be effective when
given in conjunction with medication (Tukmachi
et al. 2004), but it is possible that a smaller effect
is seen when it is combined with physiotherapy
(Scharf et al. 2006).
Vas & White (2007) conducted an exploratory
review of the evidence from RCTs for optimal
acupuncture treatment for OA of the knee.
These authors studied a recent systematic review
of 13 RCTs and four recent high-quality RCTs.
One RCT showed a much greater treatment
response to the other three. This speculative
C. Markwell
comparison of RCTs suggests that the following
factors could contribute to optimal results from
acupuncture treatment: climatic conditions, particularly high temperature (the trials that showed
a more-positive effect were conducted in Seville,
Spain); the high expectations of patients; a minimum of four needles; EA rather than manual
acupuncture; and a course of at least 10 treatments. No suggestions could be made about the
need to elicit De Qi or about the frequency of
treatment since the studies were similar in these
respects.
When reviewing RCTs on the effectiveness of
acupuncture, it is important to address the safety
of acupuncture. Yamashita et al. (2006) reviewed
trials that focused on specific reactions to acupuncture. These authors identified seven RCTs
that included information on adverse events,
but no serious effects were reported. Joint
swelling, local inflammation, haematoma and
back pain occurred more frequently in the
dummy EA or minimal acupuncture group (the
control group). Yamashita et al. (2006) confirmed that many adverse reactions to acupuncture in RCTs for knee OA are non-specific and
that not all reported events should be attributed
to acupuncture.
Discussion and conclusion
Acupuncture has been found to reduce pain and
improve function in patients with OA of the
knee. It has also been suggested that needling
could reduce the use of analgesics or NSAIDs.
Trigger point acupuncture and EA were both
found to be more effective than standard manual
acupuncture treatment. One study found that
unilateral acupuncture is as effective as bilateral
acupuncture in increasing function and reducing
pain associated with knee OA.
Most papers reported that true acupuncture
was superior to sham acupuncture and significantly better than education programmes. However, one study found no significant difference
between true and sham acupuncture, but this
might have been a result of placebo effects or the
physiological effect of needling since the sham
group still had minimal-depth needling away
from traditional acupuncture points.
In an exploratory review, optimal acupuncture
effects were found to be achieved when: per 2010 Acupuncture Association of Chartered Physiotherapists
formed in warm temperatures; the patient had
high expectations of the treatment; using a
minimum of four needles; employing EA rather
than manual acupuncture; and treatment was
conducted over a course of at least 10 sessions.
Acupuncture has a relatively small number of
adverse effects, and therefore, acupuncture is
seen as a safe and effective treatment for reducing pain and improving function in patients with
OA of the knee. It can be used as an adjunct
to conservative treatment, physiotherapy or
medication.
Acknowledgements
Many thanks to Darian Duffin, who conducted the Foundation Acupuncture Course in
Holywood, Northern Ireland, at the end of 2008.
Thanks also to my employer, Belfast Health and
Social Care Trust, for giving me the opportunity
to attend the course.
References
Ezzo J., Hadhazy V., Birch S., et al. (2001) Acupuncture
for osteoarthritis of the knee: a systematic review.
Arthritis and Rheumatism 44 (4), 819–825.
Hochberg M. C. (2003) Multidisciplinary integrative
approach to treating knee pain in patients with osteoarthritis. Annals of Internal Medicine 139 (9), 781–783.
Itoh K., Hirota S., Katsumi Y., Ochi H. & Kitakoji H.
(2008) Trigger point acupuncture for treatment of knee
osteoarthritis – a preliminary RCT for a pragmatic trial.
Acupuncture in Medicine 26 (1), 17–26.
Jubb R. W., Tukmachi E. S., Jones P. W., et al. (2008) A
blinded randomised trial of acupuncture (manual and
electroacupuncture) compared with a non-penetrating
sham for the symptoms of osteoarthritis of the knee.
Manheimer E., Lim B., Lao L. & Berman B. (2006)
Acupuncture for knee osteoarthritis – a randomised trial
using a novel sham. Acupuncture in Medicine 24 (Suppl.),
S7–S14.
Scharf H. P., Mansmann U., Streitberger K., et al. (2006)
Acupuncture and knee osteoarthritis. A three-armed
randomised trial. Annals of Internal Medicine 145 (1),
12–20.
Tillu A., Roberts C. & Tillu S. (2001) Unilateral versus
bilateral acupuncture on knee function in advanced
osteoarthritis of the knee – a prospective randomised
trial. Acupuncture in Medicine 19 (1), 15–18.
Tramèr M. R., Moore R. A., Reynolds D. J. M. & McQuay
H. J. (2000) Quantitative estimation of rare adverse
events which follow a biological progression: a new
model applied to chronic NSAID use. Pain 85 (1–2),
169–182.
35
Tukmachi E., Jubb R., Dempsey E. & Jones P. (2004) The
effect of acupuncture on the symptoms of knee osteoarthritis – an open randomised controlled study. Acupuncture in Medicine 22 (1), 14–22.
Vas J. & White A. (2007) Evidence from RCTs on optimal
acupuncture treatment for knee osteoarthritis – an
exploratory review. Acupuncture in Medicine 25 (1–2),
29–35.
White A., Foster N., Cummings M. & Barlas P. (2006) The
effectiveness of acupuncture for osteoarthritis of the
knee – a systematic review. Acupuncture in Medicine 24
(Suppl.), S40–S48.
Yamashita H., Masuyama S., Otsuki K. & Tsukayama H.
(2006) Safety of acupuncture for osteoarthritis of the
36
knee – a review of randomised controlled trials, focusing
on specific reactions to acupuncture. Acupuncture in
Medicine 24 (Suppl.), S49–S52.
Catherine Markwell qualified from the University of
Ulster in 2002. She worked in two Belfast hospitals for
over 3 years. Catherine then moved to work in the
community and has been in her current post in Intermediate Care Services in Belfast Trust since September 2005.
She attended the Foundation Acupuncture Course at the
end of 2008 because she has always been interested in
acupuncture and its many benefits.
CLINICAL AUDIT
P. Blacker
Longfield Integrated Care and Physiotherapy Centre, Longfield, Kent, UK
Abstract
This article reports on a clinical audit of a substance misuse service in Kent, UK. The audit
assessed the efficacy of auricular acupuncture treatment of the symptoms commonly associated
with addiction, as well as measuring its benefits in the clinical management of substance misuse.
The results suggest that regular auricular acupuncture treatment has significant benefits to offer
clients of drug and alcohol rehabilitation services, and that it is a safe and cost-effective
treatment that is particularly effective in helping to retain clients in treatment.
Keywords: addiction, alcohol, auricular acupuncture, drugs, ear acupuncture, NADA, rehabilitation, substance misuse.
Introduction
Evidence for the efficacy of acupuncture in the
treatment of substance misuse is sparse but
encouraging, particularly with regard to its success in retaining clients in treatment (BAcC
2005). Acupuncture has also been shown to be
effective at treating some of the symptoms commonly associated with substance misuse, such as
headaches (Vickers et al. 2004), anxiety (Apostolopoulos & Karavis 1996) and neck pain
(Irnich et al. 2001).
The use of auricular acupuncture to treat
people with substance misuse problems has
been growing steadily since the 1970s, when a
specific five-point protocol was developed at the
Lincoln Clinic in New York, NY, USA. The
National Acupuncture Detoxification Association (NADA) was established in 1985 to promote this protocol, which is now considered to
be the standard acupuncture treatment for drug
and alcohol addiction (NADA 2006). NADA
UK was formed in 2006.
The Substance Misuse Services at the Kent
and Medway National Health Service (NHS) and
Social Care Partnership Trust, Canterbury, UK,
began in January 1998, and provided regular ear
Correspondence: Paul Blacker MBAcC, Tuppence
House, Brickfield Farm, Main Road, Longfield, Kent
DA3 7PJ, UK (e-mail: [email protected]).
and body acupuncture to assist clients in various
stages of recovery. Auricular acupuncture has
been recommended by the Department of
Health as appropriate for the treatment of clients
in tiers 1 to 4 (Box 1) of their model multidisciplinary treatment framework (NTASM 2002). A
significant advantage of acupuncture treatment is
that it is complementary to conventional treatments, and easily integrates into a multidisciplinary recovery programme. In terms of research,
however, this makes it very difficult to isolate the
effects of acupuncture from those of other
interventions.
Acupuncture is readily available in 86% of
NHS pain clinics (BMA 2000), but is not yet as
widely available for the treatment of substance
Box 1. Tiers 1–4 of the Department of Health model
multidisciplinary treatment framework (NTASM 2002)
Tier 1: Non-substance-misuse-specific services requiring interface with drug and alcohol treatment
Tier 2: Open access drug and alcohol treatment services
Tier 3: Structured community-based drug treatment
services
Tier 4: Residential services for drug and alcohol misusers:
Tier 4a: Residential drug-and-alcohol-misuse-specific
service
Tier 4b: Highly specialized non-substance-misusespecific services
37
misuse. A report by the British Medical Association recommended that acupuncture should be
integrated into the NHS, and that research
should be directed towards ‘‘investigating . . .
medical conditions treated by acupuncture to
ensure that patients who could gain the most
benefit have access to acupuncture on the
NHS’’ (BMA 2000). With this in mind, the
following audit (a copy of the full audit can be
obtained from the present author) was undertaken to ascertain the benefits of regular auricular acupuncture treatment for the clients of
substance misuse services.
Table 1. Distribution of number of substances used by gender
Number of substances used
Male (%)
Female (%)
1
2
3
4
5 or more
46
13
7
17
17
17
13
31
22
17
Subjects and methods
The audit was conducted by a team of four
members of the Substance Misuse Team, all fully
trained acupuncturists and registered with the
British Acupuncture Council. The audit focused
on three main questions:
(1) Is auricular acupuncture effective in the
treatment and clinical management of substance misuse?
(2) What benefits does auricular acupuncture
bring to clients with regard to symptoms
associated with their drug use?
(3) Which areas of the service could be
improved in terms of delivery of acupuncture to the clients?
Acupuncture treatment was based on the points
used in the NADA protocol (NADA UK 2007):
bilateral Sympathetic, Shenmen, Kidney, Liver and
Lung (upper or lower). At the initial consultation
every client was asked to complete a new-patient
form, based on the Measure Yourself Medical
Outcome Profile (MYMOP) form (MYMOP
2007). After every five treatments, clients were
asked to complete a follow-up questionnaire (copies of these forms can be obtained directly from
the author). The signs and symptoms studied in
the audit were considered to be those most commonly associated with drug and alcohol withdrawal. Treatment rooms were open plan, and
whilst treatment duration was not strictly monitored, clients were encouraged to remain seated
with the needles in place for a minimum of 40 min.
Clients were able to access the service as often
as required. During the audit, 53 new clients
were seen, with 80 follow-up forms completed
38
Figure 1. Percentage of clients using individual
substances.
(over 450 completed treatments). The majority
of the service users attended the acupuncture
clinic regularly: 60% of clients attended the
acupuncture clinic over 15 times. Seventy-two
per cent of the clients were aged 30 years or
older, with just 6% aged between 18 and
25 years. Many of the clients who attended the
clinic were multiple substance users, with 17% of
both male and female clients regularly using five
or more different substances (Table 1; Fig. 1).
Results
Thirteen common drug-withdrawal symptoms
were monitored. When clients completed a newpatient questionnaire, they were asked to rate the
severity of each symptom as either mild,
medium, strong or extreme. In the follow-up
questionnaire, they were asked to re-estimate the
intensity of their symptoms. For the sake of
clarity, this article focuses only on the strong and
extreme symptoms. The following two graphs
show how the number of clients rating their
symptoms as either strong or extreme changed as
a result of acupuncture treatment (Figs 2 & 3).
In addition to rating the intensity of each
symptom (as above), each follow-up questionnaire asked clients to indicate whether specific
P. Blacker
Cravings
Acupuncture treatment did not seem to improve
clients’ experience of their cravings. Figures 2
and 3 show that strong and extreme cravings
actually increased after treatment. This is likely to
be a direct result of clients’ abstinence: a reduction in drug or alcohol intake inevitably leads to
heightened cravings for that particular substance.
Figure 2. Effect of acupuncture treatment on strong
symptoms.
Figure 3. Effect of acupuncture treatment on extreme
symptoms.
symptoms had reduced, stayed the same or
increased in intensity. The following discussion
indicates clients’ experience of changes in these
symptoms after acupuncture treatment.
Stress
Forty-eight per cent of clients reported reduced
levels of stress. Stress is an identified high-risk
event for clients; reduction in a client’s stress
levels leads to a reduced risk of reusing.
Mood swings
Fluctuations in mood are particularly problematic for clients withdrawing from drugs and
alcohol, and many will attempt to dull any
emotional distress by reusing. Forty-two per cent
of clients initially reported strong or extreme
fluctuations in their mood (see Figs 2 & 3),
which dropped to 22% after treatment.
Anxiety
Forty-four per cent of clients reported strong or
extreme anxiety at their initial consultation.
Whilst 20% of clients reported improvements in
their anxiety, 14% reported a worsening of this
symptom. Anxiety is a typical symptom associated with drug withdrawal, and this increase is
likely to be a natural consequence of reducing
drug intake.
Loss of appetite
The eating habits of people addicted to drugs
and alcohol are frequently poor. The body
requires proper nutrition in order to heal itself,
and therefore, an improvement in a client’s
appetite can be a very beneficial result of treatment. Following acupuncture treatment, 63% of
clients reported improvements in their appetite.
Depression
Forty-eight per cent of clients were experiencing
strong or extreme depression prior to acupuncture treatment; in the follow-up questionnaire,
only 29% reported this symptom.
Panic attacks
Thirty-four per cent of clients initially reported
suffering from strong or extreme panic attacks.
After treatment, this had dropped to 16%.
Physical pains
Many of the substances used by clients have
pain-relieving effects. When clients stop using
drugs and alcohol, aches and pains commonly
reappear. Thirty-two per cent of clients initially
reported strong or extreme physical pains, which
reduced to 17% after treatment.
39
auricular acupuncture services in Kent (Andrews
1998).
Discussion and conclusion
Figure 4. Effect of acupuncture on substance misuse.
Feelings of paranoia, obsessive behaviour
or obsessive thoughts
There appeared to be little improvement in
feelings of paranoia, obsessive behaviour or
obsessive thoughts.
Low energy
No clear pattern emerged with regards to
changes in clients’ energy levels. Clients rating
this symptom as strong suffered a worsening of
their energy levels, whilst those with extremely
low energy noticed an improvement.
Sleep
Many people engaged in substance abuse are
chronically deprived of proper sleep. Time spent
with the eyes closed tends to be either exhaustion or drug-induced unconsciousness. Better
sleep brings improved energy and a more stable
mood. Fifty-four per cent of clients reported
improved sleep after treatment.
Substance use
Clients were asked to state whether their substance use had altered in any way. The following
graph shows how substance use changed following acupuncture treatment.
Figure 4 clearly illustrates the effectiveness of
regular auricular acupuncture treatment in helping clients manage their addictions. The main
substances reduced or stopped were alcohol
(54%), cannabis (28%), cocaine (25%), heroin
(25%) and crack (24%). These results are supported by similar findings in a previous audit of
40
The results of this audit clearly show that regular
auricular acupuncture treatment significantly
ameliorates many of the symptoms commonly
associated with drug withdrawal, as well as helping clients to manage their use of drugs and
alcohol. Over half of the clients attending the
acupuncture clinic reduced or stopped their
alcohol use, whilst a quarter of the clients
reduced their heroin, cocaine, crack, cannabis
and tobacco use. Clients returned to the clinic
for an average of 20 treatments over the
6-month period, which, in itself, suggests that
acupuncture effectively helped them to engage in
their own recovery.
For every pound spent on the treatment of
substance misuse, there are savings of £9.50 in
the criminal justice system (Home Office 2006).
Based an average of nine treatments per clinical
session, average equipment costs (see Blacker &
Kozak 2004) and an average salary, the cost per
client per treatment would be between £2.43 and
£3.08. In a clinic treating 45 clients per week, this
could give savings to the Government of
between £1038.825 and £1316.70 per week.
Given the evidence above, this makes acupuncture an extremely cost-effective treatment option
for substance misuse services.
References
Andrews K. (1998) Complementary Clinic Auricular Therapy
First Report. Thames Gateway NHS Trust, Gillingham,
Kent.
Apostolopoulos A. & Karavis M. (1996) Overeating:
treatment of obesity and anxiety by auricular acupuncture, an analysis of 800 cases. Acupuncture in Medicine 14
(2), 116–120.
Blacker P. (2006) Efficacy of Ear Acupuncture in the Treatment
of Substance Misuse, Kent. West Kent NHS and Social Care
Trust, Maidstone, Kent.
Blacker P. & Kozak O. (2004) Auricular Therapy 5 Year
Audit 1998–2003, Kent. West Kent NHS and Social Care
Trust, Maidstone, Kent.
British Acupuncture Council (BAcC) (2005) Substance
Abuse and Acupuncture: The Evidence for Effectiveness. British
Acupuncture Council, London.
British Medical Association (BMA) (2000) Acupuncture:
Efficacy, Safety and Practice. Routledge, London.
P. Blacker
Home Office (2007) Tackling Drugs. Changing Lives: Turning
Strategy into Reality. [WWW document.] URL http://
drugs.homeoffice.gov.uk/publication-search/Archive/
strategy-facts-booklet?view=Binary
Irnich D., Behrens N., Molzen H., et al. (2001) Randomised trial of acupuncture compared with conventional
massage and ‘‘sham’’ laser acupuncture for treatment of
chronic neck pain. British Medical Journal 322 (7302),
1574.
MYMOP (2007) MYMOP Overview. [WWW document.]
URL
http://sites.pcmd.ac.uk/mymop/index.php?c=
welcome
National Acupuncture Detoxification Association
(NADA) (2006) NADA. [WWW document.] URL
http://www.acudetox.com/
National Acupuncture Detoxification Association
(NADA) UK (2007) Protocol & Procedures. [WWW document.] URL http://www.nadauk.com/nada-protocoland-procedures.html
National Treatment Agency for Substance Misuse
(NTASM) (2002) Models of Care for Treatment of Adult
Drug Misusers: Framework for Developing Local Systems of
Effective Drug Misuse Treatment in England. National Treatment Agency for Substance Misuse, London.
Vickers A. J., Rees R. W., Zollman C. E., et al. (2004)
Acupuncture for chronic headache in primary care:
large, pragmatic, randomised trial. British Medical Journal
328 (7442), 744.
Paul Blacker has practised acupuncture since 1997. He
worked for 10 years as the lead acupuncturist for the
Substance Misuse Service at Kent and Medway NHS and
Social Care Partnership Trust until May 2009. Paul
teaches acupuncture at the London College of Traditional
Acupuncture and Oriental Medicine, and the College of
Naturopathic Medicine in London, UK. He sits on the
Acupuncture Stakeholders Group and is Secretary of the
Microsystems Acupuncture Regulatory Working Group
(www.macwg.org), exploring statutory and voluntary
regulation of acupuncture in the UK.
This article is reprinted from The Journal of
Chinese Medicine by kind permission of the publishers
(www.jcm.co.uk). Original publication: The Journal
of Chinese Medicine, February 2008, No. 86,
pp. 57–60.
41
CLINICAL AUDIT
Acupuncture in general practice
I. Broad
Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
Abstract
An audit was conducted of an acupuncture service provided by a general practice. The service
was available for one day a week over a period of 3 years. One hundred and five patients
completed the Measure Yourself Medical Outcome Profile 2 (MYMOP2) questionnaire and
received a maximum of 10 treatments for a range of conditions. Seventy-four patients returned
the MYMOP2 Follow-Up questionnaire. The difference in the profile scores between the two
questionnaires was used as the outcome measure. Sixteen patients did not improve. Six patients
improved by less than 12.5%, 21 by 25%, 19 by 50%, nine by 75% and three by 100%. These
results indicate that acupuncture is associated with an improvement in a variety of symptoms.
Keywords: acupuncture, audit, general practice, MYMOP2.
Introduction
In January 2006, the present author was
employed for one day a week by Hetherington
Group Practice (HGP), London, UK, in order to
provide acupuncture treatment for both patients
and staff. This general practice has a socially and
ethnically diverse client population of 10 000.
The author trained in traditional Chinese medicine (TCM) from 1991 to 1993 and has practised
acupuncture ever since, mainly as a treatment for
patients receiving musculoskeletal physiotherapy.
Initially, HGP patients could either self-refer,
or be referred by any doctor or nurse for any
condition. The acupuncture service quickly became overwhelmed by patient demand, and therefore, the self-referral option was discontinued.
One room was used for TCM-based acupuncture.
The purpose of the present 2-year audit was to
establish the efficacy of acupuncture in general
practice for both HGP and the present author.
Subjects and methods
Each subject was given the Measure Yourself
Medical Outcome Profile 2 (MYMOP2)
Correspondence: Ingrid Broad, Hetherington Group
Practice, 18 Hetherington Road, London SW4 7NU,
UK (e-mail: [email protected]).
questionnaire (Paterson 1996) during the first
consultation. The questionnaires were initially
completed with the present author’s help, but it
became clear that problems with literacy, English
or confidence meant that it was better for
the author to transcribe the patients’ verbal
answers.
At the final treatment session, the subjects
were given the MYMOP2 Follow-Up questionnaire and a stamped addressed envelope that was
to be returned to the practice secretary. The
author filled in the same symptoms and activity
recorded on the original questionnaire on this
follow-up. A few weeks later, the author telephoned any patients who had not returned their
forms, and in some cases, sent them another
questionnaire if they had lost it.
Unless the subjects were in considerable pain
and/or impatient for the treatment to commence, in which case they received acupuncture
immediately, the first session was spent asking
questions, examining the patient’s tongue and
taking pulses in order to identify the TCM
syndrome patterns that matched the problem.
Acupuncture was explained, precautionary
advice was given and verbal consent was
obtained. A treatment plan was then devised for
each patient.
43
Acupuncture in general practice
Table 1. Conditions treated
Table 2. Percentage improvement*
Condition
Number of
patients*
Musculoskeletal
Psychological
Neurological
General and unspecified
Digestive
Female genital
Cardiovascular
Social problem
65
15
12
5
3
2
3
1
*The number of patients represents all those who completed the Measure
Yourself Medical Outcome Profile 2.
Size 0.2530 or 40 mm Korean needles
(DongBang AcuPrime, Exeter, UK) were generally used. Size 0.3070 mm Elite needles
(DongBang AcuPrime) were used for the
Stomach 31 and Gall Bladder 30 acupuncture
points. No more than 10 needles were usually
employed when treating any subject and these
were inserted to an appropriate depth to elicit a
De Qi sensation. Manual stimulation was generally used, but sometimes an electroacupuncture
unit or smokeless Japanese moxa cones were
employed. Needles were usually left in situ for
15–20 min out of a total treatment time of
35 min.
Occasionally, if requested, exercises were prescribed or lifestyle advice was given. Subjects
received no more than 10 treatments, usually
at intervals of 1–2 weeks. The majority of
patients experienced no adverse effects, although
a few reported minor symptoms such as
light-headedness, a temporary exacerbation of
symptoms or bruising.
Results
A total of 105 patients were treated. Seventy-six
subjects were female and 29 were male. The age
range of the patients was 18–83 years (mean=
47 years). Ten subjects dropped out of the study
for unknown reasons. The number of treatments
per patient varied between two and 10
(mean=8.27). The International Classification of
Primary Care (De Lusignan 2005) was used to
list the conditions treated. These are presented in
Table 1. The majority of subjects were referred
for musculoskeletal problems.
The MYMOP2 questionnaire was completed
by all 105 patients. The MYMOP2 Follow-Up
questionnaire was given to 89 patients and
44
Percentage
improvement
0
12.5
25
50
75
100
Patients
Number
Percentage
16
6
21
19
9
3
21.62
8.11
28.38
25.68
12.16
4.05
*The results are for all patients who completed the Measure Yourself
Medical Outcome Profile 2 Follow-Up.
returned by 74, a return rate of 83%. The
follow-up was not given to patients who had
difficulty with English or literacy. The MYMOP2
profile score can be summarized on both the
initial and follow-up questionnaires. The score of
the first profile is subtracted from that of the
second to calculate the outcome. The mean
difference between the MYMOP2 and the
MYMOP2 Follow-Up profile scores was 1.08
(range=0–4.58).
The number of patients who improved by 0%,
12.5%, 25%, 50%, 75% and 100% is shown in
Table 2. The percentages were rounded up or
down to the nearest appropriate percentage
grouping. Sixteen subjects did not improve, but
58 made an improvement of between 12.5% and
100%.
Discussion
Although the majority of the present subjects
were treated for musculoskeletal conditions, this
audit demonstrates that acupuncture is associated with an improvement in a variety of conditions. It is possible that the patients would
have made greater improvements if their treatments had continued, and in fact, many asked for
more than the maximum number of 10 sessions.
Other audits have demonstrated the effectiveness of acupuncture in primary care. Stellon
(2001) studied 140 acupuncture patients, and
reported that there was no effect in 31%, an
improvement in 31% and much improvement in
38%. However, these subjects were observed for
another year and it was found that 50% required
further treatment. He concluded that acupuncture was effective, but only in the short term, and
that more treatment would increase the workload
of his single-handed general practice. Freedman
(2002) audited 500 patients, reporting an overall
I. Broad
improvement in 73%, and a significant improvement or cure in 61%. Day & Kingsbury-Smith
(2004) also found that acupuncture was effective: 55 patients who completed the MYMOP2
Follow-Up showed a significant improvement in
their symptoms. These authors recommended
that acupuncture should be considered for use in
primary care.
It would have been better if the present
subjects had completed the initial MYMOP2
questionnaire by themselves. The author could
have used the pictorial version of the MYMOP
developed by Day (2004) or employed someone
else to sit with the patients while they filled in the
questionnaire. In either case, this would have
required administrative support. As it was, great
care was taken to list all the symptoms and
activities mentioned by the subjects.
The relatively high return rate for the
MYMOP2 Follow-Up (83%) could be explained
by the present author telephoning the individuals
who had not returned the form. As previously
stated, this sometimes necessitated sending out
another questionnaire. Therefore, in some cases,
there was a time lag of a few months between
the last treatment and the completion of the
questionnaire, in contrast to those patients
who returned the questionnaires promptly. It
is unknown whether the outcomes of these
subjects differed.
It would have been interesting to ascertain
whether acupuncture treatment resulted in a
reduction in medication usage. This could be
addressed in a future audit.
Nine members of staff received 42 treatments
in total, but they did not form a part of the
present audit. It is possible that treating them
resulted in there being no necessity to employ
locum staff.
Conclusion
Acupuncture for a variety of conditions has
been shown to be beneficial for the majority of
patients. Providing an acupuncture service
in primary care is an effective and popular
treatment modality.
Acknowledgements
I would like to thank Dr Carolyn Rubens for her
encouragement and assistance, and HGP for
having faith in me.
References
Day A. (2004) The development of the MYMOP pictorial
version. Acupuncture in Medicine 22 (2), 68–71.
Day A. & Kingsbury-Smith R. (2004) An audit of acupuncture in general practice. Acupuncture in Medicine 22
(2), 87–92.
De Lusignan S. (2005) Codes, classifications, terminologies
and nomenclatures: definition, development and application in practice. Informatics in Primary Care 13 (1),
65–70.
Freedman J. (2002) An audit of 500 acupuncture patients
in general practice. Acupuncture in Medicine 20 (1), 30–34.
Paterson C. (1996) Measuring outcomes in primary care: a
patient generated measure, MYMOP, compared with the
SF-36 health survey. British Medical Journal 312 (7037),
1016–1020.
Stellon A. (2001) An audit of acupuncture in a singlehanded general practice over one year. Acupuncture in
Medicine 19 (1), 36–42.
Ingrid Broad qualified as a physiotherapist in 1979 and
as an acupuncturist in 1993 after 2 years at the British
College of Acupuncture. She has been employed by Guy’s
and St Thomas’ Hospital NHS Foundation Trust,
London, since 1995, and worked in the Hetherington
Group Practice from 2006 to 2009.
45
TRADITIONAL CHINESE MEDICINE
Five-element theory: understanding the basics
Lynn Pearce
Private practice, St Neots, Cambridgeshire, UK
Abstract
The purpose of this article is to introduce some of the ideas and associations that contribute
to the five-element theory in traditional Chinese medicine (TCM). Physiotherapists who take
the AACP Foundation Course in Acupuncture are given a brief overview of the TCM
approach, but this can often come across as a confusing blur of unfamiliar words, strange
ideas and outmoded concepts about the way in which the human body works. However, as a
working clinical system, the five-element theory takes simple and logical observations of the
natural world, and uses these as analogies in order to explain human behaviour in both the
balanced state of health and the unbalanced state of illness. The scope of this paper is
necessarily limited because there is a vast amount of literature on the five elements; there are
even traditional schools of acupuncture in the UK that exclusively teach a five-element
approach. Any attempt to integrate this theory with the Western scientific model is fraught
with difficulties, but it is hoped that a more general understanding of the ideas and terms
that underlie the five elements will help readers to comprehend future articles that choose to
address this approach.
Keywords: acupuncture, five-element theory, traditional Chinese medicine.
Introduction
In a nutshell, the five-element theory is a logical
way of representing and interrelating the way we
live within the environment around us. This
concept has evolved over thousands of years,
and in traditional Chinese medicine (TCM) practice, it provides a tool for assessing many aspects
of health and illness.
The five-element theory also helps us to
identify who we are: What kind of people are we?
What are our mental and physical strengths and
weaknesses? Which environments should we
avoid that might be detrimental to our health?
These questions are not only important to us, the
practitioners, of course, but are also pertinent
to our patients, who often become their own
worst enemies by going against their own fiveCorrespondence: Lynn Pearce, 2 Audrey’s Court,
153 Great North Road, St Neots, Cambridgeshire
PE19 8EQ, UK (e-mail: [email protected]).
element type and adding to their picture of ill
health.
After presenting some aspects of the fiveelement theory and the way in which it has
evolved, the present author aims to outline some
of the more common clinical signs and symptoms that an individual may show when ill. By
relating these indications to the concept of which
type of element he or she represents, suggestions
can be made as to how best the patient may be
helped using acupuncture.
In case reports in evidence-based journals
such as the present one, or in papers printed in
more specifically TCM-orientated publications, it
is increasingly common to come across references to strange ‘‘un-medical’’ expressions like
Wood, Wind, Earth and Damp. These are only
‘‘un-medical’’ in terms of the Western scientific
model. What seems like a complex interweaving
of seemingly unconnected symptoms and signs
of pathology can actually be linked in an elegant
47
Five-element theory
and clinically useful way with some knowledge of
the system of the five elements and what this
stands for in TCM.
Therefore, as a system for assessing health, life
and everyday function, the five-element theory
could be said to be a blueprint for:
(1) healthy living, i.e. recognizing your own
strengths and weaknesses;
(2) knowing the patient you are treating and
gearing your treatment toward their ‘‘constitutional type’’; and
(3) the diagnosis of organ dysfunction.
We are all alike – but different!
Whilst we are all human beings, every individual,
be they practitioner or not, will recognize that
there is a tendency for us to be defined by our
differences! This may be in terms of ‘‘personality
types’’ or body shapes, for example, and there
are different trends in behaviour at different
stages of our lives. The five-element theory can
help to make some sense of these innate differences.
In an attempt to provide a simple base upon
which we can build the greater complexities, the
present author will consider the starting point of
this concept as the centre of a spider’s web. A
few simple truths can be found at this hub, and
as the theory extends to encompass more and
more that is related to health, living and the
treatment of ill health, the lines of connection
spread out to the edges, anchoring the system
within the fabric of all that we know of as ‘‘life’’.
That sounds very grand, but by keeping the
simple principles foremost, we can view the
five-element theory as shown in Figure 1.
Some of you will note that this is not the
conventional representation of the five elements:
traditionally, as seen in many books, on charts
and in the media, the representation more closely
resembles Figure 2.
This idea was written about long before the
theory started to encompass the way the elements related to human health and living, as seen
in this quote (Adkinson 1996):
‘‘Wood gives rise to
fire, from which ash
gives rise to earth, from whose depths is
mined metal, whose polished surface may
48
Figure 1. Earth is central to the five-element theory and
provides the solid foundation on which to build the rest
of the model. All the elements have an aspect of Earth
within them, and all are linked to each other in either a
direct or indirect way. Whatever happens to one element
will effect the others to a greater or lesser degree.
Figure 2. The interrelationship of the five elements is
based on the Sheng cycle. This is a wheel of generation in
which one element leads on to another and healthy
living is dependent on one element ‘‘feeding’’ the other.
This can be compared to the circle of life.
attract dew (water), which causes wood to
grow and thus to complete the cycle.’’
– Tsou-Yen (350–270 BCE)
Archaeological evidence has given us three
important sources of information that originated
in China between 200 BCE and 150 CE. These
have provided the literary records upon which
aspects of Chinese acupuncture have been based.
Lynn Pearce
Some schools of thought take the words within
them literally, others pay lip-service, and some,
such as many contemporary scientific medical
approaches, believe that these sources are barking
mad because they try to explain pathology in a
way that only makes sense to a Daoist monk on
top of a mountain! Much the same could be said
about the way in which we have interpreted biblical thought through the ages: different groups take
different meanings from an original source.
Nevertheless, some of the links that fiveelement theory makes with wider aspects of daily
life and illness remain useful. The aim of the
present paper is to put forward a few of those
useful facts, rather than the more esoteric elements of the concept, in order to give the reader
some sense of what authors mean when they
write that their patient had a bad attack of Liver
Wind, or that the Spleen is likely to be damaged
by ‘‘over-thinking’’ because someone is an Earth
type.
The three key sources of information are the
writings found in:
(1) the Mawangdui scrolls, dating from 168
BCE, which were found in tombs excavated
in Hunan Province in China in 1973 (Rochat
de la Vallée 2009);
(2) the Huang Di Nei Jing, which translates as The
Yellow Emperor’s Canon of Internal Medicine and
is made up of two books, the Ling Shu and
the Su Wen, that were finally collated around
150 CE (Wu 1993; Wu & Wu 1996); and
(3) the Nan-Ching, which translates as The Classic
of Difficult Issues, compiled in the first century
CE (Unschuld 1986).
Certainly, the Huang Di Nei Jing and its sister
book, the Nan-Ching, discuss the five elements at
length, but from the outset, the authors explain
that these fundamental building blocks are the
materials from which all living things in the
environment are made (Hicks et al. 2004). These
connections or correspondences then become
increasingly complex! As such, there is constant
interaction between the elements, as echoed even
in the ‘‘ashes to ashes, dust to dust’’ burial
speech from the Anglican Book of Common Prayer.
This funeral oration emphasizes that mankind is
made of the same stuff as the earth, and therefore, to broaden the comparison more widely,
the same stuff as the universe.
Table 1. Commonalities between the Greek, Japanese, Buddhist,
Tibetan and Medieval medical traditions with regard to the five
elements (bold type indicates an exact correspondence)
Greece Japan
Buddhism
Tibet
Medieval
medicine
Water
Fire
Air
Aether
Earth
Water
Fire
Air/Wind
Aether/Space
Earth
Water
Fire
Air
Space
Earth
Water
Fire
Air
Aether
Earth
Water
Fire
Air/Wind
Void/Sky/Heaven
Earth
The five elements that are described in the
Chinese literature were commonly found in
other traditions. Whilst trying to make sense of
their surroundings and their interactions within
their environment, many cultures throughout
history have used analogies that are similar to
what was to become the more coherent fiveelement theory in China.
Table 1 illustrates similar ways of thinking
about three of the elements, i.e. Fire, Water and
Earth, in the Greek, Japanese, Buddhist, Tibetan
and Medieval medical traditions. These represent: life and nourishment (Water); destruction,
but also power (Fire); and re-growth/fertile/
fertility (Earth).
When thinking about how ancient cultures
observed their surroundings, it is quite possible
to understand why these three elements were
obvious ‘‘materials’’. The more tenuous materials
are Air/Wind, which was to become the Chinese
Wood, and Space/Aether/Void/Heaven, which
was to become the Chinese Metal.
Thus, we have our final five elements:
(1)
(2)
(3)
(4)
(5)
Fire;
Earth;
Metal;
Water; and
Wood.
People understood the behaviour of each element in the world around them and began to see
similarities in the symptoms that were exhibited
by those who were ill, leading to a more complex
explanation of the elements, and how these
related to the human body and both its physical
and mental/emotional functions.
Illness appeared to be caused by certain climates (and still does) – China remains a country
of extremes – the dampness of the rice fields, the
hot, dry winds blowing across the central areas
and the cold winters in the north. In the West,
49
Five-element theory
we know that certain weather conditions have
effects on our health.
The next observations were derived from the
fact that only certain types of people seemed to
be detrimentally affected by specific climatic
conditions. If you think of people you know, you
will almost certainly be able to identify, for
example, Wood types and Earth types, who are
both very common in physiotherapy circles.
Table 2 catalogues the kinds of characteristics
that are predominant in each personality type. A
Fire type will be affected by Heat far more than
a Water type, and Earth types will be more
influenced by Damp conditions. This is one
reason why we all become rather more jolly Fire
types in the summer rather than in Autumn or
Winter, when Damp and Cold set in. This is
especially so here in the UK, where we have a
propensity for the more dour and inward elements of Metal and Water.
In addition, the theory gives us a few pointers
towards the kinds of presentation an individual
may exhibit when one element becomes slightly
out of synchronization, which can manifest as
either an excess or deficiency for many reasons.
The clinical signs and symptoms that a person
describes may give you a hint as to who you are
dealing with and which organs/points you may
find beneficial to include in your treatments.
Finally, the following are some point suggestions (these can be found on the organs that are
associated with specific elements):
(1) Wood types may benefit from Liver 3.
(2) Fire types may benefit from Heart 7 or Small
Intestine 3.
(3) Earth types may benefit from Stomach 36
and/or Spleen 6.
(4) Metal types may benefit from Lung 5 or
Large Intestine 4.
(5) Water types may benefit from Kidney 3.
Summary and conclusion
As an introduction, it is hoped that the present
paper has provided some explanation of the
background to the development of a supposedly
elaborate theory that helps to inform acupunc-
50
ture practitioners who use a TCM approach. The
concept does not have to be complex – nature
itself can be elegant in its simplicity – and the
five-element model follows observations about
nature and makes sense of these. The overall aim
is to live in harmony with the type of person we
are, to avoid climates that might damage a
system that is already vulnerable and provide
clues regarding illness so as to help practitioners
to do their best.
References
Adkinson R. (ed.) (1996) Tao (Sacred Symbols Series). Thames
& Hudson, London.
Hicks A., Hicks J. & Mole P. (2004) Five Element Constitutional Acupuncture. Churchill Livingstone, Edinburgh.
Rochat de la Vallée E. (2009) Wu Xing: The Five Elements in
Chinese Classical Texts. Monkey Press, Cambridge.
Unschuld P. U. (1986) Nan-Ching: The Classic of Difficult
Issues. University of California Press, Berkeley, CA.
Wu J.-N. (tr.) (1993) Ling Shu: or, The Spiritual Pivot.
University of Hawai‘i Press, Honolulu, HI.
Wu N. L. & Wu A. Q. (tr.) (1996) Yellow Emperor’s Canon
of Internal Medicine. China Science and Technology Press,
Beijing.
Lynn Pearce is an accredited tutor for the AACP who
runs courses ranging from foundation-level programmes to
days dedicated to continuing professional development. She
also works as a Senior Part-Time Lecturer for the MSc in
Acupuncture at Coventry University, Coventry, UK. The
focus of her teaching at Coventry is on the ideas of TCM
and questioning the way in which students, as modern
users of acupuncture, can integrate these into modern-day
practice.
Lynn has a broad range of clinical experience, having
originally qualified in 1982 from Addenbrooke’s Hospital, Cambridge, UK. In terms of acupuncture, she
qualified in 1989 after taking a course taught by Drs
George Lewith, David Dowson and Julian Kenyon at
the Centre for the Study of Complementary Therapy,
Southampton, UK. She undertook a longer and more
traditional TCM course at the British College of Acupuncture, London, UK, qualifying in 1993 as a Licentiate in Acupuncture.
From an acupuncture perspective, all of this culminated
in Lynn examining and questioning the ways in which
ideas and techniques taken from ancient sources can be
made relevant in today’s workplaces.
Qi, whatever it may be, is an unseen force that
creates movement. The things of heaven (e.g. the
spirits around us and the unseen changes in the
weather) cause the movement of the clouds
according to Chinese philosophy
Fire
Fire is all about generating Heat, rising upwards
(because heat always rises), and looking toward
heaven and spiritual things. It is a powerful force
that is capable of great destruction, but it is also
always creating new things, such as new land (e.g.
volcanoes) and new ways of thinking
The element within the external environment
Heat
Outside climate that
might cause disruption
Catchphrases:
‘‘I’m going to explode like a volcano’’
‘‘I’ve got to get outside’’
(which would suggest seeking the Cold of
the outside to counter the Heat within)
‘‘His eyes were on fire’’
(the eyes are the organs that reflect your
‘‘spirit’’ – consider mental health)
Heat: weather being too hot
Outside climate that might cause disruption
to the inner function of the organ system
Pathogens (things/conditions that cause disease)
Table 2. The big environment and the small environment of man
Continued/
Symptoms generally affect the head and top half
of the body, since the nature of Heat is to rise.
Heat rising to the head can cause more mental
health issues than ‘‘physical’’ issues. Issues with
the Shen, the spirit, are thus the more common
manifestations of Fire- and Heat-related
pathogens. Specifically affecting the Small
Intestine, Heat may give rise to a duodenal ulcer
or heartburn. Heat affecting the pericardium may
give rise to panic and nausea. However, Heat also
causes things to melt, so diarrhoea would be
caused by Heat in the intestines! Extreme Heat
will cause everything to dry up, so the end result
could be constipation!
When too much Heat is around, people become
agitated, cannot sleep, and cannot settle in either
their minds or bodies. They sweat: you can sweat
from a physical disease or simply from excess
anxiety
Fire types tend to be jolly, but may be a little
impetuous by nature (e.g. overly excitable and/or
hot-headed, with a short fuse when the Heat is
too much!). They are very sociable and happy in
crowds
Associated organs: Heart, Small
Intestine, Pericardium and Triple Energizer
The element within the internal environment of
the body
Lynn Pearce
51
52
The Earth element is a very ‘‘caring and sharing’’
element
Also encompassed within this element is the
whole concept of fertility and caring for each
other
A cycle of Damp seeping back into the earth, but
rising up from it when affected by Heat, for
example
Ploughing the earth, mixing it up, sowing seeds
and tending crops are vital for life. However,
none of this would occur without Water (so there
is a strong link between these two elements). The
Water needed here is more about the dew from
the Earth rising up and creating atmosphere,
clouds and then rain, which are also needed to
feed the crops
Earth
Earth is associated with the actual earth and the
ability to plant things in it. Good nutrition is
essential for good health
Table 2. Continued
Damp
Catchphrases:
‘‘She’s a real Mother Earth type’’
‘‘He digests things over and over again’’
‘‘I can’t concentrate, I’m feeling a bit
thick-headed’’
‘‘I’m worried sick’’
Phlegm
Damp: mist, fog and oppressive days when
the atmosphere is heavy
Continued/
Damp creates a feeling of lethargy and heaviness –
fibromyalgia and ‘‘brain fog’’
General weakness and fatigue (Damp clogging up
the entire system). Immune system under
constant sufferance. Bleeding gums
(Stomach channel). Varicose veins (usually the
Spleen channel)
Digestive issues: nausea and vomiting, and
belching/indigestion (some people may be unable
to digest what you’re saying to them!)
They can be self absorbed, which is different
from being self-centred
‘‘Over-digesting’’ things means thinking about
them in too much detail and worrying. Individuals
may seem to go over and over the same thing –
apparently not taking in what is explained to
them!
Earth types tend to be carers and are often found
within the caring professions. They may think of
others more than themselves, and this can lead to
immune system disorders. They are sympathetic/
empathetic, and gain fulfilment from doing things
for others and seeing them ‘‘grow’’. They are
thinkers and planners
Associated organs: Stomach and Spleen
the body
Five-element theory
Metal also suggests clarity – cutting through to
the things that matter. Diamonds are very hard
and very bright!
Ultimately hard, Metal can be altered by Fire –
another link between the elements
Metal
Metal encompasses the hard, deeper centre of the
Earth: actual metals come from within and were
used from the earliest times to make weapons,
utensils and decorations
Table 2. Continued
Dryness
Metal types often appear very private – a bit
aloof and quite self-contained. They don’t mind
their own company and are often theorists in
their learning style. (They may be thought of as
diamonds – hard and bright!) When ill, Metal
types will often become very pale and quiet (cf.
the Lung – not wanting to talk). They are the
element that is most susceptible to colds, coughs
and chest infections
Catchphrases:
‘‘She’s very self-contained’’
‘‘You look like death – as pale as a ghost!’’
‘‘He’s hard as nails’’
Continued/
Dry atmospheres cause illness very easily because
the Lung is the most sensitive organ to the
outside atmosphere
Skin conditions like eczema can be found in this
group and they also often they have numerous
allergies – both dietary and on their skin
Associated organs: Lung and Large Intestine
the body
Dryness: dry conditions and brittleness
Lynn Pearce
53
54
Indeed, the associated organ of the Kidney is,
physiologically, the last one to fail before death.
Heart failure can slow you down, but Kidney
failure tends to mean a much more serious state
of ill health
The overall feel for this element is that it is both
powerful, i.e. able to nourish and encourage life,
but also able to take it away
It can be as soft as mist or as hard as ice, and
thus can cause things to grow (there is a strong
link feeding into the Wood element here), but it
can destroy: our landscape has been shaped by
the actions of rivers and glaciers
As an element, it is associated with birth and
death – both the beginning and end of things
Water
In some ways, this the most abundant of the
elements – we cannot live without it. It nourishes
every nook and cranny of the Earth on which we
live and should also do the same to the living
‘‘Earth’’ of the human being
Table 2. Continued
Cold
Catchphrases:
‘‘She’s very easygoing – she goes with the
flow’’
‘‘You look like you haven’t slept’’ (dark
rings under the eyes)
‘‘He’s very fluid in his thinking’’
‘‘She just plods on and gets things done’’
‘‘I can’t stand it anymore’’ (channel signs)
Cold: Water types hate cold environments
and seek out Warm places to holiday!
Continued/
Kidneys can become damaged in situations of
sustained stress – too much running on adrenaline
and cortisol – this lead to extreme tiredness and
sometimes collapse
Unable to get warm – always cold
General ageing problems, deafness, loss of mental
function (Kidney energy is said to nourish the
brain and all neurology – it is analogous to the
flow of cerebrospinal fluid)
Fertility problems since the Kidney channel is the
only one to go over the perineum
There are obvious problems with the
Kidney/Bladder complex, but considering the
paths of the channels of these two organs, you
can see that it could lead to back pain, weakness
in the knees/osteoarthritic knees and flat feet
In illness, they may get overly exhausted and have
dark rings under their eyes
A quality of stillness but being powerful makes
Water types good people to have on your side!
Determined – like glacial movement – they are
not usually in a rush to achieve things, knowing
that they will get there in the end
Strong Water types are often the real foundation
of a team of workers. They may not stand out as
leaders – Wood or Fire types will think that they
are in charge! – but they are in the background as
strong individuals who seem to give shape and
motivation to the achievements that go on
around them
Associated organs: Kidney and Bladder
the body
Five-element theory
Green in colour, this is associated with the spring,
the time for new growth, a new direction and
driving forwards with new ideas. It is one of the
most powerful elements for providing an impetus
for new things: ‘‘There’s something in the air’’
Wood
Wood encompasses the concept of growth,
pushing upwards, and being, as plants are, strong
but flexible and able to move in the Wind whilst
strong roots keep you anchored
Table 2. Continued
Wind
Catchphrases:
‘‘There’s something in the air’’
‘‘The wind of change’’
‘Oh, give it to me – I’ll do it!’’
‘‘He’s a bit lily-livered’’
‘‘I’ve got to get outside’’
‘‘My symptoms are better when I’m
moving around’’
Wind: from a gentle breeze to a violent
gust
They tend to ‘‘bottle things up’’ and when these
are released – feelings as much as actions – the
Wood type, being a physical element, may express
themselves in acts of physical violence
The channels finish on the head, so headaches
and migraine are more common in this group
Ill health may effect the muscle system (cf. all
sports injuries, etc., and consider Gall Bladder 34)
Courageous – to be brave in Chinese is to have
‘‘a big Gall Bladder’’!
These people get things done. They don’t like
endless meetings, they want to get on with it and
so can be a little intolerant of those who want to
take things more slowly. They are real driving
forces within teams and achieve things, but may
well cause some resentment along the way since
they may not listen to all the points of view that
don’t fit their own angle!
Wood types are often sporty, outdoor people
(also a common group found within
physiotherapy). Like the trees/plants in the wind,
they like to be outside, moving, being energetic.
They can rush into things without thinking too
much – so they may have something of the ‘‘bull
in a china shop’’ about them
Associated organs: Liver and Gall Bladder
the body
Lynn Pearce
55
CASE REPORT
Acupuncture and strengthening in the treatment of knee
osteoarthritis
B. Waldock
Private practice, London, UK
Abstract
A 52-year-old female dance teacher presented with chronic left knee pain caused by
osteoarthritis (OA). The treatments chosen for the management of the subject included manual
therapy, and strength and conditioning programmes designed to restore range of motion and
function, and reduce osteoarthritic pain in the knee. Acupuncture was also introduced, primarily
reduce the subject’s anxiety and perceived pain. The patient was treated on five occasions over
a period of 10 weeks. This case report examines the potential benefits of using acupuncture in
addition to a typical physiotherapy treatment regime. The author also discusses the current
literature on the physiological and functional effects of acupuncture and strengthening, as well
as the potential benefits of these techniques in the treatment of OA of the knee.
Keywords: acupuncture, knee, osteoarthritis, pain, strength.
Introduction
Projected demographic trends based on the
increasing effectiveness of modern medicine
indicate that there will be a substantial increase in
the number of individuals aged over 65 years in
the future. In 1960, elderly people made up 9%
of the US population. It is predicted that this
figure will rise to 23% by 2050 and that there will
also be an increase in the number of individuals
aged more than 85 years, which will quadruple
over the next 30 years until they constitute 25%
of the elderly population (Bemben 1998).
This increase will require a change in the
approach to treatment, and a better understanding of age-related physiological changes and
conditions such as osteoarthritis (OA). Although
age is a major risk factor for the development of
OA, it should be noted that it is not a normal
feature of ageing, i.e. it is age-related, but not
age-dependent (Swedberg & Steinbauer 1992).
Nevertheless, it has been estimated that between
63% and 85% of US citizens over 65 years of age
Correspondence: Ben Waldock, 30 Gaskarth Road,
London SW12 9NL, UK (e-mail: benwaldock@
gmail.com).
exhibit radiographic signs of OA, while 35–50%
of them complain of pain and stiffness. Between
9% and 12 % of these elderly people are affected
to such a degree that they are unable to perform normal activities of daily living (ADLs)
(Swedberg & Steinbauer 1992; Robertson et al.
1998).
Osteoarthritis is a degenerative disease of the
joint cartilage that is characterized by joint pain,
restricted movement, crepitus and occasional
effusion. Pain and decline in function will ultimately lead to muscle weakness. It is generally
accepted that muscles help to decrease loads
through a joint. As human beings age, the
neuromuscular system alters, resulting in a
decreased force-generating capability that can
eventually lead to a decline in function and
further atrophy (Stevens et al. 2001). Such weakness could contribute to the aggravation of this
disease (Marks 1993). It would be expected that
strengthening of elderly patients suffering from
OA could reduce pain and disability through
stabilizing and reducing shock at a joint.
Quadriceps strengthening exercises are often
prescribed as part of treatment regimes to reduce
osteoarthritic pain (Marks 1993). Studies have
57
Acupuncture and strengthening in the treatment of knee osteoarthritis
also shown how a quadriceps strengthening
programme will result in improved function and
ADLs through increasing the momentum generated with respect to rising from a chair and
walking, while also improving balance (Marks
1993).
Non-steroidal
anti-inflammatory
drugs
(NSAIDs) are the most commonly used pharmacological agents for managing osteoarthritic
knee pain (Wegman et al. 2004); however, a
systematic review demonstrated that NSAIDs
are only slightly better than placebo for shortterm pain relief (Bjordal et al. 2004). Because of
this, and combined with the fact that NSAIDs
have been linked with side effects such as gastrointestinal bleeding (particularly in the elderly)
(Hernández-Diaz & García Rodriguez 2000), it
is understandable that patients are beginning to
seek other forms of pain relief. Acupuncture is
one form of non-pharmacological pain relief that
is often used in management of OA of the knee.
Figure 1. Body chart illustrating the anatomical location
of the subject’s left knee osteoarthritis.
range of motion (ROM) and function, and
impairment of her ability to teach dance.
Apart from being issued basic ROM exercises
post-operatively, the subject had not undertaken
any form of physiotherapy for either pain relief
or strength/conditioning up until this point. The
consultant suggested that she should try physiotherapy for conditioning and pain relief before
considering a total knee joint replacement
(TKJR).
Case report
Presentation
A 52-year-old female presented to the clinic
complaining of a 4-year history of chronic left
knee pain. In February 2007, she had presented
to her general practitioner after a 3-year history
of gradual-onset left knee pain that was affecting
her ability to work as a Lindy Hop dance
instructor. Further investigations were ordered,
and in July 2007, a magnetic resonance imaging
(MRI) scan revealed a left medial meniscal tear,
while an X-ray revealed medial compartment
OA. In December 2007, the subject underwent
an arthroscopic medial meniscal repair, but presented to her consultant again in April 2008
complaining of continued pain, loss of strength/
Subjective examination
The subject suffered from left knee pain and
reduced strength/ROM. Her knee pain was
distributed medially and posteriorly (Fig. 1).
She had a Visual Analogue Scale (VAS) score
of 80/100 and her pre-treatment function is
outlined in Table 1.
Sustained weight-bearing, knee flexion, walking up and down stairs, and Lindy Hop dancing
Table 1. Pre-treatment functional outcome measure of the subject’s activities of daily living
Function
Not difficult
at all
Minimally
difficult
Moderately
difficult
Extremely
difficult
Unable
to do
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
–
–
–
–
–
–
–
–
–
–
–
–
–
–
+
–
–
–
+
–
–
–
+
–
–
–
–
–
+
+
–
–
–
–
–
–
–
–
–
+
–
–
+
+
+
58
Go up stairs
Go down stairs
Kneel on the front of your knee
Squat
Sit with knee bent
Rise from a chair
Run straight ahead
Jump and land on involved leg
Stop and start quickly
B. Waldock
all aggravated her condition. Using a walking
stick or crutch, a knee support brace, a Tubigrip
support bandage and/or NSAIDs provided
some relief.
The subject experienced pain and stiffness in
the morning, and this became worse with weightbearing over the course of the day. Furthermore,
her sleep was disrupted by the discomfort.
With regard to her general health, the subject
also suffered from asthma and OA of the right
wrist.
Apart from teaching the Lindy Hop, her
sport/hobby activities also included walking.
Objective examination
The subject exhibited some knee effusion, atrophy of the left quadriceps femoris muscle and
mild valgus deformity. She had an antalgic gait
pattern, used a single gutter crutch, and was
unable to squat or hop.
Her left vastus medialis obliquus and adductor
muscles were tender on palpation. The results
for her active and passive ROMs were the same:
(left knee flexion) 100 ; (right knee flexion)
130 ; (left knee extension) 10 ; and (right knee
extension) –10 . In terms of resistance, the
subject scored four out of five for 90 flexion,
30 flexion and extension.
The Thomas test was performed on her tight
hip flexors and quadriceps bilaterally
Clinical impression
The examination findings suggested that the
subject was suffering from a mechanical knee
dysfunction consistent with her X-ray and MRI
results. Because of the sustained nature of the
condition, and the lack of pain relief or
strengthening/conditioning physiotherapy management, it was assumed that significant disuse
atrophy had occurred and that adaptive changes
needed to be made to restore day-to-day
function.
The emotional state of patients must also be
considered when planning treatment. The
present subject’s 4-year history of pain and a
progressive decline in function despite surgical
intervention, combined with the realistic prospect of requiring a TKJR and the effect that this
would have on her source of income, obviously
caused some emotional distress in this case.
Treatment and management plan
The present author devised the following treatment and management plan for the subject:
+ reduce her knee pain and restore function;
+ improve the strength of her quadriceps,
gluteal, hamstring and calf muscles;
+ reduce her anxiety and emotional distress;
+ return her to dance teaching; and
+ prevent or delay TKJR.
Physiological reasoning for treatment
selection
The subject’s major concern was her inability to
continue teaching Lindy Hop dancing. The
Lindy Hop is a fusion of many dances that
preceded it or were popular during its development, but it is mainly based on jazz, tap, breakaway and the Charleston. A well-functioning
knee with an ability to tolerate complex weightbearing tasks is obviously essential for this
patient. Her main complaint was pain with
weight-bearing tasks and restricted ROM. This
pain had led to a commonly accepted ‘‘downward spiral’’ in knee function through progressive disuse, atrophy of the quadriceps, hamstring,
gluteal and calf muscles, and tibiofemoral and
patellofemoral joint dysfunction/wear. The
resulting condition causes further joint pain
(Stevens et al. 2001).
Pain relief and return to function are considered to be the most important treatment outcomes of in the management of OA of the knee.
Strength and conditioning work has a good body
of evidence to support its use for improving
function in patients with osteoarthritic knees
(Fransen et al. 2003). However, in clinical practice, patients must have some form of pain relief
in order to allow effective strength training.
Therefore, over the first five treatments, it was
decided that a combination of acupuncture for
pain relief and a strengthening programme to
condition the surrounding lower-limb musculature would be most appropriate for pain relief,
improved weight-bearing tolerance and ROM,
and in turn, an improvement in function.
Physiological rationale of strengthening
Neural adaptations. Numerous studies have demonstrated that early strength gains as a result of
59
resistance training are primarily caused by neural
adaptations rather than those of the contractile
elements. Moritani & deVries (1979) discovered
that neural factors accounted for the improvement in strength in the initial 4 weeks of an
8-week strengthening programme, while further
progress was brought about by muscle hypertrophy between 4 and 6 weeks. This increase
in muscle size is limited in relation to strength
(Deschenes & Kraemer 2002). The above authors
found that, following 12 months of strength
training, gains could continue, but are attributed
to a secondary phase of neural adaptation.
Contractile adaptations. Early studies of strengthening indicate that the majority of improvements in
strength after the first few weeks are caused by
muscle hypertrophy and an increased contractile
capacity (Moritani & deVries 1979). The delay in
muscle ‘‘build up’’ is likely to be a result of the
relatively slow synthetic rate of myosin and actin
(Deschenes & Kraemer 2002). Hypertrophy of
muscle occurs through activation of satellite cells
(myoblasts) located between the myofibre sarcolemma and its extracellular matrix (ECM).
Insulin-like growth factor (IGF-1) is present in
the ECM, and following physical disruption (e.g.
from resistance training), it interacts with the
satellite cells, making them become mitotically
active. These fuse with the myofibre, adding
nuclei, which leads to contractile protein synthesis and hypertrophy (Deschenes & Kraemer
2002).
Neuroendocrine adaptations. Resistance causes an
acute post-exercise response in some bloodborne hormone levels. Examples of these
changes include testosterone (Izquierdo et al.
2001), growth hormone and IGF-1 (Deschenes
& Kraemer 2002). All of these contribute to
muscle hypertrophy following resistance training.
Physiological rationale for acupuncture
While a definitive Western medical answer to the
question of how acupuncture actually works to
reduce pain has yet to be discovered, there are
several possible mechanisms by which it is
thought to alter pain. Lundeberg (1998) discussed the three major categories of acupuncture
mechanisms:
60
(1) Peripheral mechanisms. It is proposed that
peripheral needling, i.e. acupuncture close to
the area of injured tissue, induces the release
of sensory neuropeptides (e.g. substance P)
from primary afferent nerve endings, which
promotes the vasodilation and local immune
responses required for tissue healing
(Lundeberg 1998).
(2) Spinal mechanisms. It has also been suggested
that acupuncture has the ability to alter
spinal mechanisms. Lundeberg (1998) proposed that it is possible to reduce nociceptive input in the dorsal horn of the spinal
cord by needling the site of an injury or any
tissue innervated by the same spinal segment
as the damaged tissue.
(3) Supraspinal mechanisms. Furthermore, acupuncture is believed to effect supraspinal
mechanisms by activating descending inhibitory systems. The descending inhibitory
pathways originate at the level of the cortex
and thalamus, and descend via the brainstem
and dorsal columns to terminate in the
dorsal horn of the spinal cord. Neurotransmitters such as noradrenaline, norepinephrine, serotonin and endogenous opioids
are released by the periaqueductal grey matter, and encephalins are discharged by the
nucleus raphe magnus. Following this, there
can also be a release of -endorphins, adrencoticotrophic hormone, leu-enkephalin and
oxytocin from the pituitary and hypothalamus (oxytocin in particular plays a
major role in descending inhibition by
increasing pain thresholds and lowering
cortisol levels).
Lundeberg (1998) proposed that the evocation
of central responses may not be dependent on
the site of needle placement, but rather, simply
requires ‘‘strong’’ points, such as those in hands
and feet [e.g. Large Intestine 4 (LI4) and Liver 3
(LV3)]. Yan et al. (2005) used functional MRI to
examine the effects of acupuncture points on the
brain. They found that LI4 deactivated some
areas of the prefrontal cortex while LV3
switched off parts of the anterior cingulated
cortex. This was significant because Créac’h et al.
(2000) had already shown that these areas
showed increased activity when healthy individuals were exposed to painful stimuli, and
B. Waldock
Table 2. Treatment regime: (LI4) Large Intestine 4; (LV3) Liver 3; (OA) osteoarthritis; (ROM) range of motion; (AROM) active ROM;
(IRQ) inner range quadrilateral; (VAS) Visual Analogue Scale; (SP9) Spleen 9; (GB34) Gall Bladder 34; (ST35) Stomach 35; and (STM) soft
tissue massage
Day Treatment
1
Potential benefits of acupuncture explained and informed consent was given
LI4 and LV3 bilaterally (four gates)
Education regarding the nature of OA, and the importance of ROM/strengthening and conditioning both pre- and (potentially)
post-operatively
Introduction to basic AROM/strengthening: knee flexion/extension; IRQ leg extension; seated knee extension; straight leg raising
Outcome measures: (VAS) 80/100; (AROM) extension=10 ; flexion=95 2
LI4 and LR3 bilaterally
SP9 (point for swelling)
GB34 (point for arthritis, muscles and tendons surrounding the knee; He-Sea point)
Belt distraction mobilizations with movement for knee: (flexion) 315; (extension) 315
Exercycle for 10 min (resistance=0)
SP9 and GB34, as previously
ST35 and Xi Yan (eyes of the knee) in 30 flexion
Belt distractions, as previously
Deep tissue release quadrilateral exercises
Added quarter wall squats (38) and swimming/pool walking
LV3 segmental effect trial
SP9 and GB34, as previously
ST35 and Xi Yan, as previously
SP10 (local medial knee pain)
ST36 (knee pain)
STM quadrilateral exercises
Outcome measures: (VAS) 75/100; tender medial knee after ++ walking over the weekend (watched son participate in run); (AROM)
extension=5 ; flexion=105 5
SP9 and SP10, as previously
GB34
ST34, ST35, ST36 and Xi Yan
STM quadrilateral exercises
Belt distractions
Exercycle for 15 min (resistance=1)
Bridging (310)
Leg press (310; 20 kg)
Outcome measures: (VAS) 55/100; (AROM) extension=3 ; flexion=115 therefore, LI4 and LV3 were likely to have
pain-modulating effects.
More recently, Bradnam (2007) combined the
current views on the physiological effects of
acupuncture and proposed a ‘‘layering method’’
for its role in the treatment of musculoskeletal
conditions. This takes into account the acupuncture effects that are specified in the treatment
plan (i.e. peripheral, spinal and/or supraspinal)
and allows for the patient’s individual pain/tissue
mechanisms.
Clinical outcome
Over 10 weeks and five treatment sessions, the
subject’s VAS scores reduced from 80/100 to
55/100 (Table 2). Furthermore, she stated that it
was subjectively easier for her to go up and down
stairs, sit with a bent knee, and rise from a chair
(Table 3).
Discussion
Acupuncture and strength training have been
accepted as suitable forms of management, and
while it would seem obvious to use both
concurrently, there is surprisingly little in the
literature that examines the effect of these treatments in combination. However, there is a large
body of evidence on both forms of treatment
individually.
Strength training for osteoarthritis
The symptoms of pain and muscle weakness
in patients with OA, as well as the decline
61
Table 3. Post-treatment functional outcome measure of the subject’s activities of daily living
Function
Not difficult
at all
Minimally
difficult
Moderately
difficult
Extremely
difficult
Unable
to do
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
–
–
–
–
–
+
–
–
–
+
–
–
–
+
–
–
–
–
–
+
–
–
–
–
–
–
–
–
–
+
–
–
–
–
–
–
–
–
–
+
–
–
+
+
+
Go up stairs
Go down stairs
Squat
Sit with knee bent
Rise from a chair
Run straight ahead
in functional ability, are well documented
(Swedberg & Steinbauer 1992; Marks 1993).
Although it was generally accepted that this
decline in strength was a result of disuse atrophy
caused by joint pain, some recent studies have
found a more complex relationship. It has been
proposed that knee OA may be caused by a
decline in the motor and sensory functions of the
quadriceps (Topp et al. 2002). Regardless of the
true cause of OA, it is thought that the primary
reason for declines in function is secondary to
pain and weakness.
An early study of strength training in OA
reported that quadriceps strengthening had benefits in relation to both pain and function
(Chamberlain et al. 1982). In this research, the
authors examined the effects of short-wave diathermy (SWD) in a hospital setting and a home
exercise programme performed twice daily
(n=24) with a home exercise programme alone
(n=18). Both groups achieved the same level of
significant improvements in quadriceps strength,
suggesting that it was strengthening and not
SWD that caused the improvement. Furthermore, both groups had a significant reduction in
perceived pain. Like many others, Chamberlain
et al.’s (1982) study was criticized for its methodology because of the lack of a control (no
strengthening) group and inadequate measures
of exercise compliance. Nevertheless, the potential benefits of this form of treatment were now
becoming apparent.
More recent studies have confirmed the possibility of making significant strength gains in
osteoarthritic populations. Ettinger et al. (1997)
performed a large study (n=439) with over-60year-olds that compared aerobic exercise with
resistance training. Both groups undertook a
3-month faculty-based and then a 15-month
62
home-based walking or resistance training programme. Both groups showed modest but significant improvements in pain and disability, as
well as strength, as measured using a Kin-Com
dynamometer (Chattecx Corp., Hixson, TN,
USA).
With convincing evidence supporting the use
of resistance training in OA management, studies
have been conducted to determine which type of
exercise would be most beneficial. Elderly subjects with OA may be prone to injuries and safe,
appropriate exercises must be used (Brown
2000). Furthermore, the issue of patient compliance with exercise must be considered
(Ettinger et al. 1997), and therefore, exercises
must be effective and not numerous.
Topp et al. (2002) studied the effect of
dynamic versus isometric resistance training in
102 subjects. These authors described how isometric training may have functional limitations
because it only strengthens over discrete joint
angles, but they mentioned a possible advantage
because it does not stress the joint over a
functional range. Dynamic training improves
strength over the functional range and enhances
functional performance, but it may cause discomfort in patients with OA. Topp et al. (2002)
found that both dynamic and isometric resistance training reduced perceived knee joint pain,
but that only dynamic training improved function. Unfortunately, the authors neglected to go
into detail regarding the blinding status of the
experiment, which brings their results into
question.
Recent studies have attempted to identify
the type of dynamic strengthening that is
most effective in the management of OA.
Krishnathasan & Vandervoort (2000) described
how eccentric strength is relatively well main 2010 Acupuncture Association of Chartered Physiotherapists
B. Waldock
tained in older adults, suggesting good potential
benefits from strengthening using the higher
forces generated during eccentric loading. Gur
et al. (2002) examined dynamic strengthening by
comparing the effects of a combined concentric
and eccentric programme versus a concentric
one alone. The above authors described how
several studies in healthy individuals have shown
that eccentric training is an effective way of
increasing muscle strength. A relatively small
sample of patients with knee OA (n=23) was
divided into either of the treatment groups or a
control (no treatment) group. Functional capacity measures were taken (including walking, rising from a chair and climbing stairs) along with
knee pain scores, muscle cross-sectional area
(CSA) and isokinetic tests using a dynamometer.
The training for the concentric strengthening
group consisted of 12 concentric extension and
then flexion movements using a Cybex
dynamometer. The combined strengthening
group performed six concentric extensions then
six eccentric extensions at a range of angular
velocities and then repeated the same for flexion.
The results supported the use of resistance
training in the management of OA. Pain scores
reduced while functional capacity increased in
both groups. Peak torque and CSA also made
significant gains. The combined concentric–
eccentric groups made greater improvements in
functional capacity, but less on perceived pain.
The results suggest that eccentric training involving high repetitions is safe, effective and well
tolerated for patients with knee OA, but further
studies are needed involving greater sample sizes.
A systematic review conducted to assess the
effect of exercise on OA of the knee reported
that land-based exercise was shown to reduce
pain and improve physical function (Fransen et
al. 2003). This review also suggested that there
was insufficient data to determine dose and type
of exercise, and that supervised exercise classes
appeared to be as beneficial as one-on-one sessions. No systematic reviews were found that
specifically assessed a quadriceps-strengthening
programme to improve muscle tone in patients
with OA.
The main goals of OA management must be
to reduce pain and disability, and improve quality
of life. The literature reports favourable results
with regard to strength training of both the
elderly and patients with OA. An emerging body
of literature is being undertaken on the types of
strengthening that are effective; however, few of
these studies specifically focus on the amount
and type of quadriceps strengthening with appropriate statistical methods and the power to
determine conclusive evidence.
Acupuncture and osteoarthritis
There is a relatively good body of evidence that
not only supports the use of acupuncture for
pain relief (as discussed above), but also for the
reduction of swelling and enhancement of ROM.
Berman et al. (1995) found that acupuncture had
the effect of reducing swelling and increasing
ROM in a 12-subject pilot study. Later, in a
larger randomized controlled trial (RCT), the
above authors again showed that it is a significantly effective adjunctive therapy to control
pain and improve function in subjects with OA
of the knee (Berman et al. 1999).
Tukmachi et al. (2004) conducted a RCT
examining the effectiveness of manual and electroacupuncture (EA) for symptom relief in
patients with knee OA. These authors used LI4,
Spleen 10 (SP10), Xiyan, SP9, Gall Bladder 34
(GB34), Stomach 36 (ST36), LV3, Bladder
(BL40) and BL37, and their 30 matched subjects
were assessed over 5 weeks of treatment and at
one-month follow-up. The Western Ontario and
McMaster Universities Osteoarthritis Index
(WOMAC) and VAS, which are validated forms
of measuring symptom changes in patients with
OA (Huskisson 1974; Bellamy et al. 1988), were
completed by the subjects. Tukmachi et al.
(2004) concluded that both EA and manual
acupuncture brought about significant improvement in osteoarthritic knee symptoms that lasted
for more than a month. Interestingly, the points
used in this study required the patient to be
treated in two separate positions: first supine for
Xiyan, SP9, ST36, LV3 and GB34, and then
prone for BL40 and BL57. Needles were left
in situ for 20–30 min. Clinically, this could be an
issue if therapists attempt to repeat the treatment
because it is often difficult to treat patients with
acupuncture for sustained periods and fit in
manual therapy/strengthening as well.
White et al. (2006) conducted a systematic
review examining the effect of acupuncture on
OA of the knee. These authors found that
63
acupuncture was significantly better than sham
acupuncture and usual care, although they suggested that further research is needed to determine the most efficient method of performing
acupuncture and to understand its long-term
benefits.
Despite the large body of evidence on acupuncture and OA, there have been relatively few
studies of its combination with strengthening in
the treatment of this condition. Foster et al.
(2007) recently highlighted the need to examine
the effect of adding acupuncture to mainstream
management (i.e. recommended strengthening,
stretching and functional exercises) and undertook an RCT to investigate the effect of acupuncture and exercise-based physiotherapy in
individuals with osteoarthritic knees. Some 352
subjects were assigned to an advice and exercise
group, an advice, exercise and acupuncture
group, or an advice, exercise and sham acupuncture group, and WOMAC scores were obtained.
The results suggest that there is no additional
benefit to adding acupuncture to a course of
advice and exercise.
Further ideas about the progression of acupuncture research have also been proposed. A
recent study by Itoh et al. (2008) showed that
another form of acupuncture has some potential
advantages and it is possible that this may have
further benefited the subject of the present case
report. Itoh et al.’s (2008) RCT compared the use
of trigger point acupuncture on knee OA with
standard and sham acupuncture. In this study,
both trigger point and standard acupuncture
were shown to bring about significant improvements in VAS scores, whereas sham acupuncture
did not. Trigger point acupuncture actually
resulted in a greater reduction in VAS scores and
these results indicate that this could be a more
effective mode of acupuncture treatment.
The purpose of the present case report was to
highlight the benefits of a combined approach
to the treatment of knee OA using strength/
conditioning and acupuncture. Both acupuncture
and strengthening were introduced gradually
over the course of the five sessions to gauge the
patient’s response to both forms of therapy. The
subject typically responded favourably to treatment and the one episode of a worsened VAS
score (day 4) can be attributed to a sustained
period of weight-bearing. The results of this case
64
report are consistent with the vast body of
evidence available on these forms of management, and their effect on knee osteoarthritic pain
and function.
Conclusion and limitations
The subject of the present study responded well
to treatment over five sessions. Strengthening
and acupuncture appeared to improve pain levels, ROM and function (walking up and down
stairs, sitting with the knee bent, and rising from
a chair). Unfortunately, WOMAC scores were
not recorded at the time of treatment. As stated
above, WOMAC scores are widely accepted as
the most validated instrument for assessing
patients with knee OA (Huskisson 1974; Bellamy
et al. 1988; Angst et al. 2002). Had these been
used instead of the subjective functional
improvement questionnaires (Tables 1 & 3), it
might have been easier to compare the present
results with those currently in the literature.
The present author’s clinic’s resources and the
subject’s financial situation limited the strengthening protocol used in the current study. There
was no access to a Cybex dynamometer (Cybex
International Inc., Medway, MA, USA) for the
concentric and eccentric training, which has
proven functional benefits when used by patients
with OA of the knee (Gur et al. 2002). The
subject was reluctant to join a gym because of
the additional cost and so she did not benefit
from any additional resistance training equipment. Therefore, her strengthening treatment
was limited to a hydrotherapy programme,
closed kinetic chain strengthening (wall squats)
and open-chain inner range quadriceps extensions. Nevertheless, the present author still
believed that this resistance-training programme
would stimulate significant strength changes, and
the functional improvements that the patient
made suggest that this was the case.
Finally, the present subject could not continue
treatment at the author’s clinic for financial
reasons. After five sessions, she was able to
receive treatment from the National Health
Service and elected to take this option. This
affected the long-term follow-up capabilities of
this case study. It would have been useful to
compare results following a period of selfmanagement.
B. Waldock
Despite these limitations, the subject did
show good functional improvements, and therefore, this case report demonstrates the potential
benefits of adding acupuncture to a typical
strength/conditioning programme in the treatment of osteoarthritic knees.
Acknowledgements
The author would like to thank Professor
Peter McNair of Auckland University of Technology, Auckland, New Zealand, and Jennie
Longbottom of Coventry University, Coventry,
UK, for their critical reading of the manuscript,
and Andrew J. Wilson for his assistance in
publishing the paper.
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Ben Waldock graduated in 2001 with a Bachelor of
Physiotherapy degree from the University of Otago,
Dunedin, New Zealand. After spending a year working
at Auckland Hospital, Auckland, New Zealand, he
went on to spend the following 7 years in private practice
physiotherapy, working with various sports teams including Harbour Rugby, and the New Zealand women’s
basketball and women’s rugby teams. Ben completed the
Post Graduate Diploma in Musculoskeletal Physiotherapy at Auckland University of Technology in 2005,
and has spent the past 3 years working as a senior
physiotherapist and clinical manager at the Crystal
Palace Physiotherapy and Sports Injury Centre, London,
UK. He completed the Acupuncture for Pain Relief
foundation course in London last year.
CASE REPORT
Acupuncture treatment for bilateral heel pain caused by plantar
fasciitis
C. C. Santha
Department of Physiotherapy, Cayman Islands Health Services Authority, George Town, Grand Cayman, Cayman
Islands
Abstract
A 37-year-old policeman presented to a physiotherapy clinic with chronic bilateral heel pain
caused by plantar fasciitis. Because the subject had experienced no significant pain relief from
either conservative physiotherapy or shoe support, he was offered acupuncture, which has been
reported to be an effective treatment for this condition. Traditional acupuncture points [Taixi
(Kidney 3), Kunlun (Bladder 60) and Sanyinjiao (Spleen 6)] were used in combination with
pain modulation (Four Gates) points [Taichong (Liver 3) and Hegu (Large Intestine 4)]. A local
Ah-Shi point was also used in the plantar region for trigger point release during treatment. All
acupuncture points were needled bilaterally. Pain was assessed before and after each treatment
session with a 10-point linear Visual Analogue Scale: (1) no pain; and (10) severe pain. A
10-point linear Foot Function Index (FFI) questionnaire was used to measure how the subject’s
pain or difficulty affected different functional activities: (1) no pain or difficulty during the
activity; and (10) severe pain or inability to perform the activity. The FFI questionnaire was
constructed on the basis of clinical experience and has not been validated. After eight sessions
of acupuncture treatment over a period of 6 weeks, the subject reported that his pain and
functional capacity had improved by approximately 90%.
Keywords: acupuncture, chronic heel pain, plantar fasciitis, trigger point release.
Introduction
The plantar fascia provides static support for the
longitudinal arch and acts as a shock absorber
during gait. Plantar fasciitis, an overuse syndrome caused by an inflammatory process, is a
common cause of heel pain that is believed to be
caused by repetitive micro-tears in the fascia near
its calcaneal insertion. This condition is most
commonly seen in individuals whose jobs require
a considerable amount of standing or walking.
The risk factors for plantar fasciitis include
obesity, repetitive athletic stress, middle age,
prolonged standing and walking, overpronation,
Correspondence: Chickandarvin Chellaswamy Santha,
Department of Physiotherapy, Cayman Islands Health
Services Authority, PO Box 915 GT, George Town,
Grand Cayman KY1–1103, Cayman Islands (e-mail:
[email protected]).
lateral tibial torsion, excessive femoral anteversion, and pes planus or pes cavus. The most
common symptom associated with the condition
is pain, which is typically located at the anteromedial aspect of the calcaneus near the origin of
the plantar fascia. This discomfort is exacerbated
by passive dorsiflexion of the toes, standing on
tiptoe, palpation of the heel and weight-bearing
after a period of rest.
The diagnosis of plantar fasciitis is usually
made by clinical examination alone. The differential diagnoses of heel pain are nerve entrapment syndromes (e.g. tarsal tunnel syndrome and
posterior tibial nerve entrapment), skeletal problems (e.g. calcaneal stress fractures and Sever
disease) and soft-tissue injuries (e.g. fat pad
syndromes and bursitis).
A wide variety of treatments for plantar
fasciitis have been proposed, but there is no
67
Bilateral heel pain caused by plantar fasciitis
consensus about which modality is most effective. Recommended conservative treatments
include resting, icing, stretching, strengthening,
exercising, modifications or restrictions, nonsteroidal anti-inflammatory drugs (NSAIDs),
orthoses, casting, night splints, ultrasound, laser
therapy, iontophoresis, and injections. Surgical
interventions are also made in cases in which the
cause is a deformity. Although the vast majority
of individuals who suffer from the condition will
recover over time with conservative management, some patients will develop persistent and
often disabling symptoms.
There is a great variety of acupuncture treatments for pain problems. The contemporary approach to the treatment of musculoskeletal pain
recognizes the need to treat ‘‘local tender spots’’,
i.e. to deactivate intramuscular trigger points in the
region of the pain and along the myotomal distribution involved in the discomfort, as necessary to
achieve a successful outcome (Hong 2000).
Many acute and chronic musculoskeletal pain
syndromes have been effectively treated using
acupuncture, including repetitive strain disorders
such as plantar fasciitis and carpal tunnel
syndrome, as well as myofascial pain.
Virchota et al. (1991) conducted a controlled,
double-blind clinical study comparing traditional
acupuncture versus sham acupuncture with conventional sports medicine therapy. They found
that traditional acupuncture produced a greater
improvement pain than conventional sports
medicine treatments. Tillu & Gupta (1998) studied 18 individuals who received a total of four
acupuncture treatments for heel pain caused by
plantar fasciitis. These subjects showed significant improvements on Visual Analogue Scale
(VAS) scores obtained after 4 and 6 weeks of
acupuncture treatments (P<0.001 for both). The
above authors concluded that acupuncture is an
effective method of treating patients with
chronic heel pain caused by plantar fasciitis, and
that the addition of trigger point acupuncture in
poor or non-responders may be useful.
Case report
Subjective assessment
The present subject was a 37-year-old policeman
who was usually fit and well. He played football,
68
ran 4–5 km three or four times a week, and
exercised for 30–60 min five times a week.
His bilateral heel pain had been present for at
least 10 months in his right foot and for
8 months in his left. He had experienced no
known traumas. Up until 3 months before presentation, the subject had managed his pain with
lifestyle modifications, but latterly, his pain had
become worse, and he found it very hard to walk
even a few steps after rest or sleep.
After 2 months of medical treatment and
conservative physiotherapy, including ultrasound, hot packs and heel cushions, without any
significant improvement, an orthopaedic surgeon
recommended a local steroid injection, but the
subject refused this treatment. He was then
referred back to physiotherapy for further
assessment and treatment.
Aggravating factors included weight-bearing
after a period of rest and walking on hard
surfaces. Factors that eased the subject’s discomfort included a hot bath, rest and continuous
activities. He took paracetamol and NSAIDs as
needed.
A bilateral X-ray revealed no abnormalities.
Objective assessment
Both the subject’s ankles and feet appeared
normal and exhibited no signs of deformity.
There was bilateral tenderness on palpation and a
calcaneal tuberosity was identified in the medial
border of the calcaneum at the head of the first
metatarsal joint. The subject’s active range of
movement was normal in both his ankle and foot
joints. Passive dorsiflexion of the toes aggravated
the pain bilaterally. The bilateral heel pain was
also aggravated by standing on tiptoe standing.
A diagnosis of bilateral plantar fasciitis was
made.
The present author explained the principles of
acupuncture, the aims of the intervention and
the treatment plan to the subject, who then
signed a consent form. The treatment had two
purposes: (1) to reduce pain; and (2) to improve
functional capacity immediately after rest.
Treatment plan
The present author decided to employ the traditional acupuncture points used by Tillu & Gupta
(1998) during all treatment sessions, i.e. Taixi
C. C. Santha
[Kidney (KI) 3], Kunlun [Bladder (BL) 60] and
Sanyinjiao [Spleen (SP6)]. The Taichong [Liver
(LV3)] and Hegu [Large Intestine (LI) 4] pain
modulation (Four Gates) points, and local
Ah-Shi points for trigger point release were also
to be considered if warranted by the subject’s condition. All points were to be needled
bilaterally.
Clinical and physiological reasoning
All findings gathered from the subjective and
objective examinations were analysed, and after
taking account the relevant literature, the
following mechanisms were proposed.
The present subject’s major complaint was
bilateral heel pain on weight-bearing after a
period of rest, on walking on hard surfaces and
on stretching the plantar fascia. Analysis of this
problem led to the conclusion that peripheral
stretch and mechanical nociceptive pain mechanisms were the dominant problems in this
patient.
Nociceptive pain relies on an intact nervous
system because it results from nociceptor stimulation of the peripheral tissues. This can be via
mechanical, inflammatory or ischaemic mechanisms, and is usually associated with acute pain
and/or tissue injury. Peripheral nerve endings
and dorsal horn neurons in the spinal cord
become sensitized, but these processes are selflimiting and resolve once the tissue has healed
(Woolf & Costigan 1999). A predictable
stimulus–response relationship exists between
the provocation and experience of pain (Gifford
& Butler 1997). Nociceptive pain has been
demonstrated to respond positively to acupuncture treatment (Lundeberg et al. 1988).
Acupuncture for pain control is becoming
more widely accepted (Lundeberg & Ekholm
2001). Needling is a painful stimulus that releases
histamine and calcitonin gene-related peptide,
causing a local inflammatory reaction (Wu et al.
1999). Small-diameter afferent -fibres are also
stimulated, causing the release of -endorphin
and -encephalin in the dorsal horn of the
affected segment of the spinal cord. These substances block the transmission of small-diameter
C-fibre-mediated nociceptive input to the
ascending sensory columns through the mechanism of pain gating (Melzack & Wall 1996), thus
modulating the experience of pain.
De Qi, and the classic description of a
‘‘heavy’’, ‘‘numb’’ or ‘‘sore’’ sensation, may be
mediated by the activation of the small-diameter
C-fibres (Wang et al. 1985). The De Qi sensation
appears to be essential for producing analgesia
via the endogenous opiate system (Lundeberg
1998). Ascending C-fibre-mediated nociceptive
input stimulates the peri-aqueductal grey matter,
hypothalamus and pituitary gland, which, in turn,
trigger the release of serotonin, norepinephrine,
histamine, bradykinin, endorphin, dopamine and
adrenocorticotrophic hormone (Chen & Han
1992). Endorphin-like substances also appear in
the cerebrospinal fluid after needling (Shen
2001). Adrenocorticotrophic hormone passes to
the kidneys and stimulates the release of cortisol
(Chen & Han 1992), which is a powerful
systemic anti-inflammatory hormone.
The subject had active bilateral myofascial
trigger points in his plantar fascia. Trigger points
are irritable areas that lie within the taut band of
muscle fibre and palpation of these regions can
cause a twist response (Simons et al. 1999). The
underlying mechanism is thought to be a motor
end-plate or sarcomere membrane dysfunction
(Simons et al. 1999). Active myofascial trigger
points are believed to be sites where nociceptors,
such as polymodal-type receptors, have become
sensitized (Kawakita 1993). Needling appears to
deactivate the trigger points either by pain gate
inhibition of C-fibre nociceptive outflow from
the muscle (Baldry 2002) or by the more direct
effect of deeper needling on the dysfunctional
motor end-plates (Simons et al. 1999). Deep
needling has been found to be more effective
than superficial acupuncture (Ceccherelli et al.
2002). Precise needling of active trigger points
provokes a brief contraction of muscle fibres.
This local twitch response should be elicited for
successful therapy, but it may be painful and
post-treatment soreness is a frequent occurrence
(Simons et al. 1999). Acupuncture or dry needling of a myofascial trigger point appears to
provide immediate relief from any pain that is
related to that point (Irnich et al. 2002; Itoh et al.
2004). Trigger point needling may simply have
been a stronger overall stimulus in this study.
Tillu & Gupta (1998) demonstrated that acupuncture is an effective treatment for subjects with chronic heel pain caused by plantar
fasciitis, and that the addition of trigger point
69
Table 1. Acupuncture points selected during the treatment programme: (BL) Bladder; (SP) Spleen; (KI) Kidney; (LI) Large Intestine; and
(LV) Liver
Acupuncture
point
Description
Rationale
BL60
Kunlun
Confluent point for the yang heel vessel;
clears fire, heat and wind;
indicated for pain in the foot, heel, ankle, back and neck
SP6
Sanyinjiao
(Three Yin Intersection)
Tonifies the Liver, Spleen and Kidney;
tonifies Blood and Qi
KI3
Taixi
(Greater Mountain Stream)
Shu stream, Earth point, Yuan source point;
connects with the spleen meridian;
tonifies Kidney yin and yang;
clears heat and dispels cold
LI4
Hegu
(Connecting Valley)
Yuan source point;
analgesic point promoting Qi, dispelling external pathogens and heat
LV3
Taichong
(Greater Surge)
Shu stream point, earth point;
clears fire and heat;
invigorates Blood
Plantar fascia
trigger point
Local Ah-Shi point
Deactivation of dysfunctional motor end-plates
and muscle cell membrane complexes
acupuncture in poor or non-responders can be
useful. The above authors used the Taixi (KI3),
Kunlun (BL60) and Sanyinjiao (SP6) traditional
acupuncture points, and local Ah-Shi points for
trigger point release. Perez-Millan & Foster
(2001) used KI1, KI3, KI6, BL60, BL67, Gall
Bladder 44 and local Ah-Shi points in a study
of low-frequency electroacupunture in the
management of refractory plantar fasciitis.
The rationale for the acupuncture points
selected during the treatment programme is
shown in Table 1.
Acupuncture points used during each
session
Session 1 (day 1). The following acupuncture
points were needled bilaterally: Taixi (KI3),
Kunlun (BL60) and Sanyinjiao (SP6); Taichong
(LR3) and Hegu (LI4); and local Ah-Shi points
in the plantar regions at the level of the anteromedial to calcaneal tuberosity and posterior to
the head of the first metatarsal joint.
Session 2 (day 4). The points treated in session 1
were needled bilaterally again.
Session 3 (day 8). Taixi (KI3), Kunlun (BL60) and
Sanyinjiao (SP6) were needled bilaterally.
70
Session 4 (day 11). Taixi (KI3), Kunlun (BL60)
and Sanyinjiao (SP6) were needled bilaterally.
Local Ah-Shi points in the right plantar regions
were needled at the level of the right anteromedial to calcaneal tuberosity.
Sessions 5–8 (days 18, 25, 32 and 39). Taixi (KI3),
Kunlun (BL60) and Sanyinjiao (SP6) were
needled bilaterally.
Strong De Qi sensations were achieved at all
points in every acupuncture treatment. The
needles were left in place for 20 min, and were
manually stimulated for about 5 s every 5 min
and just before removal. For trigger point
release, needles were inserted into the palpated
point, advanced to the targeted area and a local
twitch response was obtained using the ‘‘sparrow
pecking’’ technique. After the local twitch
response was elicited or a reasonable attempt had
been made, the needle was retained in situ for
another 10 min.
The subject reported severe pain on the insertion of the needle into the trigger points, especially one on the anteromedial aspect of the level
of the calcaneal tuberosity. However, after the
needle was positioned in the target area, he felt
only the painless needle sensation. No other side
effects were reported by the subject during or
after the treatment sessions.
C. C. Santha
Table 2. Acupuncture points needled during treatment and Visual Analogue Scale scores before and after each session: (KI) Kidney; (SP)
Spleen; (BL) Bladder; (LV) Liver; and (LI) Large Intestine
Outcome (VAS score)
Acupuncture point (bilateral)
Session
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Day
Day
Day
Day
Day
Day
Day
Day
1
4
8
11
18
25
32
39
Trigger point release
Right
Left
KI3
SP6
BL60
LV3
LI4
Right
Left
Before
After
Before
After
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
–
–
–
–
–
–
+
+
–
–
–
–
–
–
+
+
–
+
–
–
–
–
+
+
–
–
–
–
–
–
8
5
4
6
3
2
2
2
2
2
1
2
1
2
1
1
7
3
3
3
3
2
1
2
2
1
1
1
1
2
1
1
The Taixi (KI3), Kunlun (BL60) and
Sanyinjiao (SP6)] traditional acupuncture points
were stimulated bilaterally during all eight treatment sessions. The trigger point release and pain
gate points were only stimulated when indicated.
The Taichong (LV3) and Hegu (LI4) pain
modulation (Four Gates) points were only used
bilaterally during the first two treatment sessions.
Trigger point release was only indicated during first, second and fourth treatment sessions.
Bilateral passive plantar fascia stretch was given
at the end of each treatment session.
Table 2 shows the acupoints that were needled
during the treatment, and the VAS scores that
were recorded before and after each session.
Outcome measurements and results
Two scales were used to measure the level and
severity of the subject’s heel pain. The level of
pain was assessed before and after each treatment session with a 10-point linear VAS: (1) no
pain; and (10) severe pain. A Foot Function
Index (FFI) questionnaire assessed how the pain
affected different functional activities. The FFI
questionnaire consisted of 11 questions regarding the pain or difficulty/decrease in activity
caused by the foot problem. Pain severity during
each functional activity was assessed using a
10-point linear scale: (1) no pain or difficulty
during the activity; and (10) severe pain or
inability to perform the activity. This was
measured only at the start and the end of
treatment programme. The FFI questionnaire
was constructed on the basis of clinical experience and has not been validated.
The subject reported a marked bilateral
improvement in his pain scores immediately after
the first treatment session. He presented to the
second through fifth treatment sessions with
gradual reductions in his pain scores compared
to the previous pre-treatment scores. Interestingly, nil or very minimal pain scores were
reported immediately after every treatment session. After the fifth session and up to the eighth
and final session, the subject reported very minimal to nil pain scores before and after each
treatment. He added that the minimal pain that
he experienced was usually intermittent and
lasted for only few minutes or steps. The subject
also reported a marked improvement in his FFI
scores at the end of the treatment programme:
by this stage, his pain and functional capacity had
improved by approximately 90%.
Table 3 shows the subject’s pre- and posttreatment FFI scores for both heels. Figures 1
and 2 show his right and left heel VAS scores
before and after each treatment session.
Limitations
A major limitation of the present study is that the
outcomes were only measured with subjective
data provided by the subject. Furthermore, the
author did not analyse why every pre-session
VAS scores was an improvement on the previous
post-session score, and also failed to document a
complete relief in pain rates at the end of the
study. The duration of the research was not
sufficient to determine the long-term results of
the treatment. Finally, the effects of the treatment
on the subject’s analgesic drug requirement and
mobility were neither considered nor measured.
71
Table 3. Foot Function Index scores before and after treatment
Right
Left
Foot pain questions
Before
After
Before
After
(1) How severe is your foot pain:
(a) in the morning upon taking your first step?
(b) when walking?
(c) when standing?
(d) at the end of the day?
(e) at its worst?
9
6
3
2
9
2
1
1
1
3
7
4
2
1
7
1
1
1
1
2
(2) Describe how much difficulty you have:
(a) when walking in the house?
(b) when walking outside?
(c) when climbing stairs?
(d) when descending stairs?
(e) when standing tiptoe?
(f) when getting up from a chair?
5
5
5
6
8
6
1
1
1
2
2
2
3
3
2
4
7
4
1
1
1
1
2
1
Figure 1. Visual Analogue Scale (VAS) scores for right heel pain before () and after () each treatment session.
Discussion
The present study attempted to analyse the
effectiveness of acupuncture treatment with trigger point release on bilateral chronic heel pain
caused by plantar fasciitis. The subject had previously exhibited a poor response to conservative
physiotherapy (e.g. ultrasound) and shoe support
before receiving acupuncture. After assessing the
causes of the disorder, the underlying pain
mechanisms and the contraindications, the
present author proposed a course of acupuncture.
The subject exhibited an immediate improvement in pain and function after receiving his first
treatment, and continued to make a steady
72
improvement over all the following acupuncture
treatment sessions. He was treated using traditional acupoints [Taixi (KI3), Kunlun (BL60)
and Sanyinjiao (SP6)], trigger point release and
the Four Gates (LI4 and LV3). Manual acupuncture at LI4 and LV3 in healthy volunteers has
been shown to deactivate specific areas of the
brain, i.e. the prefrontal cortex and the anterior
cingulate cortex, both of which play a part in
pain modulation (Yan et al. 2005). Tillu & Gupta
(1998) demonstrated that acupuncture treatment
is effective in treating individuals with chronic
heel pain caused by plantar fasciitis, and that the
addition of trigger point acupuncture in poor or
non-responders can be useful. The above
C. C. Santha
Figure 2. Visual Analogue Scale (VAS) scores for left heel pain before () and after () each treatment session.
authors used the Taixi (KI3), Kunlun (BL60)
and Sanyinjiao (SP6) traditional acupuncture
points, and local Ah-Shi points for trigger point
release. Acupuncture or dry needling of a myofascial trigger point is believed to provide immediate relief from pain that is related to that point
(Irnich et al. 2002; Itoh et al. 2004).
The present author concludes that acupuncture treatment is a very effective treatment for
chronic heel pain caused by plantar fasciitis.
Acknowledgement
I would like to express my sincere thanks to
Jennie Longbottom, my first acupuncture
teacher; this study could never have been conducted without her instruction. I am also grateful
to the subject for allowing me to treat him.
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(1991) True acupuncture vs. sham acupuncture and
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74
236–240.
Chickandarvin Chellaswamy Santha graduated from the
RVS College of Physiotherapy in Coimbatore, India, in
2000. From 2000 to 2007, he worked at the
Dhanvantari Critical Care Centre and City Hospital in
Erode, India, where he specialized in critical care and
had a lead role in student education. In May 2007,
Chickandarvin moved to Jamaica, where he worked at
the St Ann’s Bay Hospital, St Ann’s Bay, mainly in the
musculoskeletal outpatients department. In November
2007, he moved to Grand Cayman and currently works
for the Cayman Island Health Services Authority
(HSA) at the George Town Hospital, George Town.
Chickandarvin completed the AACP Foundation Acupuncture Course in April 2008. He has developed a
particular interest in pain management and has become a
part of the HSA Pain Management Team.
CASE REPORT
Effects of acupuncture as an adjunct to standard physiotherapy
on pain levels and function in osteoarthritis of the knee
K. C. Boyle
Physiotherapy Department, King Edward VII Hospital, Windsor, UK.
Abstract
This case report examines the effects of acupuncture as an adjunct to physiotherapy for pain
reduction and return to function in a subject with severe osteoarthritis (OA) of the knee. A
54-year-old female patient with OA received five sessions of physiotherapy over a 6-week
period. These consisted of exercise and advice, and were followed by five sessions of
acupuncture with exercise and advice over a 3-week period. The subject reported that her
symptoms were unchanged after the initial 6 weeks of standard physiotherapy. After combined
acupuncture and physiotherapy treatment, she reported an 80% improvement in terms of both
pain reduction and return to function. The addition of acupuncture to standard physiotherapy
consisting of advice and exercise helps to relieve pain and increase function in osteoarthritic
knee pain, providing further evidence to promote the use of acupuncture as an adjunct to
conventional treatment.
Keywords: acupuncture, knee, osteoarthritis, physiotherapy, pain relief.
Introduction
Osteoarthritis (OA) is the most common cause
of disability in the older population (Peat et al.
2001). Present estimates suggest that as many as
40% of people in the UK aged over 65 years
have OA (Dawson et al. 2004). As the population
becomes older and levels of obesity rise, this
figure is certain to rise, and the resultant healthcare and associated costs could lead to an
increased strain on society. The main aims of
treatment for these patients are to reduce pain
and disability (White 2006). Currently, analgesia
and anti-inflammatory treatment for pain can
be limited by unwanted side effects (Tukmachi
et al. 2004). As a result, increasing numbers
of patients are investigating complementary
therapies (Berman et al. 2004).
To date, there have been numerous randomized control trials investigating the effects of
Correspondence: Kevin C. Boyle, Physiotherapy Department, North Cambridgeshire Hospital, The Park,
Wisbech, Cambridgeshire PE13 3AB, UK (e-mail:
[email protected]).
acupuncture on pain and function in OA of the
knee (Table 1). Of these, one assessed the effects
of acupuncture on osteoarthritic pain alone
(Foster et al. 2007), and six assessed the effects of
acupuncture on osteoarthritic pain and function
(Berman et al. 2004; Tukmachi et al. 2004; Vas
et al. 2004; Witt et al. 2005; Scharf et al. 2006;
Williamson et al. 2007). Berman et al. (2004)
reported significant improvements in function at
8 weeks (P=0.01) and 26 weeks (P=0.01) compared to sham, but found no reduction in pain
scores (P=0.18) until follow-up at 26-weeks
(P=0.003). These results were further supported
by Tukmachi et al. (2004), Vas et al. (2004) and
Witt et al. (2005), who reported that acupuncture
significantly decreased Visual Analogue Scale
(VAS) pain scores (P=0.012), had positive
effects on stiffness and function (P<0.0001)
(Witt et al. 2005), and increased physical capabilities (P=0.021) and psychological functioning
(P=0.046) (Vas et al. 2004).
Contrasting results have been reported in
recent studies (Scharf et al. 2006; Foster et al.
2007; Williamson et al. 2007), in which subjects
75
Acupuncture and osteoarthritis of the knee
Table 1. Acupuncture points used in the literature reviewed: (GB) Gall Bladder; (SP) Spleen; (ST) Stomach; (BL) Bladder; (KI) Kidney;
(LI) Large Intestine; (LV) Liver; (Ex-LE5) Xiyan; and (TH) Triple Heater
Reference
Points used
Comments
Berman et al. (2004)
Local: GB34, SP9, ST35, ST36, Xiyan
Distal: BL60, GB39, SP6, KI3
Six from local, two from distal
Tukmachi et al. (2004)
LI4, SP10, Xiyan, SP9, GB34, ST36, LV3, BL40, BL57
Vas et al. (2004)
Local: GB34, SP9, Ex-LE5, ST36
Distal: KI3, SP6, LI4, ST40
Witt et al. (2005)
Local: ST34, ST35, ST36, SP9, SP10, BL40, KI10, GB33, GB34, Six from local, two from distal
LV3, Heding, Xiyan
Distal: SP4, SP5, SP6, ST6, BL20, BL57, BL58, BL60, BL62, KI3
Scharf et al. (2006)
Local: ST34, ST36, Xiyan, SP9, SP10, GB34
Distal: from one to four Ah-Shi points
According to traditional Chinese medicine
Foster et al. (2007)
Local: SP9, SP10, ST34, ST35, ST36, Xiyan, GB34
Distal: LI4, TH5, SP6, LV3, ST44, KI3, BL60
Between six and 10 points used
Williamson et al. (2007) Local: LV3, GB34, ST35, ST36, SP9, SP10, Xiyan
who received acupuncture demonstrated
improvements in pain and function, as measured
by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [53.1%
(Scharf et al. 2006); P<0.0001 at 2 weeks and
P=0.004 at 6 weeks (Foster et al. 2007)] and the
Oxford Knee Score (OKS) (P=0.0497 at 7-week
follow-up; Williamson et al. 2007). However, the
subjects who received sham acupuncture in these
studies also showed significant improvements in
their WOMAC scores [51.0% (Scharf et al. 2006);
P<0.0001 at 2 and 6 weeks (Foster et al. 2007)].
Furthermore, Williamson et al. (2007) reported
that, while the initial improvements in OKS
scores seen between the groups were still present
at 12 weeks, these were no longer significant.
Two systematic reviews of the effects of acupuncture on pain and function in OA of the knee
have been conducted (Ezzo et al. 2001; White
et al. 2006). Both concluded that acupuncture
was an efficacious form of treatment. Although
Ezzo et al. (2001) only found limited evidence
that acupuncture subjects gain more benefit from
treatment than waiting list controls, they
reported strong evidence that real acupuncture
for pain relief was more effective than sham.
However, there was inconclusive evidence that
real acupuncture was more effective than sham
acupuncture for improvement in function. More
recently, Manheimer et al. (2007) carried out a
meta-analysis of the effects of acupuncture for
knee OA and concluded that the short-term
76
benefits of sham-controlled trials of acupuncture
treatment for OA of the knee were clinically
irrelevant. The above authors conceded that
waiting-list-controlled trials have suggested that
acupuncture has clinically relevant benefits, but
they proposed that some of these may be caused
by placebo or expectation effects.
It can be argued that the current climate in the
National Health Service (NHS) will not allow the
number or frequency of acupuncture sessions
that have been used in much of the recent
research. Therefore, the present case study
examines the effects of a reduced number of
acupuncture sessions for decreasing pain levels
and improving function in a patient with OA of
the knee.
Case report
Subjective history
In July 2006, Mrs T., a 54-year-old woman,
developed lateral right knee pain approximately
2 h after playing a game of badminton. She
reported that her pain was a constant dull ache
that varied in intensity. The subject rated it as
5–6/10 at its worst and 3/10 at its best on a
VAS. Aggravating factors included standing for
10–15 min, walking for more than 0.8 km, climbing stairs with her right leg leading and extending
her knees after squatting. Her symptoms were
eased by rest and painkillers.
K. C. Boyle
Mrs T. complained of knee stiffness on waking, which decreased during the day and then
increased by evening. She also suffered from
sleep disturbances, especially if she had been
walking a lot throughout the day.
The subject was referred to physiotherapy
between August and September 2007. Her treatment consisted of exercises and advice, but there
was no improvement in Mrs T.’s symptoms.
She had a magnetic resonance imaging scan in
September 2007, and this highlighted a degenerative cartilage tear and significant joint damage
consistent with OA of the right knee. Mrs T.
privately underwent an arthroscopy that confirmed the diagnosis of knee OA. She was then
referred to a rheumatologist and put on medication for her arthritis. The subject received between
eight and 10 further private sessions of physiotherapy, which consisted of exercises, continuous
passive motion, manipulation and massage. Mrs T.
reported some benefit after this treatment, but
was unable to continue private treatment because
of the cost. Therefore, she was referred for NHS
physiotherapy by her general practitioner.
The subject had visible signs of swelling of
the right knee and pain on palpation of the
anterolateral joint line.
Mrs T. lacked 5 of active knee extension and
had only 95 of active knee flexion. She had a
0–100 passive range of motion (ROM), but
pain limited both passive and active ROM.
The subject lacked 10 of extension on an
active straight leg raise (SLR).
Nothing abnormal was detected on ligament
tests (i.e. the valgus/varus and anterior/posterior
drawer tests). The McMurray Test was too painful for the subject to perform. Muscle length
tests demonstrated tight hamstrings and
gastrocnemius/soleus muscles on her right leg.
Mrs T. exhibited decreased proprioception on her
right and decreased muscle strength in right hip
abduction/extension (4/5 on the Oxford Scale).
Clinical impression
The assessment showed that Mrs T. had
decreased function as a result of pain, decreased
muscle strength in her right knee and hip, and
alterations in muscle length and proprioception
secondary to OA of the knee.
The treatment goals that were agreed with the
subject were: (1) to decrease knee pain caused by
aggravating factors by 50%; (2) to increase the
muscle strength of hip abduction/extension and
knee extension to 5/5, and achieve a full SLR;
(3) to return to walking, aiming for 3.2–6.4 km;
and (4) to sleep through the night.
Clinical reasoning for acupuncture
In agreement with current guidelines (NICE
2008), standard physiotherapy for this subject
consisted of ROM and strengthening exercises,
proprioceptive retraining, and advice regarding
pacing, diet and pain control. This was the
format of Mrs T.’s treatment both before and
during the acupuncture intervention. After 16
physiotherapy sessions based on this format (10
private and then six with the NHS), her symptoms showed no significant improvement. The
subject reported that her main problem was the
pain, which was interfering with her ability to
perform both activities of daily living and the
physiotherapy exercises. Therefore, it was
hypothesized that, if Mrs T.’s pain could be
controlled with acupuncture, then she would be
able to exercise more, and become stronger and
fitter, which could lead to decreased pain levels
and increased function (Table 2).
Outcome measurements and results
Subjectively, the subject felt that she was 80%
better by the end of her course of exercise,
education and acupuncture. Her pain levels
decreased from 3/10 to 1/10 at best and from
6/10 to 4/10 at worst on the VAS. Objectively,
Mrs T.’s ROM and muscle strength improved.
At the start of treatment, her ROM was –5 to
95 , with a 10 extension lag on her SLR. By the
end of treatment, her ROM had increased to
0–100 and she could perform a normal SLR.
Functionally, the distance walked by the subject
increased. At the start of treatment, she was able
to walk for 0.8 km, and by the final session was
walking 5.6 km comfortably. Mrs T.’s sleep pattern also improved: at the start of treatment, she
was waking between three and four times during
the night because of her pain, but by the final
session, she could sleep through the night without pain.
77
Table 2. Acupuncture point rationale: (ST) Stomach; (GB) Gall Bladder; (BL) Bladder; (R) needles rotated in situ; (ROM) range of motion
(right knee); (SLR) straight leg raise; and (EL) extension lag
Points used
3 March 2008
ST34, ST35, ST36,
GB34, BL62
11 March 2008
ST34, ST35, ST36,
GB34, BL62,
Heding
14 March 2008
ST34, ST35, ST36,
GB34, BL62,
Heding
18 March 2008
ST34, ST35, ST36,
GB34, BL62,
Heding
20 March 2008
ST34, ST35, ST36,
GB34, BL62,
Heding
Needle
size
(mm)
Time
in situ
(min)
De Qi
25
Yes
10
(R=1)
25
Yes
25
Adverse
effects
Outcome
Rationale
None
ROM: 0–105 SLR: –10 EL
ST34–36, BL62: knee pain
(Hecker et al. 2001; ALIED 2006)
GB34 (He-Sea point) arthritis
and swelling of the knee
(Hecker et al. 2001; ALIED 2006)
15
(R=2)
None
ROM: 0–110 SLR: –5 EL
Heding: osteoarthritic knee pain
(ALIED 2006)
Yes
20
(R=2)
None
ROM: 0–110 SLR: full
As above
25
Yes
25
(R=3)
None
As above
25
Yes
30
(R=3)
None
As above
Discussion
Overall, the present case report demonstrates
that acupuncture as an adjunct to physiotherapy
may lead to decreases in pain levels and an
increase in function in patients with OA of the
knee.
One of the objections to the use of acupuncture for the treatment of pain is the large number
of sessions that are required over a relatively
short period of time. This approach can be
impractical in the current climate within the
NHS. However, this case report provides preliminary evidence that, in addition to standard
physiotherapy, education and advice, a reduced
number of acupuncture sessions (i.e. five sessions over 3 weeks) can decrease pain and
improve function in a patient with knee OA.
The present results agree with those of previous studies (Berman et al. 2004; Tukmachi et al.
2004; Vas et al. 2004; Witt et al. 2005), but
contrast with those from later studies that also
utilized fewer sessions of acupuncture (Scharf
et al. 2006; Foster et al. 2007; Williamson et al.
2007) and reported that acupuncture is no more
effective than sham acupuncture or physio78
therapy at decreasing pain in patients with OA.
One possible explanation for these contrasting
results could be the kinds of sham acupuncture
used as controls (Scharf et al. 2006; Foster et al.
2007; Williamson et al. 2007). Scharf et al. (2006)
used minimal-depth needling without stimulation
at non-acupoints and Foster et al. (2007) used
non-penetrating acupuncture with blunt-tipped
needles. The shafts of these needles collapse into
the handles when pressed on the skin, creating
an illusion of insertion. It could be argued that
the insertion of the needle into or onto the skin
in the sham groups in these studies would be
enough to activate -fibres (a pinprick sensation following minimal depth insertion) and
-fibres (a touch following placement of the
needle on the skin), and then the mechanisms
previously discussed above could affect pain
intensity via the pain gate.
While the studies by Scharf et al. (2006) and
Foster et al. (2007) compared the results of real
and sham acupuncture to a control group,
Williamson et al. (2007) compared acupuncture
to exercise and reported no significant differences at a 12-week follow-up. However, it has
K. C. Boyle
been shown that exercise alone can decrease pain
and improve function in patients with OA
(Røgind et al. 1998). The present case study
showed an improvement in pain and function
when acupuncture was administered with exercise. Therefore, in accordance with current
guidelines (NICE 2008), it could be argued that
acupuncture might be effective as part of a
multifaceted approach to the management of
osteoarthritic pain.
It could also be contended that effective pain
relief from acupuncture can be attributed to the
placebo effect or compliance, where patients
improve merely because they think that they are
receiving an intervention that will help them.
Using functional imaging, a decrease in pain
rating during placebo coincided with decreases in
brain activity in areas thought to process pain, i.e.
the insular cortex, anterior cingulate cortex
(ACC) and thalamus (Wager et al. 2004; Dhond
et al. 2007). These areas of the brain have also
been shown to be affected during needling (Wu
et al. 2002; Zhang et al. 2004).
Acupuncture is believed to control pain via the
pain gate control theory (Melzack & Wall 1996).
Bowsher (1990) suggested that needling relieves
pain by closing the pain gate in two ways: (1) by
pulling it closed from the outside; and (2) by
slamming it shut from the inside. In the former
case, acupuncture is thought to activate
-(group 11 and 111) nerves (Han & Terenius
1982; Bowsher 1990), and - (Wang et al.
1985) and C-fibres (Bowsher 1991). These
nerves synapse in the dorsal horn of the spinal
cord, causing the release of analgesic substances
such as encephalins from inhibitory interneurons
that inhibit further nociceptive impulses, thereby
decreasing the patient’s pain. In the latter case,
the -fibres also synapse with Waldeyer cells in
lamina 1 of the dorsal horn. These are connected
to the somatosensory cortex (via the anterolateral funiculus and ventrobasal thalamus),
where the patient would perceive the pinprick
sensation of the needle. In addition, collaterals
are transmitted to the peri-aqueductal grey
(PAG) matter (Price et al. 1978). The PAG sends
impulses to the nucleus raphe magnus in the
lower brainstem reticular formation. This activates descending serotoninergic fibres in the
dorsolateral funiculus of the spinal cord to the
superficial dorsal horn (Basbaum et al. 1978),
which leads to the release of serotonin and
noradrenalin (Han & Terenius 1982) to further
decrease pain via the pain gate.
A search of the available clinical evidence
regarding the physiological effects of acupuncture at the acupoints used in the present case
study highlights research using functional imaging into Gall Bladder (GB) 34 (Wu et al. 2002;
Zhang et al. 2004) and Stomach (ST) 36 (Wu
et al. 1999; Biella et al. 2001; Zhang et al. 2004;
Hui et al. 2005; Napadow et al. 2005), but none
for ST34, ST35, Bladder (BL) 62 or Heding.
Activation of GB34, both alone (Wu et al.
2002) and in combination with BL57 (Zhang
et al. 2004), has been shown to activate lateral
structures within the pain matrix involved in the
sensory processing of pain, specifically the primary somatosensory cortex (SI) (Wu et al. 2002;
Zhang et al. 2004) and secondary somatosensory
(SII)/insular cortex (Zhang et al. 2004), and to
deactivate medial structures of the pain matrix,
such as the ACC (Wu et al. 2002), amygdala (Wu
et al. 2002; Zhang et al. 2004) and hippocampus
(Wu et al. 2002).
Similar results have been reported for stimulation of ST36 alone (Hui et al. 2005; Napadow
et al. 2005), and in combination with Large
Intestine (LI) 4 (Wu et al. 1999), Spleen 6
(Zhang et al. 2004) or Lung 5 (Biella et al. 2001).
The sensory structures of the lateral pain matrix
are activated by this approach, specifically the SI
and SII (Zhang et al. 2004), and the insular
cortex (Biella et al. 2001; Zhang et al. 2004;
Napadow et al. 2005), and the medial and limbic
structures are deactivated; for example, the amygdala (Wu et al. 1999; Zhang et al. 2004; Hui et al.
2005; Napadow et al. 2005), hippocampus
(Zhang et al. 2004; Hui et al. 2005), hypothalamus
(Hui et al. 2005), ACC (Hui et al. 2005) and
the orbital/pre-frontal cortex (Hui et al. 2005;
Napadow et al. 2005). These functional imaging
studies have shown that, although stimulation of
the GB34 and ST36 acupoints used in the
present case report activate the structures within
the pain matrix, these structures are the lateral
sensory structures (the SI, SII and insular cortex), which are involved in processing the sensory discriminative aspects of pain (e.g. its
location, duration and intensity) (Rainville et al.
1999; Ploner et al. 1999; Kulkarni et al. 2005).
However, crucially, deactivation was seen in the
79
medial/limbic pain structures (i.e. the amygdala,
ACC and hippocampus), which are involved in
processing the emotional salience of the
stimulus/pain (Rainville et al. 1999; Hofbauer
et al. 2001; Kulkarni et al. 2005; Vogt 2005; Kugel
et al. 2008).This implies that acupuncture at these
points works by reducing the emotional aspect of
the pain (i.e. by enhancing coping strategies).
After reflecting on the methodology used in
the present case study, the author would have
added two further distal points, LI4 and Liver
(LV) 3. In traditional Chinese medicine, these
are known as the Four Gates and are credited
with a powerful analgesic effect. Studies have
also shown that stimulation of LI4 and LIV3
deactivates areas of the brain that are involved in
pain modulation (Yan et al. 2005).
Finally, it could be contended that the objective improvements described in the present case
report are minor; however, this could not be
argued with regard to the subjective improvements (80%). In light of this and the evidence
that acupuncture modulates the pain matrix
involved in the emotional aspect of pain, future
studies involving unpleasantness scales as outcome measures in addition to VAS scores would
be interesting. The author will certainly consider
incorporating such scales and the use of acupuncture as an adjunct to standard physiotherapy
in his future practice.
However, there are limitations to the present
study. First, it is a single case study, and therefore, it is difficult to extrapolate the results to the
general population of patients with OA of the
knee (Hicks 2002). Furthermore, the subject had
already undergone six sessions of strengthening
and ROM exercises before acupuncture was
implemented. Therefore, it could be argued that
the improvements reported were brought about
by increases in strength over time rather than the
addition of acupuncture. However, this argument can be countered by the fact that, prior to
starting acupuncture, Mrs T. had already had
6 months of physiotherapy based on increasing strength, ROM and proprioception, and
therefore, any improvement should have been
manifested by the time she started acupuncture.
The second limitation is that the acupuncture
protocol described in the present case report was
not validated; however, numerous high-quality
studies have demonstrated positive results in
80
pain and functional levels in patients with
osteoarthritic knees using similar points.
Although the present author acknowledges the
above limitations, it is his opinion that case
studies such as this, along with clinical commentaries and scientific reviews, can only
further promote the importance of acupuncture as an excellent supplement to conventional
treatment.
Acknowledgements
I would like to thank the subject for participating
in this case study. I am also grateful to Jennie
Longbottom for the advice that she gave me
during my acupuncture training and Dr Yvonne
Boyle for her help with manuscript preparation.
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Kevin Boyle graduated in 2005 with a BSc (Hons) in
Physiotherapy from Leeds Metropolitan University,
Leeds, UK. He spent 21 months as a rotational Band 5
physiotherapist at Bradford Teaching Hospitals NHS
Foundation Trust, Bradford, UK, where he gained
wide-ranging experience in both inpatient and outpatient
settings. Kevin specialized in musculoskeletal outpatients
81
in May 2008, and worked for Berkshire East Primary
Care Trust, Windsor, UK, first as a Band 5 then as a
Band 6. He is now a Band 6 working with musculo-
82
skeletal outpatients in North Cambridgeshire Hospital,
Wisbech, Cambridgeshire, UK.
CASE REPORT
Efficacy of acupuncture as an adjunctive physiotherapy
treatment in knee arthroscopy
R. O’Neil
Crystal Palace Physiotherapy and Sports Injury Clinic, London, UK
Abstract
A 31-year-old woman presented with subacute knee pain and swelling, decreased range of
motion (ROM), and a marked limp after an arthroscopic partial meniscectomy of her left knee.
Treatment consisted of traditional Chinese acupuncture to address her inflammatory response
(i.e. pain and swelling), and a series of closed lower limb exercises to enhance her leg strength
and functional mobility. Cryotherapy, compression and elevation were also utilized as
adjunctive treatments in order to maximize the subject’s recovery. The outcome measures
included a Visual Analogue Scale and measurements of knee ROM. Significant reductions in
pain and swelling, a marked improvement in ROM, and a modest improvement in overall
function were achieved by the final examination.
Keywords: acupuncture, arthroscopy, functional mobility, inflammatory response.
Introduction
Meniscal injury is most commonly caused by a
rotational force when the foot is fixed to the
ground. Football players frequently present with
this condition. The severity of symptoms varies
considerably depending on the extent of the tear,
but patients with more severe meniscal injuries
can typically exhibit pain, restriction of range of
motion (ROM) and intermittent locking. On
examination, the most important signs of a
meniscal cartilage tear are joint line tenderness
and the presence of a joint effusion. Additionally,
the McMurray test is often positive when a torn
flap of cartilage is impinged in the joint, causing
a clunk that can be heard or felt (Brukner &
Khan 1995).
Meniscal tears can be managed either conservatively or, in more severe cases, operatively.
Conforming to evidence-based practice, the principles of conservative management are the same
as those following partial meniscectomy, and
include: compression, elevation, cryotherapy,
Correspondence: Robert O’Neil, Crystal Palace Physiotherapy and Sports Injury Clinic, Jubilee Stand, Crystal
Palace National Sports Centre, London SE19 2BB,
UK (e-mail: [email protected]).
anti-inflammatory agents, progression of weightbearing, range and strengthening exercises, and
proprioceptive retraining (Sackett et al. 1996;
Morrissey et al. 2006).
Case report
Subjective examination
A 31-year-old female presented to the present
author’s clinic 2 days after a rapid deceleration
and hyperextension injury. This had occurred
when her foot was fixed to the ground whilst she
was playing football. The subject was unable to
bear any weight on her left leg, there was marked
swelling at the knee, and she had limited flexion
and a feeling of locking. The McMurray test was
very painful and there was poor movement
patterning. Hamstring spasm prevented a definitive diagnosis of anterior cruciate ligament
(ACL) damage. The patient was immediately
referred to a consultant. Within days, she underwent magnetic resonance imaging (MRI) of her
left knee, which showed an ‘‘unhappy triad’’:
medial meniscal tear, medial collateral ligament
(MCL) sprain and ACL rupture with ACL pattern marrow contusion. Chondropathic changes
83
Acupuncture and knee arthroscopy
of the femoral condyle, a radial tear of the lateral
meniscus and joint effusion with some synovitis
were also reported.
It was decided that surgical intervention would
take place, but first, it was deemed necessary to
opt for conservative measures to decrease the
swelling and increase the knee flexion range to
100 to ensure a good post-operative result.
With a combination of local physiotherapeutic
modalities and home exercises, the necessary
pre-operative status was achieved and the subject
underwent an arthroscopy one month after the
injury. Interestingly, despite the MRI findings,
the surgeon found that most of the ACL and
medial meniscus were completely intact, and
therefore, ACL reconstruction was not indicated.
It should be noted that the patient had a radial
tear in the body of the lateral meniscus and an
inner rim bucket handle tear in the posterior
horn, both of which were trimmed.
The subject presented again to the author’s
clinic 4 days post-operatively, mobilizing on
elbow crutches with touch weight-bearing. She
reported a constant deep ache measuring 50/100
on a Visual Analogue Scale (VAS) that increased
to 80/100 with any weight-bearing or moving
from a prolonged position. Aggravating activities
included moving from sitting to standing,
extending the knee and climbing flights of stairs,
three of which she had at home. Her symptoms
were reduced with rest, ice, compression and
elevation (RICE), and non-steroidal antiinflammatory drugs. She reported no clicking,
crepitus, locking or giving way, but suffered from
intermittent swelling, especially with activity.
There were no yellow flags, but the subject felt
tired and drained, and was quite concerned about
the damage that she had sustained and her lack
of functional mobility. Thus, activities of daily
living (ADLs), which were adapted from the
International Knee Documentation Committee
guidelines (Anderson et al. 2006), were used as a
subjective functional outcome measure and were
also of great importance in giving this patient
achievable short-term goals.
The subject was apprehensive about bearing
weight with her left leg because of the pain in her
knee, and her gait was affected with a marked
limp and mild circumduction of the left leg.
84
There was swelling throughout the knee, puffiness over the porthole sites and moderate wasting of the left vastus medialis obliquus (VMO)
muscle in comparison to the right. Supine left
knee flexion was limited to 95 (compared to
130 on the right), being restricted by anterior
tightness and pain (VAS=60/100). Full knee
extension was reduced by 10 because of overpressure (VAS=70/100 VAS). A quadriceps lag
of approximately 5 caused by pain inhibition was
recorded (VAS=40/100).
Muscle strength testing of the left VMO produced a score of grade III– (fair minus).
Anterior cruciate ligament testing revealed a
definite end feel and there grade I laxity on MCL
stress testing. The McMurray test was avoided
because of the subject’s allodynic state.
There was tenderness on palpation over the
medial and especially the lateral joint lines and
porthole sites. Weight shift and proprioception
through the left leg was poor because of pain,
and squat in standing was limited to 60 as a
result of pain and weakness.
There was associated tightness in the hamstring and calf musculature on the left, and the
patient’s low back was developing a mild ache
because of her altered mobility pattern.
Clinical impression
The subject presented with a subacute knee
trauma that had initially been caused by a twisting injury and then more recently sensitized
by arthroscopic intervention. Although MRI
showed extensive damage, the arthroscopy
revealed that this was mostly concentrated in the
lateral meniscus and a partial meniscectomy was
deemed appropriate to resolve this. The main
problem was the woman’s current lack of functional mobility as a result of pain, swelling, and
reduced ROM and strength.
Physiological rationale for acupuncture
Acupuncture was selected in this case since it is
an effective and safe adjunctive treatment regime
(Berman et al. 1999), and because of its potential
inhibitory action on pain and swelling (Koo et al.
2002). Although some studies have found that
acupuncture analgesia has no additional effect
when given under anaesthesia to patients undergoing knee arthroscopy (Gupta et al. 1999), there
R. O’Neil
is a paucity of studies that address the effect of
acupuncture following partial knee meniscectomy. Arguably, the controlled study by
Usichenko et al. (2005), which found that auricular acupuncture (AA) decreased antiinflammatory consumption after arthroscopy in
the AA group, was more relevant to the present
case than that of Berman et al. (2004), who
found that acupuncture improved function and
pain relief in osteoarthritic (rather than arthroscoped!) knees. Tillu et al. (2002) also reported
improved knee function scores in subjects with
advanced osteoarthritis receiving acupuncture;
therefore, the present author postulated that
acupuncture could alleviate the symptoms of
pain and inflammation, and thus, bring about
an improvement in weight-bearing and overall
function.
Acupuncture analgesia and physiology
Acupuncture achieves analgesia by bringing
about a change in the perception of pain. The
insertion of fine needles into specific acupuncture points causes a phenomenon known as De
Qi in traditional Chinese medicine (TCM), a
combined deep feeling of soreness, heaviness or
pressure, numbness, and fullness or distension
(Stux et al. 2003). This restores the flow of Qi
through the meridians and harmonizes any
imbalance in the body that is causing ill health.
The question thus arises of how acupuncture
works according to the Western medical model.
Despite a great deal of excellent research
designed to answer this question, no simple
answers have been found to date. Nevertheless,
there are a variety of theories about the mechanism of acupuncture and most of these hypotheses are related to the use of this technique in
pain management.
Noxious stimuli, such as pain, activate nociceptors in the skin. Pain is mediated by several
different nociceptive fibres, i.e. the A- and
C-fibres, which have numerous different receptors on their surfaces that modulate their sensitivity to stimulation, including bradykinin,
prostaglandins, histamine and substance P. It is
thought that these nociceptors are stimulated by
De Qi. The fact that inflammation makes the
nociceptive fibres far more sensitive to stimulation (hyperalgesia) is specifically relevant to the
present case study.
The afferent fibres of these nociceptors terminate on projection neurons in the dorsal horn
of the spinal cord. Both A- and C-fibres branch
into two sections upon entering the dorsal horn.
Branches of these axons ascend and descend for
a few segments before synapsing primarily in the
superficial dorsal horn of the spinal cord, which
comprises the marginal zone (lamina I) and the
substantia gelatinosa (lamina III). Nociceptive
fibres then form connections with three classes
of neurons in the dorsal horn: (1) projection
neurons, which relay sensory information; (2)
excitatory interneurons, which relay sensory
input to projection neurons; and (3) inhibitory
interneurons, which regulate nociceptive information to higher regions of the central nervous
system. It is possible that acupuncture works
by activating the inhibitory interneurons in the
dorsal horn of the spinal cord. These pathways
ascend up the spinal cord via the spinothalamic
tracts to the thalamus, which synapses and
projects on to the somatosensory cortex. Inhibitory interneurons in the substantia gelatinosa
prevent activation of the dorsal root ganglia. Pain
can be ‘‘gated out’’ by stimulating the large
A-fibres in the painful area. This is the working
mechanism behind transcutaneous electrical
nerve stimulation, and of course, the gate control
theory of pain first proposed by R. Melzack and
P. D. Wall in 1965 (Melzack & Wall 1996).
The descending inhibitory pathways originate
at the level of the cortex and thalamus, and
descend via the brainstem (i.e. the periaqueductal grey matter, PAG) and the dorsal
columns to terminate at the dorsal horn of the
spinal cord. Neurotransmitters, such as
noradrenaline (norepinephrine), serotonin and
the endogenous opioids from the PAG, and
enkephalins from the nucleus raphe magnus are
released. Following stimulation of the PAG, the
release of -endorphins, adrenocorticotrophic
hormone, leu-enkephalin and oxytocin from the
pituitary and hypothalamus also occurs (oxytocin
plays a major role in descending inhibition by
increasing pain thresholds and lowering cortisol
levels). These opioid receptors provide antinociception through presynaptic inhibition.
It is generally accepted that the effects of
acupuncture on the body involve the release of
opioid peptides in the body. The opioid peptides
are a comprised of endorphins, enkephalins and
85
Table 1. Functional outcome measure of the subject’s activities of daily living
Function
Not difficult at all
Minimally difficult
Moderately difficult
Extremely difficult
Unable to do
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
–
–
–
–
–
–
–
–
–
–
–
–
–
+
–
–
–
–
+
+
–
–
–
+
–
–
–
–
–
+
+
–
–
–
–
–
–
–
–
–
–
–
+
+
+
Go up stairs
Go down stairs
Squat
Sit with knee bent
Rise from a chair
Run straight ahead
dynorphins, and are found in neurons throughout the body. These endogenous opioids are
released into the nervous system by the action of
acupuncture, and many studies have proven that
the effects of acupuncture anaesthesia can be
reversed by the use of naloxone, a pharmaceutical substance that blocks the effects of
-endorphins in the spinal cord (Pomeranz &
Cheng 1979).
Acupuncture points and treatment
The benefits of acupuncture were explained to
the subject, and after careful consultation, it was
agreed that this was an appropriate treatment
modality. Informed consent was given, precautions and contraindications were assessed and
documented, and the clinical environment was
checked for safety and hygiene.
Because the patient was consulting the clinic
for physiotherapy services and acupuncture was
suggested to her as an adjunctive treatment, it
was also seen as appropriate to conclude her
acupuncture sessions with a 20-min gym session
that focused on closed-chain exercises to
strengthen the VMO and increase her stable
knee range. These included squat, lunge, singleleg squat, eccentric quadrilateral, step and cycling
exercises. The two outcome measures used to
assess the progress between treatments were the
reliable and valid VAS (Carlson 1983), and ROM
of the knee into flexion and extension. A circumferential measure of 38 cm at the knee crease and
infrapatellar pole was taken before acupuncture
treatment began to determine the level of swelling. The subjective functional outcome measures
(see Table 1) were re-evaluated after 3 weeks of
twice-weekly treatment sessions.
Because of the inflammatory nature of the
subject’s post-operative condition, it was
86
assumed that there was a disturbance of Qi
caused by excess. Therefore, the goals of treatment were to decrease pain and swelling by moving Qi away from the affected area and preventing
stagnation. Because of her initial hyperalgesia and
local swelling, distal points were favoured over
local points since local needling can potentially
result in an exacerbation of symptoms in an
inflamed area. According to TCM, the Liver (LV)
meridian is responsible for the flow of Qi and
Blood in this part of the body, and clinical disturbances of this channel are often characterized by
stagnation and excess (Stux et al. 2003). Thus, this
meridian was selected for its ability to activate and
promote the flow of Qi. Settling the patient’s
hyperalgesia was of paramount importance, and
therefore, Large Intestine (LI) 4 (the most important analgesic point in the body) was used in
combination with LV3 for 20 min in a bilateral
Four Gates technique in order to calm her pain
response, increase well-being and relaxation, and
promote the flow of Qi.
Treatment was progressed by adding more
points and stimulating for 30 min on subsequent
visits. Liver 8 continues along the Liver meridian
and is a good point to use when addressing knee
stiffness. The Gall Bladder (GB) is coupled with
the Liver meridian and GB34 is known to
promote the flow of Qi, especially in instances of
the stagnation of liver Qi. Gall Bladder 34 is a
He-Sea point (i.e. it connects distal and proximal
channels) that is influential for all disorders of
muscles and tendons, and is indicated for swelling at the knee. Spleen (SP) 9, also a He-Sea
Point, was chosen for its anti-swelling effects and
the fact that it is a cardinal point for knee pain.
Other local points selected include Stomach
(ST) 34, another cardinal point in knee pain, and
ST36. Stomach 35 and medial Xiyan, commonly
R. O’Neil
Table 2. Acupuncture treatment programme: (LI) Large Intestine; (LV) Liver; (SP) Spleen; (GB) Gall Bladder; (ST) Stomach; (BL) Bladder;
and (VAS) Visual Analogue Scale
Duration of
treatment (min)
17 July 2006
20
21 July 2006
30
24 July 2006
30
27 July 2006
30
31 July 2006
30
3 August 2006
30
Acupuncture
points
De Qi
achieved
Outcome
measures
LI4 and LV3 bilaterally
as per the Four Gates
Yes
VAS=80/100
Extension=10 Flexion=95 LI4 and LV3 bilaterally
LV8
SP9
GB34
Yes
Yes
Yes
Yes
VAS=70/100
LV8
SP9
GB34
ST35
Xiyan
Yes
Yes
Yes
Yes
Yes
Unknown*
VAS=60/100
LV8
SP9
GB34
ST34, ST36
BL40
Yes
Yes
Yes
Yes
Yes
Yes
VAS=75/100†
Extension=5 Flexion=105 LV8
SP9
GB34
ST34, ST36
BL40
Heding
Yes
Yes
Yes
Yes
Yes
Yes
VAS=55/100
Extension=3 Flexion=115 LV8
SP9
GB34
ST34, ST36
BL40
Heding
Yes
Yes
Yes
Yes
Yes
Yes
VAS=40/100
Extension=2 Flexion=120 *Unclear because of puffiness.
†Tenderness in the anterior knee.
called the ‘‘calf’s nose’’ when used together, were
also considered for their location at the ‘‘eyes’’ of
the knee. Finally, Heding was used for its use in
local knee pain and Bladder (BL) 40 because of
its utility in disorders affecting knee extension
(ALIED 2005).
Clinical outcome
The initial response to treatment with the Four
Gates was positive, and there was a reduction in
the subject’s pain and an improvement in her
knee extension (Table 2). Liver 8 and points to
reduce swelling (GB34 and SP9) were added in
order to alleviate pressure on the superficial
nerves, which were likely to be hypersensitized
by the inflammation. Again, a reduction in pain
and an improvement in outcome measures were
recorded. The patient reported that it was
becoming easier to bear weight on her left leg.
The next session continued the previous treatment, but the ‘‘calf’s nose’’ of the knee was
added since it was assumed that these local
points might provide further pain reduction.
These points lay over an area of puffiness, and by
the end of treatment, the subject’s sensitivity had
actually increased. By the next presentation, her
87
VAS score had risen even though improvements
in knee ROM were still occurring. This was
perhaps a result of using local points on an area
with excessive Qi, a process that can bring Qi to
the area and increase the inflammatory response.
Therefore, it was decided to abandon the ‘‘calf’s
nose’’ points, and instead use ST34 and ST36,
which were well removed from the local puffiness, as well as BL40 to further improve knee
extension. The present author continued to use
the Four Gates to produce a calming analgesic
effect. This methodology seemed to work well,
bringing about a significant reduction in the
patient’s subjective pain whilst her ROM maintained its steady improvement. The last two
treatments continued similarly, with the addition
of the Heding point, and there was a significant
improvement in knee ROM and pain scores at
the final assessment.
There was also a reduction in the subject’s
circumferential knee measurement to 36.5 cm,
indicating that her oedema was settling. Functionally, there was an improvement in the subjective
reporting of her knee ADLs. She was able to go up
and down flights of stairs more easily, squat to 80 and perform sit to stand with equal weight through
both legs. Despite her steady improvements in
weight-bearing, the patient’s gait was still affected,
and she still could not run, hop, jump or stop
quickly. It is anticipated that she will continue to
make these steady improvements with further
physiotherapy (i.e. acupuncture and exercises).
Discussion
The acupuncture treatment programme
described in the present case report produced a
positive response with regard to decreasing pain
and swelling, and increasing ROM after arthroscopic knee surgery. Unfortunately, since a
number of external factors could have been
influential in the subject’s recovery, the author
was unable to determine whether acupuncture
was specific in its actions. Both RICE and
structured closed-chain strengthening exercise
principles were employed throughout the course
of treatment, and therefore, it is highly probable
that the improvements that were observed were
caused by a combination of these factors. Other
substitutes for acupuncture that could have benefited from further investigation in the present
88
case study include the effect of trigger points in
the quadriceps muscle on pain and ROM, and
the use of electroacupuncture to further reduce
the patient’s analgesic use, both of which have
been proven to be effective (Simons et al. 1999;
Koo et al. 2002).
There are very few reports of the effectiveness
of acupuncture after knee arthroscopy; in fact,
most studies involving the knee focus on osteoarthritis (Berman et al. 1999, 2004). Although
both conditions are essentially inflammatory,
there is still a significant difference between
meniscus versus arthritic degenerative changes
and one must be careful when making inferences. Current research encounters difficulty
with appropriate controls, small study populations, and inter- and intra-tester reliability, and
according to Molsberger et al. (2004), generally
accepted guidelines on how to perform a reliable
verum or sham treatment have yet to be established. There have been recent studies in
Germany examining the effects of designing
acupuncture research that will meet evidencedbased medical criteria, and these postulate that
the results will form a basis for the assessment of
acupuncture effectiveness (Wettig 2005).
Conclusion
The rehabilitation of knees following arthroscopic surgery should be founded on evidencebased medicine. This initially involves controlling
the inflammation with RICE and antiinflammatory agents, and then the progression of
weight-bearing, ranging, strengthening and proprioceptive exercises. The outcome of the
present case study suggests that acupuncture is a
useful adjunct in the management of arthroscopic pain and swelling in an attempt to encourage strengthening and better function. Although
acupuncture case studies contain a significant
amount of variables when compared to a randomized controlled trial, they can provide firm
anecdotal evidence in favour of acupuncture.
However, a much wider variety of reliable and
valid research is needed in this field.
References
Acupuncture – Learning and Integrated Educational
Development (ALIED) (2005) Acupuncture for Pain
R. O’Neil
Relief – AACP Approved Foundation Course Manual,
Issue 1.1. ALIED, St Neots, Cambridgeshire.
Anderson A. F., Irrgang J. J., Kocher M. S., Mann B. J. &
Harrast J. J. (2006) The International Knee Documentation Committee Subjective Knee Evaluation Form:
normative data. American Journal of Sports Medicine 34 (1),
128–135.
Berman B. M., Lao L., Langenberg P., et al. (2004)
Effectiveness of acupuncture as adjunctive therapy in
osteoarthritis of the knee: a randomized, controlled trial.
Annals of Internal Medicine 141 (12), 901–910.
Berman B. M., Singh B. B., Lao L., et al. (1999) A
randomized trial of acupuncture as an adjunctive therapy
in osteoarthritis of the knee. Rheumatology 38 (4), 346–
354.
Brukner P. & Khan K. (eds) (1995) Clinical Sports Medicine,
2nd edn. McGraw-Hill, New York, NY.
Carlsson A. M. (1983) Assessment of chronic pain. I.
Aspects of the reliability and validity of the visual
analogue scale. Pain 16 (1), 87–101.
Gupta S., Francis J. D., Tillu A. B., Sattirajah A. I. & Sizer
J. (1999) The effect of pre-emptive acupuncture treatment on analgesic requirements after day-case knee
arthroscopy. Anaesthesia 54 (12), 1204–1207.
Koo S. T., Park Y. I., Lim K. S., Chung K. & Chung J. M.
(2002) Acupuncture analgesia in a new rat model of
ankle sprain pain. Pain 99 (3), 423–431.
Molsberger A. F., Mau J., Gotthardt H., Schneider T. &
Drabik A. (2004) Designing an acupuncture study to
meet evidence-based medical criteria: methodological
considerations for logistic design and development of
treatment interventions arising from the German randomized controlled acupuncture trial on chronic shoulder pain (GRASP). European Journal of Medical Research 9
(8), 405–411.
Morrissey M. C., Milligan P. & Goodwin P. C. (2006)
Evaluating treatment effectiveness: benchmarks for
rehabilitation after partial meniscectomy knee arthro-
scopy. American Journal of Physical Medicine and Rehabilitation 85 (6), 490–501.
Pomeranz B. & Cheng R. (1979) Suppression of noxious
responses in single neurons of cat spinal cord by
electroacupuncture and its reversal by the opiate antagonist naloxone. Experimental Neurology 64 (2), 327–341.
Sackett D. L., Rosenberg W. M. C., Gray J. A. M., Haynes
R. B. & Richardson W. S. (1996) Evidence based
medicine: what it is and what it isn’t. [Editorial.] British
Medical Journal 312 (7023), 71–72.
Simons D. G., Travell J. G. & Simons L. S. (1999) Travell
& Simons’ Myofascial Pain and Dysfunction: The Trigger Point
Manual, Vol. 1: The Upper Half of the Body, 2nd edn.
Williams & Wilkins, Baltimore, MD.
Stux G., Berman B. & Pomeranz B. (eds) (2003) Basics of
Acupuncture, 5th edn. Springer-Verlag, Berlin.
Tillu A., Tillu S. & Vowler S. (2002) Effect of acupuncture
on knee function in advanced osteoarthritis of the knee:
a prospective, non-randomised controlled study. Acupuncture in Medicine 20 (1), 19–21.
Usichenko T. I., Hermsen M., Witstruck T., et al. (2005)
Auricular acupuncture for pain relief after ambulatory
knee arthroscopy – a pilot study. Evidence-based Complementary and Alternative Medicine 2 (2), 185–189.
Wettig D. (2005) Die GERAC-Gonarthrose-Studie:
Wurden Patienten und Telefoninterviewer vorzeitig
entblindet? [The GERAC Osteoarthritis Study: were
patients and telephone interviewers prematurely
unblinded?] Der Schmerz 19 (4), 330–332. [In German.]
Robert O’Neil graduated from the University of
Queensland, Brisbane, Queensland, Australia, in 1998,
and has worked in both the public and private sectors in
Australia and the UK. He moved to the UK 8 years ago
and has worked at the Crystal Palace National Sports
Center since 2005. His interests are sporting and
biomechanically related injuries, and knee dysfucntion.
89
Clinical use of long-duration press needles
Traditionally, AACP has advised its members
against the use of indwelling auricular needles
because of the slightly higher risk of skin infection associated with these instruments. Nevertheless, although we, as a clinical interest group, are
not generally in favour of teaching patients selfneedling techniques because of the risk factors
involved, I would like to familiarize members
with the use of Pyonex press needles (SEIRIN
Corporation, Shizuoka City, Japan) within clinical practice. I was introduced to this product by a
traditionally trained licensed acupuncturist just
over 18 months ago as a means of maintaining continuous acupuncture stimulation for the
management of chronic systemic conditions.
The clinical reasoning behind this intervention
derives from the fact that a full recovery is not
expected in individuals suffering from prolonged
chronic disease states. Nevertheless, when correctly applied, acupuncture may augment the
body’s attempts to restore homeostasis, and thus,
ameliorate some of the adverse effects of such
diseases (Dhond et al. 2007). The use of Pyonex
needles may offer a cheap and effective intervention, and facilitate improved coping strategies.
Other benefits can include greater well-being,
enhanced dream and deep sleep, reduced visceral
dysfunction (e.g. palpitations and irritable bowel
syndrome), and reduced levels of anxiety.
In cases presenting with a chronic disease
state, such as subjects with chronic pain (Tracey
& Bushnell 2009), acupuncture is often seen as a
passive, expensive and prolonged intervention.
We work within a healthcare system that continually uses an acute model of care in order to
address chronic conditions. Such patients do not
respond well to standard analgesic, antiinflammatory and antidepressant prescriptions,
which only exacerbates the financial burden on
the healthcare system.
Ever-increasing evidence indicates that acupuncture increases levels of serotonin (Cabioglu
& Arslan 2008) and oxytocin (Gimpl &
Fahrenholz 2001), and reduces anxiety
(Pilkington et al. 2007), pain (Carlsson 2002;
Kaptchuk 2002; Moffet 2006) and sympathetic
visceral tone (Cabioglu & Arslan 2008). As the
evidence grows, one may surmise that daily
acupuncture, with continuous stimulation, may
assist these individuals without the side effects of
prolonged medication. Unfortunately, this
approach increases the costs to the healthcare
system and patients seeking private treatment.
The current healthcare guidelines on the management of chronic pain are directed towards a
biopsychosocial model, integrating pain relief,
pacing, cognitive behaviour therapy (CBT) and
exercise with coping strategies. The very essence
of the management plan is ‘‘empowerment of the
patient’’.
With this in mind, we began a 12-week programme, which was supported by Bupa, employing Pyonex needles, education, exercise and CBT
to treat a number of volunteer subjects who were
undertaking a chronic pain management course
at our practice.
The patients were invited to participate after
extensive screening and upon fulfilling the inclusion criteria. A 12-week course involving all the
modalities listed above was undertaken. The
placement of Pyonex needles was dependent on
the presenting pain mechanism. For subjects
generally displaying poor descending inhibitory
analgesia, the ‘‘four gates’’, i.e. Large Intestine 4
and Liver 3, were chosen. For those presenting
with sympathetic excitation, parasympathetic
points, i.e. auricular Shenmen, Governor Vessel
20 and Yintang, were chosen. For individuals
experiencing increased anxiety and stress, Heart
7 and Pericardium 6 were added. It must be
stressed that all of the subjects were assessed and
the acupuncture interventions were based upon
the presenting symptoms; these points were
varied according to the feedback given by the
patients.
The subjects were taught where the points
were and what De Qi sensation was needed.
They were screened for all contraindications and
strict hygiene was applied with respect to:
+ swabbing the acupuncture point;
+ checking for adverse skin conditions;
91
Long-duration press needles
+ safe removal and disposal of needles;
+ needle stick knowledge; and
+ adverse reactions.
Each patient was supplied with a domiciliary
sharps container for the disposal of used needles,
which was returned to the clinic when full, and
all subjects signed consent forms and undertakings to adhere to the protocol for single-use,
sterile application.
None of the 12 patients involved in the trial
reported any adverse reactions or needle stick
injuries. One subject discontinued the programme, but all 11 remaining patients continued
with the whole programme, and now continue to
use the needles with support via telephone contact and open access should they have any
problems. No subjects have needed to return
to the clinic, but the practitioners perform a
telephone check once a month.
The final results of this study have not yet
been published because we have asked the
patients to continue the treatment for 6 months
after the programme. The intention is to compare outcome measurements for pain, sleep,
anxiety, depression and quality of life at discharge after 12 weeks with those obtained after
6 months.
All subjects have generally benefited from
improved sleep and well-being, and reduced
visceral problems, where present. There appears
to have been little change in the pain, anxiety and
depression scales.
The purpose of this article is to bring the
potential use of SEIRIN Pyonex needles in
long-term management to the attention of
AACP members. From the limited application
reported here, there appear to be few adverse
effects or safety issues as long as the protocol is
92
explained and patients adhere to it. It would be
beneficial to perform a larger study using comparisons with analgesia and I would urge those
members who are looking for research suggestions for future MSc dissertations to consider
this as a manageable project.
Jennie Longbottom
Practice Principal
Parks Therapy Centre
St Neots
Cambridgeshire
UK
References
Cabioglu M. T. & Arslan G. (2008) Neurophysiologic basis
of Back-Shu and Huatuo-Jiaji points. American Journal of
Chinese Medicine 36 (3), 473–479.
Carlsson C. P. O. (2002) Acupuncture mechanisms for
clinical long-term effects, a hypothesis. International
Congress Series 1238 (August), 31–47.
Dhond R. P., Kettner N. & Napadow V. (2007) Neuroimaging acupuncture effects in the human brain. Journal
of Alternative and Complementary Medicine 13 (6), 603–616.
Gimpl G. & Fahrenholz F. (2001) The oxytocin receptor
system: structure, function, and regulation. Physiological
Reviews 81 (2), 629–683.
Kaptchuk T. J. (2002) Acupuncture: theory, efficacy, and
practice. Annals of Internal Medicine 136 (5), 374–383.
Moffet H. H. (2006) How might acupuncture work? A
systematic review of physiologic rationales from clinical
trials. BMC Complementary and Alternative Medicine 6
(7 July), 25.
Pilkington K., Kirkwood G., Rampes H., Cummings M.
& Richardson J. (2007) Acupuncture for anxiety and
anxiety disorders – a systematic literature review.
Acupuncture in Medicine 25 (1–2), 1–10.
Tracey I. & Bushnell M. C. (2009) How neuroimaging
studies have challenged us to rethink: is chronic pain a
disease? Journal of Pain 10 (11), 1113–1110.
Research abstracts
Introduction
The following abstracts are another small sample
of dissertation projects from the cohort of students who undertake the MSc Acupuncture
degree at Coventry University, Coventry, UK,
each year.
Dr Val Hopwood
The effects of acupuncture and
splinting on carpal tunnel
syndrome: a single-subject
research design
Background
Carpal tunnel syndrome (CTS) is an entrapment
neuropathy of the median nerve at the wrist and
is the most common peripheral nerve compression syndrome. A myriad of treatment methods
are currently used by physiotherapists to treat
CTS; however, the only intervention to be unanimously supported in the literature is hand
splinting. Nevertheless, although research suggests that splinting can improve the symptoms of
CTS, it rarely abolishes them. No previous work
has been conducted to explore whether acupuncture could provide any additional relief to that
provided by a hand splint alone. Therefore, the
aim of this research was to investigate the effect
of acupuncture as an adjunct to splinting in the
treatment of CTS.
Methods
A single-subject alternating treatment design was
used to explore the effects of splinting alone, and
combined electroacupuncture (EA) and splinting
on individuals with CTS. Three subjects with
clinically diagnosed CTS were recruited via referrals to a physiotherapy department in South
Birmingham Primary Care Trust, Birmingham,
UK. The participants each experienced the same
interventions in 2-week blocks, as follows: no
treatment; splint; no treatment; splint and EA;
and no treatment. Outcome measures were collected weekly throughout all phases of the trial
and included: the Symptom Severity Scale (SSS);
the Functional Severity Scale (FSS); grip
strength; and the Measure Yourself Medical
Outcome Profile (MYMOP).
Results
The results were displayed in time series graphs
and visually analysed for any changes in trends
between the intervention phases. Two participants appeared to respond more favourably to
combined EA and splinting. This was evident by
a steeper downward slope in the SSS, FSS and
MYMOP graphs in the EA phase when compared to splinting alone. The remaining participant displayed marked improvements in SSS and
MYMOP scores with splinting alone; however,
there were no further improvements with the
addition of EA.
Conclusion
Electroacupuncture may provide additional
benefits to splinting alone in some individuals
with CTS. Further research in this area is
required in order for generalizations to be made
about a wider population.
Keywords: acupuncture, carpal tunnel syndrome,
splinting.
Rachel Chapman
Coventry MSc, 2005–2009
Individualized Chinese ear
electroacupuncture for
depression in primary care
Background
There are significant problems regarding both
the efficacy and concordance of antidepressant
medications and psychological therapies, which
are the two treatments recommended by the
National Institute for Health and Clinical
Excellence for moderate to severe depression.
Several Chinese ear acupuncture texts outline varying techniques for treating depressive
93
Research abstracts
symptoms, but no controlled trials of ear acupuncture for depression have been identified in
recent systematic reviews.
Methods
A case-study series studying patients with
moderate to severe depression in primary care
was undertaken. Two depression scales were
used: the 17-item Hamilton Rating Scale for
Depression and the nine-item Patient Health
Questionnaire. A validated traditional Chinese
medicine (TCM) questionnaire was also used to
measure changes in patterns of disharmony during the treatments and as an aid to Chinese ear
point selection. Four ear points were selected
from a menu of 14, first by probing for sensitive
reactive points and secondly by reference to the
scores in the TCM questionnaire. Electroacupuncture at 80 Hz was used for 30 min in a
total of eight treatment sessions over 6 weeks.
Results
In two out of the four patients, the depression
resolved during treatment; one patient showed
a partial improvement and one patient did
not improve. All four patients’ patterns of
disharmony significantly improved.
Conclusion
This reproducible individualized technique
proved to be safe. The positive trends in the
results would support further work involving a
small randomized controlled trial (RCT) with
feasibility testing of control subjects, i.e. a Phase
II trial.
Keywords: Chinese ear electroacupuncture, depression, primary care.
Martin Jordan
Physiotherapists’ experiences
and attitudes towards the use of
acupuncture as a treatment
modality
Background
Interest in acupuncture and its use among both
the public and professionals has increased over
94
the past decade. The technique offers an alternative to conventional medicine, which relies on
drugs and/or surgery. Physiotherapy has always
been recognized as a form of treatment that can
reduce dependency on medication. Acupuncture
is complementary to physiotherapy training by
virtue of its holistic approach and an increasing
number of physiotherapists are employing needling to treat their patients. Out of 47 000 members of the Chartered Society of Physiotherapy,
4800 are members of the Acupuncture Association of Chartered Physiotherapists, and 70% of
the latter work in National Health Service
(NHS). The main objective of this study was
to explore physiotherapists’ attitudes towards
and experiences of using acupuncture, and the
factors that influence their attitude towards
employing this form of treatment.
Methods
A postal questionnaire survey design was used. A
robust questionnaire was developed following
discussions with peer consultants. The respondents were all NHS physiotherapists working
in four acute and primary care trusts in the
Hounslow and Hillingdon Local Research Ethics
Committee catchment area: Hillingdon Primary
Care Trust, West Drayton, Middlesex, UK;
Hillingdon Hospital, Uxbridge, Middlesex, UK;
Hounslow Primary Care Trust, Hounslow,
Middlesex, UK; and West Middlesex Hospital,
Isleworth, Middlesex, UK. One hundred and one
questionnaires were distributed. A response rate
of 77.2% was achieved after follow-up.
Results
In general, physiotherapists hold positive attitudes towards acupuncture. Analysis of the
results showed that 92% of respondents considered acupuncture to be a useful treatment
modality, and 71% respondents either treat or
recommend patients for treatment with acupuncture. A statistically significant difference was
found between the physiotherapists’ opinions
and their experiences of acupuncture.
Conclusion
Physiotherapists’ attitudes towards the use of
acupuncture were mainly positive. The results
Research abstracts
demonstrated a steady change in physiotherapist’s attitudes when these were compared
with their year of qualification. The research also
identified differences in physiotherapists’ attitudes towards the use of acupuncture in relation
to their age and gender, and the level of their
training in acupuncture. Further research into
these different aspects could be valuable.
Keywords: acupuncture, attitudes, physiotherapists.
Noor-ul-Sabah Rehman
An exploration of the experience
of ear acupuncture of clients who
are currently attending statutory
drug and alcohol services
Background
The aim of this study was to explore the personal
meaning and experience of ear acupuncture from
the client’s perspective, and its impact on their
problematic substance use, whilst attending NHS
statutory drug and alcohol services. This qualitative pragmatic study utilized a phenomenological
approach. A purposeful sample (n=10 subjects)
was recruited from three NHS sites: an in-patient
detoxification ward; an alcohol dependency day
unit; and a drug dependency day unit. All participants were receiving psychosocial support from
within these centres.
Methods
The participants received ear acupuncture from
their usual NHS staff. Semi-structured interviews
were conducted within 24 h of an ear acupuncture session. Data from the audio recording was
transcribed verbatim. A systematic thematic
analysis ensured that the subject’s meaning
guided the process.
Results
The themes identified were related to: expectations about the first acupuncture session; personal experiences identified throughout and after
the actual session; personal interpretations of
meaning; impact on substance dependency; and
recommended changes. Important areas that
were identified included: the multifaceted nature
of the relaxation response; difficulties in describing the personal meaning of acupuncture; the
uniqueness of each individual’s acupuncture
experience; holistic and diverse valued outcomes;
combinations of factors in psychosocial support;
and replacement factors related to substance
misuse. Facilitators and barriers that may potentially influence attendance at initial and subsequent sessions were identified.
Conclusion
The findings supported previous qualitative
acupuncture studies of the experience of wholeperson/well-being effects, which are characterized by diverse and powerful descriptions of
relaxation and altered body awareness. Traditional Chinese medicine philosophy appeared to
support much of the participants’ experiences,
although their descriptions were not articulated
in TCM terms. The repeatable, non-directive,
non-verbal, ritualistic nature of the session was
sufficiently comparable with substance misuse to
act as a positive replacement. The positive effects
of acupuncture provided strong internal cues
that facilitated individualized responses. The subjects interpreted these responses according to
their own cultural and personal narratives. These
new personal resources and insights were
enhanced and embedded in NHS support services, providing opportunities to develop life
skills.
Keywords: client experience, ear acupuncture,
statutory drug and alcohol services.
Ann Childs
Is electroacupuncture a useful
adjunct in the treatment of leg
ulcers? A pilot study
Background
The prevalence of leg ulcers in those aged over
65 years of age is 3–5%, and this costs the NHS
between £300 and £600 million each year. Leg
ulcers are of direct relevance to physiotherapists
who treat elderly people because the pain that
these cause can have a significant impact on
95
Research abstracts
mobility. Some of the literature suggests that EA
at remote sites may be of benefit to ulcer healing,
pain and mobility, but it is of poor quality and
further research is warranted.
Methods
Following ethical approval, a single-blind RCT
was initiated. After the 8-week data collection
period, only three subjects had been enrolled in
the study because of recruitment problems, and
therefore, it was modified. A series of six rigorous case studies was carried out. The research
design remained largely unchanged. A standardized treatment protocol was used, consisting of
four needles inserted into each hand and forearm. Two needles on each arm were connected
to an EA machine, which was set to 2.5 Hz and
a ‘‘strong but comfortable’’ intensity. Ten treatments were carried out over a 5-week period.
Outcome measures were taken pre- and posttreatment, and 3 months after the treatment
period had finished. The selected measures
evaluated healing, mobility and pain. Healing was
measured using tracings of wound margins in
order to calculate wound area. Qualitative information regarding the condition of the wound
was also collected. Mobility was measured using
the 10-m timed walk and the Elderly Mobility
Scale (EMS). Pain was measured using the Faces
Pain Scale (FPS).
Results
Four participants had venous leg ulcers and two
had mixed venous/arterial ulcers. Five subjects’
ulcers were smaller at the end of treatment and
another’s could not be accurately measured
because of diffuse spread. At the 3-month
96
follow-up, one ulcer was fully healed, one had
continued to improve, two had regressed and
one participant was not available to have his
ulcer measured. In one subject only, pain
decreased and mobility improved in correlation
with ulcer healing. No patterns could be identified for any of the other participants. A ceiling
effect was observed for the EMS and the 10-m
timed walk in some subjects. The FPS scores did
not correlate with subjective pain reports in
some participants. Subjects reported other subjective benefits, including improved hand function (which had been affected by a stroke), a
reduction in osteoarthritic knee pain and
improved sleep. Mild bleeding on the removal of
the needles was the only side effect that was
observed.
Conclusion
The results provide some support to the findings
of previous studies and indicate that further
research is warranted. Despite the modification
of original RCT to a series of case studies, flaws
in the research design can still be identified that
should be taken into account in any future,
larger-scale studies. These problems were primarily related to the outcome measures that were
selected. Lessons were also learned with respect
to the value of case studies, and the type and size
of research that is feasible within the time frame
of a Master’s dissertation.
Keywords: electroacupuncture, leg ulcers, pilot
study.
Emma Tebbutt
Coventry MSc, 2005
Book reviews
Acupuncture in the Treatment of
Musculoskeletal and Nervous System
Disorders, 2nd edn
By Lü Shaojie
Donica Publishing, London, 2009, 670 pp.,
hardback, £49.00
ISBN 1-90114-907-2
This very large book is also very reasonably
priced for a hardback. While certainly not a
pocket guide, Acupuncture in the Treatment of Musculoskeletal and Nervous System Disorders deserves a
place in the departmental library as a useful
reference for many physiotherapy treatments.
The author has wide clinical experience, and
offers clear and helpful treatments for complaints ranging from traumatic synovitis of the
knee to Ménière’s disease.
In fact, no less than 127 conditions are covered, and for each, detailed descriptions of symptoms, helpful illustrations of point locations and
anatomical features, and comprehensive collections of points make treatment easy to approach.
Photographs are also used to illustrate common
points, offering a view of the needle in situ
together with descriptions of the techniques that
can be used.
Each disorder is carefully described, starting
with an overview, which generally uses Western
terminology, and some form of illustration.
This introduction is followed by details of
clinical manifestations or symptoms, and some
fairly brief material dealing with routine tests
and communications with hospital colleagues.
Then aetiology, pathology, pattern identification
and treatment are all dealt with at length in
purely traditional Chinese medicine (TCM)
terms.
On the plus side, there is a very good
glossary, which gives a clear and concise
description of the many TCM ideas and theories that inform the choice of points. Even
those with a very cursory grasp of this type of
acupuncture will find the explanations both
useful and helpful.
There is a glossary of Western terms as well.
Most physiotherapists will find this a bit superfluous, but the book is obviously and laudably
aimed at both acupuncturists and health professionals. There is also an appendix giving descriptions of the locations of the acupuncture points,
but I am not sure that this is helpful to either
group of professionals; there are better sources
of information.
I found the combination of information,
theory and illustration very helpful, and I think
anyone approaching these conditions for the first
time would find this a useful resource. However,
the author cites no research evidence at all! No
scientific references are offered in any part of
this otherwise substantial text. Some Western
theories are flirted with, but it is hard to see why
the full diagrams of dermatomes and myotomes,
for example, are offered with no explanation as
to why these might be of relevance. No suggestions are offered as to how acupuncture might
work in scientific, physiological terms. For
instance, rather a lot is written about the use of
acupuncture with paraplegic patients, but once
again, no scientific evidence is offered to support
this approach. In a book of this scope and
in such a contentious field, this is a serious
omission.
Acupuncture in the Treatment of Musculoskeletal and
Nervous System Disorders will be a useful reference,
and a source of good ideas for possible syndromes and associated points, but without a
good working knowledge of TCM, it will leave
physiotherapists with more questions than
answers. It may well frustrate those with an
interest in these fields who are looking for
support for their clinical reasoning. This is a
missed opportunity.
Dr Val Hopwood
Course Director
MSc Acupuncture
Department of Physiotherapy and Dietetics
Coventry University
Coventry
UK
97
Book reviews
Anatomical Atlas of Acupuncture
Points: A Photo Location Guide
By Yan Zhenguo
hardback, £39.00
ISBN 1-90114-905-6
Here is yet another book about the location of
acupuncture points! There are now so many
available that it is difficult to be sure that any new
publication is adding much to the field. However, this is, as the title states, a book of
photographs. As such, the Anatomical Atlas of
Acupuncture Points adds a welcome degree of
realism to the illustrations, and highlights structures and anomalies within the human anatomy
that may cause problems for acupuncturists.
Approximately one-third of the book has photographs of the courses of the meridians. This is
very similar to the material in the better-known
SEIRIN photographic atlas (Lian et al. 2006)
and any of the books offering line drawings
(Deadman et al. 2007; WHO 2008), and not
surprisingly, actually adds little that is new.
The following sections are of more interest.
Photographs of sagittal sections give a better
orientation with reference to the positions of the
internal organs and other structures, and since
these are taken from carefully prepared prosections, the reality of it all can become a little
overwhelming. However, the material is undeniably fascinating. It is interesting to note that such
things as the Urinary Bladder points are not
ranged one above or below the other in mathematical perfection, but according to the build
and proportion of the body, may be slightly
varying distances apart. This is obvious, if you
think about it, but the reality is not always
depicted as such in acupuncture atlases.
Transverse sections of the trunk and limbs are
offered, again from dissection material, and may
provide some comfort to those who are nervous
of needling points such as Gall Bladder 34 or
Pericardium 6 because of nearby nerves or blood
vessels. Not all points are illustrated and the
selection seems somewhat arbitrary, Bladder
40 might have been useful, but it is not mentioned. Finally, six computed axial tomography
scans are included: two of the head and neck;
one of the upper thoracic area; two of the lower
limb; and one of the hand. It is not clear what
98
these add to the overall information since they
are relatively difficult to interpret and require line
drawings to clarify the separate structures.
Personally, I am reluctant to recommend the
Anatomical Atlas of Acupuncture Points. On the plus
side, it is a well-produced and solid hardback that
should last for a while as a much-thumbed
reference in clinic. The illustrations are attractively presented and mostly clear. Care has been
taken with the dissection material to recreate
normal bulk and positioning. However, on the
minus side, once the relative novelty of the very
real – rather than just realistic – illustrations has
worn off, I don’t think it will be consulted often.
Dr Val Hopwood
Course Director
MSc Acupuncture
Coventry University
Coventry
UK
References
Deadman P., Al-Khafaji M. & Baker K. (2007) A Manual
of Acupuncture, 2nd edn. Journal of Chinese Medicine
Publications, Hove.
Lian Y.-L., Chen C.-Y., Hammes M. & Kolster B. C.
(2006) The Pictorial Atlas of Acupuncture: An Illustrated
Manual of Acupuncture Points. Könemann, Cologne.
World Health Organization (WHO) (2008) WHO Standard
Acupuncture Point Locations in the Western Pacific Region.
World Health Organization, Western Pacific Region,
Manila.
Foundations for Integrative
Musculoskeletal Medicine: An
East-West Approach
By Alon Marcus
North Atlantic Books, Berkeley, CA, 2005, 774
pages, hardback, £90.00
ISBN 978-1-55643-540-9/1-55643-540-1
The past 10 years have seen a number of
excellent books written by members of the
acupuncture profession that have focused on
the integration of Western medical concepts and
the Eastern approach to health management.
Nevertheless, Foundations for Integrative Musculoskeletal Medicine: An East-West Approach easily
outshines any other publication in this field.
Book reviews
Physiotherapists who integrate Western trigger
point acupuncture, traditional Chinese acupuncture and manual therapy will find that the author
has risen to a remarkable challenge. Alon Marcus
integrates all aspects of the Eastern and Western
models. He also adopts a fully comprehensive
approach to recent research in:
+ pain physiology;
+ acupuncture and Western physiological processes, particularly the incorporation of the
philosophy of yin and yang into a neurotransmitter paradigm;
+ manual therapy interventions;
+ herbal medicine;
+ osteopathic medicine; and
+ integrating musculoskeletal disorders into an
Eastern clinical reasoning framework.
This book is an essential aid for professional
acupuncturists in the management of musculoskeletal disorders, including pain, within clinical
practice. It also explains the necessity of
stretching and strengthening regimes following
acupuncture intervention.
Foundations for Integrative Musculoskeletal Medicine
is divided into 11 sections:
(1) ‘‘Foundations for Integrative Oriental
Medicine’’;
(2) ‘‘Foundations for Integrative Pain and
Physical Medicine’’;
(3) ‘‘Foundations for TCM and Biomedical
Anatomy, Physiology, and Pathology’’;
(4) ‘‘Foundations of Integrative Orthopaedic
and Physical Medicine Assessments’’;
(5) ‘‘Treatment Principles for Integrative
Musculoskeletal Medicine: Acupuncture and
Dry Needling’’;
(6) ‘‘Additional Acupuncture Systems and
Related Techniques’’;
(7) ‘‘Foundations for Integrative Herbal
Medicine’’;
(8) ‘‘Foundations for Integrative Electrotherapeutics’’;
(9) ‘‘Integrative Manual Therapies, Rehabilitation, and Orthosis Therapy’’;
(10) ‘‘The Management of Sprains, Strains, and
Trauma’’; and
(11) ‘‘Musculoskeletal Disorders: Integrative
Practice’’.
This book presents a lifetime of work dedicated
to the effective integration of the Western and
Eastern models of healthcare. It is a superbly
written text that contains a vast amount of detail
and many recent references. The section on pain
is probably the best that I have read in an
acupuncture text, and the chapters on manual
therapy integration offer by far the most comprehensive overview on the market.
Foundations for Integrative Musculoskeletal Medicine
is not cheap, and neither should it be. I would
suggest that this book is a must for any MSc
student undertaking acupuncture and manual
therapy integration. It is a joy to read, and will
be a lifelong source of reference for my clinical
and academic practice. I would have no hesitation in recommending this as a textbook for any
academic course on the integration of acupuncture and manual therapy.
Jennie Longbottom MSc BSc MCSP
MBAcC
Practice Principal
St Neots
Cambridgeshire
UK
Management of Cancer with Chinese
Medicine
By Li Peiwen
hardback, £47.00
ISBN 1-90114-904-8
This book, which was first published 2003, and
then reprinted in 2004 and 2008, contains a large
proportion of Chinese herbal medicine, none of
which will be very accessible or useful to physiotherapists without a TCM background and, of
course, the ability to prescribe these drugs. There
is just enough acupuncture to make Management of
Cancer with Chinese Medicine interesting to those
who work with cancer patients or in the field of
palliative care. Although it was originally written
in Chinese, the book has been ably translated and
reads very well.
Professor Li Peiwen has been Director of the
TCM Oncology Department at the SinoJapanese Friendship Hospital in Beijing, China,
99
Book reviews
since 1984. He is also Vice-Chairman of the
Chinese Association of Oncology in Integrated
Chinese and Western Medicine, and has 35 years
of clinical and research experience in the use of
integrated Chinese and Western medicine for
the prevention and treatment of cancer. He is,
therefore, well qualified to write this book.
This is a difficult subject and the treatment of
cancer by complementary therapies in the UK
has always been somewhat controversial. Management of Cancer with Chinese Medicine is not likely to
help with the arguments raging within the
National Health Service because there is no
evidence base on offer. No scientific papers are
cited to support the effects of TCM in this
condition.
However, the book provides a thorough
account of how TCM sees cancer. There are two
chapters on the history of oncology theory in
TCM, and the basic TCM theories of the
aetiology, diagnosis and treatment of tumours.
Possibly the most directly useful chapters are
those on the TCM treatment of the side effects
of conventional cancer treatment (i.e. surgery,
chemotherapy and radiotherapy).
Further chapters describe the most common
complications of cancer, such as pain, fever,
jaundice, sweating and haemorrhage, and their
treatment by TCM and the use of qigong for this
100
condition. An interesting chapter extensively discusses dietary therapy for cancer, and includes
numerous recipes for beverages, soups, congees
and main dishes, most of which combine foods
with Chinese herbs.
The final chapter covers 11 specific kinds of
cancer. Each section describes the clinical manifestations, aetiology and pathology, pattern
identification, and treatment principles and strategies for combining TCM treatment with a
conventional Western approach.
Management of Cancer with Chinese Medicine is the
first textbook that I have seen which offers a full
account of TCM strategies for dealing with
cancer. Unfortunately, the wide range of herbal
prescriptions is of little use to a physiotherapist.
The acupuncture feels a bit like an afterthought,
and although well described and explained, the
theories involved would probably be a step too
far away from Western medical acupuncture for
most AACP members.
Dr Val Hopwood
Course Director
MSc Acupuncture
Coventry University
Coventry
UK
Letters
In support of Stomach 38
(Tiaokou)
I felt I had to comment on ‘‘Effectiveness of
single-point acupuncture to Stomach 38
(Tiaokou) on pain and disability in subjects
with frozen shoulder’’, the clinical paper by
Longbottom & Green (2009) published in the
Spring 2009 edition of our fine journal. It is
always good to see AACP members’ work being
published and I would like to respond by starting
a discussion.
As we all know, acupuncture research is rarely
straightforward since there are so many factors
to take into consideration, but this study looked
at a very simple comparison of the outcomes of
one treatment with another for the same condition. The paper itself was thorough and robust,
as we would expect from these authors.
We learn in our studies that Stomach 38
(ST38) is a good distal point for treating shoulder pain, and that it should be used as part of a
formula for subacute and chronic shoulder pain.
However, it does have a particularly important
role to play as a stand-alone point for an acute
presentation of shoulder pain, although it is not
an effective point for the subacute or chronic
forms of this condition when used in isolation.
In traditional Chinese medicine (TCM) practice, empirical observation and retesting has
established ST38 as a reflex region that goes
around the leg at the ST38 level. Pain from an
acute shoulder condition is reflected to the leg
region of ST38. Therefore, if the shoulder pain
is anterior, the region would tend to be more
anterior, and if lateral, it would be closer to
ST38. To produce the most beneficial effect, the
time to use this point for an acute case of
shoulder pain is between the onset of injury and
48 h later; after that, the useful effect as a
stand-alone point then tapers off.
When using this strategy, a strong needle
technique of thrusting and rotation is the most
effective means to elicit and maintain a strong
De Qi sensation on the ipsilateral side. The
patient should try to mobilize the arm with
pendular movements during treatment until a
good range of motion and pain relief is achieved.
The resulting pain and tight tissue release first
allows a more thorough examination to be made,
and secondly, the addition of other treatment
modalities.
Several studies similar to Longbottom &
Green’s (2009) work have been published in
the past. These have employed different acupuncture points, often including the extra point,
Zuzhongping (2 cun below ST36 Zusanli),
which is a very good point for subacute adhesive
capsulitis. Had this point been used instead of
ST38, I feel that the results would have been
more favourable to acupuncture, but neither is a
point to be used in isolation.
I have been using this strategy with many
beneficial results over the years and I have often
received favourable feedback from my students.
I am not naïve enough to say that this technique
is always effective: like many other treatments, it
sometimes does not respond as anticipated, but
it works more often than not.
I recall a particularly good response while
working with an athletics team attending a major
meet in Italy. A hurdler fell after crossing the line
and suffered subluxation of his shoulder. Our
medical team were able to treat him and I used
ST38 vigorously, which released the spasm and
pain, allowing our doctor to reduce the shoulder.
This athlete went on to win a silver medal 5 h
later. I remember this well because he gave me
his medal! When I worked for spells in Accident
and Emergency, this technique was also used
with very good effect on many occasions.
I would like to say that, while good methodology is very important in research work, it is
also vital to gain a good understanding of what
the points we research can reasonably be
expected to do. This includes not only their
energetic function, but also the appropriate
depth of needling (MacPherson et al. 2002). The
rationale informing their choice is also important: Ah Shi or Luo points are thought to influence different energy systems, and therefore, the
strategy should also be clear in the protocol.
101
Letters
Finally, here is a reminder of the details that
are relevant to ST38 (Tiaokou):
+ Location: the centre of the lateral side of the
lower leg, 8 cun distal to ST35 and 1 cun
lateral to the tibial crest.
+ Depth: 0.5–2 cun, perpendicular.
+ Indications: dispels damp, wind, shoulder pain
and motor impairment; used as part of the
prescription in foot, knee, hip and back pain.
Ron Sharp
Accredited AACP Trainer
Buckinghamshire Hospitals NHS Trust
Buckinghamshire
UK
E-mail: [email protected]
References
Longbottom J. & Green A. (2009) Effectiveness of singlepoint acupuncture to Stomach 38 (Tiaokou) on pain and
disability in subjects with frozen shoulder. Journal of the
Acupuncture Association of Chartered Physiotherapists Spring,
37–46.
MacPherson H., White A., Cummings M., et al. (2002)
Standards for reporting interventions in controlled
trials of acupuncture: the STRICTA recommendations.
Re: In support of Stomach 38
(Tiaokou)
We would like to thank Ron Sharp for his
interest in our research and for his support of
our robust methodology; however, we would
also like to respond to his letter.
Primary idiopathic frozen shoulder (FS) is a
condition of unknown aetiology that presents
with no significant findings in relation to history,
clinical examination or radiological evidence
which can explain the severe restriction of glenohumeral movements in all directions (Grubbs
1993; Bunker 1997).
In TCM, FS (Jianning) is associated with a
group of disease patterns known as Bi syndrome
(Pei-Lin & Vangermeersch 1995) or painful
obstructive syndrome (Maciocia 1994), which
encompass superficial disease processes in connective tissue structures such as the capsules,
tendons, ligaments, muscles and joints. Stagnation or obstruction of Qi and Blood will cause
pain and loss of normal movement. The Large
102
Intestine (LI) and Stomach (ST) meridians are
both superficial to and cross over the shoulder
joint, creating areas that are vulnerable to invasion by external pathogens, especially cold and
damp (Needles 1982). In TCM teaching, stimulation of the distal Yang point on the channel
will ‘‘open’’ the channel and:
+
+
+
+
+
expel the external pathogen;
move the Qi and Blood;
remove the obstruction;
stimulate the Yang Ming; and
stimulate the circulation.
As its name suggests (Tiaokou, ‘‘Lines Opening’’), the ST38 acupuncture point is a distal
Yang Ming point for the movement of Qi and
Blood in the ST and LI meridians, and thus, is
indicated for the treatment of FS (ATCM 1980;
Pothmann et al. 1980; Ross 1995; Guillaume &
Chieu 1996; Tukmachi 1999; Sun et al. 2001).
In Western musculoskeletal medicine, support
for this theory is further enhanced by the knowledge that many viscera can, and often will, refer
pain to the shoulder, for example: ST through
contact with the diaphragm at the C4 dorsal root
ganglia (Laurberg & Sørensen 1985); and LI
through innervation at T11 and L1 (Boissonnault
& Bass 1990).
The ST38 acupuncture point is cited in many
classical texts as a treatment for chronic painful
obstruction of the shoulder, combined with exercise to promote Yang energy, which is essential
for the movement of Qi and Blood. Recent
literature supports the use of ST38 for the
treatment of chronic painful obstruction of the
shoulder (Birch & Ida 1998; Deadman &
Al-Khafaji 1998; Hopwood 2004; Marcus 2005;
Wang & Robertson 2008).
Although FS is often encountered in physiotherapy practice, there is little or no evidence for
effective methods of treatment. Our literature
search found scant support for the effective use
of acupuncture or the value of empirical point
ST38, although it is taught and acknowledged in
many acupuncture texts. For this reason, the
study was undertaken in order to evaluate clinical
change, and to investigate the effects of intervention using a robust methodology and acupuncture at a single empirical point, ST38, and not to
test theoretical hypothesis or predictions.
Letters
The authors acknowledge that the evidence
for practice is based upon Ron Sharp’s extensive
clinical experience. This provides a firm basis for
further robust research at higher levels within the
hierarchy of evidence.
Jennie Longbottom
Practice Principal
St Neots
Cambridgeshire
UK
Ann Green
Associate Head of Physiotherapy and Dietetics
Coventry University
Coventry
UK
References
Academy of Traditional Chinese Medicine (ATCM) (1980)
Essentials of Traditional Chinese Medicine. Foreign Languages Press, Beijing.
Birch S. & Ida J. (1998) Japanese Acupuncture: A Clinical
Guide. Paradigm Publications, Brookline, MA.
Boissonnault W. G. & Bass C. (1990) Pathological origins
of trunk and neck pain: Part I – Pelvic and abdominal
visceral disorders. The Journal of Orthopaedic and Sports
Physical Therapy 12 (5), 192–207.
Bunker T. D. (1997) Frozen shoulder: unravelling the
enigma. Annals of The Royal College of Surgeons of England 79
(3), 210–213.
Deadman P. & Al-Khafaji M. (1998) A Manual of Acupuncture. Journal of Chinese Medicine Publications, Hove.
Grubbs N. (1993) Frozen shoulder syndrome: a review of
the literature. The Journal of Orthopaedic and Sports Physical
Therapy 18 (3), 479–487.
Guillaume G. & Chieu M. (1996) Rheumatology in Chinese
Medicine. Eastland Press, Seattle, WA.
Hopwood V. (2004) Acupuncture in Physiotherapy.
Butterworth-Heinemann, Oxford.
Laurberg S. & Sørensen K. E. (1985) Cervical dorsal root
ganglion cells with collaterals to both shoulder skin and
the diaphragm. A fluorescent double labelling study in
the rat. A model for referred pain? Brain Research 331 (1),
160–163.
Maciocia G. (1994) The Practice of Chinese Medicine: The
Treatment of Diseases with Acupuncture and Chinese Herbs.
Churchill Livingstone, Edinburgh.
Marcus A. (2005) Foundations for Integrative Musculoskeletal Medicine: An East-West Approach. North Atlantic
Books, Berkeley, CA.
Needles J. (1982) Bi syndrome – Part One. Journal of
Chinese Medicine 10, 20–29.
Pothmann R., Weigel A. & Stux G. (1980) Frozen shoulder: differential acupuncture therapy with point ST-38.
American Journal of Acupuncture 8 (1), 65–69.
Ross J. (1995) Acupuncture Point Combinations: The Key to
Clinical Success. Churchill Livingstone, Edinburgh.
Pei-Lin S. & Vangermeersch L. (1995) Classification of Bi
Syndrome. Journal of Chinese Medicine 47, 8–14.
Sun K. O., Chan K. C., Lo S. L. & Fong D. Y. T. (2001)
Acupuncture for frozen shoulder. Hong Kong Medical
Journal 7 (4), 381–391.
Tukmachi E. S. (1999) Frozen shoulder: a comparison of
western and traditional Chinese approaches and a clinical study of its acupuncture treatment. Acupuncture in
Medicine 17 (1), 9–21.
Wang J.-Y. & Robertson J. D. (2008) Applied Channel Theory
in Chinese Medicine. Eastland Press, Seattle, WA.
103
Fast-track
your future
NEW COURSE STARTS AT COVENTRY UNIVERSITY
Postgraduate Certificate in Acupuncture
A shorter acupuncture course is now available, a Postgraduate Certificate
in Acupuncture can be gained in just one year!
This will award 60 M level points and can be studied as part of a full MSc
degree, but initially offers a part-time, more clinically focused opportunity
to further your knowledge of this exciting skill.
More information is available from Course Director;
Dr Val Hopwood, tel: 023 8084 5901
www.coventry.ac.uk
News from the front
Are you insured?
The AACP Office has received several queries
regarding the cover provided by Chartered
Society of Physiotherapy (CSP) professional
indemnity insurance in relation to the practice of
extended-scope acupuncture.
Margaret Revie, Chair of the CSP Professional
Practice Committee confirms that auricular acupuncture for smoking cessation is within our
scope of practice, but points out that CSP
insurance does not cover the use of acupuncture
on animals. The latter should only be carried out
by a qualified vet.
Margaret also says: ‘‘If members were to consider the use of acupuncture for facial rejuvenation, then they should enquire directly with the
CSP via the Enquiry Handling Unit (EHU).
They will refer the query on accordingly.’’
If you have any further queries about this
matter, please get in touch directly with the
EHU:
Enquiry Handling Unit
The Chartered Society of Physiotherapy
14 Bedford Row
London WC1R 4ED
Tel: (020) 7306 6666
Fax: (020) 7306 6611
Text: (020) 7314 7980
Rosemary Lillie
Australian Physiotherapy
Association Conference 2009
I was fortunate enough to be asked to attend the
Australian Physiotherapy Association (APA)
Conference, which was held at the Sydney
Convention and Exhibition Centre, Darling
Harbour, Sydney, from 1 to 5 October 2009.
I was invited to present an abstract concerning
the use of acupuncture for complex regional
pain syndrome. Even more fortunately, AACP
helped me by sponsoring my journey to Sydney
and facilitating this visit, for which I am very
grateful.
Figure 1. (Left to right) Dr Mark Strudwick, Dr Chris
Zaslawski, Dr Peter Selvaratnam (Chair), Dr Helene
Langevin, Jennie Longbottom, Dr Jay Shah and Leigh
McCutcheon (Conference Organizer) at the Australian
Physiotherapy Association Conference in Sydney.
The APA Conference provides an international forum for sharing ideas, presenting
research findings and discussing professional
issues that are relevant to the practice of physiotherapy. My personal thanks go to Leigh
McCutcheon, a private practitioner in Queensland, and Conference Organizer for the Acupuncture and Dry Needling Group, who both
welcomed me and made me feel a vital part of an
eminent group of speakers (Fig. 1).
Amongst the abstract presenters, I was lucky
enough to join in the discussion forum with Dr
Jay Shah, Senior Staff Physiatrist in Rehabilitation Medicine at the National Institutes of
Health (NIH) Clinical Center, Bethesda, MA,
USA. He presented an animated and in-depth
account of the neurophysiological processes taking place during myofascial pain and acupuncture
intervention. Dr Shah discussed the results of his
collaborative work at the NIH on the utilization
of novel micro-analytical techniques to study the
unique biochemical milieu of myofascial trigger
points. This was an essential evidence-based
presentation that provided support for the use
of trigger-point needling in therapeutic interventions.
Dr Chris Zaslawski, Director of the College
of Traditional Chinese Medicine (TCM) at the
University of Technology, Sydney, discussed his
105
News from the front
work on the use of TCM within a clinical
reasoning paradigm for the management of
chronic pain as an integrated physiotherapy
model. This was a refreshing presentation that
introduced the more-intricate issues involved in
the methodology of TCM and the complexity of
future integrated research in clinical practice.
Dr Mark Strudwick, an engineer, physicist and
acupuncturist by profession, introduced the audience to the increased use of medical imaging in
the clinical practice of acupuncture. The presentation offered delegates an in-depth overview of
functional magnetic resonance imaging (fMRI)
as a means of validating complementary medicine, particularly TCM. The areas of particular
interest were fMRI of the central and autonomic
effects of acupuncture, a subject very dear to my
own practice.
Finally, Dr Helene Langevin presented a practical session about diagnostic ultrasound focused
on connective tissue mechanical signal transduction as a mechanism common to acupuncture,
manual and movement-based therapies. Dr
Langevin is an Associate Professor of Neurology,
Orthopedics and Rehabilitation at the University
of Vermont College of Medicine, Burlington,
VT, USA, and Principal Investigator of two
NIH-funded studies investigating acupuncture,
connective tissue and low back pain, and she and
her work will be familiar to members from her
appearances at AACP conferences. Her presentation demonstrated that mechanical tissue
stimulation during both tissue stretch and acupuncture causes dynamic cellular responses in
connective tissue.
This Conference was a tremendous success. It
featured the world’s leading researchers in the
field and offered novel sessions that were
designed to help clinicians catch up with findings
from the rapidly growing bodies of clinical
research in their own and other sub-disciplines.
A number of remarkable presentations related
to each field of clinical interest: musculoskeletal
disorders, mental health and neurology, to name
but a few, were all addressed, offering delegates
an insight into recent research and the development of the profession within these areas. The
conference was well organized, the venue outstanding and I must congratulate the Congress
team, who were chaired by Ann Green, for their
efforts in offering the membership an excellent
experience.
Our Association was represented by a lecture
on the use of acupuncture in mild depression
and anxiety, which was reported in Frontline
(Ogden 2009) and well received.
Jennie Longbottom
Reference
Ogden J. (2009) Acupuncture ‘‘a Proven Technique’’ for Anxiety.
[WWW document.] URL http://www.csp.org.uk/director/members/newsandanalysis/frontlinemagazine/
archiveissues.cfm?ITEM_ID=B4C33E4DDB5CD2F18
F0684776F591169&article=
Chartered Society of
Physiotherapy awards
CSP Fellowship for Jennie Longbottom
Our congratulations go to Jennie Longbottom,
who has been made a Fellow of the CSP (Fig. 2).
The citation reads:
‘‘A Fellowship of the Chartered Society of
Physiotherapy is conferred on Jennifer Evelyn
Longbottom for her outstanding contribution
Jennie Longbottom
Chartered Society of
Physiotherapy Congress 2009
The 2009 CSP Congress, held at the Liverpool’s
BT Convention Centre on 16 and 17 October,
was nothing less than stimulating and fun.
106
Figure 2. Jennie Longbottom and Ann Green at the
Chartered Society of Physiotherapy awards ceremony.
News from the front
to the field of acupuncture as part of physiotherapy practice.
‘‘A substantial part of Jennie’s professional
life has been focused on advancing the knowledge base and scope of physiotherapy practice
in the area of acupuncture. Acupuncture is now
considered a cornerstone of physiotherapy practice and Jennie is the foremost nationally recognised champion of acupuncture. Jennie has
advanced the knowledge base through teaching
at undergraduate and post-qualifying levels,
developing a framework for education and training linked to membership with the Acupuncture
Association of Chartered Physiotherapists and
through her own research. She has selflessly
advanced the interests and livelihoods of members either by challenging attempts to restrict
practice, or by working collegiately with other
professions such as medicine and the British
Acupuncture Council.’’
who will not fit into the standard acupuncture
regulatory framework. This builds on her work
with the Herbal Medicine Working Group,
which successfully identified the use of a number
of health preparations that will be accepted by
the European Commission for the regulation of
Chinese herbal formulae.
The citation concludes:
The citation notes that Jennie has made a substantial contribution to the work of the CSP by
serving on a number of the Society’s committees.
She has also contributed to the advancement of
the profession as a leader in acupuncture and
musculoskeletal physiotherapy, chronic pain
management and women’s health. Jennie delivers
approximately 20 evidence-based short courses
across the UK annually and has, as an individual,
a university-accredited Master’s-level module of
study, the AACP Foundation Module.
In terms of the Association, she has been
instrumental in ensuring that the AACP has the
highest standards of education, training and
research, and quality assurance.
Jennie was the first physiotherapist to be
admitted to the British Acupuncture Council
without having to compete the entrance examination, but by making the case for her membership based on qualifications, experience and a
successful viva voce, ‘‘trail blazing’’ a model for
others to follow. She is currently involved with
the Prince’s Foundation for Integrated Health,
working with them to ensure that organizations
that want to achieve self-regulation adhere
to professional standards and that membership
fulfils the requirements laid down for statutory
self-regulation. Jennie is also Chair of the
Microsystems Acupuncture Regulatory Working
Group, representing auricular acupuncturists
Andrew J. Wilson
‘‘Jennie is an excellent physiotherapist and has
made a substantial contribution to physiotherapy through tireless campaigning for the
CSP, AACP membership and the general
public around safe and effective, evidence
based acupuncture. Her collegiate contribution to the practice of acupuncture in the UK
has established her as a leader and champion
for physiotherapists practising acupuncture.’’
We congratulate Jennie on this well-deserved
honour.
Promising newcomer to the profession
Laura Goldie was awarded the prestigious prize
of Newcomer to the Year at the CSP awards
ceremony on Monday 16 November 2009 (Figs
3 & 4). She is an AACP student member who
has just completed her acupuncture training and
works in private practice with Vivienne Fort,
Director of AACP, at a physiotherapy and sports
injury clinic.
Described by her nominator as conscientious
and committed to enhancing her patients’ quality
of life, comfort and happiness, Laura is based in
a private clinic in Peterborough. When working
with a local charity for people with disabilities,
she overcame the limitations in physiotherapy
staff time by providing detailed and individualized written and illustrated exercise programmes,
which she prepared in her own time.
We congratulate Laura for her achievement
only 18 months after qualification.
Jennie Longbottom
Acupuncture and Women’s
Health Course
The Acupuncture and Women’s Health Course
was held in the Royal Alexandra Hospital,
107
News from the front
Figure 4. Jennie Longbottom and Laura Goldie at the
Chartered Society of Physiotherapy awards ceremony.
Figure 3. Laura Goldie with her Newcomer to the Year
award at the Chartered Society of Physiotherapy awards
ceremony.
will greatly augment the treatment methods at
your disposal.
Wendy Rarity
Paisley, UK, on 28 and 29 November 2009. The
tutor was Jennie Longbottom.
The topics covered included myofascial and
pelvic pain, continence and incontinence,
urgency/frequency syndrome, dysmenorrhea and
amenorrhea, the menopause, and anxiety management. The aims of the course were to
enhance the attendees’ clinical reasoning skills
and offer a wider range of clinical tools to
manage women’s health conditions, as well as
encourage the incorporation of acupuncture
techniques within the more global picture of
women’s health, with an emphasis on the emotional management of these conditions. The
information was dispensed to the participants
with Jennie’s usual wit and wisdom.
Everyone who attended this course found it to
be extremely enlightening and pertinent to their
workload, and we all went away full of inspiration. I would encourage anyone working in
women’s health to attend this course because it
108
Integrated Care and the
Management of Chronic Illness:
The Patient’s Agenda for Healthy
Living
I was fortunate to attend this conference, which
was organized by Professor George Lewith and
held at the Royal College of Physicians, London,
UK, on Wednesday 9 December 2009. The
event was primarily aimed at healthcare professionals who are contemplating the integration of
complementary and alternative medicine (CAM)
with orthodox medicine (OM). It was very
refreshing to attend a conference where the
principal focus was on the patient’s perspective. I
congratulate the organizers for accommodating
patients’ priorities, thoughts and preferences.
The theme of the conference was the integration of CAM in the management of chronic
illness to alleviate symptoms, reduce the use of
News from the front
OM and improve coping strategies. The main
aim was to balance OM and CAM in order to
empower patient choice and decision-making.
Professor Lewith gave a thought-provoking
presentation on research at the University of
Southampton, Southampton, UK, demonstrating
that CAM use is viewed by patients as a supplement – not an alternative – to OM. The subjects
integrate the two in identifiably different ways
and individualize different approaches in order to
manage their chronic conditions. What these
patients require from OM is help in order to
direct them to appropriate CAM practitioners
and support their decision. Professor Lewith
called for greater support for patient choice
from OM practitioners, and the maintenance
and encouragement of open dialogue with
patients and CAM practitioners, so as to support
their need for additional, not replacement,
therapy.
The keynote speaker, Professor Brian Berman
of the Center for Integrative Medicine at the
University of Maryland School of Medicine,
Baltimore, MD, USA, gave a rather worrying but
fascinating presentation of the current health
status of the UK and USA. The world faces an
epidemic of chronic disease: 16.5 million cases in
the UK and 80% of all general practitioner
consultations are related to chronic conditions.
In the USA, 50% of the population suffer from
chronic disease and this is the number one cause
of death in America. Globally, 75% of the world
population have one or more chronic conditions,
and 50% have more than two. With these facts in
mind, we were informed that the developing
world health systems still apply an acute model
of care to the management of chronic pain, and
continue to prescribe increasing doses of analgesics, anti-inflammatory drugs and even, dare I say
it, rest. For those of us working in the field of
chronic pain, this is not only disturbing, but
actually opposes all the National Institute for
Health and Clinical Excellence guidelines and the
evidence that we adhere to, providing a negative
model of patient management.
The presentations given were:
+ ‘‘Acupuncture for Irritable Bowel Syndrome
(IBS)’’ (Hugh MacPherson);
+ ‘‘Hypnosis for IBS’’ (Professor Peter
Whorwell);
+ ‘‘Integration of Mindfulness and CBT for
Chronic Management’’ (Dr Florian Ruths);
+ ‘‘Herbal Medicine for Depression’’ (Professor
Claudia Witt); and
+ ‘‘Homeopathy’’ (Dr Peter Fisher).
Each expert presented their research, and this
was then followed by a panel discussion with
questions and answers.
The conclusion from the day was that it is
necessary for us to enter into a therapeutic
relationship with our patients, and that we must
respect and support their choices and decisionmaking, learning from their individual experiences, both negative and positive, and judging
the results not only on research evidence, but
clinical evidence from patient sources. I hope
that this may generate a new level of understanding so that patients becomes the co-authors of
their treatment plans, not merely the recipients.
I would like to ask a few questions to those
working in OM and CAM, and would encourage
you to respond to these questions either via a
letter to the Journal or through the AACP website
(www.aacp.uk.com):
(1) Do you integrate OM and CAM within your
treatment choice?
(2) Do your patients ask for CAM when attending physiotherapy?
(3) Do you work with a patient advisory group?
(4) Do the requirements of your patients take
precedence in the formulation of a treatment
plan?
(5) Do you receive OM referrals for CAM?
(6) Is your physiotherapy practice either preventative or treatment-only, or do you combine the two?
Jennie Longbottom
Ann Green
The Association would like to thank Ann Green
for her sterling work chairing the Education,
Training and Research Committee (ETRC) over
the past year. We are sorry to see her go: she has
performed essential work within the ETRC,
bringing a wealth of experience in educational
planning at higher educational levels. Equally, we
would also like to congratulate Ann on her new
post as CSP Chair of Council (Fig. 5). We have
109
News from the front
past 4 years, and giving recommendations on the
development of the educational framework for
AACP members and tutors. She has played a
major
role in raising the profile of physiotherapy and
influencing the agenda, working to improve and
transform the profession.
We wish her luck. She will be greatly missed,
having worked alongside me during my term as
Chair of the Association. However, we are also
equally delighted to see Dr Higgins join AACP in
the capacity of Chair of the Education, Training
and Research Committee, which she assumed in
January.
Jennie Longbottom
Blood donor certificates
Figure 5. Ann Green at the Chartered Society of
Physiotherapy awards ceremony.
no doubt that she will bring her usual level of
enthusiasm, work ethics, and ability to spearhead
and lead the necessary changes within this post,
and we look forward to increased interaction and
collaboration between AACP and CSP for the
benefit of our membership.
Jennie Longbottom
Dr Jill Higgins
We would like to offer our best wishes to Dr Jill
Higgins (Fig. 6), Director of Practice and Development, who has left the CSP to take up a new
post as senior advisor with a strategic health
authority.
Dr Higgins has
had
extensive
experience with
our Association,
advising and supporting the development of AACP
Figure 6. Dr Jill Higgins.
Limited over the
110
The national blood transfusion services accept
blood donor certificates from all AACP members, including those who work outside the
National Health Service.
Any donor who has received acupuncture in
the 4 months prior to giving blood requires one
of these documents. It must record the name
of the physiotherapist who administered the
treatment.
Only current AACP members can issue blood
donor certificates. If you still possess the oldstyle leaflets, please contact the AACP Office
directly. You will be sent a booklet containing
the new certificates, which are only issued to
named members.
The UK blood transfusion services also accept
blood donor certificates from members of the
British Acupuncture Council, the General Chiropractic Council and the General Osteopathic
Council.
Rosemary Lillie
Erratum
As a result of a copy-editing error during the
production of the Autumn 2009 edition of the
Journal, the attributions for two of the Conference 2009 reports were transposed.
Dianne Allan wrote the review of Rosa N.
Schnyer’s ‘‘Transformation: an integrated East–
West complex model for treating depression’’
News from the front
(pp. 100–101), not Debbie Yates. Debbie was
the author of the report on ‘‘Optimizing performance in a sport and exercise context – what
can we do to help?’’ by Graham Smith (p. 105),
not Dianne.
We would like to apologize to both Dianne
and Debbie for the mix-up, and to Dianne for
spelling her first name incorrectly.
Andrew J. Wilson
111
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Guidelines for authors
Introduction
Always refer to a recent edition of the Journal of the
Acupuncture Association of Chartered Physiotherapists.
Please follow the style and layout of an article or
item that is similar to your own contribution. If
something is submitted for publication, then it is
implied that it has not been simultaneously submitted to another journal or any other type of
publication. Reprints may be considered, but these
must be clearly identified as such and permission
must be obtained from the original publisher.
Templates for clinical papers and case reports
are available on the AACP website (www.aacp.
org.uk) or by e-mail on request. These templates
should be not be deviated from if used. Manuscripts may be returned to authors if they have
not adhered to the guidelines. If necessary, the
Editor should be consulted in the initial stages
for clarification.
Authors may submit clinical papers, literature
reviews, clinical commentaries, case reports,
book reviews, course reports, news items, letters
or photographs for consideration for inclusion in
the Journal. Academic and clinical papers are
subject to review by the Editorial Committee and
may require revision before being accepted.
A Portable Document Format (PDF) file of
the final version of any academic article is
available free of charge if notice is given to the
Editor when the article is submitted.
All published material becomes the copyright
of Association.
All submissions should be sent directly to the
editor:
Mr John Wheeler
Windsor Centre of Traditional Acupuncture
5a St Leonards Road
Windsor
Berkshire SL4 3BN
UK
Preparation of manuscripts
Authors should submit material by e-mail or on
CD-ROM. All articles must be typed with wide
(3-cm) margins and the pages should be numbered consecutively. Articles should be a maximum 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 affiliation(s) should run consecutively below the title.
Again, there are no full stops.
Abstract
A summary of not more than 250 words outlining the purpose, scope and conclusions of the
paper should be submitted. This should be
followed by a minimum of three and a maximum
of five keywords that best represent the contents.
Text
The layout of the Journal is that the main heading
of each section is in sentence case and bold.
Notice that, again, there are no full stops and no
underlining.
The first paragraph is left-justified; subsequent
paragraphs in the same section are indented, as is
this part of the guidelines. When including diagrams and photographs, these should be numbered in the order in which they appear in the
text, and should be submitted in separate files
(do not embed images in the text). Any figure
captions should be left-justified and run after the
author’s biography at the end of the text. Any
tables should come after the figure legends, if
there are any. Please indicate placement in the
text (e.g. ‘‘Fig. 1’’ and ‘‘Table 1’’). All figures and
tables must be referred to in the text.
When using numbers in the text, these should
be written out in words up to and including nine
unless they are measurements, numbers in tables
or units of time. Always use the International
System of Units (SI).
113
Clinical papers: referencing
All clinical papers must be fully referenced and
the citations verified by the author. No exceptions 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 publication in brackets (e.g. ‘‘Smith 1998’’), or if the
main author’s name is part of a sentence, then
only the year is in brackets [e.g. ‘‘as described by
Smith (1998)’’]. For more than one author,
reference can be made in the text to ‘‘Smith et al.
(1998)’’ (note the italics). However, when writing the reference list, the convention is as follows: for up to five authors, write all the authors’
names; for six or more authors, write the first
three author’s 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 doubleblind randomized controlled study. Clinical Journal of Pain
18 (3), 149–153.
For books, give the author’s/editor’s surname
and initials, the year of publication, the book title
in italics, and the publisher and city of publication:
Williams P. L. & Warwick R. (eds) (1986) Gray’s Anatomy,
36th edn. Churchill Livingstone, Edinburgh.
For a chapter or section in a book by a named
author (who may be one of several contributors),
both chapter and book title should be given,
along with the editor’s name(s), and the first and
last page numbers of the chapter:
Bekkering R. & van Bussel R. (1998) Segmental acupuncture. 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
114
followed by all initials, the year of publication in
brackets, the document title in italics, an indication 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 be colour or
black-and-white, but will be printed in monochrome. Images must be in sharp focus. Photographs 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 twodimensional and all images must be monochrome. As with photographs, line illustrations
should be numbered and their placement indicated 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
introduction, a concise description of the patient
and condition, and an explanation of the assessment, 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 on
request.
Book reviews
General points to note
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 paperback, number of pages, and ISBN number. The
reviewer’s name should appear at the end of the
review in bold, right-justified, followed by their
title and place of work in italics. Reviews of
DVDs and DVD-ROMs should follow the same
format. Book reviews and reports are normally
no more than 500 words in length; query for
longer.
Please contact the Editor before writing a
review.
Please enclose your home, work and e-mail
addresses, and telephone number.
It is the author’s responsibility to obtain and
acknowledge permission to reproduce any
material that has appeared in another journal or
textbook.
A brief biographical note about the author(s)
should be included at the end of a clinical paper
in italics.
All notes and news should have clinical relevance to the AACP. Please refer at all times to
the style and layout of previous issues of the
Journal for whatever you are writing. Using these
guidelines will save time for the editorial team.
115
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www.scarboroughs.co.uk
Spring 2010
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Acupuncture & Clinical Supplies
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Books, Charts and Models .cta
Electroacupuncture & Lasers uk.n
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Journal of the
of Chartered
Physiotherapists
Spring 2010
ISSN 1748-8656