Aip Autumn 2018

Acupuncture in PhysiotherapyTM
Acupuncture in Physiotherapy TM
Journal of the Acupuncture Association

of Chartered Physiotherapists
Sports & Physical Therapies
Autumn 2018
including Acupuncture, Moxibustion
Volume 30, Number 2
Cupping, Magnetic and much more...
ACUPUNCTURE & MOXA TREATMENT ROOM TAPING MASSAGE

© Martinmark | Dreamstime
Volume 30, Number 2, Autumn 2018
REHAB & EXERCISE CUPPING SPORT SUPPORTS & BRACES
www.harmonymedical.co.uk
ISSN 2058-3281
t: +44 (0)208 5187337 e: admin@harmonymedical.co.uk
AACP ANNUAL
CONFERENCE
2019 Save The Date!
:ŽŝŶƚŚĞW
^ŽĐŝĂůDĞĚŝĂ
Celebrating our...
DATE: Saturday 18th May 2019

TIME: 9:00am - 5:00pm
DoubleTree by Hilton,
London Docklands,
London,
ŽŵŵƵŶŝƚǇ
SE16 5HW
dŚĞW
4-for-3 GROUP DISCOUNTS
Join us in London for our biggest conference yet. We will also be celebrating our 35th anniversary on Friday
17th May with an evening of fun, food and festivities...with a few surprises! We are offering complimentary ΛWͺWŚǇƐŝŽ
tickets to the anniversary celebrations for a limited number of conference delegates. Full speaker line-up to be
announced soon. Join us on Facebook, Twitter and LinkedIn to make sure you don’t miss any announcements.
ĐƵƉƵŶĐƚƵƌĞ ƐƐŽĐŝĂƟŽŶ ŽĨ
www.aacp.org.uk ŚĂƌƚĞƌĞĚWŚǇƐŝŽƚŚĞƌĂƉŝƐƚƐ>ƚĚ͘
#AACP35
ZZZVFDUERURXJKVFRXN
)ROORZXV
6FDUERURXJKV/LPLWHG
6LPHQH+RXVH
'RWWHU\
%ULGSRUW &XVWRPHU6HUYLFH
'7+6
8QLWHG.LQJGRP VDOHV#VFDUERURXJKVFRXN
W
KE>/E
^ŚŽƉ
ǆĐůƵƐŝǀĞƚŽWŵĞŵďĞƌƐ
KE>z&KZWDDZ^ >Kt^dWZ/^'hZEd d,^dYh>/dzWZKhd^
WKE>/E^,KWEKtKWE
dŚĞ W ŽŶůŝŶĞ ƐŚŽƉ ŽīĞƌƐ ĞǀĞƌǇƚŚŝŶŐ ǇŽƵ ŶĞĞĚ ĨŽƌ ǇŽƵƌ ĂĐƵƉƵŶĐƚƵƌĞͲƉŚǇƐŝŽƚŚĞƌĂƉǇ ƉƌĂĐƟĐĞ Ăƚ
ĞǆĐůƵƐŝǀĞƉƌŝĐĞƐ͊
ůů ƉƌŝĐĞƐ ĂƌĞ ƚŚĞ ůŽǁĞƐƚ ƉŽƐƐŝďůĞ ǁĞ ĐĂŶ ĂĐŚŝĞǀĞ͖ ǁŝƚŚ ŶŽ ŬŝĐŬͲďĂĐŬƐ ĨŽƌ ƚŚĞ W Žƌ ĂŶǇ ŽƚŚĞƌ ƉĂƌƚǇ͕
ƐŽ ĂƐ ĂŶ W ŵĞŵďĞƌ ǇŽƵ ďĞŶĞĮƚ ƚŚĞ ŵŽƐƚ͘
WƌŽĚƵĐƚƐ ŝŶĐůƵĚĞ͗
ĐƵƉƵŶĐƚƵƌĞŶĞĞĚůĞƐ
ƵƉƉŝŶŐƉƌŽĚƵĐƚƐ
<ŝŶĞƐŝŽůŽŐǇƚĂƉĞ
WŽƌƚĂďůĞĐŽƵĐŚĞƐ
ůŝŶŝĐĂůƐƵƉƉůŝĞƐĂŶĚŵŽƌĞ͘͘͘
WƌŝĐĞDĂƚĐŚWƌŽŵŝƐĞ͊
tĞ ĂƌĞ ĐŽŵŵŝƩĞĚ ƚŽ ƉƌŽǀŝĚŝŶŐ ǇŽƵ ǁŝƚŚ ƚŚĞ ďĞƐƚ ƉƌŽĚƵĐƚƐ Ăƚ ƚŚĞ ŵŽƐƚ ĐŽŵƉĞƟƟǀĞ ƉƌŝĐĞƐ͘ /Ĩ ǇŽƵ ǁŝƐŚ
ƚŽ ƉƵƌĐŚĂƐĞ ĂŶǇ ƉƌŽĚƵĐƚ ŽŶ ŽƵƌ ŽŶůŝŶĞ ƐŚŽƉ ĂŶĚ ĂƌĞ ĂǁĂƌĞ ŽĨ ƚŚĞ ƉƌŽĚƵĐƚ ďĞŝŶŐ ƐŽůĚ Ăƚ Ă ůŽǁĞƌ ƉƌŝĐĞ
ǁŝƚŚŝŶ ƚŚĞ h< ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƵƐ ĂŶĚ ǁĞ ǁŝůů ŵĂƚĐŚ ƚŚĞ ƉƌŝĐĞ Žƌ͕ ŝĨ ƉŽƐƐŝďůĞ͕ ďĞĂƚ ŝƚ͘
y>h^/s>z&KZ WZ/Dd, WZKhd^KhZ/E'

WDDZ^ WZKD/^͊ ^Zs/
EŽƚ ĨŽƵŶĚ ǁŚĂƚ ǇŽƵ͛ƌĞ ůŽŽŬŝŶŐ

KīĞƌƐ Θ ŝƐĐŽƵŶƚƐ ĨŽƌ͍ ZĞƋƵĞƐƚ ƵƐ ƚŽ ƐƚŽĐŬ ŝƚ͊
Contents
Autumn 2018
Editorial..................................................................................... 5
Chairman’s report.................................................................... 7
Chief Executive Officer’s report.......................................... 9
AACP Annual Conference................................................... 11
Literature review
Mechanisms and dose parameters of electric needle
Acupuncture in Physiotherapy stimulation: clinical considerations – Part I by T. Perreault,
S. O. Flannagan, M. T. Grubb & R. Grubb.......................... 17
www.aacp.org.uk Paradigm
The interaction and outcomes of acupuncture, both
Acupuncture in Physiotherapy is printed twice a year traditional Chinese medicine and intra-muscular
for the membership of AACP. It aims to provide stimulation, with Deep Oscillation® Treatment: a case
information for members that is correct at the time study-based discussion by C. Boynes.................................... 27
of going to press. Articles for inclusion should be
Practical applications of meridian theory in pain
submitted to the clinical editor at the address below
or by email. All articles are reviewed by the clinical management – the meridian wave approach by A. Ziv &
editor, and while every effort is made to ensure I. Levi........................................................................................ 35
validity, views given by contributors are not
necessarily those of the Association, which thus Research
accepts no responsibility. Types of control in acupuncture clinical trials might
affect the conclusion of the trials: a review of
Editorial address acupuncture on pain management by H. Chen, Z. Ning,
Dr Val Hopwood W. L. Lam, W.-Y. Lam, Y. K. Zhao, J. W. F. Yeung,
18 Woodlands Close B. F.-L. Ng, E. T.-C. Ziea & L. Lao.................................. 45
Dibden Purlieu How placebo needles differ from placebo pills by
Southampton SO45 4JG Y. Chae, Y.-S . Lee, P. Enck.................................................... 55
UK
Case reports
email: val.hopwood@btinternet.com
Acupuncture/dry needling as part of the physiotherapy
approach to greater trochanteric pain syndrome: a case
The Association
study by A. Manso.................................................................. 67
The British association for the practice of Western
research-based acupuncture in physiotherapy, Left elbow lateral epicondylalgia, treated successfully
AACP is a professional network affiliated with the with acupuncture combined with typical physiotherapy
Chartered Society of Physiotherapy. It is a intervention by Justin Walsh.................................................. 77
member-led organization, and with around 6000 The use of Seirin Pyonex indwelling needles in the
subscribers, the largest professional body for treatment of non-traumatic low back pain – a case study
acupuncture in the UK. We represent our members by D. Giura............................................................................... 83
with lawmakers, the public, the National Health Acupuncture for pain relief in a patient following hip
Service and private health insurers. The organization arthroscopic surgery by D. Atkinson................................... 87
facilitates and evaluates postgraduate education. The Acupuncture for the treatment of whiplash associated
development of professional awareness and clinical disorder by Suzanne Cronin.................................................... 95
skills in acupuncture are founded on research-based
evidence and the audit of clinical outcomes. Opinion
Electricity and electroacupuncture – a quick overview by
AACP Ltd
Sefton House, Adam Court, Newark Road, L. Pearce................................................................................. 105
Peterborough PE1 5PP, UK
Reviews
Tel: 01733 390007 Product review..................................................................... 109
Book reviews........................................................................ 111
Printed in the UK by Henry Ling Ltd News, views and interviews............................................... 115
at the Dorset Press, Dorchester DT1 1HD Guidelines for authors........................................................ 117
© 2018 Acupuncture Association of Chartered Physiotherapists 3

The greatest Chinese medicine resource
in the English language
Special offer - one month
free access to the entire JCM
online archives
three print
issues a year 1. Register on the website (jcm.co.uk) if
you haven’t already done so
2. Send an email to info@jcm.co.uk with
‘Special offer’ in the subject line (offer
valid until December 31st 2018)
exclusive 24/7 online 3. Wait for an email from us explaining
access to over 2000 how to access our vast 40-year archive
articles and abstracts of articles, abstracts and research news
Prices per year UK Europe

Practitioner £43 £46
Student £33 £36
exclusive online Student group* £28 £31
access to full 2000+ How to subscribe
*(minimum ten subscriptions mailed to a single address)
item JCM Research
Archive Online at www.jcm.co.uk/subscribe
Editorial
Welcome to the Autumn 2018 edition of

Acupuncture in Physiotherapy. After our long hot
summer, now it’s time to concentrate on the
interesting cases and current research in our
chosen field. As usual we have a varied selec-
tion. In this issue we have included three papers
previously published in other journals. On the
research front we offer Chen et al. (“Types of
Acupuncture in control in acupuncture clinical trials might
affect the conclusion of the trials: a review of
Physiotherapy acupuncture on pain management”) (pp. 45–53),
a really good look at some of the problems and
also some of the solutions.
www.aacp.org.uk In the same vein we have offered Chae et al.
(“How placebo needles differ from placebo
Journal Committee
pills?”) (pp. 55–66), which originates in the
Clinical Editor field of psychiatry and provides an overview of
Dr Val Hopwood FCSP
the characteristics of placebo needles and how
Corporate Editor they differ from placebo pills in two aspects:
Bethan Griffiths (1) physiological response and (2) blinding
(email: bethan@athene-communications.co.uk)
efficacy. The authors discuss alternative control
Book Review Editor strategies for the placebo effects in acupuncture
Wendy Rarity
(email: Wendy.Rarity@hotmail.com) therapy.
Amos Ziv has allowed republication of
News Editor
Rosemary Lillie his article “Practical applications of meridian
(email: wimbledonphysio@tiscali.co.uk) theory in pain management – the meridian wave
Public Relations and Marketing Officer
approach” (pp. 35–43), which previously featured
Jennifer Clarkson in the Journal of Chinese Medicine (October 2017).
(email: jennifer@aacp.uk.com) We also have an opinion piece on electro
AACP Office Manager acupuncture by Lynn Pearce (pp. 105–107) and
Lisa Stephenson an excellently comprehensive introduction to dry
(email: lisa@aacp.uk.com)
needling from Dr Thomas Perreault (pp. 17–26).
As usual, our members have provided an
AACP Ltd Board Members absorbing collection of case studies:
Chairman: Jon Hobbs • André Manso on trochanteric bursitis
Lesley Pattenden • Justin Walsh on epicondylalgia
Paul Battersby
Diana Giura • Suzanne Cronin on whiplash associated
Suzanne Nitta disorder
Chris Collier MBE
Wendy Rarity • Daniel Atkinson on hip arthroscopic surgery
Caspar van Dongen • Diana Giura on low back pain.
Chief Executive Officer: Caspar van Dongen

Additionally, we also have some short sum-
Auditor: Rawlinsons, Peterborough maries (compiled by Robert Millett) of the
Company Secretary: Michael Tolond contributions from the speakers at the May
conference, including John Cross, Lynn Pearce,
Thomas Perreault, Johnny Wilson and Cheryl
Mason.

Editorial
Finally, you’ll find a selection of book Dr Val Hopwood FCSP, FAACP
reviews, an equipment review and some exciting Clinical Editor, Acupuncture in Physiotherapy
news regarding Helene Langevin.
6 © 2018 Acupuncture Association of Chartered Physiotherapists

Acupuncture in Physiotherapy, Volume 30, Number 2, Autumn 2018, 7–8
Chairman’s report
Welcome to the latest edition of the being on the editorial board for the International
Acupuncture Association of Chartered Journal of Childbirth. Dr Lokugamage presented
Physiotherapists (AACP) journal Acupuncture in an insightful talk exploring “Why Women Seek
Physiotherapy, in autumn 2018. Even through the Acupuncture and Complementary Medicine for
long hot summer, the team at the AACP office Women’s Health.” Another speaker of note
has been working diligently to ensure the latter was Chris Nortley. Chris brings 30 years of
half of 2018 is as productive as the former was. experience to the AACP stage, first as a clini-
Following on from the success of the AACP’s cal specialist nurse in psychiatry, and then as an
annual conference held on 19 May in Reading, acupuncturist treating inpatients and outpatients
we had two other key dates for the AACP diary with a range of mental health and general medi-
in the autumn: 13 October for the AACP’s cal conditions in the National Health Service
conference in Leeds, and 3 November for the (NHS). A clinician of considerable standing,
AACP’s Scotland study day in Edinburgh. These Chris was presented with an award by HRH
are part of the continuing efforts of the AACP The Prince of Wales for his work in integrating
to reach members across the country and to acupuncture into the NHS in 2003; in 2004 he
improve access to ever expanding knowledge in was featured in the Independent on Sunday as one
research and approaches in clinical practice. of the ten leading acupuncturists in the UK,
Notable speakers in Leeds included Dr and in 2011 he received an ‘Acupuncture Hero’
Giovanna Franconi, Dr Daniel Keown and Dr award from the British Acupuncture Council.
Amali Lokugamage. Dr Giovanna Franconi is Chris presented “an Introduction to Traditional
assistant professor of Internal Medicine at Tor Chinese Medicine.” Other speakers included the
Vergata University in Rome, and a member ever popular Andy Harrop presenting the rela-
of the editorial board of the European Journal tionship of “the Adrenal Glands in Diagnosis
of Integrative Medicine. Dr Franconi presented and Treatment,” and AACP Fellow, David
the intriguing topic of “Traditional Chinese Mayor, who was “Exploring Amplitude in
Medicine (TCM) and Acupuncture in the Omics Transcutaneous Electroacupuncture Stimulation
Era.” Making a welcome return to the AACP (TEAS).”
conference stage was Dr Daniel Keown, author The Scotland study day in Edinburgh wel-
of the critically acclaimed book What God Forgot comed four practicing clinicians to the stage
To Tell Surgeons. Following in the theme of this to share their wealth of knowledge and clinical
popular treatise, Dr Keown informed those in experience which informed their approaches to
attendance why “Qi Exists!” Also presenting was a variety of clinical scenarios. Subjects vary from
internationally renowned consultant obstetrician “Acupuncture, Pain and the Emotional Mind”
and gynaecologist, and fellow of the Royal presented by John Wood, to “Acupuncture
College of Obstetricians and Gynaecology, Dr Within Sport” with Johnny Wilson, to
Amali Lokugamage. Dr Lokugamage has been “Acupuncture in Neurology” with Caroline
lauded for her work in promoting respectful care, McGuire. The day opened with Lynne Pearce’s
dignity and autonomy in maternity services as insightful reflections on “Fascial Connections”
well as lecturing on the origins of compassionate and their relationship and influence within acu-
behaviour and social cohesion. Dr Lokugamage puncture. Further information on the Leeds and
is a member of the board of directors of Edinburgh events can be found on the AACP
the UN- recognized International Motherbaby website.
Childbirth Organization and sits on the advisory This summer saw the appointment of a
board of Human Rights in Childbirth, as well as new AACP clinical advisor in the person of

Chairman’s report
longstanding AACP tutor and acupuncture BSc one and obtaining free places, then please con-
lecturer, Paul Battersby. Paul has taken up the tact course administrator Claire Buckingham at
reins and has relished the new challenge of claire@aacp.uk.com.
dealing with members’ enquiries in addition to The AACP’s public relations and marketing
reviewing research and supporting the devel- officer Jennifer Clarkson (jennifer@aacp.uk.com)
opment of a variety of AACP projects and has been busy this year across a number of
member benefits. For support with your clinical media platforms promoting the skills and expe-
queries please contact Paul directly at paulb@ rience of AACP members to the general public.
aacp.uk.com. Recent statistics show that over 9 million media
Following a recent update in IT services, the contacts have been made in the last 12 months
AACP has also opened up the archives and now with potential patients of AACP members via
the last ten years of the journal of the AACP a variety of print and electronic publications.
is searchable online for members. Log in as Feel free to contact Jennifer directly to discuss
an AACP member and search Acupuncture in promotional and media queries further.
Physiotherapy with a keyword, subject or author This summer, the AACP team has also been
name. The system is updated every six months working on the development of a significant
and forms a great research aid and another use- new member benefit that is set for launch
ful AACP member benefit. soon. Watch out for updates in the monthly
There is also now more continuing profes- e-newsletter on this great new resource free to
sional development (CPD) available than ever AACP members.
this year with one-and two-day courses cover- Thank you as ever for your ongoing support
ing a variety of topics, from brushing up on for the AACP. Thanks to you, the AACP is
basic skills to advanced needling techniques and approaching another milestone anniversary, with
concepts. Included within the CPD portfolio 2019 seeing its 35th year! Thirty-four years on,
this year is the addition of another “Anatomy and the AACP administrative and management
for Acupuncture” day. Now in its third year, team continues to work hard to support mem-
this CPD event gives members the opportunity bers and deliver the best member experience
to work with Luke Welsh, Anatomy Teaching possible. If, however, you feel there are issues
Fellow at Keele School of Medicine, and use the AACP need to be addressing or you have
state-
of-
the-art technology and cadavers to any ideas on how you would like to see the
explore in intimate detail the human anatomy AACP develop or improve, particularly as we
beneath the acupuncture points. From 2018 reach another landmark together, then please
there will now be two events per year, one in feel free to get in touch with the office or me
May and one in November. This course is unique directly (chair@aacp.uk.com). As ever, I look
for the UK and has already attracted attendees forward to catching up with you in person at an
from across the world who have an interest in AACP event somewhere soon.
expanding their knowledge of anatomy related
to clinical application of acupuncture. If you Jonathan Hobbs
are interested in attending any of the courses AACP Chairman
listed on the AACP website, or even hosting

Acupuncture in Physiotherapy, Volume 30, Number 2, Autumn 2018, 9
Chief Executive Officer’s report
Musings on membership a clear majority of board members are drawn

mutuality from the membership. All income generated
As we approach the AACP’s 35th anniversary by the organization is spent for the benefit of
year in 2019, I would like to thank all AACP AACP members now or in future years.
members, past and present, for their support How much you are able to influence the
of the Association through all those years. This AACP and what we do depends very much on
has made us and kept us by far the longest your involvement with the organization. AACP
established and largest organization represent- committees regularly have a vacancy that needs
ing acupuncture in the UK. to be filled. It isn’t necessary to wait for that,
At the AACP’s inaugural meeting in the though; we are always open to ideas from
autumn of 1984, its very first chairman, Mr members and sometimes a simple email may
Neville Greaves, couldn’t have imagined that be sufficient to influence direction. Just let me
someday the AACP would represent around know via ceo@aacp.uk.com if there is anything
6000 acupuncture-physiotherapists. you would like to share or discuss. It might be
Thirty-
five years after its conception, as a that one idea that makes the difference!
mature organization, the AACP is going strong We may be 35 soon, but we will never stop
in representing your interests and promoting innovating. In the coming few months we will
your acupuncture services to the British public be able to present some new technological
at large. In turn, we wouldn’t be able to do developments that will be available to AACP
this without the continued support of you, our members only. These new developments to sup-
members. For many years now you have helped port you in your application of acupuncture in
us to be the largest acupuncture association in physiotherapy are in turn only possible through
the country, and our size and clout is important your continued membership of, and support
in offering you the best possible support. This for, your AACP.
mutuality, this circularity of support, is the basis The continuation of this synergetic mutuality
of our success: yours and AACP’s. for another 35 years will strengthen the founda-
This mutuality expresses itself also in our tions of the AACP, ensuring that we are able
organizational structure. As a company limited to improve and enhance the support for our
by guarantee, we are owned by and operate only members for many years to come.
for the benefit of our members. The AACP
is run by a board of directors elected by the Caspar van Dongen
membership at the annual general meeting. And Chief Executive Officer

AACP Annual Conference, 19 May 2018
Introduction compared three groups of pregnant women

This year’s annual conference took place at with back pain. One group received standard
the Hilton Hotel in Reading, where delegates care that included two to four sessions of one-
were presented as usual with a wide range of to-
one physiotherapy and a self- management
informative and thought provoking material to booklet. The second group received standard
develop their professional understanding and care, plus six to eight sessions of acupuncture.
incorporate into their daily practice. The third group received standard care, plus
Summaries of the majority of these presenta- non-penetrating sham acupuncture.
tions follow below, while Chris Boynes’ personal “At the eight-week follow-up they found that
and clinical perspectives on the interaction and 74% of participants favoured the addition of
outcomes of Deep Oscillation® Therapy with acupuncture,” said Ms Mason. She told delegates
acupuncture can be found in his article on pp. there were three possible ways acupuncture
27–34 in this issue of Acupuncture in Physiotherapy. may ease pain: via a mechanical local action, a
neurological action or a hormonal one. “The
needles create a local trauma response – a flood
Acupuncture in women’s health of antihistamines, a mast cell response. And
Cheryl Mason they have an influence on the muscle spindle,
A key question for delegates at the confer- which is great if you are treating pelvic girdle
ence was whether acupuncture could provide pain, because you can treat local points and get
relief from pelvic girdle and low back pain in results with the muscles, tissues and fascia. We
pregnancy. It was posed by Cheryl Mason, an also know acupuncture produces a neurological
acupuncturist with a private clinic in Leeds effect. For instance, there is the work of Hugh
who has experience of working in NHS nurs- McPherson, who featured on the BBC’s ‘Trust
ing, midwifery and pain management teams. In Me I’m a Doctor’ in October 2014, using
her presentation, she outlined research findings MRI scanners to show that pain modification
which indicate that acupuncture can provide centres in the brain light up during acupunc-
relief to pregnant women with these types of ture. A lot of scientific research shows it’s not
pain. placebo. There are real effects produced by the
“A 2006 study (Van de Pol et al.) showed that needles.”
acupuncture did appear to reduce low back pain Delegates also heard that acupuncture
and pelvic girdle pain during pregnancy, increas- could also have an effect on hormones, so it
ing people’s capacity to exercise and carry out was important not to needle contraindicated
daily activities,” she said. “Another study in points when treating pregnant women. “We
2009 (Wang et al.), using one week of continu- know acupuncture can stimulate serotonin and
ous auricular acupuncture on the ears, showed oxytocin production, as well as other neuro-
a significant reduction in pain compared to transmitters,” said Ms Mason. “In pregnancy
sham acupuncture control groups.” She also the nervous system and endocrine system are
cited the findings of a 2016 feasibility study quite delicate and predisposed for labour. If we
and pilot randomized controlled trial which are stimulating oxytocin production by insert-
evaluated acupuncture and standard care for ing needles into certain points we could theo-
pregnant women with back pain. It was led by retically stimulate labour. We need to be aware
Chartered Society of Physiotherapy member which points are safe to use.” She referred to a
Nadine Foster from Keele University. The study Cochrane Database review into acupuncture or

Conference 2018
acupressure for induction of labour, published self-limiting, but I’ve had two players over the
in October 2017. The review highlighted that last nine years whose careers have ended due to
acupuncture showed some benefit in improving low back pain.”
cervical maturity, making it more favourable for Mr Wilson, who has worked in professional
labour. Therefore, using the wrong points could sport for 17 years, said the high incidence of
potentially result in this effect. low back pain was down to the extreme physi-
Ms Mason said there had been more than cal demands of the sport. He explained that
8000 randomized controlled trials into acupunc- professional footballers usually played in at least
ture in the last eight years. “But there is still 60 games and 160 training sessions over a 10-
some confusion over its effectiveness, so we month season. In addition, while sprinting, play-
need more quality research,” she said. “What ers can reach top speeds of 32.8 km per hour
we do know, however, is that acupuncture has and often cover in excess of 10 km per game.
a good safety profile and is especially relevant “Because of these demands we incorporate as
for pregnancy and the treatment of pelvic girdle many strategies as we can to keep the guys on
pain and other pregnancy- related conditions.” the pitch.”
She added that, if attendees were planning a He also told delegates that low back pain
treatment protocol for women with pregnancy- often presented a “conundrum” because there
related pelvic girdle and low back pain, research was a lack of consensus about how to provide
by Matthew Bauer (2016) indicated that 16 or the best care. This had led to what he described
more treatments of acupuncture lead to the as a “management vacuum”. However, he said
greatest success rates. several research groups have suggested that
longstanding low back pain can be generated
Robert Millett and maintained at the local tissues (the site of
pain), as well as in the corresponding spinal
Acupuncture-physiotherapy in segment and at a cortical level. As a result, he
regularly offers acupuncture to athletes who
sports complain of low back pain, as research has
Johnny Wilson conclusively shown it can inhibit the sensation
Professional football players often experience of pain locally, segmentally and cortically.
low back pain which can be challenging and Mr Wilson said he advocated integrating
complex to treat, but acupuncture can help as acupuncture into a multimodal sports medicine
part of a multimodal approach. approach and provided details of a case study
This was the message at the conference from of how this had worked with a young profes-
Johnny Wilson, clinical director of Athlete sional footballer. The player had complained of
Rebuild and former head physiotherapist for an intermittent dull ache at rest. This rose to a
professional football clubs Notts County, high pain level (8 out of 10) whenever he ran
Scunthorpe and Chesterfield. He shared his or engaged in extension-based exercises in the
experience of how acupuncture could improve gym. He also experienced stiffness, discomfort
the outcomes of injuries in professional sport. in sustained postures and could only maintain
Mr Wilson said: “In professional football we a neutral pelvic tilt in any position. Adding to
deal, on a day-to-day basis, with what are com- this, he had high anxiety levels as the pain was
monly known as ‘the big four’, because they preventing him from playing or training at full
carry quite a high burden of injury. They are intensity. He feared he might lose his place
hamstring, ankle, knee and groin injuries. But on the team. No red flags were identified and
what is less well known is the prevalence of low nothing remarkable was found on examination.
back pain, which is what I spend the majority In addition, an MRI scan showed no structural
of my time dealing with. Players come to the abnormalities. ‘So we hypothesized that it must
clinic and have a lot of mobilization and manual be neurophysiological and tested him using
therapy on their lumbar spines. It’s generally Peter O’Sullivan’s movement and functional

Conference 2018
impairment system for assessing low back pain,” During his presentation, which focused on
Mr Wilson said. “We did a lot of education the use of clinical acupressure for neurological
with him, which was important, and his anxiety conditions, Mr Cross said: “Why do we use
settled down. We talked about pain and tissue acupressure? Because it’s non- invasive, which
damage and possible neurophysiological drivers, is great for patients and also, sometimes, for
which he thought were plausible. After that, he practitioners – because not all of us like nee-
was keen to try acupuncture, which he’d never dles. Also, I found that acupressure allows you
had before.” to have a greater rapport and oneness with
A multimodal approach was implemented, your client, because you receive constant feed-
which included eight 20-min sessions of acu- back and confirmation about how treatment is
puncture and the outcomes were “very good . . . progressing. Patients tend to relax more easily
The sports medicine department was happy to and it allows you to teach self-help procedures,
advocate acupuncture as part of his programme which you can show them after a session and
because it kept him in training and helped to which they can use between treatments.”
increase his levels of participation in terms of Mr Cross said there were many types of acu-
intensity of running and gym training,” said Mr pressure, and shared his theory that acupressure
Wilson. “He also did other things as well, such and reflexology are synonymous, citing examples
as practising mindfulness. But post-acupuncture, of their similarity. “Every acupressure-point on
he told us something had changed for him. He the body is a reflex of something. A reflex is
felt looser and we could all see a difference in a reflected point or pathway, and every reflex
him.” point can be touched, massaged or needled.
Delegates heard that it was common for And there is a misconception that reflexology is
athletes to report reduced pain levels, improved just concerned with the feet and hands. Reflex
lumbar range and improved function on poste- points and areas are all over the body, not just
rior chain strength tests after acupuncture. Mr on the feet and hands.”
Wilson uses it in conjunction with an extensive He described how therapists could use
running, strength, power, neuromuscular con- acupressure and reflexology to ease symptoms
trol and lumbo-pelvic-hip complex stability and associated with neurological conditions, includ-
education programme. “I also offer it as an ing stress, thermal imbalance, flaccidity, spasms,
option to players to help modulate pain levels, fatigue, incoordination and pain.
help them carry out their rehab and return to With the aid of pictures, he showed delegates
training and competing in a timely and safe relevant acupressure points and described their
manner.” therapeutic uses. Mr Cross also highlighted how
the spine, brain, cranial nerves and autonomic
Robert Millett nervous system are thought, by some cultures
and branches of traditional medicine, to be
Acupressure for neurological ‘reflected’ on other regions of the body.
conditions Robert Millett
John R. Cross
Acupressure is not a diluted version of acu-
puncture, as some people mistakenly believe,
Temporomandibular disorders
and has the advantage of providing non-invasive Dr Thomas Perreault
treatment. This was one of the messages from Dr Thomas Perreault, clinical specialist physical
Chartered Society of Physiotherapists Fellow therapist from the US, presented “Dry Needling
John Cross. Mr Cross, a retired physiotherapist for Myofascial Temporomandibular Disorders:
who has used acupressure for almost 40 years, Case Study and Review of the Literature.”
was the first chartered physiotherapist to Dr Perreault opened by defining tempo-
become a registered acupuncturist. romandibular disorder (TMD) as pathologies

Conference 2018
of the temporomandibular joint, masticatory In summary, Dr Perreault’s presentation gave
muscles, and related anatomical structures. an insight into the clinical application of needl
Presenting a review of the current literature, ing for TMD supported by relevant published
he stated that myofascial TMD is prevalent literature. With reference to an example case
in patients with orofacial pain and is strongly study, he discussed the practical application of
linked to central sensitization. He proposed that needling regarding angle of insertion, depth
trigger point dry needling and acupuncture are of needling, safety aspects and the accurate
widely accepted therapies used in the treatment and effective location of target structures.
of myofascial pain syndromes (MPS) which Overall, he drew together the integral aspects
include myofascial TMD. He outlined several of evidence-based practice; namely the integra-
studies that showed that needling to trigger tion of individual clinical expertise and experi-
points of the temporalis, masseter, and lateral ence blended with the best available published
pterygoid can help to alleviate TMD pain and evidence, whilst considering patient preference
improve function. to obtain a positive outcome. His style of
Based on these opening statements, Dr presentation was fluid, engaging and informa-
Perreault went on to present a case study of a tive throughout and raised several interesting
13-year-
old female with intermittent left-sided clinically-
related questions which he answered
jaw and facial pain that had been ongoing for directly following his session.
two months. The outcome of her case dem-
onstrated the positive benefits of needling to Jonathan Hobbs
trigger points within the masticatory muscles AACP Chairman
with subacute myofascial TMD. The needling
techniques chosen included direct needling of It’s all in the anatomy – the
the masseter and lateral pterygoid. Dr Perreault merging worlds of fascia and
supported the outlined needling protocols with
direct evidence from the literature that con-
meridian theory
firmed the positive effects of accurate and direct Lynn Pearce
needling into the involved masticatory muscles. Lynn Pearce has been working with her acu-
Discussing other interventions for TMD, he puncture and physiotherapy skills and slowly
proposed that needling was selected as the moving towards a place of integration of the
primary intervention as literature reviews now reality of anatomy which is our baseline as
conclude the lateral pterygoids are inaccessible physiotherapists and the sometimes more eso-
to intraoral palpation, thus rendering manual teric concepts of meridians. She freely admitted
therapy to this muscle ineffective. Describing that this talk was still a work in progress as there
the specifics of needling technique, he discussed are so many avenues to try and pull together,
empirical evidence that suggests that eliciting a but hoped there might be some new ideas and
local twitch response (LTR) during needling is ways of looking at the body as a whole.
essential. He then, however, highlighted a recent Starting with the anatomy, Ms Pearce outlined
review of more up-to-date studies showing that where we are with the study of fascia and the
eliciting a LTR does not necessarily correlate development of new ideas on its functional and
with positive changes in pain and disability but sensory role, making it more than just a mechani-
is linked to increased pain and inflammation. cal tissue. The ‘new organ’ – the interstitium,
He went on to state that restoration of normal as suggested by Neil Thiese – adds another
mandibular movement, function, and rapid dimension to fascial anatomy that deserves
relief of pain was observed at the conclusion of enquiry. Challenging where people actually place
treatment. Treatment consisted of four sessions their needles, the idea was to think about how
using manual needle winding to trigger points techniques within superficial fascia can seem to
without inducing a LTR, as this approach was have a widespread effect by relating that back to
well supported in the literature. the nature of fascia itself.

Conference 2018
Ms Pearce pointed to The Fascia Research responsive to changes in the autonomic nervous
Society – a group including Helene Langevin, system (ANS). This could provide some expla-
Robert Schliep, Tom Myers, Siegfried Mense and nation as to how emotional stress can cause an
many more – which is pushing the boundaries increase in nociceptive pain and far flung signs
as to our understanding of the most interesting and symptoms.
tissue of the day. Dan Keown, author of the Looking at the combined pictures of main
book The Spark in the Machine, also outlines a meridians, musculoskeletal meridians, trigger
fascinating view of the spaces within fascia as points and their referral, or Tom Myers’ anat-
meridians and the concept that surgeons use omy trains, Ms Pearce showed that if we pick
these spaces to get round the body, not realising key acupuncture points based on anatomical
they may be using the meridian network. intersections, those points will readily transpose
Through works by Leonardo da Vinci, from one system to another, occurring in the
whose anatomical studies show us clearly the same place and yet having different effects
‘valleys and grooves’ of the body/meridians, dependent on the therapist’s belief systems.
as explained in the Huangdi Neijing, Ms Pearce Regardless of those belief systems, the place-
explored the placement of needles, and what ment of an acupuncture needle will have far
you feel for as therapists, in longitudinal planes reaching effects, partly described by the role
as opposed to transverse. She highlighted how and structure of the fascial network that we
Langevin’s work shows that tissue displacement needle into. Whether Qi, or current, or fluid,
along fascial planes is more effective if a needle or all of them, flow through that target region,
is placed in a ‘groove’ – i.e. within the inter- that is the mental struggle of definition that we
muscular tissue as opposed to intra-muscular tis- face as scientific therapists who also play with
sue. This may also account for the bidirectional energy in its raw form. We all like to have an
report of sensation some people get when answer, but sometimes there isn’t just the one
having acupuncture. The effect of stress on answer, and merging worlds just explain things
the sympathetic system is well known, and Ms in different ways.
Pearce drew attention to Mense’s work which
shows a proportionally high number of free Robert Millett
nerve endings within superficial fascia which are

literature review
Mechanisms and dose parameters of electric

needle stimulation: clinical considerations –
Part I
T. Perreault
Northern New England Spine Center, Department of Physical Therapy, Wentworth-
Douglass Hospital, Dover, New Hampshire, USA
S. O. Flannagan
Founder One Accord Physical Therapy, Phoenix, Arizona, USA
M. T. Grubb
The University of Tennessee, Chattanooga, Tennessee, USA
R. Grubb
The University of Tennessee, Chattanooga, Tennessee, USA
Abstract
Recent studies support that electric needle stimulation (ENS) provides superior analgesic
effects compared to manual needle stimulation alone, making it preferable for the clinical
management of chronic pain. An electronic database search was performed with the aim
of completing a narrative review of the literature to explore the neuronal mechanisms trig-
gered by ENS from a clinical standpoint. The majority of studies on ENS mechanisms
support the use of strong, noxious needle stimuli for greater pain inhibition at the spinal
and supraspinal levels. Multiple studies support that noxious ENS enhances spinal serotonin
(5-HT) and noradrenaline (NA) levels by activating supraspinal neurons that project down
to the level of the spine, and that both NA and 5-HT have an overall effect of creating
anti-nociception. Further, arginine vasopressin (AVP) is released due to noxious ENS leading
to amplified effects of the descending pain inhibitory systems. Various studies supported the
use of lower frequency ENS for inducing a potent anti-nociceptive effect in the periphery
by enhancing anandamide levels, increasing the availability of its target receptor, and up-
regulating the endogenous opioid system in the periphery. Additionally, longer durations of
electric stimulation (between 15 to 30 min) resulted in longer lasting analgesic effects and
increased pressure pain thresholds in human subjects. A multitude of analgesic mechanisms
are triggered with electric needle stimulation; however intensity of stimulation, needle place-
ment within the segmental distribution of pain and duration of ENS seem to be the most
important dose parameters for greater anti-nociceptive effects.
Keywords: acupuncture, analgesia, needle, pain, stimulation.
Correspondence: Thomas Perreault, Physical Therapy Introduction

Department, Wentworth- Douglass Hospital, 789 Dry needling and acupuncture are routinely
Central Avenue, Dover, New Hampshire 03820, administered treatments for the management
USA (email: thomas.perreault@wdhospital.com). of chronic pain conditions (Zhou et al. 2015).

Mechanisms and dose parameters of electric needle stimulation – Part I
Both procedures use needle stimulation to parameters of electric needle stimulation for
trigger endogenous mechanisms that are anti-nociception. With the intent of perform-
advantageous for altering sensory perception ing a narrative review, included articles were
(Baeumler et al. 2014) and decreasing pain in not limited to randomized controlled trials,
neuromusculoskeletal (NMSK) disorders (Yuan systematic reviews or meta- analyses, nor were
et al. 2016). According to a recent review, the they limited to studies only on human subjects.
analgesic effects following a course of needling An electronic database search of PubMed,
treatments in patients with chronic pain have MEDLINE, Science Direct and Google Scholar
been reported to last for up to a 1-year period was performed using the following terms: dry
(MacPherson et al. 2017). Fundamentally, manual needling, acupuncture, electroacupuncture,
stimulation occurs when needles are inserted electric AND needle stimulation, dry needling
into the body and positioned to the desired AND segmental, acupuncture AND segmental,
depth; however, manipulation of the indwelling acupuncture AND analgesia. No restrictions
needle is required for the activation of local were placed on date of article publication and
(Yin et al. 2018), spinal (Kagitani et al. 2010, only articles written in English were reviewed.
Huang et al. 2018) and supraspinal (Niddam et al. Additionally, the reference lists of included
2007) analgesic effects. It is currently unknown studies were also hand searched to identify any
what an optimal needling dosage is for any articles relevant to the selected topic. Irrelevant
musculoskeletal condition, however, strength of articles were discarded.
needle manipulation (Choi et al. 2013), increas-
ing the number of needles used (MacPherson
et al. 2013) and administering repeated needling
Discussion
sessions (Vickers et al. 2018) are dosage param- ENS effects are intensity dependent
eters that have been shown to enhance clinical The neural pain inhibitory mechanism that is
outcomes. Clinically, electrical stimulation of activated via ENS is dependent on the intensity
needles is added to enhance or even replace of stimulation. Whether the intensity parameter
the therapeutic effects of manual needling due is noxious or non- noxious will govern which
to the elicitation of unique biological effects afferent fibres are stimulated and also if local,
(Langevin et al. 2015). Recent studies support spinal segmental, or more systemic analgesic
that electric needle stimulation (ENS) provides effects are triggered. According to Xin et al.
a greater analgesic effect making it preferable (2016), segmental analgesia is triggered by
to manual stimulation alone (Manheimer et al. applying ENS of low intensity (i.e. below pain
2010; Baeumler et al. 2015), and that repeated threshold) to a local point on the side of pain.
application of strong ENS can be safely used Applied at higher intensities (i.e. at or above
with other therapies for both reducing pain and the noxious level), ENS was shown to increase
opioid medication usage (Zheng et al. 2018). thermal and mechanical pain thresholds within
The aim of this narrative review is to explore and beyond the segmental distribution of
the neuronal mechanisms triggered by ENS needle stimulation on the ipsilateral and con-
from a clinical perspective. More specifically, tralateral sides, respectively (Xin et al. 2016). In
this review will summarize relevant literature an earlier study on human subjects, depression
focusing on dosage and stimulation parameters of the nociceptive reflex and pain sensation was
of ENS that best contribute to analgesic effects achieved using ENS applied at and beyond pain
in patients with painful NMSK conditions. thresholds, reaching depression levels of 58.8%
and 60.7% respectively (Xu et al. 2003). Taken
together these studies support the use of strong,
Materials and methods noxious needle stimuli for greater segmental
Literature research pain inhibition. However, according to both
Literature for this narrative review was sought studies, ENS had no effect on pain or reflex
that investigated mechanisms and/or dosage inhibition when low intensity ENS was applied

T. Perreault et al.
to a contralateral acupoint within the same released by noxious ENS suppress ascending
segmental level. Zhu et al. (2004) reported that nociceptive activity, triggering a potent supra
at the segmental level, analgesia was enhanced spinal mechanism that induces trans-segmental
in an intensity- dependent manner with ENS or global pain inhibition.
and strongest when applied to homo-segmental
locations. More specifically, as the strength of ENS induces segmental inhibition
needle stimulation increased, thereby reaching Pain inhibition occurs in a pattern relative to
and surpassing activation range of Aδ and/or the spinal segmental distribution of the patient’s
C-fibres, it resulted in greater and longer last- symptoms when needles are inserted (and elec-
ing depression of the C-fibre reflex response. trically stimulated) within that same distribution
In addition, contralateral stimulation to the (i.e. segmental inhibition). Using non- painful
same acupoint also produced potent inhibi- electrical stimuli, Baeumler et al. (2015) con-
tory effects in an intensity dependent manner. cluded that short term increases in pain pressure
However, only noxious contralateral stimulation threshold (PPT) were confined to a sensory
to the same point was effective in inducing region of the L4-L5 segment in close proximity
segmental effect; while innocuous stimuli was to the needling sites. This was noted on both
ineffective (Zhu et al. 2004). Additionally, strong the treated limb and contralateral lower leg. In
stimulus to a remote heterotopic acupoint (i.e. comparison to manual acupuncture, electrical
remote to the side of pain) in the forelimb stimulation provided a more robust improve-
was shown to produce trans- segmental anal- ment in PPT, however, no changes in pressure
gesia through involvement of diffuse noxious sensitivity were observed heterosegmentally
inhibitory controls (DNIC) and induced a clear when measured at the C6 segment with either
depression of the C- fibre reflex response on modality (Baeumler et al. 2015). Similarly, Lang
the ipsilateral hind limb. It is known that Aβ et al. (2010) reported using non-noxious electric
afferent fibres, which mediate light touch, are stimuli to four needles in the anterior lower leg
preferentially stimulated with innocuous ENS and found a bilateral increase in PPT over the
(Kagitani et al. 2010), resulting in the activa- sensory region of the peroneal nerve within
tion of GABAergic inhibitory interneurons in the L4 segment. Manual needle stimulation was
the superficial laminae of the dorsal horn that similar in effect for providing bilateral increases
inhibit Aδ and C-fibre input, which leads to pain in PPT with unilateral stimulation (Lang et al.
relief within the stimulated segment (Baeumler 2010). Collectively, the above studies support the
et al. 2015). Noxious stimulation also triggers a concept of a segmental needling approach that
release of endogenous opioids and inhibitory can be complemented with ENS. A limitation in
neurotransmitters (GABA and glycine) in the the above studies is that they were performed
spinal cord (SC). Several studies show ENS on healthy volunteers and not on patients
induces a release of spinal endogenous opioids with pain. However, a recent meta-analysis of
(Zhao 2008), up-regulates the release of GABA 85 studies reported significant short-term and
(Qiao et al. 2017), and potentially leads to a long- term effects of acupuncture on PPT in
release of glycine in the SC (Zhou et al. 2008; patients with painful musculoskeletal disorders.
Butts et al. 2016). Accordingly, this contributes Additionally, it was concluded that ipsilateral
to spinal segmental inhibition and suppression needling close to the measurement sites elicited
of glutamate activity in post- synaptic dorsal the strongest effects on sensory thresholds
horn neurons. It is proposed that inhibition than remote or contralateral needling (Baeumler
will also occur in ascending spinal neurons that et al. 2014). This supports the concept that seg-
project to the basal forebrain, leading to activa- mental inhibition is dependent on stimulation
tion (i.e. dis-inhibition) of a spino-supraspinal of primary afferents that carry noxious and
opioid- dependent mechanism in the nucleus non-noxious input to the spinal level, thereby
accumbens (Tambeli et al. 2002; Tambeli et al. assisting with analgesia in the same segment of
2003). That is, endogenous neuromodulators the needle stimulus. Thus, there do appear to be

compelling clinical precedents for using a spinal and the dorsal horn of the SC to alter pain
segmental approach to needling for painful sensation.
musculoskeletal disorders.
ENS reduces inflammatory pain
ENS local analgesic effects ENS has been shown to reduce pain from
ENS can help to relieve inflammatory pain via inflamed tissue through activating the endo-
down- regulation of nociceptive ion channels. cannabinoid and endogenous opioid systems.
Manual needle manipulation has been shown to Anandamide is an endogenous cannabinoid that
mechanically activate pain channels that induce activates two receptor types (CB1 and CB2) that
nociceptive effects (Wu et al. 2014). The
anti- inhibit nociceptive input to the SC dorsal horn.
aim with ENS, however, is to reduce influx of CB1 receptors are localized on primary afferent
cation currents to sensory receptors to inhibit neurons, within the spinal dorsal horn, and the
pain related action potentials. More specifically, Central Nervous System (CNS). CB2 receptors
ENS has been shown to target and suppress are located primarily on immune cells to include
transient receptor potential vanilloid-1 (TRPV1), mast cells, macrophages, keratinocytes, and
a channel that is involved in detection of T-lymphocytes. Application of low or high fre-
mechanical, thermal, and acid-induced pain in quency ENS can elevate anandamide levels in the
the periphery, dorsal root ganglion (DRG), and periphery by promoting its synthesis and release
SC level (Yang et al. 2017). TRPV1 activation from epidermal keratinocytes. Importantly, the
occurs under inflammatory conditions, leading anti-nociceptive effects of ENS are correlated
to both increased nociceptive action potentials with the subsequent increase in peripheral anan-
and enhanced expression of the TRPV1 recep- damide levels that rely on activation of local
tor in neurons of the DRG and spinal dorsal CB2 receptors (Chen et al. 2009). Additionally,
horn. A novel study reported that low frequency ENS of high or low frequency can up-regulate
ENS to a point segmentally related to the area the expression of CB2 receptors on resident
of pain induction decreased inflammatory pain immune cells and leukocytes that are recruited
in an animal model by reducing the expression to areas of inflamed tissue (Zhang et al. 2010).
of TRPV1 and TRPV4 receptors in ipsilateral By activating CB2 receptors, anandamide can
DRG neurons projecting to the L3- L5 seg- stimulate opioid-containing leukocytes to release
ments (Chen et al. 2012). Additionally, non-local β-endorphin and contribute to analgesia by
ENS applied contralaterally but within the binding to peripheral opioid receptors (Su et al.
spinal segment of inflammatory- induced pain 2011). Additionally, contralateral ENS applied
can similarly decrease TRPV1 expression and pre-treatment away from the site of pain was
decrease sodium current influx at the DRG and effective at reducing inflammatory pain and
SC dorsal horn neurons respectively (Lu et al. involves specific μ- opioid receptor activation
2016). A recent study reported that strong low at the spinal level (Yang et al. 2011). Taken
frequency ENS triggers release of adenosine together, these studies show that ENS induces
to activate A1 receptors (A1R) and opioids to a potent anti-nociceptive effect in the periphery
act on the μ-receptors, resulting in suppression by enhancing anandamide levels, increasing
of nociceptive ion channels in DRG neurons. the availability of its target receptor, and up-
More specifically, A1R activation may lead to regulating the endogenous opioid system in the
decreased adenylyl cyclase activity and inhibi- periphery.
tion of protein kinase A (PKA), resulting in At the spinal level, cannabinoids have an
receptor down- regulation by limiting receptor inhibitory effect on primary afferents and at
phosphorylation (Chen et al. 2011; Liao et al. the substantia gelatinosa of the dorsal horn
2017). Taken together, these studies suggest by decreasing glutamate release from primary
that low frequency ENS can treat inflammatory afferent terminals through CB1 receptor activa-
pain detected by primary afferents by reduction. Several studies show that low concentra-
ing synaptic transmission in DRG neurons tions of anandamide are sufficient to activate

T. Perreault et al.
CB1 receptors, significantly reduce calcitonin nuclei that extend fibres down the dorsolateral
gene- related peptide (CGRP) release in the funiculus (DLF), delivering serotonin (5- HT)
spinal dorsal horn, and reduce neuronal excit- and NA to superficial laminae of the SC dorsal
ability (Morisset et al. 2001). This modulation of horn to inhibit pain when activated. Li et al.
neuropeptide release in the dorsal horn likely (2007) reported that creating a spinal lesion
occurs through a reduction in adenylyl cyclase. on the DLF in an inflammatory pain model
In contrast, high concentrations of anandamide eradicates the pain inhibition ENS created by
will elicit excitatory nociceptive input to dorsal eliminating the delivery of 5- HT and NA at
horn neurons by activating the TRPV1 receptor the spinal level (Li et al. 2007). The authors also
that enhances the release of substance P (SP) reported low ENS intensity was sufficient to
and CGRP (Ahluwalia et al. 2003a; Ahluwalia increase ipsilateral (but not contralateral) pain
et al. 2003b). Thus, anandamide has a regulatory thresholds, indicating that the SC on the side of
effect on neurotransmitter release at the spinal pain is hyper-responsive to the needle stimulus
level and the subsequent effect is concentration compared to the contralateral uninvolved side
dependent (Tognetto et al. 2001). at the same level. Zhang et al. (2012) concluded
that ENS alleviates pain in part through 5-HT1A
ENS duration parameters receptors on post-synaptic dorsal horn neurons
ENS activates all afferent nerve fibre groups resulting in modulation of the NMDA receptor.
according to nerve conduction velocity measures Additionally, the authors provided supporting
in animal models (Kagitani et al. 2010). ENS has evidence that ENS enhances spinal serotonin
an initial pain modulatory effect through either levels by activating supraspinal serotonin-
noxious Aδ or innocuous Aβ fibre stimulation containing neurons that project to the level
that results in segmental inhibition. A supraspi- of the spine. Furthermore, ENS increased
nal mechanism may also be triggered with spinal release of norepinephrine by activating
longer time durations of ENS, shifting away noradrenergic-spinal projection neurons in the
from pain inhibition that is spinally mediated locus coeruleus. NA preferentially activates the
to a form of descending pain inhibition that alpha-adrenergic receptors (α2A) on primary
is much more potent and global in effect. In a afferent nerve fibres (Aδ fibres specifically),
study by Leung et al. (2008), bilateral increases leading to pre-synaptic reduction of glutamate
in sensory thresholds were confined to the L4 release to the SC (Zhang et al. 2012). Both
dermatome of the lower leg and correlated NA and 5-HT have an overall effect of anti-
to the areas of unilateral needle insertion that nociception. Both also produce membrane
received brief electrical stimulation. However, a hyperpolarization in neurons of the substantia
longer duration of electric stimulation (between gelatinosa of the dorsal horn, decrease excita-
15 to 30 min) resulted in longer lasting analgesic tory neurotransmitter (glutamate) release from
effects and increased pressure pain thresholds primary Aδ and C- fibres pre-synaptically, and
that extended beyond just the segmental levels increase inhibitory neurotransmitter release
of the needling sites (Leung et al. 2008). In (GABA and glycine) from interneurons
contrast, even a short stimulation time of 5 min (Yoshimura & Furue 2006).
with ENS is sufficient to deliver strong and fast Importantly, noradrenergic descending inhibi-
onset analgesia compared to manual needling tory system activation can enhance the opioid
but the effect is limited to only a few minutes effects at the SC level during periods of inflam-
duration (Schliessbach et al. 2011). mation. When the opioid effect is not strong
enough to induce anti-nociception, the effects
ENS and descending pain inhibition are enhanced by spinal adrenergic mechanisms.
ENS triggers descending pain inhibition by Thus, painful stimulation applied ipsilater-
activating neurons in the rostral-ventral region ally can stimulate the noradrenergic system
of the medulla and the locus coeruleus of (or even serotonergic system) to provide this
the pons. These regions contain supraspinal effect. One study reported that ENS applied at

noxious levels stimulated α2A receptor activa- ganglia (Deng et al. 2015). AVP is synthesized in
tion via spinal NA, promoting analgesic effect selected neurons of the hypothalamus, mainly
in the SC. This may perhaps be more power- in the PVN and supraoptic nucleus (SON).
ful than the opioid effect, as α2A receptor Painful stimulation has been shown to increase
anatagonists abolished ENS effects whereas noradrenaline (NA) that interacts with PVN
opioid receptor antagonists did not (Koo et al. neurons to promote synthesis and secretion of
2008). Mechanistically, α2A receptor activa- AVP that can assist in pain modulation (Zhou
tion increases K+ conductance in dorsal horn et al. 2010). AVP also enhances descending
neurons, causing hyperpolarization, decreased pain inhibition by stimulating the synthesis and
neuron excitability, and decreased glutamate secretion of the endogenous opioids enkephalin
release in the dorsal horn leading to analgesia. and β-endorphin in the PAG (Yang et al. 2007b),
This is mainly brought about through Aδ-fibre stimulating the serotonergic system in the NRM
stimulation that leads to adrenergic system acti- (Yang et al. 2009) that leads to 5- HT release
vation. Furthermore, the analgesic actions of in the dorsal horn, and the subsequent spinal
opioid receptors are enhanced under inflamma- release of endogenous opioids via activation of
tory conditions and thereby more potent on the serotonin receptors (Pan et al. 2012). Thus, ENS
affected side of inflammation (Stein & Kuchler of noxious intensity can trigger release of AVP
2013), thus demonstrating why α2A receptor and has a potent effect on analgesia at the spi-
agonists exhibit enhanced effects at the level of nal level leading to increased pain thresholds. In
the SC during inflammation. the treatment of primary sciatica, a positive cor-
ENS has also been shown to restore relation between pain relief and levels of AVP
descending pain inhibitory system function in the cerebrospinal fluid (CSF) was observed
in chronic pain situations. Low frequency and after a session of bilateral ENS to segmentally-
moderate intensity (2 Hz and 1 mA) ENS related acupuncture points. More specifically,
has also been shown to enhance CB1 receptor 60 min of low frequency and low intensity ENS
levels on GABAergic neurons in the midbrain induced larger increases in AVP levels than a
periaqueductal gray (PAG). Activation of the 30-min duration (Zhao et al. 2015). AVP levels
CB1 receptor will inhibit GABA release from in the CSF increased dose- dependently when
PAG neurons, disinhibit serotonin release from treatment duration was the dosage parameter.
neurons in the PAG and Rostral Ventromedial A recent review supports that needling inhib-
Medulla (RVM) and promote restoration of and its pain via supraspinal increase of oxytocin lev-
improved function to diffuse noxious inhibi- els, resulting in transport to oxytocin receptors
tory controls (DNIC) and the descending pain on spinal neurons, interneurons, and primary
inhibitory systems by reversal of the reduced afferents at the dorsal horn (Butts et al. 2016).
CB1 receptor expression in situations of chronic Several studies suggest oxytocin acts to inhibit
pain. (Yuan et al. 2018). inflammatory pain by modulating acid sensing
ion channel (ASIC) function through activation
ENS induces supraspinal analgesic of vasopressin receptors and upregulation
effects of calcineurin to decrease current amplitudes
At the level of the brain, there are potent on sensory receptors (Yang et al. 2007a; Qiu
mechanisms triggered with ENS that originate et al. 2014). ENS has been shown to promote
and act centrally and then transport spinally to release of oxytocin from the SON of the hypo-
inhibit pain. Noxious electric needle stimulation thalamus and facilitate the transfer of oxytocin
has been shown to trigger the release of argi- to the PAG, NRM, and spinal cord, thereby
nine vasopressin (AVP) from the hypothalamic resulting in analgesia through its influence on
paraventricular nucleus (PVN) and promote its endogenous opioid release in neurons of the
transport via nerve fibres and ventricles in the DRG. Interestingly, AVP was able to induce
brain to the PAG, nucleus raphe magnus (NRM) the same ASIC regulation and analgesic effect
of the medulla, and caudate nucleus in the basal as oxytocin by activating the same V1a receptor

T. Perreault et al.
Figure 1. Diagram showing primary mechanisms of ENS-induced analgesia.
that mimics the effect of oxytocin (Qiu et al. resulting in greater activation of the seroton-
2014). Collectively, these studies display that ergic and noradrenergic descending inhibitory
supraspinal mechanisms are triggered with the systems that amplify analgesic effects at the
application of ENS and pain control is heavily spinal level. Locally, strong low-frequency ENS
modulated at the spinal level through activation has been shown to suppress inflammatory pain
of endogenous neuromodulators (see Fig. 1). by increasing anandamide concentrations, up-
regulating the endogenous opioid system in the
periphery and regulating neuropeptide release
Conclusions
According to clinical studies on subjects with in the SC. Additionally, ENS triggers release of
pain conditions, electrical stimulation of needles adenosine locally resulting in activations of A1
applied in place of, or in addition to, manual receptors and suppression of nociceptive ion
manipulation may result in superior analgesic channels in DRG neurons and pain suppression.
effects. The anti-nociceptive effects of ENS are A multitude of analgesic mechanisms are trig-
strongly mediated by spinal segmental inhibitory gered with electric needle stimulation, however,
processes that are engaged when afferent nerve intensity of stimulation, needle placement within
fibres are stimulated. At the spinal level, strong the segmental distribution of pain, and duration
low frequency ENS promotes release of 5-HT, of ENS seem to be the most important dose
NA, anandamide and endogenous opioids parameters for better anti-nociceptive effects.
that act to decrease excitability of nociceptive
neurons and decrease glutamate release in the References
dorsal horn leading to analgesia. Beyond this, Ahluwalia J., Urban L., Bevan S. & Nagy I. (2003a)
noxious ENS triggers AVP release supraspinally Anandamide regulates neuropeptide release from

capsaicin-sensitive primary sensory neurons by activat- Langevin H. M., Schnyer R., MacPherson H., et al. (2015)
ing both the cannabinoid 1 receptor and the vanilloid Manual and electrical needle stimulation in acupunc-
receptor 1 in vitro. European Journal of Neuroscience, 17 ture research: pitfalls and challenges of heterogeneity.
(12), 2611–8. Journal of Alternative and Complementary Medicine 21 (3),
Ahluwalia J., Yaqoob M., Urban L., et al. (2003b) 113–28.
Activation of capsaicin- sensitive primary sensory Leung A. Y., Kim S. J., Schulteis G. & Yaksh T. (2008)
neurones induces anandamide production and release. The effect of acupuncture duration on analgesia and
Journal of Neurochemistry 84 (3), 585–91. peripheral sensory thresholds. BMC Complementary and
Baeumler P. I., Fleckenstein J., Benedikt F., et al. (2015) Alternative Medicine 8 (18).
Acupuncture-induced changes of pressure pain thresh- Li A., Wang Y., Xin J., et al. (2007) Electroacupuncture
old are mediated by segmental inhibition – a random- suppresses hyperalgesia and spinal Fos expression
ized controlled trial. Pain 156 (11), 2245–55. by activating the descending inhibitory system. Brain
Baeumler P. I., Fleckenstein J., Takayama S., et al. (2014) Research 1186, 171–9.
Effects of acupuncture on sensory perception: a Liao H. Y., Hsieh C. L., Huang C. P. & Lin Y. W. (2017)
systematic review and meta-analysis. PLoS One 9 (12): Electroacupuncture attenuates CFA- induced inflam-
e113731. matory pain by suppressing Nav1.8 through S100B,
Butts R., Dunning J., Perreault T., et al. (2016) Peripheral TRPV1, opioid, and adenosine pathways in mice.
and spinal mechanisms of pain and dry needling medi- Scientific Reports 7: 42531.
ated analgesia: a clinical resource guide for health care Lu K. W., Hsu C. K., Hsieh C. L., et al. (2016) Probing the
professionals. International Journal of Physical Medicine & effects and mechanisms of electroacupuncture at ipsi
Rehabilitation 4 (327). lateral or contralateral ST 36-ST 37 acupoints on CFA-
Chen L., Zhang J., Li F., et al. (2009) Endogenous induced inflammatory pain. Scientific Reports 6: 22123.
anandamide and cannabinoid receptor-2 contribute to MacPherson H., Maschino A. C., Lewith G., et al. (2013).
electroacupuncture analgesia in rats. Journal of Pain 10 Characteristics of acupuncture treatment associated
(7), 732–9. with outcome: an individual patient meta-analysis of
Chen W. H., Tzen J. T., Hsieh C. L., et al. (2012) 17,922 patients with chronic pain in randomised con-
Attenuation of TRPV1 and TRPV4 expression and trolled trials. PLoS One 8 (10): e77438.
function in mouse inflammatory pain models using MacPherson H., Vertosick E. A., Foster N. E., et al.
electroacupuncture. Evidence-Based Complementary (2017) The persistence of the effects of acupuncture
Alternative Medicine 2012: 636848. after a course of treatment: a meta-analysis of patients
Chen Y., Yang C. & Wang Z. J. (2011) Proteinase-activated with chronic pain. Pain 158 (5), 784–793.
receptor 2 sensitizes transient receptor potential vanil- Manheimer, E., Cheng, K., Linde, K., et al. (2010)
loid 1, transient receptor potential vanilloid 4, and tran- Acupuncture for peripheral joint osteoarthritis. Cochrane
sient receptor potential ankyrin 1 in paclitaxel-induced Database of Systematic Reviews CD001977.
neuropathic pain. Neuroscience 193, 440–51. Morisset V., Ahluwalia J., Nagy I. & Urban L. (2001)
Choi Y. J., Lee J. E., Moon W. K. & Cho S. H. (2013) Possible mechanisms of cannabinoid-induced
Does the effect of acupuncture depend on needling antinociception in the spinal cord. European Journal of
sensation and manipulation? Complementary Therapies in Pharmacology 429 (1–3), 93–100.
Medicine 21 (3), 207–14. Niddam D. M., Chan R. C., Lee S. H., et al. (2007). Central
Deng X.-H., Wang Y.-L., Yuan Y., et al. (2015) The roles modulation of pain evoked from myofascial trigger
of vasopressin in acupuncture analgesia. Journal of point. Clinical Journal of Pain, 23 (5), 440–8.
Pharmaceutical Medicine 3, 11–16. Pan Y.-J., Yin Z.-K., Yang J., et al. (2012) Serotonin influ-
Huang M., Wang X., Xing B., et al. (2018) Critical roles ences the endogenous opiate peptides in the rat spinal
of TRPV2 channels, histamine H1 and adenosine cord to participates in pain modulation. Open Journal of
A1 receptors in the initiation of acupoint signals for Anesthesiology 2 (2), 29–35.
acupuncture analgesia. Scientific Reports 8: 6523. Qiao L. N., Liu J. L., Tan L. H., et al. (2017) Effect of
Kagitani F., Uchida S. & Hotta H. (2010) Afferent nerve electroacupuncture on thermal pain threshold and
fibers and acupuncture. Autonomic Neuroscience 157 expression of calcitonin- gene related peptide, sub-
(1–2), 2–8. stance P and gamma-aminobutyric acid in the cervical
Koo S. T., Lim K. S. Chung K., et al. (2008) dorsal root ganglion of rats with incisional neck pain.
Electroacupuncture-induced analgesia in a rat model of Acupuncture in Medicine 35 (4), 276–283.
ankle sprain pain is mediated by spinal α-adrenoceptors. Qiu F., Qiu C. Y., Cai H., et al. (2014) Oxytocin inhibits
Pain 135 (1–2), 11–19. the activity of acid-sensing ion channels through the
Lang P. M., Stoer J., Schober G. M., et al. (2010) Bilateral vasopressin, V1A receptor in primary sensory neurons.
acupuncture analgesia observed by quantitative sensory British Journal of Pharmacology 171 (12), 3065–76.
testing in healthy volunteers. Anesthesia and Analgesia Schliessbach J., van der Klift E., Arendt- Nielsen L.,
110 (5), 1448–56. et al. (2011) The effect of brief electrical and manual

T. Perreault et al.
acupuncture stimulation on mechanical experimental involved in the endogenous opiate peptide and seroto-
pain. Pain Medicine 12 (2), 268–75. nin system. Peptides 30 (7), 1355–61.
Stein C. & Küchler S. (2013) Targeting inflammation Yin N., Yang H., Yao W., et al. (2018). Mast cells and
and wound healing by opioids. Trends in Pharmacological nerve signal conduction in acupuncture. Evidence-Based
Sciences 34 (6), 303–12. Complementary and Alternative Medicine 2018: 3524279.
Su T. F., Zhang L. H., Peng M., et al. (2011) Cannabinoid Yoshimura M. & Furue H. (2006) Mechanisms for the
CB2 receptors contribute to upregulation of anti-nociceptive actions of the descending noradrener-
β-endorphin in inflamed skin tissues by electro gic and serotonergic systems in the spinal cord. Journal
acupuncture. Molecular Pain 7: 98. of Pharmacological Sciences 101 (2), 107–17.
Tambeli C. H., Parada C. A., Levine J. D. & Gear R. W. Yuan Q. L., Wang P., Liu L., et al. (2016) Acupuncture
(2002) Inhibition of tonic spinal glutamatergic activity for musculoskeletal pain: a meta- analysis and meta-
induces antinociception in the rat. European Journal of regression of sham- controlled randomized clinical
Neuroscience 16 (8), 1547–53. trials. Scientific Reports 6: 30675.
Tambeli C. H., Quang P., Levine J. D. & Gear R. W. Yuan X. C., Zhu B., Jing X. H., et al. (2018)
(2003) Contribution of spinal inhibitory receptors in Electroacupuncture potentiates cannabinoid receptor-
heterosegmental antinociception induced by noxious mediated descending inhibitory control in a mouse
stimulation. European Journal of Neuroscience 18 (11), model of knee osteoarthritis. Frontiers in Molecular
2999–3006. Neuroscience 11: 112.
Tognetto M., Amadesi S., Harrison S., et al. (2001) Zhang J., Chen L., Su T., et al. (2010) Electroacupuncture
Anandamide excites central terminals of dorsal root increases CB2 receptor expression on keratinocytes
ganglion neurons via vanilloid receptor- 1 activation. and infiltrating inflammatory cells in inflamed skin tis-
Journal of Neuroscience 21 (4), 1104–9. sues of rats. Journal of Pain 11 (12), 1250–8.
Vickers A. J., Vertosick E. A., Lewith G., et al. (2018) Acu- Zhang Y., Zhang R. X., Zhang M., et al. (2012)
puncture for chronic pain: update of an individual
Electroacupuncture inhibition of hyperalgesia in an
patient data meta-analysis. Journal of Pain 19 (5), 455–474. inflammatory pain rat model: involvement of distinct
Wu S. Y., Chen W. H., Hsieh C. L. & Lin Y. W. (2014) spinal serotonin and norepinephrine receptor subtypes.
Abundant expression and functional participation of British Journal of Anaesthesia 109 (2), 245–52.
TRPV1 at Zusanli acupoint (ST 36) in mice: mecha- Zhao X. Y., Zhang Q. S., Yang J., et al. (2015) The role
nosensitive TRPV1 as an “acupuncture- responding of arginine vasopressin in electroacupuncture treat -
channel”. BMC Complementary and Alternative Medicine 14 ment of primary sciatica in human. Neuropeptides 52,
(96). 61–5.
Xin J., Su Y., Yang Z., et al. (2016) Distinct roles of ASIC3 Zhao Z. Q. (2008) Neural mechanism underlying
and TRPV1 receptors in electroacupuncture- induced acupuncture analgesia. Progress in Neurobiology 85 (4),
segmental and systemic analgesia. Frontiers in Medicine 355–75.
10 (4), 465–472. Zheng Z., Gibson S., Helme R. D., et al. (2018) Effects of
Xu W. D., Zhu B., Rong P. J., et al. (2003) The pain- electroacupuncture on opioid consumption in patients
relieving effects induced by electroacupuncture with with chronic musculoskeletal pain: a multicenter ran-
different intensities at homotopic and heterotopic acu- domized controlled trial. Pain Medicine [Epub ahead of
points in humans. American Journal of Chinese Medicine print.] doi: 10.1093/pm/pny113.
31 (5), 791–802. Zhou H.-Y., Zhang H.-M., Chen S.-R. & Pan H.-L. (2008)
Yang E. J., Koo S. T., Kim Y. S., et al. (2011) Contralateral Increased C-fiber nociceptive input potentiates inhibi-
electroacupuncture pretreatment suppresses tory glycinergic transmission in the spinal dorsal horn.
carrageenan-induced inflammatory pain via the opioid- Journal of Pharmacology and Experimental Therapeutics 324
mu receptor. Rheumatology International 31 (6), 725–30. (3), 1000–1010.
Yang J., Hsieh C. L. & Lin Y. W. (2017) Role of transient Zhou K., Ma Y. & Brogan M. S. (2015) Dry needling
receptor potential vanilloid 1 in electroacupuncture versus acupuncture: the ongoing debate. Acupuncture in
analgesia on chronic inflammatory pain in mice. Biomed Medicine 33 (6), 485–90.
Research International 2017: 5068347. Zhou X. J., Yang J., Yan F. L., et al. (2010) Norepinephrine
Yang J., Yang Y., Chen J. M., et al. (2007a) Effect of oxy- plays an important role in antinociceptive modulation
tocin on acupuncture analgesia in the rat. Neuropeptides of hypothalamic paraventricular nucleus in the rat.
41 (5), 285–92. International Journal of Neuroscience 120 (6), 428–38.
Yang J., Yang Y., Xu H. T., et al. (2007b) Arginine Zhu B., Xu W. D., Rong P. J., et al. (2004) A C-fiber reflex
vasopressin induces periaqueductal gray release of inhibition induced by electroacupuncture with different
enkephalin and endorphin relating to pain modulation intensities applied at homotopic and heterotopic acu-
in the rat. Regulatory Peptides 142 (1–2), 29–36. points in rats selectively destructive effects on myeli-
Yang J., Yuan H., Chu J., et al. (2009) Arginine vasopres- nated and unmyelinated afferent fibers. Brain Research
sin antinociception in the rat nucleus raphe magnus is 1011 (2), 228–37.

Part II of this Literature Review will appear in the outpatient orthopedic setting for 10 years. Dr Perreault
Spring 2019 issue of Acupuncture in Physiotherapy. is currently a Clinical Specialist at Wentworth Douglass
Hospital in Dover, New Hampshire for the Northern
Dr Thomas Perreault graduated with a BSc in New England Spine Center with a focus on dry
Kinesiology from The University of Maine in 2004 needling for chronic spinal pain, temporomandibular
and earned his doctoral degree in Physical Therapy from disorders and headache. He lectures internationally on
Franklin Pierce University in 2008. Dr Perreault dry needling for the management of musculoskeletal dis-
is a graduate of the Institute of Orthopedic Manual orders. Dr Perreault is also lead author of “The local
Therapy Clinical Fellowship in Woburn, Massachusetts twitch response during trigger point dry needling: is it
and he is a Board Certified Orthopedic Specialist necessary for successful outcomes?” which was published
through the American Physical Therapy Association. in 2017 in the ever popular Journal of Bodywork and
He is also a member of the Acupuncture Association Movement Therapies.
of Chartered Physiotherapists and has practiced in the

paradigm
The interaction and outcomes of acupuncture,

both traditional Chinese medicine and intra-
muscular stimulation, with Deep Oscillation®
Treatment: a case study-based discussion
C. Boynes
Private Practice, Norfolk, UK
Abstract
This article first explains what Deep Oscillation® Treatment (DOT) is and how it works,
then focuses on four case studies in which the author has used acupuncture and DOT
together effectively as part of overall patient treatment and management.
Keywords: Electrostatics, lymphatics, oscillation, pain reduction, tissue response.
Introduction (semiconductor); the adhesive electrodes as

DOT is an internationally- patented electro well as the metal plate, the applicator, and the
mechanical therapy method based on the titanium element held by the patient perform
Johnsen-Rahbek effect in physics. It supplements as the electrodes. It is a biphasic application
and intensifies all types of connective tissue in microampere range, thus metal implants are
work without pressure, and reaches to a depth not contraindicated. To explain the working
of 8 cm as proven by a burns study by Tápanes electrostatic field, the circuit is in the Deep
et al. (2010) and in a diagnostic ultrasound visual Oscillation® machine. As the circuit changes
verification test by Medina Cabezas. polarity, the tissue is dropped and the circuit
Research into the therapeutic uses of this stopped temporarily through an active discharge
effect on tissue was first carried out by two device in the machine, which is part of the
German physiotherapists, Wolfgang Walder therapy’s patented circuitry. There is no prob-
and Hans Seidl, in the early 1980s. It works lem using the oscillator all day by the therapist
on the theory that if a semi-conductor is put or patient. Studies conducted in 1988 saw no
between two electrodes and a voltage is applied, adverse effects to therapist (Portnov & Zabelina
2002). The Deep Oscillation® machine can
it creates an electrostatic force similar to rub-
produce an electrostatic field at a low, medium
bing a balloon on your clothes and holding it
or high frequency ranging from 5 Hz to
over your head so your hair stands up. This
250 Hz. This alternating current is able to
generates a minimal electrostatic field, and with
pick up treated tissue and then drop it at a
a semiconductor layer this force can be trans-
variable speed, depending on the selected
ferred to human tissue without heat or the use
frequency. For example, at 5 Hz this occurs
of electrical stimulation. If we transfer this to
at 5 times a second, and at 250 Hz it occurs
deep oscillation, the membrane of the applica- at 250 times a second. In treatment, this deep
tor or gloves of the therapist are the vinyl layer oscillation massage penetrates a depth of 8 cm
Correspondence: Chris Boynes, Corner House, through the skin, connective tissue, fat tissue
3 The Street, Helhoughton, Nr Fakenham, Norfolk, and muscle, to reach its sphere of activity
NR21 7AH (email: chris@chrisboynesphysio.com) (Fig. 1).

The interaction and outcomes of acupuncture with Deep Oscillation® Treatment
DOT has effects on the microcirculation
of the interstitial connective tissue. Treatment
results in a normalization of the steady state,
i.e. of the permanent fluid flow between the
tissue surrounding the cells and the lymph and
blood cells.
When one considers the physiological effects
with DOT, it is highly effective in reducing pain
and has an anti- inflammatory effect. There is
promotion of wound healing and an improve-
ment in tissue quality and it is also effective
in resorbing oedema. Tissue detoxification and
improvement in trophicity have been noted;
there is an anti-fibrotic effect and it can have a
rubor reduction.
The clinical effects include pain relief and
increased functional mobility and movement.
It relaxes muscle and tissue, thereby increasing
range of movement (ROM). It is highly effec-
tive in decreasing swelling and encouraging the
movement of fluids.
DOT is an integral part of a treatment pro-
gramme involving manual therapy, connective
tissue release and exercise programming.
In a visual verification test of Deep
Figure 1. Deep Oscillation® permeates a 8 cm depth. Oscillation® using diagnostic ultrasound, Dr
Luis Felipe Medina Cabezas concluded: “Although
Treatment this is an initial trial, resonance and kinetic movement
The treatment is applied through vinyl-gloved of the connective tissue effected by an electrostatic field
hands or applicators, which also enable self- generated by Deep Oscillation® can be evidenced and
management. The patient holds an electrode, visualized. The illustrated test series visualizes for the
and another is adhered to the physiotherapist’s first time the impact on tissue of Deep Oscillation® in
forearm. The physiotherapist wears vinyl gloves real time. The method offers an interesting methodical
and treats normally, while the electrostatic field approach for future studies” (Fig. 2; Fig. 3).
comes through the gloves and into the tissue.
With the mechanical therapy effect reaching to Treatment time and frequency
a depth of 8 cm into the tissue, there is no need DOT is used in a range of treatment times and
to exert pressure during a treatment session. frequencies in relation to the presenting tissue
Also, since no heat is produced by the treat- and musculoskeletal condition (Table 1; Table 2;
ment, it can be used immediately after injury or Table 3).
day one after surgery, as it is suitable for use on
hot or swollen joints and tissue. Contraindications
Brenke and Siems (1996) have described how Contra-indications for DOT include:
the technique uses electrostatic attraction and • acute infections
friction “to produce mechanical vibrations in treated • acute systemic inflammations with patho-
tissues of the body, not only at the skin but also in genic germs participation
deeper tissues.” Schönfelder and Berg (1991) refer • active tuberculosis
to a “penetrating vibration and pumping effect deep in • acute venous diseases (untreated thrombosis)
the tissue.” • untreated malignant diseases

C. Boynes
of Deep Oscillation®: “Why does DOT pre-
needling make the needles go in more easily?”
According to Dr Reinhold, there are four
possibilities:
(1) The fact that acupuncture points are more
sensitive to thermal or mechanical stimuli,
involving a higher temperature, might be
due to an increased number of TRPV1
pain receptors on the cells. A study by
Boisnic and Branchet (2013) showed DOT
Figure 2. Still image from video of verification test of
Deep Oscillation® by Dr Luis Felipe Medina Cabezas. led to a significant reduction in the number
of TRPV1 pain receptors represented on
keratinocyte cells which is an explanation
for the statistically significant pain alleviat-
ing potential DOT.
(2) The mechanical resonance vibrations of
DOT and their effects on afferent neurons
might simply have analgesic effect by influ-
encing the gate control mechanism.
(3) Kuti- visceral or somato- visceral effects
resulting from DOT could have effects
on pain reception, resulting in ‘tissue
Figure 3. Still image from video of verification test of softening’.
Deep Oscillation® by Dr Luis Felipe Medina Cabezas. (4) Depending on the overall physiological
and psychological condition of the patient,
Table 1. Deep Oscillation®: treatment time and frequency it may be the case that DOT just relaxes
range in relation to tissue condition. the patient who ‘lets go’ and tolerates the
Treatment needles better.
Condition time Duration Frequency range
acute short approx. 8–10 min high frequency Practitioner feedback
approx. 5 min low frequency
A questionnaire was sent out to medical profes-
subacute long approx. 10–20 min high frequency
approx. 5 min low frequency
sionals in the UK who are currently utilizing
chronical long approx. 5 min medium frequency
Deep Oscillation® as part of their treatment
approx. 15 min high frequency protocols. Responses to the questions asked
approx. 10 min low frequency were as follows:
Question: Do you use Deep Oscillation®

• erysipelas or cellulitis pre-or post-acupuncture? What is the
• patients with cardiac pacemakers or other effect on tissue; does it help needling?
electronic implants
Answers:
• untreated heart complaints and diseases • Pre-acupuncture:
• pregnancy •
“Helps ease muscles, relaxes patient”
• hypersensitivity to electrostatic fields •
“Needle insertion more comfortable after using
• infectious skin diseases. DOT”
Deep Oscillation® therapy and

• Post-acupuncture:
•
“Lessens the discomfort of needling”
acupuncture •
“Generally used to enhance physiological changes
The following question was asked of Dr Jens brought on by needle insertion”
Reinhold, CEO of Physiomed, the manufacturer •
“Good for pain and spasm”

Table 2. Examples of different frequencies used to treat musculoskeletal (MSK) presentations.
MSK presentation Treatment
an arthritic setting 160 Hz × 10 min followed by 85 Hz × 5 min

tennis elbow/golfer’s elbow 160 Hz – 180 Hz followed by 85 Hz × 5 min
sciatica setting 170 Hz – 200 Hz × 10 min followed by 28 Hz – 40 Hz × 5 min
mixed tissue response 250 Hz × 20 min, then 60 Hz × 20 min (considering what the different frequencies do to the
tissue – a ‘pain’ setting initially followed by a more ‘pumping’ effect)
adhesive capsulitis 25 Hz – 80 Hz × 5 min then 80 Hz – 250 Hz × 15 min then 5 Hz – 25 Hz × 10 min
Table 3. The effect of different Deep Oscillation® frequencies.
Frequency Effect
high frequencies (80–250 Hz) • pain significantly reduced

• lymphatic drainage pathways opened and activated
• trapped cellular metabolic waste/abnormal fluid build-up broken down
• hardened fibrotic tissue & scar tissue dispersed
medium frequencies (25–80 Hz) • microcirculation in the interstitial spaces of the connective tissue is boosted
• tissue layers are relaxed
• biological waste products move out to the lymph system for removal
low frequencies (5–25 Hz) • vasodilation causes slight lowering of blood pressure.
• a powerful, gentle, pumping action causes strong movement in the tissue.
• re-instigation of flowing fluids encourages essential nutrients back to the tissue
• “Use a combination of DOT and acupuncture • “Each treatment complements each other; it offers a
for stubborn injuries” calming and soothing effect on clients”
• “Positive changes with acupuncture and DOT on • “Encourages relaxation prior to needling; relaxation
lymphatic presentations” both of the patient mentally, and of the tissues
physically”
Question: Do you feel that using
acupuncture and Deep Oscillation® has Question: What do your patients feel
reduced treatment times? If so, by how about your use of DOT; what feedback
much? do you regularly get?
Answers: Answers:
• “Not sure if it has reduced treatment times, but • “Players generally comment that they feel that have
result is more effective” come back more quickly than they expected and feel
• “Each treatment is longer but I’m seeing faster a lot more mobile following treatment”
results in fewer sessions” • “They love it. They are surprised it is effective as it
• “DOT has helped with pain and movement in feels so comfortable”
85–90% of patients” • “Reduction in pain, feels less tight and looser”
• “Patients see results in probably 25% fewer • “Most patients respond favourably to DOT and
sessions” are quite intrigued by its concept. Most have found
• “Not treatment times, but perhaps the frequency of relief of symptoms when applied to painful neck and
treatments” shoulders”
Question: What do you feel DOT does to Case studies

help/interact with acupuncture? Used in conjunction with acupuncture as part
Answers: of the treatment protocol, the author has found
• “Decreases tissue tension so needles insert easier” that the use of DOT prior to (and post-) nee-
• “Increased ROM with DOT and needles” dling helps the tissue feel softer, allowing the
• “It softens tissue in areas where manual massage is needles to go in better, particularly with intra-
difficult” muscular stimulation (IMS).

C. Boynes
Case study 1 upper cervical spine rotation and neck/shoulder
Fifty-eight-year-
old Ms C. first came to see ROM.
the therapist having had problems with her After eight 1-h sessions, the patient felt the
neck, left- sided shoulder girdle pain and left- pain had reduced significantly and was 98%
sided facial pain. Her previous medical history improved. She was no longer suffering from the
included 15 years of neck pain; diagnosis with neuralgic-type constant pain.
left-
sided facial neuralgia in the summer of Clinical reasoning: Firstly the TCM points
2016; and diagnosis in 2017 with left- sided abolished the neuralgic-type problem. Secondly,
temporomandibular (TMJ) problems. the IMS changed the tissue pain/tension.
Her problem list included a lack of neck Thirdly, the DOT helped the tissue stiffness
movement with both rotations and side flexions and ‘pain,’ and encouraged ROM and ultimately
along with a loss of cervical spine extension daily function. An important point here to note
and combined rotation with extension. She was was that when needling post-DOT, the tissue
stiff in the thoracic spine from the cervico was softer and less ‘crampy’ then pre- DOT
thoracic junction (CTJ) to T8- T9 and had treatment.
stiffer first ribs bi-laterally. She was also having
regular neuralgic type left-sided neck and cheek Case study 2
pain which was sharp most of the time and Seventy-three-year-old Mr P. attended the clinic
had not cleared since some dental work in with severe migraine and blurred vision. His
2014. previous medical history included suffering with
Treatment included manual therapy for joint headaches and migraines since his twenties. His
work, including sustained natural apophyseal past treatment included drug therapy which had
glides (SNAGs); posterior- anterior (P–A) and helped, although he did feel that when he was
anterior-posterior (A–P) joint mobilizations; on beta blockers it had made things worse. He
rotational mobilizations plus adjustments at the also had longstanding stiffness with his neck
cervical spine and thoracic spine; and connec- and shoulders.
tive tissue releases for soft tissue on the anterior, After initial assessment, his problem list
lateral and posterior neck and shoulders. DOT included joint and connective tissue tightness,
was used for stiffness, pain and tissue ‘soften- and a reduced ROM with both shoulder joints,
ing’ with frequencies of 200 Hz and 60 Hz for but there was no neural referral or signs and
20 min each or more in a session. symptoms of such. The migraines were in an
Further treatment included IMS to the neck, area that suggested the GB channel, with pain
shoulders and thoracic spine for tissue changes. in the area of GB 14 and GB 20 in the neck.
Notably the upper trapezius, levator scapulae, Initial treatment included Mulligan’s headache
splenius capitas and cervices, and sternocleido- SNAG at C0/C1 and rotation at C1/C2, but this
mastoid (SCM) and further into the rhomboids only made small changes for the better. TCM
and the thoracic spine. Traditional Chinese points were then applied at GB 20 initially, then
medicine (TCM) points for the neuralgic- type at BL 10, GB 41, LI 4 and Stomach (ST) 8, and
pain (mostly upper cervical spine) were given, IMS at the upper trapezius, levator scapulae,
also for symptoms of headache and migraine, rhomboids, infraspinatus (IS) and pectoral major
which included Gall Bladder (GB) 20, GB 21, and minor, subscapularis, deltoids/splenius
Bladder (BL) 10, Large Intestine (LI) 4, BL 60 capitas and cervices. Further manual therapy
and Kidney (KI) 3, plus manual therapy for involved SNAGs, mobilizations and adjustments
joint range of movement (ROM) improvement to the CTJ and thoracic spine. DOT was added
at C1/C2 to C3/C4. Also, left- sided points at 200 Hz and 60 Hz between 20 and 40 min
were used for the neuralgic-type pain affected in a session for pain and tissue softening. This
by the upper cervical points such as Governor always left the patient’s neck moving more easily
Vessel (GV) 20, BL 7, BL 9, BL 10 and BL and it was even more comfortable with warmth
11. Specific home exercises were given for the applied after the treatment sessions.

It should be noted that while some patients Clinical reasoning: Overall, the TCM and
talk of feeling a warmth from the gloves during IMS points eradicated his headaches and
DOT, this is not from the machine but from decreased much of his neck and shoulder ten-
the friction of the gloves on the skin. DOT sion. According to the patient, the whole of his
does not produce warmth. neck and shoulders felt much improved after
The patient was given exercises to do at the DOT treatment. He had more mobility and
home and advice. Within five sessions over six the tissue felt relaxed. He was discharged with a
weeks he had no further headaches/migraines home exercise programme.
and less joint stiffness.
He had been pain-free for almost ten months Case study 3
when he returned to the clinic with similar prob- Thirty-year-old Mr M. was a professional singer
lems although not as acute as initially. A similar working on a Christmas show over 12 weeks.
choice of acupuncture treatment was carried He presented with an achy and very stiff back
out at GB 20, GB 21, GB 14 and ST 44, ST with loss of forward flexion and increased left-
7, ST 8, Ex-3 and GV 20. DOT was also used sided pain. He had no neural problems but had
again at the same frequencies. This reduced his been gradually worsening over the last month
problems, significantly decreasing his headaches or so.
and joint stiffness within two weeks. After two His main problems were very limited move-
months he returned with some minor problems ment with lumbar spine flexion and left- side
wishing to ‘nip them in the bud’. Treatment flexion, but he also had a positive cough and
included IMS as before with some manual trac- sneeze suggestive of a central problem, possibly
tion; TCM points at GB 20, BL 10, GB 14, ST discal.
7, ST 8, Ex-3 and LI 4; plus DOT as before. Initial treatment was for just 10 min in the
Again, he was significantly better. first aid room at the theatre, using myofascial
At review two months later, the patient said trigger points (MFTPs) and adjustments to
he was still 95% better. Treatment included T5-T8 and L5/S1 bi-laterally. The patient was
manual therapy with upper cervical techniques given self-flexion SNAGs. He left feeling 70%
including manual traction and joint mobiliza- improved. In the clinic four days later, he had
tions and SNAGs; TCM points at GB 20, GB improved ROM but still some pain. Treatment
21, GB 1 and Ex-3; IMS points as previously; included IMS at the left quadratus lumborum
plus DOT as before. (QL), tensor facia latea (TFL) and extensor
Five months later, the patient returned to the muscles from L1- L5, and DOT for 5 min at
clinic with only intermittent headaches, but his 200 Hz for pain relief. He was also advised to
eyes were cloudy and he found it hard to keep do extension work regularly in standing and
them open. Treatment included both TCM and lying to counteract the flexion ‘tension,’ using a
IMS approaches: GB 20, GB 21, BL 10, Ex-1, centralization type of approach.
GB 1, plus DOT at chronic tissue settings for A week later he was moving more easily but
15 min (initially done with 200 Hz × 20 min still had some left-sided pain with sneezing and
and 60 Hz × 20 min) plus an occipital stretch. turning over in bed. He was more sensitive in
Post-treatment the patient felt the DOT had the mornings. He was able to continue on stage.
eased the tissue and joint stiffness. His eyes Treatment included adjustments at the CTJ,
were clearer, and he had no problem keeping thoracic spine and lumbar spine as above; IMS
them open. at T8-L5 on the left side in spinalis thoracis,
He returned one week later with clear eyes longissimus and iliocostalis and QL; also DOT,
and no headaches. Treatment included GB 20 as above, for pain and movement release up to
and BL 10. DOT was repeated for chronic tis- 20 min at 200 Hz and 60 Hz. He was much
sue for 30 min (5 min at a medium frequency, improved after this session.
then 15 min at a high frequency and 10 min at He was reviewed just over a week later for
a low frequency). an in-depth session looking at specific exercises

C. Boynes
to enable improved movement and counterac- softening) plus IMS at the extensor MFTPs
tion of his flexion- based normal movements. and re-taping. The therapist adjusted him at the
He continued to sing – sometimes two shows a CTJ – T4/T5 and at C6/C7 bi-laterally – and
day – until the end of the run. was questioning the need for an ultrasound to
Clinical reasoning: Overall, the IMS had good ascertain possible elbow tendinopathy and other
outcomes. DOT decreased his pain and move- further interventions.
ment stiffness and when used before IMS, the However, in clinic six days later the patient
needle entry was smoother and easier until the was 70% better, although his thumb EPL power
trigger point was hit. The DOT was used at and active movement were still decreased. All his
200 Hz and 60 Hz × 15–20 min for pain relief other muscles had increased power but with the
and tissue changes. EPL and APL there was ‘weakness’. Treatment
involved IMS to these areas, deep soft tissue
Case study 4 massage and DOT on a fibrosis setting again.
Forty-two-year-old Mr J. is a carpenter who pre- He felt much better after treatment. He was re-
sented in the clinic with a severely painful and taped for TE fascially, not mechanically.
limited right elbow and forearm. He was unable Six days later he was 90% better with an
to shake hands and was carrying his elbow in a increase in his extensors power. There was still
supported position with his left arm. Although some ‘weaknesses’ with his EPL and APL, how-
his forearm/elbow had been getting worse over ever IMS to these muscles improved the EPL,
the last few months, John had continued to although less with APL. DOT was also given.
work due to commitment pressure. He often On review two weeks later, he was working and
used a nail gun repeatedly and he now felt the functioning well. There was still some slight
forearm area was ‘dead’/numb. weakness with his thumb, but this was not
His main problems included a painful and preventing him from being able to work fully.
decreased grip, elbow extension and resisted DOT was repeated for 30 min at 200 Hz and
supination. He was unable to do wrist extension 60 Hz for pain and tissue mobility.
and had a positive resisted test. There was pain The patient continued with self- treatment
at the teno-osseous site and muscle bellies of involving tissue massage plus Mulligan’s self-
the extensors. After assessment there was a sug- TE mobilizations with movement and was

gestion of some neural inhibition with possible discharged.
interosseous nerve entrapment and an extensor Clinical reasoning: Overall, the IMS worked
tendinopathy. very well, while the DOT decreased the pain
Initial treatment included IMS to the exten- and ‘deep’ ache felt by the patient. In addition,
sors (brachioradialis, extensor carpi radialis the tissue/skin felt softer and less sore. The
longus, extensor digitorum, abductor pollicis therapist has observed that this is the case for
longus (APL), extensor pollicis longus (EPL), the majority of his patients who find that DOT
supinator, pronator teres) and he was fascially used after IMS eases the needling soreness and
taped to ‘offload’. On return to clinic four days tissue tension.
later he was 20% improved. At this session he
was treated with DOT, used at a fibrosis setting
(160 Hz – 180 Hz × 15 min then 60 Hz – Research
100 Hz × 5 min) as the tissue was still sore Deep oscillation has been successfully applied
from the IMS. He was taped for a tennis elbow therapeutically for more than two decades
(TE) and more fascial offloading. Four days and concomitantly examined scientifically with
later he had an increased active wrist dorsi- respect to its tissue effects and clinical results
flexion which was still quite severely restricted (Melzak & Wall 1983). Currently there exist a
due to pain and dysfunction/neural inhibition substantial number of randomized controlled
of muscle power. Treatment included DOT on trials, pilot studies, case studies, field reports and
the fibrotic setting (for pain relief and tissue studies (several in PubMed-indexed international

journals) to provide a medical evidence base for document.] http://www.physiopod.co.uk/assets/
deep oscillation. images2017/2017-MLD-6pp-web.pdf
Schönfelder G. & Berg D. (1991) Nebenwirkungen nach
Full references for Deep Oscillation® research
brusterhaltender therapie des mammakarzinoms. erste
and studies can be obtained via the website ergebnisse mit Hivamat® 200. [Therapy for a carci-
https://www.physiomed.de/en/products/deep- noma of the breast followed by early treatment with
oscillation-evident-clinics/#bibliography and in Deep Oscillation® therapy] Gynaekologische Praxis 15,
Reinhold (2017). 109–122.
Tápanes S. H., Suárez A., Acosta T. B., et al. (2010) Value
of deep oscillation therapy in the healing of AB burns.
References Cuban Journal of Physical Medicine & Rehabilitation RNPS
Boisnic S. & Branchet M.- C. (2013) Anti-
inflammatory 2244, Folio 148.
and draining effect of the Deep Oscillation® device
tested clinically and on a model of human skin Chris Boynes is a chartered physiotherapist, manual
maintained in a survival condition. European Journal of and sports specialist, and acupuncture practitioner. He
Dermatology 23 (1), 59–63. has thirty years of experience treating musculoskeletal
Brenke R. & Siems W. (1996) Adjuvante therapie beim lym-
conditions, has practised acupuncture for over twenty
phödem [Adjuvant therapy in lymphedema]. Zeitschrift
fur Lymphologie 20 (1), 31–35. years, and has worked in professional rugby and other
Medina Cabezas L. F. Visual verification of deep oscil- elite sports. At the May 2018 AACP Conference,
lation with diagnostic ultrasound. [Online video.] Mr Boynes discussed his use of acupuncture with Deep
https://youtu.be/LiiiktcNENM Oscillation® Treatment, both of which he uses as an
Portnov V. & Zabelina Y. (2002) New method for deep mas- interactive tool with all his physiotherapy skills, and gave
sage of tissues: first results of Hivamat 200 system clinical
his personal observations on how effective they had been
application in Russia. President Affairs Department of
the Russian Federation Medical Center Central Clinical in helping with pain relief, muscle and tissue relaxation
Hospital, Moscow, Russia. and improving functional mobility and movement.
Reinhold J. (2017) Mechanisms of deep oscillation.
The Journal: Manual Lymphatic Drainage UK [WWW

paradigm
Practical applications of meridian theory in pain

management – the meridian wave approach
A. Ziv
Heaven and Earth TCM specialty clinic, Rehovot, Israel
I. Levi
Heaven and Earth TCM specialty clinic, Rehovot, Israel
Abstract
Meridian theory serves as a fundamental concept in classical Chinese medicine. Yin yang
and five phase theory, zang fu internal organ theory and channel theory comprise a theoreti-
cal foundation often described as the ‘Three Pillars’ of Chinese medicine. Meridian wave
acupuncture is an effective, evidence-based system for pain management based on classical
channel theory. This article outlines the basic theory and main techniques of this system for
clinical application in pain management. A key element discussed involves the arrangement
of the channel system into six pairs of functional physiological units. These six channels
act as connecting pathways between the external environment and the internal environment
of the internal organs. Each channel resonates with a distinct wave quality. By tapping into
the correct channel with acupuncture treatment, a strong wave-like movement of Qi can be
induced in order to vigorously resolve obstruction. Three main actions are performed dur-
ing the acupuncture session and include a ripple ‘wave initiation’ through bleeding jing-well
points, a channel Qi-leveraging ‘wave propagation’ through needling distal ends of the same
channel, and immediate assessment of the result that is described as ‘wave effect’. Although
many additional elements support this system, the key aspects presented here serve as an
immediately applicable and effective tool for pain management. Much of the work and
theory described in this article is based on the teachings of the late Professor Dr Wang Ju
Yi, a contemporary master of channel theory-based acupuncture.
Keywords: acupuncture, bleeding, channels, injury, leverage, meridians, meridian wave, musculo-
skeletal, obstruction, pain, Qi, wave.
Authors’ note and accuracy, which help to convey the practical

The use of the term ‘channel’ rather than essence of this acupuncture system.
‘meridian’ has been debated by modern scholars
of Chinese medicine (Ellis et al. 1989). ‘Channel’ Preface
is often preferred as a term that better describes Meridian theory forms a fundamental aspect of
their concept and function. Nevertheless, the classical Chinese medicine. Together with yin
authors use the term ‘meridian’ in this article yang and five phase theory, and zang fu theory,
as it includes the notions of spatial direction it comprises the foundational theory known
as the ‘Three Pillars’ of Chinese medicine as
Correspondence: Amos Ziv, Heaven and Earth TCM described in the Nei Jing (Inner Classic). For
specialty clinic, Rehovot, Israel (email: aaziv10@ historical reasons beyond the scope of this arti-
netvision.net.il) cle, meridian theory has been less emphasized
© Journal of Chinese Medicine 35

Practical applications of meridian theory in pain management – the meridian wave approach
in the teachings of modern traditional Chinese Zang fu theory
medicine (TCM). Practising acupuncture with- Zang fu (internal organ) theory is a major
out a thorough understanding of meridian subject of discussion in the classic texts of
theory undermines the theoretical framework Chinese medicine. It refers to the physiology
of classical Chinese medicine, and may lead to a and pathology in the body as governed by
significant reduction in therapeutic effectiveness. functional organ systems, whose major role is
Understanding meridian theory provides the production, preservation and storage of the
insight into the classical Chinese medicine vital substances: Qi, blood, jing- essence and
perspective of how the body works internally, body fluids. With analogy to Western science,
and how it interacts with the outer world and zang fu theory has parallels with the subjects of
universe. Because of this, meridian theory- anatomy, physiology and pathology.
based acupuncture often produces significantly
improved outcomes in practice. This article
outlines an effective and practical application of Meridian theory
meridian theory-based acupuncture. Specifically While the rules of the outer universe and
focused on the treatment of pain and move- climates are conveyed by the language of yin
ment limitation, the meridian wave acupuncture yang and the five phases, and physiology and
system is rooted in classical Chinese medicine pathology are mainly categorized according to
meridian theory. It has been used on thousands zang fu functions, meridian theory is the con-
of patients in China, Europe, the United States necting pathway between these theories. The
and Israel. This pain management acupuncture meridians represent the connection between the
system has been validated successfully in a inner physiology of the body and the climates
randomized controlled trial of acupuncture of the outer universe. With analogy to Western
for acute back or neck pain in the emergency science, meridian theory has parallels with phys-
(A&E) room of a major hospital in Israel (Ziv ics and chemistry, through which we see the
et al. 2012). Compared to sham acupuncture mathematical laws of the universe manifesting
and no treatment control, results showed a in physiology and pathology. That is, physical
decrease in total pain of more than 40% and and chemical laws such as thermodynamics and
an increase in spinal flexion-extension of more biochemistry, are at the basis of all physiological
than 26%. and pathological processes in the living body.
Likewise, from a Chinese medicine perspective
the meridian system is the basis of all physio
Introduction logical and pathological processes in the living
As described in the Nei Jing, Chinese medicine body.
is based on three theories that form a funda-
mental organizational framework, collectively
referred to as the ‘Three Pillars’ of Chinese The emergence of meridian
medicine (Wang & Robertson 2008). theory
Scholars of the Nei Jing formed their holistic
Yin yang and five phase theory view of the universe and the human body by
These two theories form a basic language or observing nature. These theorists of classi-
code that can be used to describe all phenomena cal Chinese sciences strove to understand the
in the universe, including the human body. With relationship between the human body and its
this language all existence and events, including environment, between the microcosm and the
disease and healing, can be categorized and macrocosm. The meridians are a key concept
described. With analogy to Western science, in actualising this holistic nature. According to
these theories can be likened to the mathemati- this view, the meridians have distinct pathways
cal formulae that describe the workings of the which connect the organs internally, and are
universe. involved in processes through which the body
36 © Journal of Chinese Medicine

A. Ziv & I. Levi
interacts with the environment. Understanding ‘evil’ Qi if the meridian system is impaired and
the unifying role of the meridians is what unable to maintain balance with the climates or
gives life to the concept of holism in Chinese if the climatic influences are excessively strong
medicine: “Without channel theory the principle of and invade the body. The climate-meridian rela-
‘holism’ in Chinese medicine makes little sense ” (Wang tionships are specific, and the meridians bond
Ju Yi). each of the six Qi to a specific organ system:
It is important to emphasise that in the clas- Tai Yang (Small Intestine, Bladder) – cold
sics the meridians are not described as ‘hollow Shao Yang (San Jiao, Gall Bladder) –
pipes’ but as a physiologically active units that summer-heat
act as networks (wang lou), pathways (tong dao) Yang Ming (Large Intestine, Stomach) – dryness
and communication systems (tu jing) (Wang Tai Yin (Lung, Spleen) – dampness
1999). Thus the meridians are a living network Shao Yin (Heart, Kidney) – fire
that bind yin and yang, external to internal, Jue Yin (Pericardium, Liver) – wind
and conduct necessary external influences into The meridian system has both external and
the internal environment and vice versa. They internal functions. The external role is to bal-
thus facilitate healthy physiological activity and, ance and regulate the movement of the six Qi
in case of dysfunction, actively participate in into and out of the body. The meridians may
rebalancing pathology. Information about the allow the climates to enter, or else push them
state of the organs and their surroundings away, thus regulating the internal climate. As
(the inner ‘climate’) is continuously commu- extensions of the organs, the internal role of
nicated by the meridians in order to facilitate the meridians is to balance and regulate the
physiological balance. For example, a state of functions of the zang fu through an intricate
excess dampness in the Tai Yin Spleen may web of inner connections, thus maintaining the
be communicated to the Yang Ming system in appropriate inner climatic environment for each
order to promote a response of increasing dry- organ. Thus the meridians regulate organ activ-
ness. Dryness is the inner climate of the Yang ity and serve as pathways for information and
Ming, which is regulated by the Large Intestine substance to flow to and from the organs.
absorbing excess fluids from the intestines. This As an example of the external role of the
explains the rationale behind needling Zusanli meridian system, consider the response of the
Stomach (ST) 36 for Spleen damp-related diar- Tai Yang meridian to external cold. Tai Yang,
rhoea. Thus the meridians are referred to in the the outermost yang channel, has the role of
early classics as an integral part of the organs dispersing yang Qi and heat to the surface (i.e.,
themselves, yet contain functions that surpass wei-defensive Qi) in order to prevent invasion
the general function of the organs due to their of excess cold into the body. It also controls the
role in interacting with the outer environment skin pores, which are opened or closed to prevent
and climate (Wang 2000). or induce sweating according to needs of warm-
ing or cooling the surface. Using the warming
yuan-source points (Wangu Small Intestine (SI)
Meridian theory and external 4 and Jinggu Bladder (BL) 64) on this meridian
climates – the six Qi can rapidly resolve symptoms of external cold
The meridians connect the Qi of the body to such as runny nose, aversion to cold and wind,
the Qi of the external environment. The exter- itchy throat, low grade fever and stiffness in the
nal climatic influences are also referred to as the upper back and neck caused by cold stagnation
six Qi. These are cold, summer-heat/fire, damp- in the upper part of the Tai Yang.
ness, dryness, fire and wind. It is important to As an example of the inner role of the
note that the six Qi are functional climatic forces meridian system, consider the functions of the
which are necessary for the function of the Tai Yin meridian. Among many other functions,
internal organs and are therefore not necessarily Tai Yin is the receiver and balancer of damp-
‘evil’ factors. The six Qi may become the six ness. Moisture that is needed for the proper

Figure 1. Each meridian has a specific Qi wave quality that resonates throughout its whole pathway.
functioning of the Lung is absorbed from the to say that each meridian operates at a different
air during breathing. This process is governed energetic resonance. By identifying the correct
by the hand Tai Yin Lung meridian. Internally, meridian wave quality and selecting appropriate
the balance of fluids and nutrients manifested point combinations, the whole meridian can be
physiologically by the nourishing dampness pro- activated through a strong therapeutic wave-like
duced by the Spleen (i.e., ying-nutritive Qi) is movement of Qi. This method enhances acu-
governed by the transporting and transforming puncture stimulation and yields an immediate
functions of the foot Tai Yin Spleen merid- response with instant and measurable clinical
ian. Thus, the hand and foot Tai Yin meridian outcomes. Key principles that will allow practi-
system is constantly balancing the external and cal utilization are introduced below.
internal environments with regard to moisture
and nourishment.
This pairing of the channels into six func- Method overview
tional units that operate in relationship to The following section introduces the guiding
specific climatic factors lays the foundational principles and concepts of meridian wave acu-
basis of physiology and pathology according to puncture, which are later explained in detail in a
meridian theory. pragmatic step-by-step fashion.
1. Treating the meridian as a whole

The meridian wave acupuncture In order to fully grasp the principles of merid-
system ian wave acupuncture, it is important to re-
Each meridian relates to a distinct wave emphasise the fundamental concept of paired
quality of Qi and correlates to a specific cli- meridians acting as one system (see above).
mate, tissue, organ and meridian Qi movement/ Thus, when considering pain or discomfort in a
transformation (Qi hua). One can easily under- specific location, the meridian passing through
stand that a meridian that responds to cold that area is identified and acupuncture points
would operate with a distinctively different Qi from both the hand and foot manifestation of
wave quality than a meridian that responds to that meridian are selected. For example, with
heat. Thus each meridian operates and reso- pain on the lateral side of the shoulder, points
nates with a distinct wave-quality of Qi (Fig 1.). from the hand Shao Yang Triple warmer and
A complete discussion of the actuality of this foot Shao Yang Gall Bladder meridian are used.
notion is beyond the scope of this article, suffice Pain on the dorsal aspect of the shoulder or

A. Ziv & I. Levi
shoulder blade area will be treated with points and another needle on the foot on the opposite
from the hand Tai Yang Small Intestine and side of the same meridian, we are engaging the
foot Tai Yang Bladder. Qi of the whole meridian. The ripple at one
end of the meridian creates a vigorous wave-like
2. Bleeding jing-well points – wave movement of Qi when it reaches the other end,
initiation similar to a whip where a small motion at the
The importance of jing- well points for the handle lashes hard at the other end.
treatment of pain and discomfort cannot be
overemphasized. This point category is one 4. Moving Qi through the blockage
of the strongest for vigorously moving Qi and (rather than to the blockage)
blood. Their location at the tips of the fingers When stagnation collects in a meridian, local
and toes is a place of yin and yang exchange, needling will draw attention to the blocked area
where the initial flow of the channel builds, rather than promote the flow of Qi through
eventually entering the interior of the body at the blockage. Increasing the flow of meridian
the he-sea points of the elbows and knees. In Qi through the affected area rejuvenates the
addition, these points are known for their abil- compromised surrounding tissue. Consider a
ity to activate the tendo-muscular channels (jing small classroom crowded with students. After a
jin) which are important in cases of pain and while the room becomes stuffy and a sense of
limitation. The jing-well points function through stagnancy fills the space. A common solution
their ability to ‘‘drain excess and dispel stagnation’’ is turning on a fan. However, this approach
and ‘‘disband obstruction and open clumps’’ (Wang & will merely circulate the foul air in the room.
Robertson 2008) and thus clear both excess and Another approach would be to open a window
deficient manifestations of blockage throughout on one side of the room and a door on the
the whole meridian pathway. Moreover, since other. Instantly, fresh air would flow through
both acute and chronic pain always involve a the room and rejuvenate the space. Meridian
certain degree of blood stasis, the ability of wave acupuncture utilizes a similar concept.
these points to strongly move blood, dispel By bleeding the jing-well point on the affected
stagnation and affect the whole meridian makes meridian we are effectively ‘opening a window’
them highly attractive for use in pain manage- and directing the flow. By needling acupoints at
ment. As blood stasis involves stagnancy of the opposite distal end of the meridian we are
matter, bleeding technique – which physically promoting a fresh flow of meridian Qi through
draws blood out of the meridian – works much the compromised area similarly to the window-
faster than just regulating Qi through needling. to-door air flow in a room (Fig. 2).
Thus, when blood is stagnant, always bleed first
to draw physical stasis out. This in turn signals
to the body the direction of the Qi wave move-
ment we wish to induce through the needling
that follows the bleeding (see below).
3. Distal needling – engaging the whole

meridian
Keeping in mind that meridian Qi flows
throughout the whole pathway of each of the
six channels, we can understand the importance
of engaging the whole meridian. Local needling
often engages only a small portion of meridian
Figure 2. The flow of Qi through the compromised
Qi. By using points distal to the blockage (pain area produced by Meridian Wave Acupuncture is like
area) we can create leverage in the wave of Qi. For wind moving through a room from a window and
example, by inserting one needle near the hand leaving out of the door.

5. Addressing the underlying condition step. Since results of the treatment are assessed
Differential diagnosis is one of the jewels of during the acupuncture session, and since an
Chinese medicine. A thorough understanding of immediate improvement of 20 to 100% is
the underlying imbalance involved in a problem expected, an accurate initial assessment is neces-
is a key to clinical success. Apart from bleeding sary to provide feedback on treatment efficacy.
and needling to activate meridian Qi flow, we The assessment must actively engage the patient,
must always address any underlying imbalances. and it is best to scale the limitation from 1 to
When using meridian wave acupuncture, we 10. Whether the complaint is pain, discom-
commonly experience that after the immediate fort, numbness, tingling or decreased range
improvement in pain and/or movement limita- of motion, a quantified measurement should
tion after bleeding and needling to activate the be pursued. Initially simply ask the patient to
meridian wave, we achieve additional instant gently show what movement or posture gener-
improvement if we add one or two needles to ates the most discomfort and to quantify this
address the underlying condition. It is almost on a scale of 1 to 10. The assessment should
as if the body ‘released’ Qi flow to the merid- be used repeatedly throughout the treatment
ian wave as it felt secure that its underlying to identify which intervention (point combina-
conditions are also being attended to by the tion, meridian selection, etc.) yields the best
treatment. therapeutic effect. Three approaches should be
considered:
6. Repeatedly assessing the results of (1) Palpation: the patient feels the pain as a
the treatment – wave effect reaction to palpation at a specific location.
As discussed below, repeated assessment of (2) Range of motion: the pain arises during
the treatment effect is an integral part of this specific movements (flexion, extension,
system, since results are expected immediately, rotation, etc.). This includes both passive
during the treatment session. range of movement (ROM) testing, where
the pain arises when the practitioner
initiates the movement, and active ROM
Practical step-by-step meridian testing, where pain arises when the patient
wave acupuncture initiates the movement.
In the majority of the cases treated with this (3) Resistance: the pain arises as a reaction to
system, results are expected within minutes. In resistance to certain movements.
fact, if results are not achieved instantly, the
steps conducted should be re- examined. This In addition, the nature of the patient’s problem
is not to say that we should expect immedi- is likely to provide important information about
ate results in 100% of patients. However, in the type of stagnation that is blocking the
most cases this is what we have seen. For over meridian. This may be heat or cold sensations,
15 years, this system has been used in our clin- aggravation due to specific factors, heaviness,
ics and taught to hundreds of practitioners. weakness, moving pain, fixed pain, and so on.
The feedback received supports this notion. This information is crucial for selecting the cor-
In addition, this system has been adopted as rect points on the meridian to activate the wave.
treatment of choice in a major hospital’s ortho- For example, with pain associated with redness
paedic emergency room (A&E) for acute pain and a sensation of heat, ying-spring points are
after being validated in a randomized controlled often selected due to their ability to clear heat.
study.
Step two: Identifying the correct meridian
Step one: Establishing a pain/limitation After completing the assessment, identifying
scale the correct meridian should be easy: simply
Establishing an objective assessment of the ask the patient to point at the area of dis-
degree of pain and/or limitation is a crucial comfort. Remember that the channel has two

A. Ziv & I. Levi
outputs, one on the hand and one on the foot. performed in the first three or four treatments
More than one meridian may be involved, in and substituted with needling with a small nee-
which case identify all the meridians involved. dle in later treatments.
However, insist on isolating which meridian is
compromised the most (i.e., most painful or Step four: Reassessment of pain/
limited in motion). limitation scale – wave effect
Since bleeding is the first intervention to be
Step three: Wave initiation – bleeding the conducted, its effect should be immediately
jing-well point assessed. A major improvement (30 to 60%)
After identifying the correct meridian and quan- indicates that the degree of blood stasis in the
tifying the pain or limitation of ROM, the ini- meridian is high. This may help to decide how
tiation of the meridian Qi wave is achieved by many bleeding sessions will be conducted dur-
bleeding the jing-well point. Since each meridian ing later treatments.
has two jing-well points, one on the hand and
one on the foot, the selected point should be Step five: Wave propagation –
on the limb closest to the obstruction. For oppositional distal needling
example, for right-sided anterior shoulder pain After bleeding to initiate the meridian Qi wave,
involving the Yang Ming meridian, bleeding is the ‘whip’ action of promoting and propagating
done at right Shangyang Large Intestine (LI) 1, the wave is pursued. Points are selected to cre-
for left-sided medial knee pain involving the Jue ate the greatest leverage of meridian Qi. The
Yin meridian, bleeding is done at left Dadun more distal the points are, the greater ‘wave
Liver (LR) 1, or for lower back pain radiating leverage’ can be achieved. Therefore, needling
to the back of the left thigh, bleeding is done is conducted in a contralateral manner across
at left Zhiyin BL 67. More complex examples the body. Points are selected to include the
require an understanding of the meridian sys- obstruction area in the wave. This is to say
tem: for left-sided upper neck pain along the that the obstruction (pain) should be on the
Shao Yang Gall Bladder meridian, bleeding is meridian between the two points selected. For
done at left-sided Guanchong San Jiao (SJ) 1, example, when treating left sided ankle sprain
since this the end of the meridian closer to the along the foot Shao Yang Gall Bladder (GB)
obstruction. For right- sided upper back pain meridian (at Qiuxu GB 40), bleeding is done
along the Tai Yang Bladder meridian, bleeding first at left Zuqiaoyin GB 44, and then needles
is done at right- sided Shaoze SI 1, again as can be inserted at right Zhongzhu SJ 3 and
this is the end of the meridian closer to the left Diwuhui GB 42. This will initiate a merid-
obstruction. As a general rule, pain below the ian Qi wave that includes the obstruction area
navel is addressed by bleeding jing-well points near Qiuxu GB 40. In this example, needling
on the feet, and pain above the navel, by bleed- left Yanglingquan GB 34 instead of Diwuhui
ing those on the hands. GB 42 would create a shorter wave that would
Before bleeding, massage the meridian not cover the compromised area. After needle
downwards towards the jing-well point several insertion, the best technique is to simultane-
times. It is best to wet the point area with an ously manipulate both needles (using the right
ethanol swab, as apart from sanitizing reasons, and left hands simultaneously). If this cannot
this expands the blood vessels and aids the be achieved, then the needle most distal to
bleeding process. Bleeding should be conducted the painful area is manipulated first, followed
swiftly, piercing with a lancet at a location immediately by the paired needle.
two to three millimetres away from the corner
of the nail. Eight to twelve drops of blood Step six: Point selection according to
should be drawn (in cases of blood deficiency meridian obstruction
or post-menstruation this should be reduced to Apart from the principle of point selection
three to four drops). Normally, bleeding is only described above, points may also be selected

according to degree of sensitivity on palpation. the underlying condition. A thorough intake,
Optimal point selection would involve point including pulse, tongue and meridian assess-
categories and functions according to the five ment are the essential tools for accurate dif-
shu-transporting or five phase theories. Other ferential diagnosis. As mentioned earlier, adding
points such as xi-cleft points or any other point just one or two points to address the underlying
categories that add clinical value in relation to condition according to differential diagnosis can
the nature of the obstruction in the meridian profoundly increase results during treatment,
(damp, cold, heat, stasis etc.) may be selected. and cumulative success during the treatment
For example, a swollen right sided tennis elbow series. In fact, in cases of severe deficiency,
along the Yang Ming Large Intestine meridian progress is difficult to achieve without applying
could be treated by bleeding right Shang yang this principle.
LI 1, followed by needling right Sanjian LI 3
and left Xiangu ST 43 to propagate the wave. Summary example
These shu-stream points would further enhance To summarize with an example, consider the
the wave effect by addressing the dampness case of a 42- year-
old male with left- sided
(swelling) obstructing the meridian. medial knee pain due to a medial meniscus tear.
The pain is fixed, localized and often accompa-
Step seven: Reassessment of pain/ nied by a burning sensation. There is no local
limitation scale – wave effect swelling. The pain is worse in the morning
As in step four, another assessment is con- and slightly better after moving around. Other
ducted. The importance of this principle cannot symptoms from the intake as well as pulse and
be over-emphasised. Good results indicate cor- tongue diagnosis indicate Liver Qi stagnation.
rect meridian and point selection. Poor results, Following the steps described above, the practi-
on the other hand, require reanalysis of the tioner would first assess and quantify the degree
meridian and point selection. In addition, any of pain and limitation – in this case by asking
positive change is normally reassuring for both the patient to bend the knee (knee flexion)
the patient and practitioner. to the point where pain arises. The degree of
motion (knee angle) and pain score should be
recorded. The second step would involve asking
Step eight: Enhancing wave Qi flow the patient to point to the exact area of discom-
through physical movement fort during the movement – in this case reveal-
To further enhance the wave Qi flow through ing that the obstruction is on the foot Jue Yin
the obstructed area, physical movement is Liver meridian. Step three would be to initiate a
added. This is preferably done during needle meridian Qi wave by bleeding left sided Dadun
manipulation. If simultaneous manipulation and LR 1. Step four would involve reassessing pain
movement are not feasible, movement should and range of motion. Step five would involve
follow immediately after needle manipulation wave propagation through opposite hand and
for wave propagation. If possible, the initial foot meridian selection. For this patient this
movement that was selected for assessing pain would mean selecting the right hand Jue Yin
level (step one) is gently repeated during this Pericardium (PC) meridian and the left foot
phase. Movement of the compromised area Jue Yin Liver meridian. Step six would involve
enhances wave Qi flow and further rejuvenates point selection following the principles of dis-
the surrounding tissues with fresh flow of Qi tal needling to propagate a wave that includes
and blood. the obstruction using points that address the
nature of the obstruction. A good combina-
Step nine: Addressing the underlying tion in this case would thus be right- sided
condition Neiguan PC 6 with left-sided Xingjian LR 2 (a
The final acupuncture points needled during ying-
spring point to clear heat). Simultaneous
a treatment session are aimed at balancing needle stimulation would then be performed.

A. Ziv & I. Levi
command point of the sinews and tendons.
An illustration of this process is outlined in
Fig. 3.
References
Ellis A., Wiseman N. & Boss K. (1989) Grasping the
Wind. An Exploration into the Meaning of Chinese
Acupuncture Point Names, pp. 375. Paradigm Publications,
Brooklyn.
Wang J. Y. & Robertson J. D. (2008) Applied Channel Theory
in Chinese Medicine. Eastland Press, Seattle.
Wang J. Y. (1999) Notes from teaching sessions, San Francisco,
1999.
Wang J. Y. (2000) Notes from internship, Beijing, 2000.
Ziv A., Yoav M., Guy A., et al (2012) A randomized
controlled trial of an integrative approach utilising
acupuncture for back and neck pain in an emergency
department setting. European Journal of Integrative
Medicine 4 (1), 23–24. A summary of this research was
presented by Amos Ziv at the European Conference
of Integrative Medicine in Florence (Italy) and at vari-
ous orthopaedic conferences in Israel. In addition the
study was presented by Dr Samuel Bar-Chaim, head of
the Asaf Harofeh Medical Centre Emergency Services,
at the MEMC Emergency Medicine conference in
Marseille, France.
Figure 3: Key steps of meridian wave acupuncture
treatment in a left medial meniscus tear along the foot
Jue Yin Liver meridian. Amos Ziv MSc LAc is a researcher and an entre-
1. Pain/limitation scale assessment preneur. He is the founder and former director of the
2. Meridian selection clinical research unit of the Shiram Integrated Medicine
3. Wave initiation – bleed LHS Dadun LR 1
4. Reassessment
Services in Asaf Harofeh Medical Center, Israel, where
5. Wave initiation – point selection he headed the Acupuncture for Back and Neck Pain
6. Point stimulation – RHS Neiguan PC 6 and LHS in the Emergency Room Clinical Trial (ABNP study).
Xingjian LR 2 He is a graduate of the American College of TCM,
7. Reassessment
8. Knee movement San Francisco, California and an expert in TCM chan-
9. Addressing the underlying condition – RHS nel theory applications in pain management and cardio-
Yanglingquan GB 34 vascular conditions. Amos studied as a personal student
LR=Liver; PC=Pericardium; GB=Gall Bladder;
LHS=left hand side; RHS=right hand side
of Professor Wang Ju Yi in California and China
since 1999. He has published numerous articles in both
TCM and scientific journals and is an invited speaker
Step seven would involve reassessment. Step to international conferences. He has taught the meridian
eight would involve asking the patient to gently wave acupuncture system to hundreds of practitioners in
bend the knee several times (without reaching Europe and Israel. Amos was a co-founder and chair-
the pain threshold), preferably whilst the points man of SIRF, the Sino- Israeli Research Foundation
are simultaneously stimulated. Step nine would and is the founder and CEO of ReguRate Advanced
involve adding one or two points to address the Integrative Technologies in Cardiovascular Health. He
underlying condition. There are many options is the owner and manager of Heaven and Earth TCM
here, one possibility would be Yanglingquan GB specialty clinic in Rehovot, Israel.
34 on the opposite side. This point not only Idan Levi is a Chinese medicine practitioner who
treats stagnation in the Liver but also addresses specialised extensively in meridian theory acupuncture,
the tissue damage (torn ligament) as it is the corrective exercise and lifestyle management. He has

studied meridian wave acupuncture system with Amos This article is reprinted with kind permission
Ziv and worked with him since 2009, and has served from the Journal of Chinese Medicine. Original
as an assistant teacher. He has presented his work and publication: Ziv A. & Levi I. (2017) Practical
techniques in leading TCM conferences. Idan has gained applications of meridian theory in pain
vast clinical experience in leading physical therapy clinics management – the meridian wave approach.
in Israel and is currently the Head of the Chronic Pain Journal of Chinese Medicine (115), 5–12.
and Orthopaedic Injury Department at Heaven and
Earth TCM specialty clinic in Rehovot, Israel, and the
Head of the Chinese Acupuncture unit at MedLeader
Physiotherapy clinic in Raanana.

research
Types of control in acupuncture clinical trials

might affect the conclusion of the trials: a
review of acupuncture on pain management
H. Chen
School of Chinese Medicine, University of Hong Kong, Hong Kong, China and
Department of Chinese Medicine, University of Hong Kong-Shenzhen Hospital,
Shenzhen, China
Z. Ning
School of Chinese Medicine, University of Hong Kong, Hong Kong, China
W. L. Lam
W.-Y. Lam
Y. K. Zhao
J. W. F. Yeung
School of Nursing, Hong Kong Polytechnic University, Hong Kong, China
B. F.-L. Ng
Chinese Medicine Department, Hospital Authority, Hong Kong, China
E. T.-C. Ziea
Chinese Medicine Department, Hospital Authority, Hong Kong, China
L. Lao
School of Chinese Medicine, University of Hong Kong, Hong Kong, China and
Department of Chinese Medicine, University of Hong Kong-Shenzhen Hospital,
Shenzhen, China
Abstract
Analgesic effects of acupuncture have been extensively studied in various clinical trials.
However, the conclusion remains controversial, even among large scale randomized con-
trolled trials. This study aimed to evaluate the association between the conclusion of the tri-
als and the types of control used in those trials via systematic review. Published randomized
controlled trials (RCTs) of acupuncture for pain were retrieved from electronic databases
(Medline, AMED, Cochrane Libraries, EMBASE, PsycINFO, Clinicaltrials.gov, and CAB
Abstracts) using a pre-specified search strategy. One hundred and thirty-nine studies leading
to 166 pairs of acupuncture-control treatment effect comparisons (26 studies comprised of
53 intervention-control pairs) were analyzed based on the proportion of positive conclusions
© 2016 Medical Association of Pharmacopuncture Institute 45

A review of acupuncture on pain management
in different control designs. We found that treatment effects of acupuncture compared with
nontreatment controls had the highest tendency to yield a positive conclusion (84.3%), com-
pared with nonneedle- insertion controls (53.3%). Whereas with needle- insertion controls,
the lowest tendency of positive conclusions was observed (37.8%). Consistently, in studies
reporting successful blinding, a higher tendency of positive findings on the treatment effect
of acupuncture was found in the noninsertion sham controls compared with that in the
insertion sham controls. We conclude that the type of control is likely to affect the conclu-
sion in acupuncture analgesic trials. Appropriate control should be chosen according to the
aims of studies.
Keywords: acupuncture, control, pain, randomized controlled trial.
Introduction and insertion sham acupuncture, are utilized

The number of randomized controlled trials to evaluate the true effects in RCTs (Chen &
(RCTs) conducted on acupuncture have dra- Lao 2014). Arguments have been raised on the
matically increased over the past decade. The efficacy of acupuncture controls (Goddard et al.
efficacy of acupuncture for pain is one of the 2005; Irnich et al. 2011; Lee et al. 2011). Meng
most interesting outcomes in studies. Although et al. (2011) reviewed acupuncture RCTs on pain
many basic science studies have revealed the published in 2006 to 2007 and found that trials
analgesia mechanisms of acupuncture (Lin using noninsertion shams yielded more positive
& Chen 2008; Zhang et al. 2014), the effi- outcomes (six of seven trials) than those using
cacy of acupuncture remains controversial in insertion shams (two of eight trials). Madsen
clinical trials, e.g., in knee osteoarthritis (KOA) et al. (2009) found that the type of placebo acu-
(Berman et al. 2004; Witt et al. 2005; Scharf puncture was not associated with the estimated
et al. 2006; Witt et al. 2006; Lin & Chen 2008; analgesic effect of acupuncture. In this study, we
Mavrommatis et al. 2012; Hinman et al. 2014; aimed to examine whether positive conclusion
Zhang et al. 2014). The diverse mechanisms is correlated with the type of controls in RCTs
and complicated manual procedures involved of acupuncture for pain. We systematically
in acupuncture treatment have contributed to reviewed clinical trials of acupuncture for pain
the challenges of evaluating acupuncture trials from 2004 to 2014. The association between
(Chen & Lao 2014). For example, acupuncture the type of controls used in these studies and
produces a specific physiological effect and conclusion of acupuncture efficacy were further
nonspecific needling effect (e.g., diffuse noxious analyzed.
inhibitory control) during the treatment (Le
Bars et al. 1991). Patient expectations, acu- Materials and methods
puncturist experience, number and specificity
of acupoints, depth of needling, and dosage Database
of acupuncture (duration, frequency and time) A systematic search of RCTs with acupuncture
also affect the efficacy of acupuncture analgesia was conducted to evaluate the proportion of
in RCTs (White et al. 2001). The benefits dur- positive conclusions in the different controls in
ing the treatment are usually explained by: (1) RCTs. The search strategy was defined as below.
treatment effects; (2) nonspecific effects; or Databases searched included Medline, AMED,
(3) spontaneous remissions (Turner et al. 1994; Cochrane Libraries, EMBASE, PsycINFO,
Lao et al. 2001). A proper control or controls, Clinicaltrials.gov, and CAB Abstracts.
e.g., waitlist, noninsertion sham acupuncture,
Search strategy
Correspondence: L. Lao, School of Chinese Medicine, The search keywords were as follows:
University of Hong Kong, 10 Sassoon Road, Pokfulam, “acupuncture*”, “acupoint*”, “acupress*”,
Hong Kong, China. (email: lxlao1@hku.hk). “meridian*”, “needle*”, “sham acupuncture”,
46 © 2016 Medical Association of Pharmacopuncture Institute

H. Chen et al.
“placebo acupuncture”, “control acupuncture”, the blunt end of the acupuncture needles, non-
“acupuncture control”, and “pain”. Studies insertion sham devices (e.g., Streitberger or Park
were limited to RCTs and journals in Science sham devices), and other needle- resembling
Citation Index (SCI). The search was conducted devices such as toothpicks and needling guid-
in March 2015. ing tubes; (3) insertion sham: usually involves a
superficial insertion of needles to acupoints or
Screening nonacupoints; (4) combined noninsertion and
The retrieved studies were imported into insertion sham; and (5) comparator (positive
Endnote and any duplicates were removed. The control): refers to active treatments, such as
abstracts of the studies were screened, followed specific mediations and physiotherapies, some
by full-text screening according to the selection usual care, or standardized care, etc., which
criteria below. The screening was performed by were thought to be effective.
two individuals. Discrepancies were resolved by Usual care refers to standardized patient
discussion with a third reviewer. Information on care practices that have not been validated by
the type of controls and acupuncture efficacy rigorous clinical evidence, or uniform practices
conclusion from eligible studies were extracted that have not been identified as the “best current
according to the definition of outcomes. therapy” in clinical practices while the individual-
ized cares are available (Thompson et al. 2007).
Selection criteria The role of usual care remains controversial
1. Inclusion criteria (Thompson et al. 2007; Freedland et al. 2011).
Studies: (1) were RCTs; (2) used pain score as In pain trials, usual care commonly refers to
an outcome; (3) used needling acupuncture (tra- standardized management that is not sufficient
ditional acupuncture, electroacupuncture, and to kill pain but is routinely provided to patients
medical acupuncture) as the major intervention (Thompson et al. 2007; Freedland et al. 2011).
(not restricted to auricular acupuncture and scalp In this study, if both arms of intervention and
acupuncture as the secondary intervention); and control used usual care, we classified the type
(4) were published from 2004 to 2014. of control into no treatment control. Also
participants in no treatment or waitlist control
2. Exclusion criteria group have access to nonstudy healthcare
Studies: (1) used bee venom acupuncture as the services (Silverman & Miller 2004). There are
intervention; (2) used acupoint injection as the other study designs where usual care serves as
intervention; (3) of poor quality design (unclear the comparator, and is only used in the control
randomization method, incorrect concealment, arm but not the intervention arm. In that case,
and individual assessment), with low risk items we classified usual care as a positive control or
less than five of seven (according to risk bias comparator.
assessment tool in Cochrane review handbook); If a study contained two or more controls,
and (4) used active treatment of any acupunc- information on each acupuncture- control
ture modalities (e.g., active acupuncture, auricu- comparison pair was extracted according to the
lar acupuncture, etc.) as control(s). control types.
Outcomes 2. Type of conclusions in clinical trials

1. Type of acupuncture controls Positive conclusion was defined as acupuncture
We classified acupuncture controls into several showing statistically significant superiority to
types according to the purpose of controls: (1) the control (p < 0.05) in the primary outcome
“nontreatment” control: patients usually received of clinical studies. If no primary outcome was
nontreatment, delayed treatment (waiting list), stated in the studies, the general conclusion of
usual care, or/and rescue medication in consid- the study was judged as a positive conclusion
eration of medical ethics; (2) noninsertion sham: when it indicated acupuncture was better than
these do not penetrate the skin, but usually use the control.

Negative conclusion was defined as acu- Results
puncture not showing statistically significant According to the search strategy, 2934 studies
superiority to the control (p 0.05) in the pri- were retrieved. The flowchart of screening
mary outcome of clinical studies. If no primary is shown in Fig. 1. One hundred and thirty-
outcome was stated in the studies, the general nine studies were included with 166 pairs of
conclusion of the article was judged as a nega- intervention controls as 26 studies contributed
tive conclusion if it indicated acupuncture was 53 intervention- control pairs. The follow-
not better than the control. ing analysis was performed according to 166
An inconclusive conclusion was defined as intervention-control pairs in 139 studies.
acupuncture showing statistically significant su- Using Fisher’s exact test, there was a statisti-
periority to the control in some primary outcomes cally significant relationship between the type
but not in all primary outcomes. If no primary of control and study conclusion (p < 0.0001;
outcome was stated in the studies, the general Table 1). Robustness of the result was demon-
conclusions of the study was as inconclusive strated by sensitivity analysis that excluded the
when it indicated acupuncture was somewhat combined control studies and/or inconclusive
better than the control but not in all outcomes. studies.
Figure 1. Flowchart of screening. One hundred and thirty-nine studies with 166 pairs of intervention-controls were
analyzed.
RCT=randomized controlled trial; SCI=Science Citation Index.

H. Chen et al.
Table 1. Types of control by study conclusion in acupuncture clinical trials.
Study conclusions
Type of control No. of studies Positive n (%) Negative n (%) Inconclusive n (%)
Nontreatment 51 43 (84.3) 6 (11.8) 2 (3.9)

Noninsertion sham control 30 16 (53.3) 13 (43.3) 1 (3.3)
Insertion sham control 37 14 (37.8) 20 (54.1) 3 (8.1)
Positive comparison 46 26 (56.5) 16 (34.8) 4 (8.7)
Combined controls 2 2 (100) 0 (0) 0 (0)
Total 166 101 (60.8) 55 (33.1) 10 (6)
Nontreatment control intervention-insertion shams were inconclusive

Patients in this type of control usually received (8.1%).
nontreatment or delayed treatment (called wait-
ing list). Usual care or rescue medications were Combined controls
introduced in both the treatment group and As shown in Table 1, two studies used the com-
nontreatment control group during the clinical bined controls. Berman et al. (2004) used non-
studies. As shown in Table 1, 84.3% of inter- invasive guide tubes at local acupoints around
vention nontreatment pairs in clinical trials had the knee and lower leg and inserted two needles
positive efficacy conclusions (43/51). A nega- on the abdomen at points away from meridians
tive conclusion was yielded in 11.8% of them in a clinical trial of KOA. Another study used
(6/51). Two pairs of intervention nontreatment double-dummy design to evaluate the efficacy
were inconclusive. of acupuncture for migraine prophylaxis (Wang
et al. 2011). The treatment group consisted of
Noninsertion sham control real acupuncture and placebo medication, and
The noninsertion control resembles the real the control group had true medication and
acupuncture needling procedure but does sham acupuncture (perpendicularly needling at
not really penetrate the skin. Many types sham acupoints with lifting, thrusting, and twirl-
of noninsertion control have been used in ing to obtain De Qi) (Wang et al. 2011). Both of
acupuncture trials, e.g., empty guiding tube, them had positive conclusions of acupuncture
semiblunt needling, toothstick, nonpenetrating efficacy.
needle devices, etc. (Cho et al. 1976; Kennedy
et al. 2008; Mavrommatis et al. 2012; Miller et al. Positive comparison
2011; White et al. 2012). As shown in Table 1, Medications, physiotherapies, and other treat-
53.3% of intervention noninsertion sham pairs ments were used as comparators in many studies.
in clinical trials had positive efficacy conclusions As shown in Table 1, 56.5% of intervention-
(16/30), while 43.3% of them yielded negative insertion sham pairs in clinical trials had posi-
conclusions (13/30). One pair of intervention tive efficacy conclusions (26/46), while 34.8%
noninsertion shams were inconclusive (3.3%). of them yielded negative conclusions (16/46).
Four pairs of intervention- comparison sham
Insertion sham acupuncture control were inconclusive (8.7%).
The needle-insertion sham acupuncture control
usually penetrates the skin but at nonacupoints Positive conclusion in blinding validated
or the acupoints which are believed to have studies
no specific effect (He et al. 2004; Witt et al. Only 12 studies reported blinding validation
2005; Alecrim-Andrade et al. 2006; Scharf et al. tests in the clinical trials, accounting for 7.2%
2006; Haake et al. 2007). As shown in Table of all included studies. All studies reported
1, 37.8% of intervention-insertion sham pairs successful blinding. Studies that used insertion
in clinical trials had positive efficacy conclu- sham controls had 100% negative conclu-
sions (14/37), while 54.1% of them yielded sions. Among studies that used noninsertion
negative conclusions (20/37). Three pairs of sham controls, 28.6% had positive conclusions

Table 2. Conclusions of studies with blinding credibility.
Study conclusions
Type of control No. of studies Positive n (%) Negative n (%) Inconclusive n (%)
Noninsertion sham control 7 2 (28.6) 4 (57.1) 1 (14.3)

Insertion sham control 5 0 (0) 5 (100) 0 (0)
Total 12 2 (16.7) 9 (75) 1 (8.3)
and 57.1% had negative conclusions (Table duration of acupuncture), optimize the duration
2). However, the relationship between study of treatment, select proper measurements and
control type and study conclusion in these measurement time points, or examine the safety
studies was not significant (Fisher’s exact test, in a pilot study or at the early stage of develop-
p = 0.47). ing a certain acupuncture treatment.
However, patients assigned to receive non-
treatment usually prefer to get real treatment.
Discussion Their feeling worse in the disease condition
In this study, we systematically reviewed RCTs for not having the opportunity to receive the
that studied the efficacy of acupuncture for real treatment is called nocebo effect (Enck
pain. Potential association between the conclu- et al. 2008). The nocebo effect is regarded as
sions of acupuncture efficacy and the types of negative placebo effect which has been raised
controls was analyzed. We found that studies from expectation and psychological condition-
had the highest tendency to yield positive con- ing (Enck et al. 2008). Wait list control offers
clusions (84.3%) when nontreatment controls patients the same treatment as the treatment
were used, compared with a lower tendency group after the patient completes treatment
(53.3%) observed in the noninsertion controls, so that nocebo effect is minimized as much as
and lowest tendency (37.8%) in the insertion possible. In fact, few studies restrict patients to
controls. Consistently, in studies reporting suc- take medications or other therapies if patients
cessful blinding, a higher tendency of positive really need treatments. Taking into considera-
conclusion was found in non-insertion sham tion the ethical issue and nocebo effect, usual
controls compared with that in insertion sham care, medical education, or rescue medications
controls. are used as the “nontreatment” control (Cherkin
In clinical practice, acupuncture analgesia et al. 2001; Cherkin et al. 2009).
may be explained by various effects, such as the Studies using the noninsertion controls have
specific therapeutic effect, nonspecific physiol- a higher tendency of positive conclusion com-
ogy effect, placebo effect, or disease spontane- pared with those using needle insertion controls
ous remission. These effects are commonly in acupuncture for pain studies. It could be
distinguished by adopting specific controls or explained that needle insertion controls may
are excluded by appropriate trial design step by produce more nonspecific physiological effects,
step. e.g., the diffuse noxious inhibitory controls (Le
The nontreatment control determines Bars et al. 1991). The difference in pain scale
whether the disease has spontaneous remis- between acupuncture treatment groups and nee-
sion. It had the highest positive conclusion dle insertion controls is likely to be smaller than
of acupuncture efficacy and the cost is lower studies using noninsertion controls. However,
than RCTs using other controls such as sham noninsertion controls may reduce the success of
control. It is more feasible to conduct a clinical blinding as patients with acupuncture experience
trial using nontreatment control compared with are more likely to identify the sham treatment,
using other types of controls. With this advan- which lowers patient expectancy and attendance.
tage, nontreatment control is recommended The noninsertion sham controls can be used
to establish the adequate dose of acupuncture for the short-term trials, e.g., acute pain study,
(e.g., number of acupoints, frequency, and or trials recruiting acupuncture naïve patients.

H. Chen et al.
Insertion sham controls are more similar to real or other active treatments (physiotherapies,
acupuncture. In the reviewed studies, most of radiotherapies, and chemotherapies, etc.) were
the studies used superficial needling, and needle introduced as the comparators, rather than
points were selected out of the meridians, distal controls, for acupuncture treatment. These
acupoints, or acupoints with no effects (He et al. comparators serve as “positive controls” so that
2004; Linde et al. 2005; Witt et al. 2005; Alecrim- the effectiveness of acupuncture can be meas-
Andrade et al. 2006; Scharf et al. 2006; Haake ured. The proportion of positive conclusions in
et al. 2007; Molsberger et al. 2010). Needle such studies was 56.5%. It could be varied with
manipulation should not be applied to partly the strength of therapeutic effects of the com-
reduce the nonspecific effect of insertion sham. parator. If researchers choose strong positive
However, this superficial, distal needling may comparators for acupuncture treatment, there
also produce similar effects to real acupuncture. would be less positive conclusions in the study.
For example, Vas et al. (2012) used both needle A double dummy design for acupuncture and
insertion sham to study point specificity and comparator could enhance the blinding effect in
noninsertion to control acupuncture technique. clinical trials, e.g., introduce placebo medication
They found that all three treatments – real in acupuncture and sham acupuncture in com-
acupuncture, insertion sham and noninsertion parison groups (Wang et al. 2011).
sham – had better effects than conventional There are limitations in this study. Firstly,
treatment, and there was no significant differ- we only studied the association between the
ence among the three treatments (Vas et al. control type and study outcome. Although we
2012). To achieve the advantages of both inser- had excluded the potential influence from the
tion and non-insertion sham controls, Berman methodological quality, a few factors might
et al. (2004) applied a combined control in a affect the study outcome, e.g., the dose of
KOA trial. The acupuncture treatment consisted acupuncture intervention, the severity of
of real needling at five local points, four distal disease, the experience of acupuncturists, the
points, and tapping plastic guiding tube at two effectiveness of controls, the success of blind-
sham points (noninsertion sham control) at the ing, etc. The potential effects should be fully
abdomen, and the sham control consisted of considered in the clinical trial design. Secondly,
inserting two needles at sham points (insertion as pain is a very common symptom, it mani-
sham control) and tapping at nine real points fests in various diseases. The search strategy we
(noninsertion placebo control) (Lao et al. 2001; used in the study might not have retrieved all
Berman et al. 2004). acupuncture clinical trials which were related to
The masking effectiveness or the blinding pain management. In the retrieved studies, pain
credibility should be measured for both real was the major complaint. The findings from
acupuncture and sham acupuncture treatments. these studies should mainly reflect the trend of
Only 7.2% of studies assessed blinding success. association in control type and study outcome.
No study with blinding credibility assessed Lastly, given the difficulties to obtain the full
indicated unsuccessful blinding. In the KOA text of many non-SCI publications, we limited
study, the combined control produced accept- the search in SCI publications. The restric-
able masking effects (Berman et al. 2004), 25% tion of studies in SCI publications may lead
and 33% of the patients were unsure of their to bias.
assignment in the real acupuncture or sham acu- Selection of controls in acupuncture trials
puncture group, and 67% and 58% believed that is likely to affect the study conclusion. Studies
they were receiving true acupuncture (p = 0.06), using nontreatment controls have the highest
respectively. In addition to the combined con- tendency of positive conclusions, followed by
trol, to avoid the nonspecific effect of needling, noninsertion controls, and the lowest tendency
the number of needling should be minimized. in insertion sham controls. To improve the
In some studies, treatments with positive quality of acupuncture trials, the control needs
effects, such as conventional medications to be appropriately selected.

Disclosure statement neck and shoulder pain in sedentary female workers:
a 6-month and 3-year follow-up study. Pain 109 (3),
The authors declare that they have no conflicts
299–307.
of interest and no financial interests related to Hinman R. S., McCrory P., Pirotta M., et al. (2014)
the material of this manuscript. Acupuncture for chronic knee pain: a randomized
clinical trial. JAMA 312 (13), 1313–1322.
Irnich D., Salih N., Offenbacher M. & Fleckenstein J.
Acknowledgements (2011) Is sham laser a valid control for acupuncture tri-
This project was supported by Hospital als? Evidence-Based Complementary and Alternative Medicine
Authority, Hong Kong (HA105/48P T18). Article ID: 485945.
Kennedy S., Baxter G. D., Kerr D. P., et al. (2008)
Acupuncture for acute non-specific low back pain: a
pilot randomised non-penetrating sham controlled trial.
References Complementary Therapies in Medicine 16 (3), 139–146.
Alecrim-Andrade J., Maciel-Junior J. A., Cladellas X. C., Lao L., Ezzo J., Berman B. & Hammerschlag R. (2001)
et al. (2006) Acupuncture in migraine prophylaxis: a Assessing clinical efficacy of acupuncture: considera-
randomized sham- controlled trial. Cephalalgia 26 (5), tions for designing future acupuncture trials. In: Clinical
520–529. acupuncture, pp. 187–209. Springer, Berlin.
Berman B. M., Lao L., Langenberg P., et al. (2004) Le Bars D., Villanueva L., Willer J. & Bouhassira D. (1991)
Effectiveness of acupuncture as adjunctive therapy in Diffuse noxious inhibitory controls (DNIC) in animals
osteoarthritis of the knee: a randomized, controlled and in man. Acupuncture in Medicine 9 (2), 47–56.
trial. Annals of Internal Medicine 141 (12), 901–910. Lee H., Bang H., Kim Y. et al. (2011) Non-penetrating
Chen H. Y. & Lao L. (2014) Challenges in evaluating sham needle, is it an adequate sham control in acu-
acupuncture trials. In: Acupuncture in pain management puncture research? Complementary Therapies in Medicine
(ed. C. Lucy), pp. 163–172. Nova Science Publishers, 19 (Suppl. 1), S41-S48.
Hauppauge. Lin J. G. & Chen W. L. (2008) Acupuncture analgesia: a
Cherkin D. C., Eisenberg D., Sherman K. J., et al. (2001) review of its mechanisms of actions. American Journal
Randomized trial comparing traditional Chinese medi- of Chinese Medicine 36 (4), 635–645.
cal acupuncture, therapeutic massage, and self- care Linde K., Streng A., Jurgens S., et al. (2005) Acupuncture
education for chronic low back pain. Archives of Internal for patients with migraine: a randomized controlled
Medicine 161 (8), 1081–1088. trial. JAMA 293 (17), 2118–2125.
Cherkin D. C., Sherman K. J., Avins A. L., et al. (2009) Madsen M. V., Gøtzsche P. C. & Hróbjartsson A. (2009)
A randomized trial comparing acupuncture, simulated Acupuncture treatment for pain: systematic review of
acupuncture, and usual care for chronic low back pain. randomized clinical trials with acupuncture, placebo
Archives of Internal Medicine 169 (9), 858–866. acupuncture, and no acupuncture groups. BMJ 338,
Cho Y. J., Song Y. K., Cha Y. Y., et al. (2013) Acupuncture a3115.
for chronic low back pain: a multicenter, randomized, Mavrommatis C. I., Argyra E., Vadalouka A. & Vasilakos
patient-assessor blind, sham- controlled clinical trial. D. G. (2012) Acupuncture as an adjunctive therapy to
Spine (Phila Pa 1976) 38 (7), 549–557. pharmacological treatment in patients with chronic pain
Enck P., Benedetti F. & Schedlowski M. (2008) New due to osteoarthritis of the knee: a 3-armed, random-
insights into the placebo and nocebo responses. Neuron ized, placebo-controlled trial. Pain 153 (8), 1720–1726.
59 (2), 195–206. Meng X., Xu S. & Lao L. (2011) Clinical acupuncture
Freedland K. E., Mohr D. C., Davidson K. W. & Schwartz research in the West. Frontiers of Medicine 5 (2), 134–140.
J. E. (2011) Usual and unusual care: existing practice Miller E., Maimon Y., Rosenblatt Y. et al. (2011) Delayed
control groups in randomized controlled trials of effect of acupuncture treatment in OA of the knee:
behavioral interventions. Psychosomatic Medicine 73 (4), a blinded, randomized, controlled trial. Evidence-Based
323–335. Complementary and Alternative Medicine Article ID:
Goddard G., Shen Y. S., Steele B. & Springer N (2005). 792975.
A controlled trial of placebo versus real acupuncture. Molsberger A. F., Schneider T., Gotthardt H. & Drabik
Journal of Pain 6 (4), 237–242. A. (2010) German Randomized Acupuncture Trial
Haake M., Muller H. H., Schade-Brittinger C., et al. (2007) for chronic shoulder pain (GRASP) – a pragmatic,
German Acupuncture Trials (GERAC) for chronic low controlled, patient- blinded, multicentre trial in an
back pain: randomized, multicenter, blinded, parallel- outpatient care environment. Pain 151 (1), 146–154.
group trial with 3 groups. Archives of Internal Medicine Scharf H. P., Mansmann U., Streitberger K., et al. (2006)
167 (17), 1892–1898. Acupuncture and knee osteoarthritis: a three- armed
He D., Veiersted K. B., Høstmark A. T. & Medbø J. I. randomized trial. Annals of Internal Medicine 145 (1),
(2004) Effect of acupuncture treatment on chronic 12–20.

H. Chen et al.
Silverman H. J. & Miller F. G. (2004) Control group Witt C., Brinkhaus B., Jena S., et al. (2005) Acupuncture in
selection in critical care randomized controlled trials patients with osteoarthritis of the knee: a randomized
evaluating interventional strategies: an ethical assess- trial. Lancet 366 (9480), 136–143.
ment. Critical Care Medicine 32 (3), 852–857. Witt C. M., Jena S., Brinkhaus B., et al. (2006) Acupuncture
Thompson B. T. & Schoenfeld D. (2007) Usual care as in patients with osteoarthritis of the knee or hip: a
the control group in clinical trials of nonpharmaco- randomized, controlled trial with an additional non-
logic interventions. Proceedings of the American Thoracic randomized arm. Arthritis and Rheumatism 54 (11),
Society 4 (7), 577–582. 3485–3493.
Turner J. A., Deyo R. A., Loeser J. D., et al. (1994) The Zhang R., Lao L., Ren K. & Berman B. M. (2014)
importance of placebo effects in pain treatment and Mechanisms of acupuncture- electroacupuncture on
research. JAMA 271 (20), 1609–1614. persistent pain. Anesthesiology 120 (2), 482–503.
Vas J., Aranda J. M., Modesto M., et al. (2012) Acupuncture
in patients with acute low back pain: a multicentre This is an Open Access article distributed under the
randomised controlled clinical trial. Pain 153 (9), terms of the Creative Commons Attribution Non-
1883–1889. Commercial License (http://creativecommons.org/
Wang L. P., Zhang X. Z., Guo J., et al. (2011) Efficacy of licenses/by-nc/4.0) which permits unrestricted non-
acupuncture for migraine prophylaxis: a single-blinded,
double-dummy, randomized controlled trial. Pain 152
commercial use, distribution, and reproduction in any
(8), 1864–1871. medium, provided the original work is properly cited.
White A. R., Filshie J. & Cummings T. M. (2001) This article was originally published in the Journal
International Acupuncture Research Forum. Clinical of Acupuncture and Meridian Studies. Original publi-
trials of acupuncture: consensus recommendations cation: Chen H., Ning Z., Lam W. L., et al. (2016)
for optimal treatment, sham controls and blinding. Types of control in acupuncture clinical trials might
Complementary Therapies in Medicine 9 (4), 237–245.
White P., Bishop F. L., Prescott P., et al. (2012) Practice,
affect the conclusion of the trials: a review of acupunc-
practitioner, or placebo? A multifactorial, mixed- ture on pain management. Journal of Acupuncture and
methods randomized controlled trial of acupuncture. Meridian Studies, 9 (5), 227–233. https://www.science
Pain 153 (2), 455–462. direct.com/science/article/pii/S2005290116301492

research
How placebo needles differ from placebo pills

Y. Chae
Department of Anatomy and Meridians, College of Korean Medicine, Gachon
University, Seongnam, South Korea
Y.-S. Lee
Department of Anatomy and Meridians, College of Korean Medicine, Gachon
University, Seongnam, South Korea
P. Enck
Department of Internal Medicine, Psychosomatic Medicine and Psychotherapy, University
of Tübingen, Tübingen, Germany
Abstract
Because acupuncture treatment is defined by the process of needles penetrating the body,
placebo needles were originally developed with non- penetrating mechanisms. However,
whether placebo needles are valid controls in acupuncture research is the subject of an
ongoing debate. The present review provides an overview of the characteristics of placebo
needles and how they differ from placebo pills in two aspects: (1) physiological response
and (2) blinding efficacy. We argue that placebo needles elicit physiological responses similar
to real acupuncture and therefore provide similar clinical efficacy. We also demonstrate that
this efficacy is further supported by ineffective blinding (even in acupuncture-naïve patients)
which may lead to opposite guesses that will further enhance efficacy, as compared to no-
treatment, e.g., with waiting list controls. Additionally, the manner in which placebo needles
can exhibit therapeutic effects relative to placebo pills include enhanced touch sensations,
direct stimulation of the somatosensory system and activation of multiple brain systems.
We finally discuss alternative control strategies for the placebo effects in acupuncture
therapy.
Keywords: acupuncture, blinding, control, physiology, placebo.
Introduction trials (RCTs) (Streitberger & Kleinhenz 1998;

Acupuncture is a therapeutic intervention per- Park et al. 2002). Due to the indistinguishably
formed by “inserting one or more needles into specific inert nature of placebo controls compared with
sites on the body surface for therapeutic purposes” (Liu active treatments, placebo- controlled studies
2009). Placebo needles were developed and enable determination of the therapeutic effects
validated to evaluate the efficacy of acupunc- of target treatments from unspecific treatment
ture treatment in randomized controlled clinical effects, such as medical context and consequent
expectation. Similarly, placebo needles must be
Correspondence: Younbyoung Chae, Department of indistinguishable from real acupuncture needles
Anatomy and Meridians, College of Korean Medicine, and not produce any physiological therapeutic
Gachon University, Seongnam, South Korea (email: effects. To achieve this, non-penetrating needles
ybchae@khu.ac.kr). with a similar appearance to real acupuncture
© 2018 Frontiers in Psychiatry 55

How placebo needles differ from placebo pills?
needles, which retract telescopically into the injections, transcutaneous electrical nerve stimu-
needle handle when pressed on the skin, were lation, manual therapy, and surgical interventions.
developed because they provide patients with Placebo devices, including placebo injections and
the visual illusion that their skin is being pen- placebo acupuncture needles, exhibit stronger
etrated, much like a stage dagger in theatre effects than do oral placebo pills (Kaptchuk
performances. et al. 2000). Similarly, a meta- analysis showed
Non-penetrating needles have been com- that subcutaneous placebo administrations pro-
monly used as placebo controls for acupunc- duce greater effects than do oral placebos for
ture research over several decades (Dincer & the acute treatment of migraine (De Craen et al.
Linde 2003), and are often seen as standard 2000). A more recent meta-analysis of the effects
when investigating the mechanisms under of placebo interventions across all clinical con-
lying the acupuncture effects (Hu et al. 2017). ditions showed that physical placebo interven-
Interestingly, several studies have shown that the tions, including acupuncture, have greater effects
effectiveness of placebo acupuncture needles is than do pill controls (Hróbjartsson & Gøtzsche
similar to that of real acupuncture needles. A 2010); sham acupuncture has been shown to
systematic review of clinical trials revealed only have even greater effects than other physical pla-
a small difference between real and placebo cebos (Linde et al. 2010). A clinical trial revealed
needles in terms of pain relief, whereas a mod- that placebo needles have greater effects than
erate difference was found between placebo placebo pills on self-reported pain and severity
treatment and no treatment at all, e.g., during of symptoms in patients with persistent arm
a waiting period (Madsen et al. 2009). RCTs pain (Kaptchuk et al. 2006). Expectations on
have shown that real and placebo acupuncture the potential benefit induced in the recipient,
treatments are equally effective and that both influenced by the magnitude of the invasiveness
are superior to “treatments as usual” (TAU) of the intervention, leads to therapeutic effects
for chronic pain (Schneider et al. 2006; Cherkin following a placebo treatment (Weimer & Enck
et al. 2009). Taken together, these findings imply 2014). The greater effect of placebo devices
that acupuncture treatment is equally effective compared with placebo pills may be due to the
as placebo acupuncture and therefore, that acu- additional physical contact or the tactile com-
puncture treatment effects are placebo effects ponent of the intervention, which is minimally
(Solomon 2017). However, the adequacy of the present with the use of pharmaceutical pills.
controls being used in these studies remains Therefore, the contextual effects associated
to be determined (Enck et al. 2010). Many with the preparation of acupuncture treatment
discussions of whether placebo needles are devices are multisensory and have a broader
appropriate controls for acupuncture research impact on the patient. The tactile context of
have followed the development of these needles treatment devices such as during acupuncture
(Langevin et al. 2006), and there has been some is essential for the establishment of therapeutic
criticism from a physiological perspective that effects (Chae & Olausson 2017). In contrast to
placebo needles may not be proper controls for the use of oral placebo pills, this context has
acupuncture studies (Lundeberg et al. 2008). In two components: physiological action and inef-
fact, placebo needles are neither fully indistin- fective blinding, which initially takes effect once
guishable from regular needles nor physiologi- the treatment is applied, and which, therefore,
cally inert (Chae et al. 2011; Kang et al. 2011). is different from the gradual unblinding due to
Similarly, a recent meta-analysis suggested that experiences of adverse events during the drug
neither the Streitberger device nor the Park applications.
Sham device is adequate inert controls for clini- Thus, the purpose of the present article
cal studies (Zhang et al. 2015). was to review the two components of placebo
This issue pertains not only to acupuncture devices, physiological action and effective blind-
needles, but also to other treatment devices that ing, and to discuss how these features result in
involve physical contact with the patient, such as stronger placebo effects relative to oral pills.
56 © 2018 Frontiers in Psychiatry

Y. Chae et al.
Physiological actions of placebo improve the healing process relative to other
needles placebo interventions (Lee & Chae 2018). The
effect of the tactile component on the patient
The “specific” effect of placebo needles can be categorized accordingly into sensory-
due to tactile stimulation discriminative and affective-social aspects. These
Pharmaceutical research involving a placebo aspects of the tactile component play important
requires a verum preparation with a specific roles in the therapeutic effect of acupuncture
drug and a placebo preparation without that treatment in clinical practice (Chae & Olausson
drug, with the difference in the effects of these 2017), which is examined in the context of
two preparations indicating the effectiveness placebo needles in the following sections.
of the target drug. The aims of this type of
study design are to exclude any other possible The sensory-discriminative aspect of the
factor that might influence the general effects touch component of placebo needles
of medical treatment, such as natural history, Several studies have examined in depth the
regression to the mean, and/or methodological sensory-discriminative aspect of acupuncture
biases, and to test the “true” therapeutic effects needles. The process of needle insertion and
of the novel compound (Enck et al. 2013). the types of needle manipulation (Seo et al.
Additionally, the nonspecific effects of the 2014) activate diverse touch perception pro-
treatment can be observed by comparing the cesses and stimulate mechanically sensitive pain
response with placebo to a no-treatment con- fibres (Zhao 2008). This tactile stimulation
trol condition, e.g., a waiting list; these effects process produces what is known as the De Qi
are caused by the treatment preparation itself sensation (a combination of various sensations
within a medical context, i.e., the attention that include heaviness, numbness, soreness,
the patient receives. The context provided by and distention), which is fundamental for the
the medical setting may be referred to as the therapeutic outcome of acupuncture treatment
“specific” effect of the placebo (Wager & Atlas (Kong et al. 2005; Choi et al. 2013). Placebo nee-
2015). In fact, placebo effects are regarded as dles were first validated as a sufficient control in
brain–body responses to contextual information acupuncture studies under the assumption that
that promote health and well-being (Wager & a lesser degree of De Qi sensation would be
Atlas 2015). evoked, thereby leading to less effective clini-
In the case of placebo needles, tactile stimu- cal outcomes (Streitberger & Kleinhenz 1998;
lation is an additional component that is associ- Park et al. 2002). In the initial validation studies
ated with the treatment context of acupuncture, of placebo needles, participants were not able
which is absent in a pharmaceutical context. to distinguish the placebo needles from real
Due to this component, the expected difference needles, but they experienced a greater degree
in effect between placebo needle treatment and of De Qi sensation with real needles than with
waiting list groups includes a tactile context that placebo needles (Streitberger & Kleinhenz 1998;
has been overlooked in previous studies. The Park et al. 2002; White et al. 2003) (Fig. 1).
tactile context provided by the placebo needles, On the other hand, a recent validation study
much like the medical context under which a of the Streitberger needle conducted with a large
pill is given, cannot be physiologically inert, and population showed no significant difference in
this stimulation can even exert similar thera- De Qi sensation between patients treated with
peutic actions by enhancing touch sensations real and placebo needles, even though the pla-
in the body (Kerr et al. 2011). Furthermore, the cebo needle does not penetrate the skin (Xie et al.
touch of the placebo needles experienced by 2013). Additionally, a study investigating Park
the patient initiates a multisensory process and Sham devices revealed that the De Qi sensation
thereby activates bodily self-awareness. Overall, induced by real and placebo needles is not dis-
tactile stimulation provides a broader range tinguishable (Liang et al. 2013). De Qi sensation,
of contexts that contribute to the effect and a composite of unique sensations produced

Figure 1. Additional components involved in the effects of placebo needles. In pharmaceutical trials, the nonspecific
effects of treatments can be ruled out by comparing the placebo pill group with an untreated group, e.g., on a waiting
list. In acupuncture trials, tactile stimulation is an additional factor that affects the placebo needle and untreated groups.
Enhanced touch sensations, which are distinct during acupuncture treatment, but absent with placebo pills, remain
substantial during placebo needle administration. Thus, placebo needles not only play a role as a cue for treatment
expectations, but also evoke the somatosensory system and directly activate multiple brain systems.
during acupuncture, has been considered to be with real acupuncture (Chae et al. 2013). When
one of the essential components for clinical the placebo needle touches the skin and evokes
efficacy (Chae & Olausson 2017). Considering activity in cutaneous afferent nerves, it seems
the lack of a significant difference between to act in the brain and result in a limbic touch
treatments administered with real and placebo response (Lund et al. 2009).
needles, we can assume that the placebo needle In the pharmaceutical trials, active pills have
exerts an action that is similar to those exerted “true” therapeutic effects of the novel com-
during real acupuncture. The somatosensory pound in the capsules while placebo pills use
system is activated directly by placebo needles, the same types of capsules without active com-
which exert various physiological actions in the ponents. Placebo pills, of course, can induce
body that are similar to those exerted by real tactile sensation on the tongue, but it is not
acupuncture needles. Real and placebo needles likely that such tactile sensation can be related
produce enhanced skin conductance responses with the therapeutic effects in the trials. On the
and decrease the heart rate, suggesting that other hand, placebo needles can induce tactile
placebo needles are not physiologically inert in sensations around the acupoints that is similar
terms of autonomic response patterns (Kang to real acupuncture needles; these tactile sensa-
et al. 2011). Furthermore, these autonomic tions themselves could produce physiological
responses to placebo needles might be derived actions through the body in the acupuncture
from the patient’s orienting responses, or bodily trials.
self-awareness (Napadow et al. 2013). A func-
tional magnetic resonance imaging study dem- The affective-social aspect of the touch
onstrated that tactile stimulation, which mimics component of placebo needles
acupuncture stimulation, not only induces acti- The process of treatment with placebo needles
vation in sensorimotor processing regions and involves a component of touch between the
deactivation in default- mode network regions, patient and the practitioner. This affective-social
but also modulates higher cognitive areas in aspect, involving slow gentle touch stimulation,
the brain (Napadow et al. 2009). Additionally, a activates unmyelinated C tactile fibres (CT
meta-analysis of brain imaging studies showed afferents) and induces feelings of calm and
that placebo needles produce weaker, but well-being (Campbell 2006; Lund & Lundeberg
similar, patterns of brain activation compared 2006). Prior to inserting and stimulating the

Y. Chae et al.
needle, the practitioner touches the patient to the somatosensory system, strengthening the
assess the skin tissue and identify the region to doctor–patient relationship, and enhancing the
which the needle will be applied. This process patient’s general condition. The biophysical
of gently touching the patient’s skin activates effects of placebo needles influence the patient’s
CT afferents and alleviates unpleasantness. expectations and contextualization, which likely
Furthermore, this type of pleasant touch re- also play roles in his or her cognitive percep-
establishes the patient’s sense of self- esteem tion during the treatment process regarding the
and wellbeing by inducing a limbic touch alleviation of symptoms.
response (Lund & Lundeberg 2006). A clinical
study (Kaptchuk et al. 2008) supports the role Blinding of placebo needle
of affective-social touch in treatments with
acupuncture and placebo needles because the
applications
enhanced patient–doctor relationship produced The blinding components of placebo
greater improvements in patients with irritable needles
bowel syndrome. Additionally, the entirety of Placebo needles were developed based on
the procedure, including warmth, empathy, and a visual illusion that induces the belief that
the communication of positive expectations, one’s skin has been penetrated (Streitberger &
might influence clinical outcomes (Kaptchuk Kleinhenz 1998; Park et al. 2002). The tip of
et al. 2008). the placebo needle is blunt and retracts into
Gentle touch, which is always a component the needle’s handle; thus, a placebo needle has
of acupuncture treatment, plays a crucial role in a shape similar to that of a real needle, but
the overall outcome of the medical treatment. is dissimilar in that it does not penetrate the
Gentle touch by a nurse before a surgical opera- skin. Because the placebo needle induces the
tion decreases subjective and objective levels sensation of pricking and appears to penetrate
of stress in the patient (Whitcher & Fisher the skin, the patient is more likely to classify
1979). Furthermore, gentle touch plays a direct placebo needle treatment as active relative to
moderating role in the physiological responses placebo pills. Placebo pills are indistinguishable
of the patient such that it lowers blood pres- in appearance from the active drug, but the
sure, enhances transient sympathetic reflexes, patient must be convinced that they are receiv-
and increases pain thresholds (McGlone et al. ing real treatment. The chance of determining
2014). The affective- social components of whether a pill is a placebo or an active treatment
gentle touch also enhance the patient– doctor is theoretically equal in pharmaceutical trials due
relationship, even when patients are treated to the indistinguishable appearance, smell, and
with placebo needles (Kaptchuk et al. 2008). taste of placebo pill compared to active drugs;
Although the gentle touch component prior to in contrast, the chance of determining whether
the application of real or placebo needles is not a needle is placebo or real is not completely
considered to be part of the active component equal, since the patient receiving the treatment
of placebo treatment, it is nevertheless part of while looking at and feeling the needle would
the placebo preparation in a clinical acupuncture be inclined to believe that the placebo treat-
trial. Thus, compared with the effects observed ment is active. Consequently, the probability of
in a waiting list group or a group receiving a patient determining placebo and real needle
another placebo intervention, this component would be even more biased, if they have prior
generates a stronger doctor–patient relationship experience of acupuncture needling and have
and enhances the placebo effect. felt its therapeutic effects.
Although the placebo needle acts as a control Blinding is another important issue that can
due to its non-penetrating qualities, the tactile minimize bias or the potential effect of context
component is not completely removed; thus, its on the outcomes of RCTs (Wood et al. 2008).
application in acupuncture trials may additionally The blinding index (BI) was developed to assess
produce crucial effects such as directly evoking the success of blinding in clinical trials (Baethge

2013) and is interpreted as a “correct guess beyond the experience of the De Qi sensation, which
chance.” For example, a BI of 1 indicates that all could contribute to the correct identification
guesses are correct, a BI of −1 indicates that all of the treatment (Vase et al. 2015), even though
guesses are incorrect, and a BI of 0 indicates placebo needling sessions produce substantial
that the probabilities of correct and incorrect levels of this sensation. Another possible
guesses are equal (Bang et al. 2004). When clas- explanation is that smaller insertion and pullout
sifying the blinding results of trials, BI values forces are used during placebo needling (Chae
> 0.2 are considered to indicate failed blinding et al. 2011). Differences in biomedical forces
because more participants guessed correctly, BI may be a crucial reason for the association of
values < 0.2 and > −0.2 are considered to be different somatosensory processes with the use
random guesses, and BI values < −0.2 are also of real and placebo needles (Schneider et al.
considered to indicate failed blinding because 2006) (Figure 2).
more participants guessed incorrectly (Bang
et al. 2004). An assessment of blinding in tri- Greater expectations during placebo
als involving pharmacological interventions for needling produced greater placebo
psychiatric disorders yielded average BI values effects
of 0.18 and 0 in the active treatment and pla- According to systematic reviews of the BI in
cebo control groups, respectively (Freed et al. clinical trials, pharmacological placebo pills have
2014). This finding implies that blinding was an approximately 50% chance of being per-
established successfully, which is an ideal result ceived as active, whereas this assumption is not
from a scientific perspective. necessarily true for placebo needles (Zhang et al.
In contrast, people more often respond to 2015; Freed et al. 2014). While in the aforemen-
placebo needles because they are more likely tioned studies the adverse events of drug trials
to believe that they are receiving active treat- indicate the risk of unblinding, the BI index
ment, which is also known as an opposite guess seem to have been uncompromised, possibly
(Zhang et al. 2015; Freed et al. 2014). Although a due to the occurrence time and the frequency
recent systematic review of the use of placebo of such events.
needles for acupuncture in clinical trials with The discussed BI patterns are often thought
limited reporting of the credibility of blinding to indicate adequate blinding, but a greater prob-
showed that participant blinding was successful ability of believing that a placebo is real might
in most cases (Zhang et al. 2015), participants be due to wishful thinking rather the well-known
were less likely than chance levels to believe psychological preference toward real or better
that the needles were real, rather than placebos. treatment (Bang 2016). The greater probability
When a BI calculation was applied to this review, of opposite guesses in placebo needle groups
the average BI values were 0.55 and −0.33 for may be related to greater expectations regard-
the real and placebo needle groups, respectively ing symptom alleviation. Placebo effects, or any
(Zhang et al. 2015), indicating unsuccessful improvement in the symptoms or physiological
blinding. Additionally, based on the classifica- condition of an individual receiving a placebo
tion rules for blinding scenarios, 86% of studies treatment (Enck et al. 2013), are based largely
have involved unblinded participants in the real on the expectation of receiving actual treat-
acupuncture group (BI > 0.2) and participants ment, cued and contextual conditioning, and/
making opposite guesses in the placebo group or observational and social learning (Colloca
(BI< −0.2) (15). & Miller 2011). Thus, patients may have higher
A recent acupuncture study showed that levels of expectation during placebo needling
61 and 68% of patients administered real and than when receiving placebo pills, which could
placebo treatments, respectively, perceived treat- contribute to treatment efficacy (Colloca et al.
ment type correctly, which implies that blinding 2004). In this manner, placebo responses may
was unsuccessful (Vase et al. 2015). One pos- be more frequent in placebo needles than in
sible reason for this unsuccessful blinding is placebo pills because patients are more likely

Y. Chae et al.
Figure 2. The blinding components of placebo needles. (A) Differences in blinding characteristics between placebo needles and
placebo pills. In pharmaceutical trials, the similar shapes and tastes of the active and placebo pills prevent patients from
correctly guessing whether they are in the treatment group. In acupuncture trials, placebo needles are similar to real
acupuncture devices in terms of shape, but not in terms of penetration when applied to the skin. (B) Both active and
placebo pills have a 50% chance level of being perceived as active in the pharmaceutical trials, whereas both real and
placebo acupuncture causes a tendency to believe that they are receiving active treatment in the acupuncture trials.
Differences in blinding scenarios for placebo needles and placebo pills. In pharmaceutical trials, successful blinding in the treatment
and placebo groups results in patients making random guesses about whether they are receiving active or placebo pills.
Acupuncture trials involve different blinding scenarios: “unblinded participants” in the real acupuncture group and
participants making “opposite guesses” in the placebo needle group. Due to this unique pattern of blinding, individuals
more often respond to placebo needles because they are more likely to believe they are receiving active treatment (i.e.,
opposite guess).
Tx=treatment
to perceive the use of placebo needles as active than with a parallel- group design. However,
treatment (Figure 2). cross-over designs carry another risk: that of
carry-over effects from one phase to the next.
If the carry-over effect is based on Pavlovian
Alternative control strategies conditioning of responses (Suchman & Ader
When blinding becomes difficult (as with sham 1992), even longer wash- out phases cannot
acupuncture needles) or even impossible (such prevent it to occur.
as with psychotherapy), alternative control strat- A number of design alternatives have been
egies are required to separate specific therapy discussed which all exhibit both specific advan-
effects from unspecific (e.g., contextual) effects tages and pitfalls.
as well as from spontaneous remission and
response biases (Enck et al. 2013). Ineffective or No treatment controls (NTC)
impossible blinding also precludes conventional To separate “spontaneous variation” from
cross-over designs where each patient serves as “placebo responses”, a “no-treatment” control
his/her own control, thereby reducing the data group appears necessary that determines how
variance and allowing trials with far less patients much of the unspecific effects can be attributed

to spontaneous variation and recovery. Since with another drug already available rather than
this is rarely done, the exact size of the contri- with placebos (Saarto & Wiffen 2007; Quilici
bution of spontaneous variation to the placebo et al. 2009).
response is known only for minor and benign
clinical conditions and may account here for Comparative effectiveness research
approximately 50% of the placebo effect (CER)
(Krogsboll et al. 2009). In experimental settings, One approach to circumvent the placebo
“no treatment controls” may also serve to dilemma in RCT (for ethical as well as for meth-
control for habituation and sensitization effects odological reasons) has recently been favoured
that may occur with repetitive stimulation, e.g., by drug approval authorities, by boards of medi-
in pain and placebo analgesia experiments. cal societies, and by ethics committees, namely
NTC are limited by ethical rules when to avoid utilization of placebos in clinical trials.
patients with a severe clinical condition require CER compares novel treatments to already
treatment and cannot be offered trial participa- approved therapies: to the best of our knowl-
tion that would assign them to a NTC group, as edge, this has never been done for acupuncture
set by the Declaration of Helsinki of the World therapy, e.g., in chronic pain conditions.
Medical Association (World Medical Association However, as has been shown in a number
2013). of meta- analyses in depression, schizophrenia
and other diseases, comparing a new therapy
Waiting list control (WLC), treatment as to a comparator increases the response solely
usual (TAU) driven by the higher likelihood of patients to
Assigning patients to a “no treatment” group receive active treatments (100%) as compared
may be ethically problematic, e.g., in case of to placebo-controlled trials (Weimer et al. 2015).
severe diseases, or when for other reasons the In such trials therefore, the placebo response
patients require treatment; in such cases WLC is high but cannot be controlled anymore. Of
and TAU are control strategies for non- drug specific interest is the fact that CER studies
testing when an inert “placebo” is not available, need to test for “non-inferiority” of the novel
e.g., in psychotherapy, physical/manual therapy, drug, resulting in higher patient numbers (Leon
surgery, and “instrumental” therapies (TENS, 2011).
transcranial magnetic or direct current stimula-
tion, laser or light therapy), including acupunc- Cohort multiple randomized controlled
ture (see above). While some of these therapies trial (CMRCT) design
have “sham therapy techniques” that can serve The “cohort multiple randomized controlled
as placebo controls, e.g., in acupuncture, others trial” (CMRCT) (Relton et al. 2010) – formerly
must rely on WLC and TAU as their only con- also known as the Zelen design (Zelen 1979) –
trol condition. splits the “no treatment” control arm of a drug
However, WLC and TAU face significant trial (done for the purpose of mere observation
limitations: while patients expect to receive of the natural course of the disease) from the
effective therapy, they are randomized to rou- drug trial itself, by recruiting a large cohort of
tine treatment most of them have had in the patients for an “observational study” in which
past (TAU), or (in case of WLC) have to wait patients are followed under their TAU condition.
for the treatment they were recruited for, result- The observational cohort then serves as the
ing in disappointment and potentially nocebo basis for the recruitment of a subsample for
effects (Weimer & Enck 2014). This affects only the treatment study, either placebo- controlled
recruitment and compliance, and biases patient or CER: patients are randomly approached, but
populations in such studies. can be selected based on a number of factors
To avoid WLC and TAU and the associated accounting for statistical representativeness.
disadvantages, studies in acute and chronic pain A number of limitations apply, however: “the
are often conducted comparing a novel drug observational cohort needs to be monitored over time (a

Y. Chae et al.
cross-sectional sample analysis would not be sufficient to when using placebo needles without control-
account for changes occurring over time), and it needs ling for the tactile components, which suggests
to be representative for complete patient cohort affected some level of clinical efficacy. Placebo needle
by the diseases, both in terms of disease features (e.g., administrations may inadvertently, albeit less
symptom severity) as well as disease management (diag- robustly, activate the somatosensory system and
nosis, TAU). Once such a cohort it established it may induce regulatory mechanisms that are also trig-
be used for more than one RCT ” (Weimer & Enck gered by acupuncture needling. Furthermore,
2014). placebo needles, or what we have considered to
be control needles for experimental studies, may
be a form of acupuncture treatment that is low
Discussion and conclusion dose or that provides weak stimulation.
Similar to other placebo types, placebo needles In clinical trials, the placebo control should
play an important contextual role in treatment be indistinguishable from the active treatment
expectations; however, they also directly evoke (i.e., blinding success) and yet physiologically
the somatosensory system and activate multiple inert (less De Qi sensation in this case). In the
brain systems. Placebo preparations are applied case of acupuncture, however, it is difficult to
in studies to blind participants, and they enable meet these two criteria simultaneously (Chae
the calculation of chance levels for patients’ 2017). Most importantly, our argument on the
guesses about whether interventions are thera- inadequacy of placebo needles as controls in
peutic or inert. However, the probability of acupuncture trials should not inhibit further
making an opposite guess is greater for placebo acupuncture trials with randomized, controlled
needles than for placebo pills, which is often designs. Placebo needles indeed are more likely
explained by patients’ greater expectations. to induce placebo responses than placebo pills,
Because patients are more likely to perceive which is largely due to the tactile component
placebos as active treatment in placebo needle that cannot be separated from the components
trials, placebo responses may be observed more of the real acupuncture needles. In other
frequently to placebo needles than to placebo words, conversely, our arguments imply that
pills. acupuncture needles contain a substantial level
The tactile components of acupuncture of placebo effect, which was not completely
needle use are crucial factors during treatment ruled out by controlling the penetration. It
preparation and could not be fully controlled for is also important to note that waiting lists do
as placebo needles were being developed. The produce unspecific effects on their own (Gold
distinctive touch sensations experienced during et al. 2017). Furthermore, recent studies in
acupuncture treatment are substantial, even acupuncture have employed study designs such
during the administration of placebo needles. as pragmatic trials, which compare acupuncture
Due to the physical contact necessary when treatment with waiting lists and usual care (Witt
applying placebo needles, the validity of these et al. 2006; MacPherson et al. 2012; Chung et al.
needles as controls has been in question from 2016), while other innovative control strategies
the perspectives of physiological inertness and still await validation with acupuncture. In the
blinding. These factors may result in placebo meantime, the discussion on the effect of the
needles exerting stronger placebo effects than tactile components of placebo needles in its
do other types of placebo preparation that do effectiveness as placebos, as well as effective
not include tactile components. Thus, the devel- blinding, needs to be continued.
opment of a technique to control for the tactile Taken together, the placebo needles do have
components of acupuncture interventions while different characteristics from placebo pills in
participants are consciously receiving treatment clinical trials. Our exploration does not imply
is an important consideration. The studies that acupuncture may be more effective than
reviewed here demonstrated that the De Qi placebo, but suggests that we have to consider
sensation cannot be completely accounted for these unique characteristics of placebo needles

before we draw premature conclusions that sensation and manipulation? Complementary Therapies in
acupuncture itself is just a placebo. Medicine 21 (3), 207–214.
Chung V. C., Ho R. S., Liu S., et al. (2016)
Electroacupuncture and splinting versus splinting
Author contributions alone to treat carpal tunnel syndrome: a randomized
Conceived and designed the paper: Y. C. and P. controlled trial. Canadian Medical Association Journal 188
(12), 867–875.
E.. Wrote the first draft of the paper: Y. C., Y.- Colloca L., Lopiano L., Lanotte M. & Benedetti F. (2004)
S. L. and P. E.. Revised the paper and approved Overt versus covert treatment for pain, anxiety, and
the final version: Y. C., Y.-S. L. and P. E. Parkinson’s disease. Lancet Neurology 3 (11), 679–684.
Colloca L. & Miller F. G. (2011) How placebo responses
are formed: a learning perspective. Philosophical
Acknowledgements Transactions of the Royal Society of London, Series B Biological
This research was supported by Basic Science Sciences 366 (1572), 1859–1869.
Research Program through the National De Craen A. J., Tijssen J. G., De Gans J. & Kleijnen
Research Foundation of Korea (NRF) funded J. (2000) Placebo effect in the acute treatment of
migraine: subcutaneous placebos are better than oral
by the Ministry of Education, Science and placebos. Journal of Neurology 247 (3), 183–188.
Technology (2014K2A3A1000166 & 2015 Dincer F. & Linde K. (2003) Sham interventions in
R1D1A1A01058033 & 2015M3A9E3052338). randomized clinical trials of acupuncture – a review.
Complementary Therapies in Medicine 11 (4), 235–242.
Enck P., Klosterhalfen S. & Zipfel S. (2010) Acupuncture,
References psyche and the placebo response. Autonomic Neuroscience
Baethge C., Assall O. P. & Baldessarini R. J. (2013) 157 (1–2), 68–73.
Systematic review of blinding assessment in random- Enck P., Bingel U., Schedlowski M. & Rief W. (2013) The
ized controlled trials in schizophrenia and affective placebo response in medicine: minimize, maximize
disorders 2000–2010. Psychotherapy and Psychosomatics 82 or personalize? Nature Reviews. Drug Discovery 12 (3),
(3), 152–160. 191–204.
Bang H., Ni L., & Davis C. E. (2004) Assessment of Freed B., Assall O. P., Panagiotakis G., et al. (2014)
blinding in clinical trials. Controlled Clinical Trials 25 (2), Assessing blinding in trials of psychiatric disorders:
143–156. a meta- analysis based on blinding index. Psychiatry
Bang H. (2016) Random guess and wishful thinking are Research 219 (2), 241–247.
the best blinding scenarios. Contemporary Clinical Trials Gold S. M., Enck P., Hasselmann H., et al. (2017) Control
Communications 3, 117–121. conditions for randomized trials of behavioural inter-
Campbell A. (2006) Role of C tactile fibres in touch and ventions in psychiatry: a decision framework. Lancet
emotion–clinical and research relevance to acupunc- Psychiatry 4 (9), 725–732.
ture. Acupuncture in Medicine 24 (4), 169–171. Hróbjartsson A. & Gøtzsche P. C. (2010) Placebo inter-
Chae Y., Um S. I., Yi S. H., et al. (2011) Comparison of ventions for all clinical conditions. Cochrane Database of
biomechanical properties between acupuncture and Systematic Reviews Issue 1, Art. No.: CD003974.
non-penetrating sham needle. Complementary Therapies in Hu B., Bai F., Xiong L. & Wang Q. (2017) The endo-
Medicine 19 (Suppl. 1), S8–12. cannabinoid system, a novel and key participant in
Chae Y., Chang D. S., Lee S. H., et al. (2013) Inserting acupuncture’s multiple beneficial effects. Neuroscience
needles into the body: a meta-analysis of brain activity and Biobehavioural Review 77, 340–357.
associated with acupuncture needle stimulation. Journal Kang O. S., Chang D. S., Lee M. H., et al. (2011)
of Pain 14 (3), 215–222. Autonomic and subjective responses to real and sham
Chae Y. & Olausson H. (2017) The role of touch in acupuncture stimulation. Autonomic Neuroscience 159
acupuncture treatment. Acupuncture in Medicine 35 (2), (1–2), 127–130.
148–152. Kaptchuk T. J., Goldman P., Stone D. A. & Stason W.
Chae Y. (2017) The dilemma of placebo needles in B. (2000) Do medical devices have enhanced placebo
acupuncture research. Acupuncture in Medicine 35 (5), effects? Journal of Clinical Epidemiology 53 (8), 786–792.
382–383. Kaptchuk T. J., Kelley J. M., Conboy L. A., et al. (2008)
Cherkin D. C., Sherman K. J., Avins A. L., et al. (2009) Components of placebo effect: randomized controlled
A randomized trial comparing acupuncture, simulated trial in patients with irritable bowel syndrome. BMJ 336
acupuncture, and usual care for chronic low back pain. (7651), 999–1003.
Archives of Internal Medicine 169 (9), 858–866. Kaptchuk T. J., Stason W. B., Davis R. B., et al. (2006)
Choi Y. J., Lee J. E., Moon W. K. & Cho S. H. (2013) Sham device v inert pill: randomized controlled trial of
Does the effect of acupuncture depend on needling two placebo treatments. BMJ 332 (7538), 391–397.

Y. Chae et al.
Kerr C. E., Shaw J. R., Conboy L. A., et al. (2011) Placebo McGlone F., Wessberg J. & Olausson H. (2014)
acupuncture as a form of ritual touch healing: a neuro- Discriminative and affective touch: sensing and feeling.
phenomenological model. Consciousness and Cognition 20 Neuron 82 (4), 737–755.
(3), 784–791. Napadow V., Dhond R. P., Kim J., et al. (2009) Brain
Kong J., Fufa D. T., Gerber A. J., et al. (2005) encoding of acupuncture sensation–coupling online
Psychophysical outcomes from a randomized pilot rating with fMRI. NeuroImage 47 (3), 1055–1065.
study of manual, electro, and sham acupuncture treat- Napadow V., Lee J., Kim J., et al. (2013) Brain correlates
ment on experimentally induced thermal pain. Journal of phasic autonomic response to acupuncture stimula-
of Pain 6 (1), 55–64. tion: an event-related fMRI study. Human Brain Mapping
Krogsbøll L. T., Hróbjartsson A. & Gøtzsche P. C. (2009) 34 (10), 2592–2606.
Spontaneous improvement in randomized clinical trials: Park J., White A., Stevinson C., et al. (2002) Validating
meta-analysis of three-armed trials comparing no treat- a new non-penetrating sham acupuncture device: two
ment, placebo and active intervention. BMC Medical randomised controlled trials. Acupuncture in Medicine 20
Research Methodology 9 (1). (4), 168–174.
Langevin H. M., Hammerschlag R., Lao L., et al. (2006) Quilici S., Chancellor J., Lothgren M., et al. (2009) Meta-
Controversies in acupuncture research: selection of analysis of duloxetine vs. pregabalin and gabapentin in
controls and outcome measures in acupuncture clinical the treatment of diabetic peripheral neuropathic pain.
trials. Journal of Alternative and Complementary Medicine 12 BMC Neurology 9 (6).
(10), 943–953. Relton C., Torgerson D., O’Cathain A. & Nicholl J.
Lee Y. S. & Chae Y. (2018) Powerful effects of placebo (2010) Rethinking pragmatic randomized controlled
needles. Acupuncture in Medicine 36, 197–199. trials: introducing the “cohort multiple randomized
Leon A. C. (2011) Evolution of psychopharmacology controlled trial” design. BMJ 340:c1066.
trial design and analysis: six decades in the making. Saarto T. & Wiffen P. J. (2007) Antidepressants for neuro-
Journal of Clinical Psychiatry 72 (3), 331–340. pathic pain. Cochrane Database of Systematic Reviews Issue
Liang Z. H., Xie C. C., Li Z. P., et al. (2013) De Qi 4, Article No.: CD005454.
sensation in placebo acupuncture: a crossover study on Schneider A., Enck P., Streitberger K., et al. (2006)
Chinese medicine students. Evidence-Based Complementary Acupuncture treatment in irritable bowel syndrome.
and Alternative Medicine 2013, Article ID: 620671. Gut 55 (5), 649–654.
Linde K., Niemann K. & Meissner K. (2010) Are sham Seo Y., Lee I. S., Jung W. M., et al. (2014) Motion pat-
acupuncture interventions more effective than (other) terns in acupuncture needle manipulation. Acupuncture
placebos? A reanalysis of data from the Cochrane in Medicine 32 (5), 394–399.
review on placebo effects. Forschende Komplementarmedizin Solomon S. (2017) Acupuncture for Headache. It’s Still
17 (5), 259–264. All Placebo. Headache 57 (1), 143–146.
Liu T. (2009) Acupuncture: what underlies needle admin- Streitberger K. & Kleinhenz J. (1998) Introducing a
istration? Evidence- Based Complementary and Alternative placebo needle into acupuncture research. Lancet 352
Medicine 6 (2), 185–193. (9125), 364–365.
Lund I. & Lundeberg T. (2006) Are minimal, superfi- Suchman A. L. & Ader R. (1992) Classic condition-
cial or sham acupuncture procedures acceptable as ing and placebo effects in crossover studies. Clinical
inert placebo controls? Acupuncture in Medicine 24 (1), Pharmacology and Therapeutics 52 (4), 372–377.
13–15. Vase L., Baram S., Takakura N., et al. (2015) Can acupunc-
Lund I., Naslund J. & Lundeberg T. (2009) Minimal ture treatment be double- blinded? An evaluation of
acupuncture is not a valid placebo control in random- double- blind acupuncture treatment of postoperative
ized controlled trials of acupuncture: a physiologist’s pain. PLoS ONE 10 (3), e0119612.
perspective. Chinese Medicine 4 (1). Wager T. D. & Atlas L. Y. (2015) The neuroscience of
Lundeberg T., Lund I., Naslund J. & Thomas M. (2008) placebo effects: connecting context, learning and
The Emperors sham – wrong assumption that sham health. Nature Reviews. Neuroscience 16 (7), 403–418.
needling is sham. Acupuncture in Medicine 26 (4), 239– Weimer K. & Enck P. (2014) Traditional and innova-
242. tive experimental and clinical trial designs and their
Madsen M. V., Gøtzsche P. C. & Hróbjartsson A. (2009) advantages and pitfalls. In: Handbook of Experimental
Acupuncture treatment for pain: systematic review of Pharmacology (eds J. E Barrett, V. Flockerzi, M. A.
randomised clinical trials with acupuncture, placebo Frohman et al.) pp. 237–272. Springer, Berlin.
acupuncture, and no acupuncture groups. BMJ 338, Weimer K., Colloca L. & Enck P. (2015) Placebo effects in
a3115. psychiatry: mediators and moderators. Lancet Psychiatry
MacPherson H., Tilbrook H., Bland J. M., et al. (2012) 2 (3), 246–257.
Acupuncture for irritable bowel syndrome: primary Whitcher S. J. & Fisher J. D. (1979) Multidimensional
care based pragmatic randomised controlled trial. BMC reaction to therapeutic touch in a hospital setting.
Gastroenterology 12, 150. Journal of Personality and Social Psychology 37 (1), 87–96.

White P., Lewith G., Hopwood V. & Prescott P. (2003) Zhao Z. Q. (2008) Neural mechanism underlying
The placebo needle, is it a valid and convincing placebo acupuncture analgesia. Progress in Neurobiology 85 (4),
for use in acupuncture trials? A randomised, single- 355–375.
blind, cross-over pilot trial. Pain 106 (3), 401–409.
Witt C. M., Jena S., Selim D., et al. (2006) Pragmatic
randomized trial evaluating the clinical and economic Conflict of Interest Statement
effectiveness of acupuncture for chronic low back The authors declare that the research was con-
pain. American Journal of Epidemiology 164 (5), 487–496. ducted in the absence of any commercial or
Wood L., Egger M., Gluud L., et al. (2008) Empirical
evidence of bias in treatment effect estimates in con-
financial relationships that could be construed
trolled trials with different interventions and outcomes: as a potential conflict of interest.
meta-epidemiological study. BMJ 336 (7644), 601–605.
World Medical Association (2013) World Medical This is an open- access article distributed under the
Association Declaration of Helsinki: ethical principles terms of the Creative Commons Attribution License
for medical research involving human subjects. JAMA (https://creativecommons.org/licenses/by/4.0/). The
310 (20), 2191–2194.
Xie C. C., Wen X. Y., Jiang L., et al. (2013) Validity of the
use, distribution or reproduction in other forums is per-
“Streitberger” needle in a Chinese population with acu- mitted, provided the original author(s) and the copyright
puncture: a randomized, single-blinded, and crossover owner are credited and that the original publication in
pilot study. Evidence-Based Complementary and Alternative this journal is cited, in accordance with accepted aca-
Medicine 2013, Article ID: 251603. demic practice. No use, distribution or reproduction is
Zelen M. (1979) A new design for randomized clinical tri- permitted which does not comply with these terms.
als. New England Journal of Medicine 300 (22), 1242–1245.
Zhang C. S., Tan H. Y., Zhang G. S., et al. (2015) Placebo
This article is reprinted from Frontiers in Psychiatry.
devices as effective control methods in acupuncture Original publication: Chae Y., Lee Y.- S . & Enck
clinical trials: a systematic review. PLoS ONE 10 (11), P. (2018) Frontiers in Psychiatry 9, article 243. doi:
e0140825. 10.3389/fpsyt.2018.00 243

case REPORTS
Acupuncture/dry needling as part of the

physiotherapy approach to greater trochanteric
pain syndrome: a case study
A. Manso
North Hampshire Physiotherapy and Podiatry service, Basingstoke, UK
Abstract
This case study presents the inclusion of Western medical acupuncture in the treatment
plan for greater trochanteric pain syndrome (GTPS). A patient with an 18-month history
of lateral right hip pain was referred for physiotherapy due to its significant impact on her
activities of daily living and sleep.
A physiotherapy plan including manual therapy, exercise, advice and three acupuncture/
dry needling sessions was applied through six sessions, after which the patient reported sig-
nificant improvement in the Numerical Pain Rating Scale (NPRS) and in the Hip Disability
and Osteoarthritis Outcome Score (HOOS) at 2 weeks follow-up.
The detailed treatment plan and clinical reasoning is discussed, including the rationale for
acupuncture and comparison with currently available literature but, as a case study, sensible
generalization is advised.
Keywords: acupuncture, dry needling, greater trochanteric pain syndrome.
Introduction maximus bursae and sometimes bursae between

Greater trochanteric pain syndrome (GTPS) is the iliotibial band and GT) (4% to 46%) and/or
an expression that has been suggested to make external coxa saltans. Understanding which of
terminology more accurate regarding localized these is more relevant and in which phase they
lateral hip, thigh and buttock pain with focal are, along with the mechanical analysis for each
point tenderness over the greater trochanter case, may get the physiotherapist more prepared
(GT) (Reid 2016; Brennan et al. 2017). Up until to address the patient’s full presentation.
recently, clinicians and researchers would refer Currently, there is no defined treatment
to this condition as trochanteric bursitis or protocol and the first line of treatment often
gluteal tendinopathy, among others, but recent includes a range of conservative interventions,
research shows that, often, inflammation is not such as “physiotherapy, local corticosteroid injection
involved (Brennan et al. 2017). According to (CSI), platelet-rich plasma injection, shockwave therapy
Klauser et al. (2013) and Reid (2016), different (SWT), activity modification, pain- relief and anti-
conditions can be present in GTPS: degenerative inflammatory medication and weight reduction” with
tendinopathy/tears of gluteus minimus (glut- success rates of over 90%. A few cases persist
min) and medius (glutmed) (18% to 50%), along despite treatment and time, which “may require
with muscle waste/dysfunction, calcification and surgical intervention in the form of bursectomy, iliotibial
fat degeneration; bursitis of one of the bursae band (ITB) lengthening techniques or gluteal tendon
around the GT (subgluteus minimus, medius, repair ” (Reid 2016, p.16).
Correspondence: André Manso (email: pt.andremanso@ Three studies were found that measure the
gmail.com). effects of acupuncture (dry needling (DN)) on

Acupuncture/dry needling as part of the physiotherapy approach to greater trochanteric pain syndrome: a case study
GTPS. Brennan et al. (2017) (N = 43, no control Patient A enjoys being outside as she is a keen
group) compared its effects with the ones of walker (2–4 h walks) and walks her large dog daily.
CSIs and found DN effects not to be inferior
to CSI at 6 weeks follow- up, which supports History of present condition
the idea that the effects obtained with the CSI 18-month history with gradual onset of right
are due to the needling, rather than the sub- lateral hip/thigh pain as detailed in Table 1.
stance used as first suggested by Lewit (1979). No history of recent falls/trauma, road traf-
Pavkovich (2015a) (N = 4, no control group) fic accident or lower back pain. No red flags
suggests that strengthening and stretching exer- identified. Patient’s x-ray shows early degenera-
cises combined with DN along the lateral thigh tive changes with superior marginal acetabular
aspect leads to significant changes in pain and osteophytes on the right hip joint.
function at short-and long-term (12 months). Past medical history
A Pavkovich (2015b) case report shows signifi- No previous right hip pain; one episode of
cant changes in function and average pain levels acute severe lower back pain about 10 years ago,
post-8 weeks of “DN only” treatment, but no which resolved completely. No history of hip/
changes in maximum pain level. lower back pain around her two pregnancies.
Considering the proposed mechanisms of Patient has had a coronary artery bypass graft-
action and principles of DN and acupuncture, ing in 2006.
one can justify their use to treat GTPS as: 1)
it is a condition that mostly affects soft tissue, Drug history
therefore there is reasoning for the use of trig- Co-codamol, pro re nata (PRN) (stopped after
ger points (MTrPs) DN to improve the muscle the first appointment); aspirin (75 mg 1x day);
tightness/dysfunction/fatigue and myofascial Ramipril (2.5 mg 1x day), Bisoprolol (2.5 mg 1x
pain (Dommerholt & Fernandez-de-las-Peñas day); Atorvastatin (40 mg 1x day).
2013); 2) the high levels of pain sometimes Diagnosis and clinical reasoning
experienced often prevent a normal gait pat- Patient A was diagnosed with GTPS with
tern and affect sleep and, consequently, rest significant component of gluteus minimus ten-
and muscle recovery, which can be helped by dinopathy (possible tear) and possible bursitis,
the acupuncture effects on the pain pathways aggravated by lumbo-pelvic posture, poor spinal
and opioid system, and by relaxation induction, stability strategies and tight hip flexors/tensor
through its central effects (White et al. 2008); fasciae latae (TFL). These changes are likely
3) it can be a longstanding (months) condi- to have been aggravated by Patient A’s lifestyle
tion with the potential for central sensitization, (keen walker versus office-based job). For the
which is believed to take place at central levels patient, the main problem was the severity of
such as the dorsal horn, where acupuncture can Pain 1 (P1) and Pain 2 (P2) and the impact it
stimulate the opioid peptide system to modulate was having on some of her activities of daily
this event (White et al. 2008); 4) by the trig- living (ADLs), such as walks, walking the dog,
gering of local effects mediated by the release and the regular sleep disruption.
of neuropeptides which induce vasodilation,
increasing local blood flow to surrounding tis- Acupuncture treatment
sues and promoting healing (White et al. 2008; Before considering acupuncture, Patient A had
Sandberg et al. 2003). already undergone three physiotherapy treat-
ments, focusing on:
Case report • education on the importance of work pos-
ture and daily activity modification regarding
Patient profile work and 2 to 4 h walks
Patient A is a 56-year-old female who works as • manual release of glutmin/TFL, active myo-
a receptionist at a community hospital, which fascial trigger points (MTrPs) and muscle
confines her to desk-based work for 8 h shifts. energy techniques (MET)

A. Manso
Table 1. Patient A clinical assessment and examination findings
Symptoms and their behaviour
P1 (grey) – constant ache (NPRS

3–5), intermittently shooting
down the lateral thigh aspect and
sometimes lower leg
P2 (asterisk) – occasional sharp

“twinge”, that lingers as an ache for
5–15 minutes (up to NPRS 9)
No neurological symptoms
described
Aggravating factors: Easing factors: 24 h pattern:

• standing/walking for over 1 h • non-weight-bearing rest • morning stiffness/pain which eases through the
• lying on the right side • painkillers day as she gets more active
• with the first steps after sitting • some days, the pain is worse at the end of the day,
especially if standing/walking for long periods
Clinical examination
Posture/gait: Patient A stands in significant anterior pelvic tilt with hyperlordotic lumbar spine, both in static stance and whilst walking
ROM: Lumbar full ROM, except in flexion which was stiff at the end of ROM. Right hip flexion is restricted to 110º and IR to 20º
before P1, ER is 30º before P2. The left hip ROM was also significantly restricted – flexion 120º, IR 30º, ER 40º – but asymptomatic
through or at the end of available ROM
Functional assessment: Functionally, there is poor hip external rotation control on single leg squats which is more evident after the first
five repetitions and triggers lateral hip ache. Patient reports P1 after right single leg weight bearing for 15 s, but there’s no Trendelenburg
sign. There is poor spinal control in bridging and active SLR. Strength: L hip extension – grade 5 (discomfort in the lumbar spine); hip
abduction is grade 4 with P1 especially after 5 s hold.
Special tests: There is marked tightness of hip flexors and TFL (positive Thomas/Obers tests) and gluteus medius/gluteus minimus
group is also moderately tight. There is some apprehension with FABER, but Trendelenburg sign, snapping hip sign, quadrant and
FADDIR tests are all negative. Passive SLR and slump test are negative and symmetrical on both sides. No neurological changes found
through the clinical examination.
Palpation: Gluteus minimus, gluteus medius and TFL (active MTrPs) are very tender on palpation as well as the gluteus medius/gluteus
minimus tendons on the greater trochanter.
P1=Pain 1; P2=Pain 2; NPRS=Numerical Pain Rating Scale; ROM=range of movement; IR=internal rotator; ER=external rotator; SLR=straight leg raising;
TFL=tensor fasciae latae; MTrP=myofascial trigger points; FABER=flexion-abduction-external rotation; FADDIR=flexion-adduction-internal rotation
• home exercise programme (HEP) treatment. Due to limitations of the service,

• spinal control/core activation exercises only three acupuncture sessions were provided
• stretching exercises for TFL, hip flexors, on a weekly basis (making a total of six ses-
glutmed, glutmin sions: 3x physiotherapy; 3x physiotherapy with
• strengthening and eccentric loading exercises acupuncture).
for hip abductors/external rotators (ERs) Patient A expected acupuncture to help her
(non-weight-bearing and weight-bearing) to manage her pain levels in order to improve
• advice on heat therapy and self-massage with sleep quality and enjoy her walks again. Patient
spiky ball. A had no previous experience of acupuncture
and expected it to be painful, therefore some
Patient A was then considered for acupuncture expectation and anxiety management was
as per the evidence and justification presented needed to get the best outcome from acupunc-
earlier and advised to continue with previous ture from the very first treatment as White et al.

(2008) report the negative effect anxiety may of all the parameters (symptoms, pain, function,
have on the acupuncture outcomes. sports, quality of life; each are scored from
0–100, of which 0 indicates extreme problems
Medical screening consent form and 100 indicates no problems) and centred
An explanation was given to the patient on what on the patient’s perspective (Mistry et al. 2016).
acupuncture is, its effects and how it is meant to HOOS was applied at the very first physio-
help her condition. Patient A was screened for therapy treatment and two weeks after the end
contraindications and precautions and was given of the acupuncture treatment and NPRS was
two sheets with information and a checklist measured prior to physiotherapy, then prior to
(AACP 2017b) to make sure the treatment was acupuncture and two weeks after physiotherapy
safe and patient had no questions, before sign- intervention.
ing an acupuncture pre-treatment consent form.
As Patient A takes daily aspirin, to prevent any First treatment (Table 2)
adverse event, vigorous pressure was applied Apart from introducing the patient to acu-
post the removal of the needle, and particular puncture, the goals were to work on the local
care was given when needling near the joints, as and referred pain with Gall Bladder (GB) 30
advised by White et al. (2008). (essential local point for hip joint and significant
point for leg disorders: atrophy, stiffness, pain
Outcome measures and contraction (Deadman et al. 2017)) and GB
The Numeric Pain Rating Scale (NPRS) and 31 (distal point for hip pain, iliotibial band ten-
the Hip Disability and Osteoarthritis Outcome sion and lateral thigh pain (AACP 2017a)) and
Score (HOOS) were used as outcome measures. to release the glutmin and TFL (MTrP DN)
HOOS is intended to be used for hip disability to allow the recovery of the glutmin tendon.
with or without osteoarthritis (Roos 2008) and, Working with MTrPs would partially address
in a review of hip outcome measures, it was the cause of the problem perpetuation (muscle
found to be the score with the greatest coverage tightness/fatigue/dysfunction), normalizing
Table 2. Acupuncture session 1
Position: Patient A was laid on her left side with knees semi-flexed, double pillow under her head in a position she found comfortable to
hold for the treatment duration.
Note: It was explained to the patient prior to the technique that the MTrP DN was a different technique that could elicit sharp deep pains
shooting down the thigh.
Acupuncture points Needle size Technique Duration/stimulation Response
GB 30 0.25 × 70 mm perpendicular insertion 15 min, stimulated every 5 min Good De Qi

to 2.5 cun depth with clockwise rotation
to 1.5 cun depth with clockwise rotation/sparrow
pecking
to 1 cun depth with clockwise rotation
TFL MTrPs (x2) 0.25 × 50 mm dry needling lancing motion for 30 s 2 LTRs noticed through the
needle
Gluteus minimus distal/ 0.25 × 70 mm dry needling lancing motion in several 1 x sharp pain with referred
anterior MTrP according directions for 30 s pain down the lateral aspect
to White et al. (2008) MTrP of the thigh reported by the
charts patient, no LTR noticed
Post-acupuncture: At the end of the first treatment, the patient reported a sensation of a deep ache, especially at the MTrPs location at
which pain lingered more noticeably as an ache post-treatment.
The meaning of the ache (De Qi) was explained to the patient, and the importance of achieving it as a sign that the treatment was
achieving its effects. No adverse reactions to report.
After the MTrP DN of TFL and gluteus minimus, a stretch and muscle energy technique (contract-relax) was applied to both muscles in
order to potentiate the needling effect as suggested by Yeganeh Lari et al. (2016).
MTrP=myofascial trigger points; DN=dry needling; GB=Gall Bladder; TFL=tensor fasciae latae; LTR=local twitch response

A. Manso
Position: as per previous session
Note: As Patient A was sore after the dry needling on the first treatment and at the second treatment gluteus minimus was the main
location of soreness (not TFL), only the gluteus minimus was needled.
GB 30 0.25 × 70mm perpendicular insertion, 15 min, stimulated every strong De Qi

2,5 cun depth 5 min with clockwise rotation
GB 31 0.25 × 40 mm perpendicular insertion, 15 min, stimulated every mild De Qi
1,5 cun depth 5 min with clockwise rotation/
sparrow pecking
GB 34 0.25 × 30 mm perpendicular insertion, 15 min, stimulated every strong De Qi
1 cun depth 5 min with clockwise rotation
BL 25 0.25 × 40 mm oblique towards spine, 20 min, stimulated every good De Qi
GB 29 0.25 × 60 mm oblique posteriorly 20 min, stimulated every good De Qi
insertion, 2,5 cun depth 5 min with clockwise rotation
Gluteus minimus MTrP 0.25 × 70 mm dry needling as per previous session and 2 x LTR felt through
as per last session 5 min post stimulation the needle
Post-acupuncture: At the end of the second treatment, the patient reported she didn’t feel as sore as after the first treatment and that
the Bladder points triggered a warmth sensation on the lower back. No adverse reactions to report
As per last session, MET were applied to gluteus minimus after the removal of the needles.
TFL= tensor fasciae latae; GB=Gall Bladder; BL=Bladder; MTrP=myofascial trigger points; LTR= local twitch response; MET=muscle energy techniques
muscle tone (Dommerholt & Fernandez-de-las- and another “layer” (as proposed by Bradnam
Peñas 2013) and facilitating the HEP. 2007) was added by working on the segments
Additionally, GB 34 was selected as it is a that provide motor supply to the glutmin (L4-
main point for stiffness of joints/muscles and a S1) through Bladder (BL) 25–27, to increase the
major point for lower limb disorders (Deadman segmental effects (White et al. 2008). GB 29 was
et al. 2017). As it was Patient A’s first acupunc- added for further local and segmental effects
ture experience, no more than six needles were (White et al. 2008).
used, of which only three were in place at the
same time for a short period of 15 min. Third treatment (Table 4)
At this stage, Patient A reported 80% overall
Second treatment (Table 3) improvement from the beginning of physiother-
Patient A reported that after the first acupunc- apy intervention and symptoms were as described
ture treatment and with the HEP/self-massage on Table 5. On examination, P1 was quite local-
she was feeling more relaxed and “less achy” ized on antero-superior aspect of the GT (not
when lying on her right at night, feeling she shooting even on deep palpation), Obers’ test
could achieve a deeper sleep. Patient A reported was negative and hip abduction strength (pain-
she was recently getting able to walk for periods free) was Grade 5 which, in some way, added
of 1 h with ache onset just towards the end to a non- muscular source hypothesis, such as
of it. Patient still reported P2 (NPRS 8). On the bursae. Right hip had symmetrical range of
examination, right hip ER improved to 40º, still movement (ROM) when compared with left hip,
with P2 at end of range, Obers’ test was better, with similar end-feel, but P2 would still be trig-
but still showing a mild tightness. On palpation, gered at the end of range of ER (NPRS 7).
the discomfort was more localised to the glut- Thus, on the third appointment the emphasis
min and at its insertion on the GT. was given to local (bursae) and segmental effects
As there were no adverse reactions following by working with the “fencing the dragon”
the first treatment, the same points were used technique (White et al. 2008) and adding a

Position: as per previous session
BL 23 0.25 × 40 mm oblique medial towards the 15 min, stimulated every good De Qi

spine insertion to 1 cun 5 min with clockwise
depth rotation
depth rotation
depth rotation
“Fencing the Dragon” 0.25 × 30 mm (x5) needles with maximum of 15 min stimulated every no De Qi reported,
around area of pain 2,5 mm in between and with 5 min but good histamine
transversal insertion towards response in the whole
the centre of the area of area surrounding the
pain, 0,5 cun depth as the needles and painful
pain was reported deeply area
Post-acupuncture: Patient reported the pain was less sharp on palpation and this was the treatment after which there was less soreness,
likely due to the fact that no dry needling was performed. No adverse reactions to report
As per last session, MET were applied to gluteus minimus after the removal of the needles.
BL=Bladder; MET=muscle energy techniques
Table 5. Symptoms and their behaviour at the third acupuncture session
P1 (grey) – occasional dull ache

(NPRS 2)
P2 (asterisk) – occasional sharp

“twinge”, that lingers as an ache for
5–10 min (up to NPRS 7).
Aggravating factors: Easing factors: 24-hour pattern:

• standing/walking for over • non-weight-bearing rest • morning mild stiffness which eases quickly as she gets more
90 min • heat therapy and HEP active
• some days, the pain is worse at the end of the day,
especially if standing/walking for long periods
P1=Pain 1;P2=Pain 2; NPRS=Numerical Pain Rating Scale; HEP=home exercise programme
“layer” with Bladder points at the same level of ADLs normal levels and felt she could self-
the bursae innervation (L2–4) (Genth et al. manage her condition, we agreed to follow-up
2012). with a quick consultation two weeks later, in
As Patient A reported good and consistent view to discharge in case the improvement was
improvement, was slowly getting back to her maintained.

A. Manso
Results
The maximum level of P1 NPRS has evolved

from 5 (initial assessment) to 4 (pre-acupuncture)

and then to 2 (2 weeks after physiotherapy
intervention), which is even more relevant if
we consider the pain has changed from con-
stant to intermittent (which occurred after the
third physiotherapy session). The level of P2
NPRS evolved from 9 (initial assessment) to 8
(pre-acupuncture) and then to 6 (2 weeks after
physiotherapy intervention) (Fig. 1).
Using the HOOS five dimensions, the symp-
toms (S) subscale has evolved from 35 to 90, ^ W & ^W YŽ>
the pain (P) subscale has evolved from 28 to +226 35( 75($70(17
78, the function (F) subscale has evolved from +226 7:2 :((.6
37 to 90, sports/recreational activities (SP) has $)7(5 7+,5' 6(66,21
evolved from 25 to 75, and quality of life (QoL)
Figure 2. Hip Disability and Osteoarthritis Outcome
has evolved from 31 to 75 (Fig. 2). Score (HOOS) results
Discussion there is a place for acupuncture in the physio-

As reported by Pavkovich (2015a; 2015b) therapy approach to GTPS. Patient A reported
and Brennan (2017), this case study suggests good improvement and, even though there were
still meaningful pain levels, the HOOS scores
reflected the improvement in her participation
in the ADLs, which was her main goal.
One of the comorbidities often associated
with GTPS is the existence of some level of
joint osteoarthritis (Reid 2016), which was pre-
sent in this condition and one can hypothesize
the present osteophytes are one of the factors
causing the remaining P2.

Limitations
There are several limitations to this study. The
case study design itself lacks rigour as there
is no randomization, no control group and
7 7 7 it is very hard to generalize the results based
on the observation of one individual (Zainal
3 3 2007; Crowe et al. 2011). On the other hand,
the detailed description of the intervention and
reflection associated with a case study may help
the physiotherapist to reflect on his practice,
7LQLWLDODVVHVVPHQW adapting some of the ideas described.
7SUHDFXSXQFWXUH Due to service protocols, only three weekly
7ZHHNVSRVWLQWHUYHQWLRQ sessions of acupuncture were provided, when
“acupuncture is often given as a course during which
3 3DLQ3 3DLQ its effects accumulate,” and for “most conditions,
Figure 1. Numerical Pain Rating Scale (NPRS) results. patients and practitioners should be prepared to commit

themselves to a course of about six to eight treatments”. for his inspiring and very approachable way of
However, “some MTrPs and other soft tissue injuries teaching. Finally, I’d like to thank my fiancée for
may respond after just one or two treatments” (White her support and patience as I stuck needles into
et al. 2008, p. 151). her in the name of professional development.
The inclusion of acupuncture as part of
a multi- faceted treatment plan may result in
the inability to identify the contribution and References
merits of each of the parts but, as suggested Acupuncture Association of Chartered Physiotherapists
(AACP) (2017a) AACP Acupuncture Foundation Course
by Wilson (2017), one can argue that the same
Manual. AACP, Peterborough.
multi-modal nature of the approach can be part Acupuncture Association of Chartered Physiotherapists
of the reason for its success. (AACP) (2017b), Safe Practice Guidelines for Acupuncture
Physiotherapists, V3. AACP, Peterborough.
Bradnam L. (2007) A proposed clinical reasoning model
Alternative acupuncture approaches for Western acupuncture. Journal of the Acupuncture
Reflecting on the chosen intervention, the tech- Association of Chartered Physiotherapists Spring 2007,
nique known as “periosteal pecking” could have 21–30.
been used at the distal insertion of the glutmin Brennan K. L., Allen, B. C. & Maldonado, Y. M. (2017)
Dry needling versus cortisone injection in the treatment
and glutmed, as it has been showing promising
of greater trochanteric pain syndrome: a noninferiority
results in clinical practice (Hanson et al. 2008) randomized clinical trial. Journal of Orthopaedic and Sports
and suggested by a significant part of a group Physical Therapy 47 (4), 232–239.
of 15 experts for the treatment of tendinopathy Crowe S., Cresswell K., Robertson A., et al. (2011) The
(Webster-Harrison et al. 2002). case study approach. BMC Medical Research Methodology
Furthermore, additional Bladder points (BL 11 (100).
Deadman P., Al-Khafaji M. & Baker K. (2017) A Manual
19-BL 23) could have been used to influence
of Acupuncture. [WWW document.] http://www.amanual
the sympathetic outflow to the lower limbs ofacupuncture.com [Accessed October 2017–January
(Bradnam 2007) on the second treatment, in 2018].
order to achieve normalization of the glutmin/ Dommerholt J. & Fernandez- de-
las-
Peñas C. (2013)
glutmed tone, possibly facilitating gradual Trigger Point Dry Needling. An Evidenced and Clinical-
muscle/tendon loading and function recovery. Based Approach, 1st edn. Churchill Livingstone/Elsevier,
London.
Genth B., Von During M., Von Engelhardt L. V., et al.
Future research (2012) Analysis of the sensory innervation of the
greater trochanter for innovating the treatment of the
Reflecting on this case and considering GTPS
greater trochanteric pain syndrome. Clinical Anatomy 25
incidence, research focusing on the effects (8), 1080–1086.
of dry needling versus acupuncture, needling Hanson Y., Carlsson C. & Olsson E. (2008) Intramuscular
techniques and physiotherapy versus needling and periosteal acupuncture in patients suffering from
alone, versus physiotherapy alone, would help chronic musculoskeletal pain – a controlled trial.
understand the contribution of each of these Acupuncture in Medicine 26 (4), 214–223.
Klauser A. S., Martinoli C., Tagliafico A., et al. (2013)
parts and in planning how much of and which
Greater trochanteric pain syndrome. Seminars in
components to include in each specific case. Musculoskeletal Radiology 17 (1), 43–48.
Additionally, it would be interesting to better Lewit K. (1979) The needle effect in the relief of myo-
understand periosteal pecking in tendon pathol- fascial pain. Pain 6 (1), 83–90.
ogy and its comparison with other modalities, Mistry J. B., Jauregui J. J., Lerner A. L., et al. (2016) An
such as SWT. assessment of the comprehensiveness of various
hip outcome scores. Surgical Technology International 28,
267–274.
Pavkovich R. (2015a) Effectiveness of dry needling,
Acknowledgements stretching, and strengthening to reduce pain and
I’d like to acknowledge the patient for her com- improve function in subjects with chronic lateral hip
pliance and availability throughout this process. and thigh pain: a retrospective case series. International
I’d also like to acknowledge Andrew Oliver Journal of Sports Physical Therapy 10 (4), 540–551.

A. Manso
Pavkovich R. (2015b) The use of dry needling for a Wilson J. (2017) Acupuncture for low back pain in a
subject with chronic lateral hip and thigh pain: a case professional footballer. Acupuncture in Physiotherapy 29
report. International Journal of Sports Physical Therapy 10 (2), 59–64.
(2), 246–255. Yeganeh Lari, A., Okhovatian F., Naimi S. S. & Baghban,
Reid D. (2016) The management of greater trochanteric A. A. (2016) The effect of the combination of dry
pain syndrome: a systematic literature review. Journal of needling and MET on latent trigger point upper trape-
Orthopaedics 13 (1), 15–28. zius in females. Manual Therapy, 21, 204–209.
Roos E. (2008) HOOS User’s Guide 2003 (updated May Zainal Z. (2007) Case study as a research method. Jurnal
2008) Institute of Sports Science and Clinical Biomechanics, Kemanusiaan 5 (1), 1–6.
University of Southern Denmark [WWW document.] www.
koos.nu [Accessed November 2017-January 2018].
Sandberg M., Lundberg T., Lindberg L.-G. & Gerdle B. André Manso graduated as a physiotherapist in Portugal
(2003) Effects of acupuncture on skin and muscle
blood flow in healthy subjects. European Journal of
and has worked in the UK over the last four years.
Applied Physiology 90 (1–2), 114–119. He has always kept an enthusiastic interest in musculo
Shbeeb M. I. & Matteson E. L. (1996) Trochanteric skeletal conditions as he worked in public, medico-legal,
bursitis (greater trochanter pain syndrome). Mayo Clinic private and sports settings and, even though his practice
Proceedings 71 (6), 565–569. is mostly clinical, he is keen to have permanent contact
Webster-Harrison P., White A. & Rae J. (2002) with the academic side of physiotherapy. André is a
Acupuncture for tennis elbow: an email consensus
study to define a standardized treatment in a GP’s
member of the Chartered Society of Physiotherapy
surgery. Acupuncture in Medicine 20 (4), 181–185. and the Acupuncture Association of Chartered
White A., Cummings M. & Filshie J. (2008) An Introduction Physiotherapists, and currently works in Basingstoke in
to Western Medical Acupuncture. Churchill Livingstone/ the local NHS musculoskeletal physiotherapy service.
Elsevier, Edinburgh.

case reports
Left elbow lateral epicondylalgia, treated

successfully with acupuncture combined with
typical physiotherapy intervention
J. Walsh
Crystal Palace Physio Group, London, UK
Abstract
This case study documents the use of acupuncture in addition to typical physiotherapy
modalities in the management of a 41-year-old manual worker with lateral epicondylalgia
(tennis elbow). The patient responded well to the intervention, with subjective improve-
ments on functional scales, as well as objective improvements in pain-free grip strength.
Acupuncture appeared to provide a worthwhile reduction in pain within at least the short-
to medium-terms, although the true effect of acupuncture cannot be fully understood from
this case study as other modalities were also used. Nevertheless, the case presents a com-
prehensive description of the successful management of a patient with lateral epicondylalgia
where acupuncture was effectively included and was likely to have played a positive role.
Keywords: acupuncture, lateral epicondylalgia, physiotherapy, tennis elbow.
Introduction with movement techniques (Vicenzino et al.

Lateral epicondylalgia is a musculoskeletal condi- 2007).
tion affecting the lateral elbow, most commonly A systematic review (Trinh et. al. 2004) has
due to mechanical overload of the relevant described acupuncture as an effective modality
tissues. The pathophysiology of the condition for the short-term relief of lateral epicondylalgia
is characterized by tendinopathy at the com- pain. The relief of pain in the short term is an
mon extensor origin, where the tendons of the important consideration in the treatment of lat-
forearm extensors are affected, in particular eral epicondylalgia, as it is likely to assist in the
the extensor carpi radialis brevis tendon. Fibre patient’s compliance to physiotherapy appoint-
necrosis, abnormal blood vessel infiltration and ments and home exercise programmes. This can
matrix substance infiltration stimulate periten- assist the therapist to introduce and progress an
dinous nociceptors, resulting in pain (Khan & appropriate tendon loading programme, which
Cook 2000). is considered the mainstay of treatment for
Numerous treatments have been described in long-term relief of any tendinopathy (Cook &
the literature for lateral epicondylalgia, includ- Purdam 2009).
ing rest, nonsteroidal anti- inflammatory drugs There are numerous studies demonstrating
(NSAIDs) (Green et al. 2001), corticosteroid this pain relieving effect of acupuncture in lat-
injections (Coombes et al. 2010), strength- eral epicondylalgia. Fink et al. (2002) compared
ening exercises (Tyler et al. 2010), forearm acupuncture to sham acupuncture (5 cm away
bracing (Calfee et al. 2008) and mobilization from true acupuncture points and avoiding
Ah Shi and trigger points). They demonstrated
Correspondence: Justin Walsh, Crystal Palace Physio greater reductions in pain within the acu-
Group, Jubilee Stand, Crystal Palace Park, London puncture group at 2 weeks, with both groups
SE19 2BB, UK (j.walsh@cppg.co.uk). demonstrating pain reductions that were not

Left elbow lateral epicondylalgia, treated successfully with acupuncture combined with typical physiotherapy intervention
statistically significant by 2 months. This study
demonstrates the potential value of acupuncture
in the early treatment phase, when the therapist
is trying to establish “buy-in” from the patient
to establish trust in the treatment pathway and
compliance with the exercise programme. In
regard to pain reductions in the medium term,
although this study demonstrated equal pain
reductions between groups at 2 months, the
pain reduction in both groups were clinically sig-
nificant. This is a relevant consideration for the
therapist deciding whether to use acupuncture
or not with their patient, as sham acupuncture
will still have many of the positive physiological
effects of real acupuncture. In other muscu-
loskeletal conditions, it has been shown that
compared to more inert placebo interventions,
Figure 1. Pain map
sham acupuncture has a greater pain-relieving
effect (Ezzo et al. 2000).
In addition to the above randomized con- therefore thought that the pain would reduce
trolled trial (RCT), a systematic review by Trinh by itself. After 3 months of reduced lifting, the
(2004) included six studies and concluded that patient reported no improvement in symptoms
“acupuncture was effective in the short-term relief of and sought treatment via his private medical
lateral epicondyle pain”. Furthermore, a meta- insurance, which was linked to his contract of
analysis by Bisset et al. (2005) showed that employment. He had a phone conversation
acupuncture seems to have a positive effect for with a representative of the insurance company
at least 2–8 weeks. and was referred for physiotherapy without
In summary, the available evidence suggests any further investigations. He presented for his
that acupuncture can provide effective lateral initial physiotherapy appointment at 4 months
elbow pain relief in (at least) the short term. post-onset of symptoms.
Thus it is indicated as an adjunct to traditional The patient reported a mild to moderate con-
physiotherapy management, in particular a stant dull ache (Fig 1.), which changed in severity
structured tendon loading programme, and is depending on preceding physical activity, as well
likely to play an important role in a patient’s as sharp pain when gripping objects or shaking
overall treatment pathway. hands. The patient reported that the sharp pain
was worst when gripping and lifting objects
Description of the case in wrist pronation and elbow extension. The
The patient was a 41-year-old left-handed male patient reported some mild night pain, which
who worked as a full- time elevator engineer. was usually not severe enough to affect sleep, as
The patient lived with his wife and two adoles- well as some morning elbow stiffness that lasted
cent children. The patient reported a 4-month only for the initial few joint movements.
history of insidious onset left lateral elbow Past medical history included childhood
pain, which the patient associated with a period asthma and Achilles tendinopathy 5 years ago,
of increased lifting at work as he removed and which resolved with rest and time. The patient
installed elevator counterweights. The patient denied any red flags for inflammatory pathol-
made the condition known to his relevant work ogy, infection or neurological conditions. The
supervisor at the time of onset but did not seek patient also denied any history of neck pain,
treatment immediately as he had completed wrist/hand pain or previous elbow pain on
the job that required the increased lifting, and either side.

J. Walsh
Physical examination revealed full range of reduce the patient’s pain 2–3 days following
motion of the hand, wrist, elbow, shoulder and treatment.
cervical spine. Cervical quadrants and Spurling’s As well as the low number and localization
were negative. The patient had pain on palpation of needles, the treatment duration was limited
of the left lateral epicondyle and proximal 2 cm to 10 min, and 0.25 mm needles were used,
of the extensor tendons. Both stretching as well which was also to ensure the treatment dose
as loading of the extensor tendons reproduced was low to begin with.
the patient’s symptoms. Pain-free grip strength
(PFGS) (grip strength to the first onset of pain) Treatment 2 (week 1)
with the elbow flexed to 90º and the forearm Subjective: After the initial treatment 1 week
in mid-prone was measured at 4.5 kg vs 48.2 kg ago, the patient reported he had a mild increase
for the left and right respectively. With the in pain for 24 hours, followed by a modest
elbow extended and the forearm pronated, reduction in pain.
pain-free grip strength was 1.4 kg vs 51.2 kg for
the left and right respectively. The patient had Objective: When outcome measures were reas-
mild reproduction of pain on upper limb neural sessed, PFGS with the elbow flexed to 90º
tension testing (radial nerve bias), but no reduc- and the forearm in mid- prone had increased
tion in neural range of motion. The patient to 15.1 kg for the left hand. With the elbow
completed the patient specific functional scale extended and the forearm pronated, PFGS had
questionnaire (PSFS), with an initial result of increased to 5.1 kg. PSFS remained at 3/10.
3/10 (note: 0/10 = total impairment; 10/10 = no
impairment). Rationale for prescription used in treatment 2:
As outlined in the table, a multimodal treat- Due to the improvement in outcome measures
ment approach was taken. This included educa- and the lack of adverse reaction to treatment,
tion and advice regarding the presenting com- it was decided to progress treatment, includ-
plaint and activity modification, prescription of ing acupuncture dose. Needling duration was
a counterforce brace, mobilization, acupuncture increased to 15 min, with stimulation at 5 and
and a home exercise programme of tendon 10 min. Large Intestine (LI) 4 was also added
loading exercises. to increase distal stimulation, which has been
suggested to activate supraspinal mechanisms
and result in descending pain inhibition from
Treatment the periaqueductal grey matter and the release
Treatment 1 (week 0) of natural opioids (Bradnam 2003; Zhao 2008).
Rationale for prescription used in treatment 1: This analgesic mechanism is also thought to be
As this was the patient’s first experience with important for longer- term effects (Lundeberg
acupuncture, the number of points selected 1998). Traditional Chinese medicine considers
was limited to four and all were local to the LI 4 to be a master point for pain and relaxa-
injured area. This was to introduce the patient tion because it is a distal point along the Large
to acupuncture gently and gauge sensitivity. Intestine meridian (White et al. 2008).
The local points were selected to stimulate A–δ
and C fibres in order to encourage the release Treatment 3 (week 2)
of calcitonin gene- related peptides (CGRP), Subjective: After the second treatment 1 week
substance P and neurokinin. Through these ago, the patient again reported a mild increase
mechanisms, acupuncture can stimulate: 1) local in pain for 24 hours before a proceeding
vasodilation and increased vascular permeability reduction.
(Sandberg et al. 2003), which may have a posi-
tive effect on pain and healing due to increased Objective: When outcome measures were
blood flow to the treatment site; 2) peripheral reassessed, PFGS with the elbow flexed to 90º
opioid analgesia (Stein et al. 2001), which may and the forearm in mid- prone had increased

further to 22.4 kg for the left hand. With the that trigger point needling can reduce hyper
elbow extended and the forearm pronated, activity of the muscle spindle and therefore the
PFGS had also further increased to 7.2 kg. stretch reflex, decreasing acetylcholine release
PSFS began to demonstrate change, with an and reducing unnecessary muscle contraction
improvement to 5/10. (Norris 2001), in turn reducing the ischaemia
which can cause muscle pain.
Rationale for prescription used in treatment 3: In addition to the addition of trigger point
Due to further improvement and no adverse therapy, the dose was also increased through the
reaction, it was decided to progress treatment use of 0.30 mm needles for all the acupuncture
again, including acupuncture dose. Triple points (with the exception of LI 4 and the new
Energizer (TE) 5 was added to take the total trigger point needles).
number of needles to six. TE 5 was chosen to
increase the stimulation along the same dermat- Treatment 5 (week 6)
ome as the affected area. This had the intention Subjective: After the fourth treatment 2 weeks
of increasing dermatomal receptive input in ago, the patient reported no post- treatment
the dorsal horn of the spinal cord and increase soreness and continued to report reductions in
endogenous pain modulatory systems (Carlsson pain and return to normal activities at home
2002; Bradnam 2003). To further progress dose, and work.
the needles were also stimulated twice rather
than once, at 5 and 10 min. Objective: When outcome measures were reas-
sessed, PFGS with the elbow flexed to 90º and
Treatment 4 (week 4) the forearm in mid-prone was now pain free
Subjective: After the third treatment 2 weeks at 46.2 kg for the left hand. With the elbow
ago, the patient reported no post- treatment extended and the forearm pronated, PFGS was
soreness and continued to report reductions in now 40.1 kg, eliciting only very mild pain. PSFS
pain. The patient did report some mild, inter- was now 9/10.
mittent “tightness” developing in the region of
the forearm extensor muscle bellies, possibly an Rationale for prescription used in treatment 5:
effect of the loading exercise progressions. The patient was keen to continue the home
exercise programme and make this treatment his
Objective: When outcome measures were reas- final appointment. Due to the positive response
sessed, PFGS with the elbow flexed to 90º and from the fourth treatment and the fact that the
the forearm in mid-prone had increased further patient would not be followed-up after the fifth
to 40.3 kg for the left hand. With the elbow treatment, it was decided to repeat the same
extended and the forearm pronated, PFGS had acupuncture intervention provided in the fourth
also further increased to 17.3 kg. PSFS also treatment.
improved to 7/10. The patient will be followed-up via email in
a further 4 weeks (after the submission of this
Rationale for prescription used in treatment 4: case report) to ensure he is still on track for a
Due to further improvement and no adverse full resolution of symptoms.
reaction, as well as a muscular type “tightness”
reported by the patient, it was decided to add
two needles to the belly of the extensor mus- Discussion
cles. Two active trigger points were identified The patient responded well to the physiother-
along the extensor muscle compartment and a apy treatment provided, which included acu-
needle was inserted into each, using a fanning puncture. Subjective improvements in function
technique of repeated penetration while chang- were demonstrated over the treatment period
ing the direction of the needle until a twitch with a change in PSFS from 3/10 to 9/10. This
response was elicited. It has been proposed was accompanied by objective improvements

J. Walsh
demonstrated by the change in pain- free grip epicondyle and thrusted several times to touch
strength from 1.4 kg to 40.1 kg with the elbow the periosteum at the insertion of the extensor
extended and wrist pronated. tendons. If the patient was unresponsive to the
Due to the multimodal treatment applica- treatment described above and the acupuncture
tion, it is hard to isolate the positive effect of thus far was well tolerated, I would have consid-
the acupuncture from the other treatments ered using this technique.
applied. The patient received a structured and
graded tendon loading programme in paral- Future research considerations
lel with his acupuncture treatment. There is When investigating the use of acupuncture with
evidence for the effectiveness of loading pro- this patient, it was clear that the overall body
grammes in lateral epicondylalgia and therefore of evidence for acupuncture in the management
this may be the main reason for the patient’s of lateral epicondylalgia is limited, with only a
improvement. In this evidence, however, treat- small number of good quality RCTs. Therefore,
ment effects from loading programmes do not further trials would be of value to strengthen the
tend to occur until at least the 6–8 week mark understanding of this intervention. In addition,
and often not until 12–24 weeks. As described further research with longer term follow- ups
above, this patient received a modest pain relief would be valuable due to the high recurrence
as early as 24 h following the initial session rates of lateral epicondylalgia. Research explor-
and was reporting lasting pain relief within the ing this question would be worthwhile to assess
first few weeks. This does seem to support the whether acupuncture in combination with a
efficacy of acupuncture in this patient, however tendon loading programme resulted in a lower
it must be mentioned that activity modification recurrence rate than a loading programme alone,
and prescription of the counterforce brace may as well as compared to other interventions such
have also contributed strongly to this effect. as corticosteroid injection. As is the case with
the use of acupuncture in other pathologies,
Alternative acupuncture approaches much of the lateral epicondylalgia research is
The acupuncture protocol used with this complicated by the lack of a true therapeutically
patient was chosen based on a combination inert placebo comparison. Further RCTs which
of evidence from the literature, physiological utilize a truly passive placebo would be of value
rationale and patient response. Other methods to further tease out the benefit of acupuncture
have been described in the literature and could as an intervention.
have been used with this patient. Molsberger &
Hille (1994) describe an alternative treatment References
protocol that utilizes the pain-relieving effects Bisset L., Paungmali A. & Vicenzino B., et al. (2005) A
of a non-segmental distal point (Gall Bladder systematic review and meta-analysis of clinical trials on
34) on the ipsilateral leg to the affected lateral physical interventions for lateral epicondylalgia. British
epicondyle. The needle was inserted to 2 cm Journal of Sports Medicine 39 (7), 411–422.
depth and stimulated until De Qi was elicited Bradnam L. (2003) A proposed clinical reasoning model
while the patient performed movements with for Western acupuncture. New Zealand Journal of
Physiotherapy 31 (1), 40–45.
the painful arm. This resulted in a 55% pain Calfee R. P., Patel A., DaSilva M. F. & Akelman E. (2008)
reduction for an average of 20 h in the inter- Management of lateral epicondylitis: current concepts.
vention group. This method could have been Journal of the American Academy of Orthopaedic Surgeons 16
used as an alternative if the patient tolerated (1), 19–29.
the local acupuncture poorly or had other Carlsson C. (2002) Acupuncture mechanisms for clini-
local contraindications to acupuncture in the cally relevant long-term effects-reconsideration and a
hypothesis. Acupuncture in Medicine 20 (2–3), 82–99.
area, such as skin scarring or cutaneous nerve Cook J. L & Purdam C. R. (2009) Is tendon pathology
compromise. Another technique that could a continuum? A pathology model to explain the clini-
have been used was periosteal pecking, whereby cal presentation of load-induced tendinopathy. British
a needle is inserted into the area of the lateral Journal of Sports Medicine 43 (6) 409–16.

Coombes B. K., Bisset L. & Vicenzino B. (2010) Efficacy Stein C., Machelska H. & Schäfer M. (2001) Peripheral
and safety of corticosteroid injections and other injec- analgesic and anti- inflammatory effects of opioids.
tions for management of tendinopathy: a systematic Zeitschrift fur Rheumatologie 60 (6), 416–24.
review of randomized controlled trials. The Lancet 376 Trinh K. V., Phillips S. D., Ho E. & Damsma K. (2004)
(9754), 1751–1767. Acupuncture for the alleviation of lateral epicon-
Ezzo J., Berman B., Hadhazy V. A., et al. (2000) Is acu- dyle pain: a systematic review. Rheumatology 43 (9),
puncture effective for the treatment of chronic pain? 1085–1090.
A systematic review. Pain 86 (3), 217–225. Tyler T. F., Thomas G. C., Nicholas S. J. & McHugh M.
Fink M., Wolkenstein E., Karst M. & Gehrke A. (2002) P. (2010) Addition of isolated wrist extensor eccentric
Acupuncture in chronic epicondylitis: a randomized exercise to standard treatment for chronic lateral epi-
controlled trial. Rheumatology 41 (2), 205–209. condylosis: a prospective randomized trial. Journal of
Green S., Buchbinder R., Barnsley L., et al. (2001) Shoulder and Elbow Surgery 19 (6), 917–922.
Nonsteroidal anti- inflammatory drugs (NSAIDs) for Vicenzino B., Cleland J. A. & Bisset L. (2007) Joint
treating lateral elbow pain in adults. Cochrane Database manipulation in the management of lateral epicon-
of Systematic Reviews, Issue 4. Art. No.: CD003686. dylalgia: a clinical commentary. Journal of Manual and
DOI:10.1002/14651858.CD003686. Manipulative Therapy 15 (1), 50–56.
Khan K. M. & Cook J. L. (2000) Overuse tendon injuries: White A., Cummings M., Filshie J. (2008) An Introduction
where does the pain come from? Sports Medicine and to Western Medical Acupuncture. Churchill Livingstone/
Arthroscopy Review 8 (1), 17–31. Elsevier, Edinburgh.
Lundeberg T. (1998) The physiological basis of acupunc- Zhao Z.- Q. (2008) Neural mechanism underlying
ture. Conference presentation, MANZ/PAANZ Annual acupuncture analgesia. Progress in Neurobiology 85 (4),
Conference, Christchurch, New Zealand, August 1998. 355–375.
Molsberger A. & Hille E. (1994) The analgesic effect of
acupuncture in chronic tennis elbow pain. British Journal Justin Walsh is a physiotherapist with experience of
of Rheumatology 33 (12), 1162–1165.
Norris C. M. (2001) Acupuncture: Treatment of Musculoskeletal
working in the public and private sectors of both the
Conditions. Butterworth-Heinemann, Oxford. United Kingdom and Australia and is currently work-
Sandberg M., Lundeberg T., Lindberg L. G. & Gerdle ing within the private sector in south east London. He
B. (2003) Effects of acupuncture on skin and muscle has a particular interest in treating musculoskeletal
blood flow in healthy subjects. European Journal of injuries, including tendinopathy.
Applied Physiology 90 (1–2), 114–119.

case REPORTS
The use of Seirin Pyonex indwelling needles in

the treatment of non-traumatic low back pain –
a case study
D. Giura
Physiotherapy Department, Coalville Community Hospital, Leicestershire, UK
Abstract
Many people suffer at one time or another with lower back pain. Treatments used over the
years have varied from advice to rest on the bed, medication, consultants and, eventually, a
referral to our profession. Since the start of the NHS, 70 years ago, we have managed to
gain respect as a profession and to be trusted in our assessments and treatments. We have
been careful to keep in mind evidence-based practice (EBP) as we justify our reasoning. The
AACP has fought and will continue to fight to keep acupuncture within the guidelines. We
all know acupuncture works and, mostly, how, and yet commissioners find it expensive, time
consuming and poorly supported by the research.
Lower back pain (LBP) has multiple causes. In the light of the National Institute for
Health and Care Excellence (NICE) 2016 guideline on low back pain, acupuncture has been
used less in its treatment, mostly in favour of more medication, although the experience of
physiotherapists has shown this treatment method can be effective. This case study presents
one of the cases the author has treated with Seirin Pyonex indwelling needles (SPIDN) over
the last few years.
Keywords: AACP, acupuncture, indwelling needles, low back pain, Pyonex needles.
Introduction to infection than with normal acupuncture.

The most common use of indwelling needles Auricular acupuncture was preferred on some
is for auricular acupuncture. In 1999, Ernst occasions, due to the closer connection with the
and White published an article in the BMJ central nervous system.
about reported side effects post- acupuncture. Newton stated: “for every action, there is an equal
Indwelling needles were reported to be respon- and opposite reaction” (the third law of physics).
sible for auricular perichondritis and cardiac Simplify this and then apply this to the nerv-
tamponade. Since then, indwelling needles have ous system. As we now know, any skin surface
been widely used to treat addictions and general stimulus will cause a reaction at the central
pain, using the auricular points. Due to the sites nervous system level, which in turn will create
of the needle insertion when using body points, a response at the level of stimulus. Of course,
the patients were thought to be more prone these connections are many and very fast due
to the nature of the fibres that transfer the
Correspondence: Diana Giura, Physiotherapy information between systems.
Department, Coalville Community Hospital, Broom In 2013, Nitta published a review of indwell-
Leys Road, Coalville, Leicester, LE67 4DE (email: ing Japanese needles in the AACP journal. The
lacrarudiana29@hotmail.com) literature discussed in this review was of variable

The use of Seirin Pyonex indwelling needles in the treatment of non-traumatic low back pain
quality and variable outcomes were reported. chair in reception. He asked if he could stand
However, there does seem to be some reason- during the session due to his pain. He was due
ably strong evidence to support the use of to fly out for pilgrimage to Mecca in 2 weeks.
indwelling needles (IDNs) in the treatment of He had difficulty driving, so was brought to the
post-operative pain (Kotani et al. 2001) and post- first treatment session by his wife.
operative nausea (Andrzejowski & Woodward Examination was difficult due to his pain,
1996). There is also weak evidence to support therefore the therapist concentrated on his
the use of IDNs in breathlessness (Filshie et al. immediate goal that day, which was to be able
1996; Davis et al. 2001), and some to suggest that to sit. The pain scale was 9–10/10 (where 10 is
IDNs can be used as a self-acupuncture treat- the highest pain and zero is no pain).
ment to prolong the effects of needling (Filshie The patient was afraid of needles, however
et al. 1996; 2005) or as an independent treatment he consented to the Pyonex needles after dem-
(Longbottom 2010). All of the authors reviewed onstration and explanation.
agreed that IDNs are a convenient, practical, A verbal consent was gained, and the acu-
cost-effective and efﬁcient method of applying puncture consent form was signed before the
acupuncture when used appropriately and with treatment commenced.
all aspects of safety considered.
Part of this therapist’s work was, and still is, First treatment
based on the use of these needles in different Extra points were used on the patient’s left
situations. Since then, the SPIDN have been hand: EX-UE-7 (Yaotongdian). The patient was
used for different problems such as labour and asked to move gently for 5 min. The pain score
caesarean section, child constipation, etc. reported was 7–8/10. At this point, the thera-
There are only a few SPIDN sizes, from pist was able to assess his standing and sitting
0.6 mm to 1.5 mm needle length, on a 0.20 mm flexion. Positive standing flexion was discovered
diameter. The ones this therapist usually uses are on his left side. The patient was asked if he
0.20 mm x 0.6 mm, for the treatment of lower could lie down so the therapist could release the
back pain, tennis and golfer’s elbow, whiplash, tissue. He managed to do so for 10 min. After
sprains etc. The following is a description of tissue release, the therapist reassessed standing
the treatment of a case of acute non-traumatic flexion. The patient was still in pain and had
lower back pain. difficulties sitting for more than 30 s. Pyonex
needles were applied on the side of the pain
reported by patient. The number of needles
Case study applied at the side was five. The patient was
Patient profile asked again to move gently. His reported pain
A 37-year-old male who was on the floor for was now 5/10. He was able to sit for 5 min but
a few hours playing with his son. He stood up had discomfort on standing. He was sent home
and felt a twinge in the left side of his back. with gentle back stretchings taught by therapist
He rested for 2 days, using a hot water bottle and advised on Pyonex needle management.
and hot baths. However, there was no improve-
ment and his condition started to deteriorate. Second treatment
He did not attend his GP as there were no The second treatment followed four days after
appointments for a few days. He took no medi- the first. The patient managed to drive himself
cation as he was fasting. to work and to the clinic. He reported he was
The patient was normally fit and well, and doing the exercises as advised and that he felt the
would go to the gym where he worked on combination of the exercises and the indwelling
his upper body using weights and ran on the needles helped, however he was still anxious
treadmill. as he was due to fly soon. Sitting and standing
He now found it difficult to sit, and was flexion were re-assessed, and both were found
observed sitting very close to the edge of the to be negative. The patient’s reported pain was

D. Giura
4–5/10 and he was able to sit down during the US armed services have used both indwelling
initial conversation. The second treatment con- ear needles and the more usual type in bat-
sisted of tissue mobilization and re-application tlefield medicine (mostly dealing with acute
of the indwelling needles at the side of the pain pain.) (Niemtzow et al. 2015). In Japan, they
reported by the patient, which was now around can be bought by the public. In the UK there
L2-L5 left side -4 needles at EX-B-2 (Hua Tuo are no restrictions as you can buy them even
Jiaji points). As he was able to move more, a from Amazon. The needles are also sold at the
core stability exercise was added. AACP conferences. However, the AACP does
not seem to encourage the use of this type of
Third treatment needle.
The third treatment took place three days In my experience during and after the use of
before the patient’s flight. He reported an this type of needle in an outpatient and even in
improvement to 2/10 on the pain scale, how- an inpatient setting, I have not encountered any
ever he felt stiffer. On examination, his skin side effects in relation to infections at the needle
was fine, with no change in the skin condi- site, nor any reaction to the needle or plaster.
tion noticed post-Pyonex needles. No redness However, if the needles are kept in situ longer
nor any allergic reaction was reported by the than advised, or the patient’s skin is not clean,
patient. He managed to keep the needles in as there is a danger of infection (Longbottom
advised (3–5 days). Treatment consisted of tis- 2010; Campbell & Hopwood 2007). I do not
sue mobilization and application of K-tape to use the needles on frail skin or if the skin is
the left lumbar area. The patient was advised to not intact.
continue with the exercises and stretchings to Personally, I feel that the AACP should
maintain his mobility. review the policy as I’m convinced that there
could be a benefit from indwelling needles.
Discussion
I have been using this type of needle for a
References
while now. I do believe they have changed my
Andrzejowski J. & Woodward D. (1996) Semi-permanent
practice. I have found them very effective in the acupuncture needles in the prevention of post-
early stages of musculoskeletal problems, and I operative nausea and vomiting. Acupuncture in Medicine
recently realized that they can also be effective 14 (2), 68–70.
in the chronic stages. I also advise my patients Campbell A. & Hopwood V. (2007) Debate – patients
to use them, although this could be controver- should be encouraged to treat themselves. Journal of
sial. The disposal of the needles can be done the Acupuncture Association of Chartered Physiotherapists
Autumn 2007, 57–61.
in a normal bin as the needle is so small and Davis C. L., Lewith G. T., Broomﬁeld J. & Prescott P.
unlikely to produce any needle stick injury. Best (2001) A pilot project to assess the methodological
practice would be to dispose of them in a regu- issues involved in evaluating acupuncture as a treat-
lar sharps box. However, for the longer needles ment for disabling breathlessness. Journal of Alternative
the practitioner and the patient should be aware and Complementary Medicine 7 (6), 633–639.
of the possibility of an injury if not disposed Ernst E. & White A. R. (1999) Indwelling needles carry
greater risks than acupuncture techniques. [Letter.]
of appropriately. BMJ 318 (7182), 536.
I have to say that the patient’s initial reaction Filshie J., Penn K., Ashley S. & Davis C. L. (1996)
to the application of the Pyonex needles was Acupuncture for the relief of cancer- related breath-
better than expected. I feel that these needles lessness. Palliative Medicine 10 (2), 145–150.
can be a good way of using acupuncture for Kotani N., Hashimoto H., Sato Y., et al. (2001) Preoperative
people who are nervous of needles. The success intradermal acupuncture reduces postoperative pain,
nausea and vomiting, analgesic requirement, and sym-
of the treatment also depends on the patient’s pathoadrenal responses. Anesthesiology 95 (2), 349–356.
commitment to get better. Longbottom J. (2010) Clinical use of long-duration press
The use of Pyonex indwelling needles has needles. Journal of the Acupuncture Association of Chartered
become more popular in the last few years. The Physiotherapists Spring 2010, 91–92.

The use of Seirin Pyonex indwelling needles in the treatment of non-traumatic low back pain
National Institute for Health and Care Excellence (NICE) Association of Chartered Physiotherapists Interested
(2016) Low Back Pain and Sciatica in Over 16s: Assessment in Neurology and the Acupuncture Association of
and Management. NICE Clinical Guideline 59. National
Chartered Physiotherapists (AACP). Diana is a
Institute for Health and Clinical Excellence, London.
Niemtzow R. C., Belard J.-L & Nogier R. (2015) Battlefield Member of the AACP Board and its regional repre-
acupuncture in the U. S. military: a pain- reduction sentative for the East Midlands. She studied Chinese
model for NATO. Medical Acupuncture 27 (5), 344–348. at Beijing Language and Culture University, Beijing,
Nitta S. (2013) Is there a place for Japanese-style body China from 1999 to 2000 and then acupuncture at
indwelling needle acupuncture in physiotherapy prac- Beijing University of Chinese Medicine from 2000 to
tice? Journal of the Acupuncture Association of Chartered
2001. She has been a clinical educator for students on
Physiotherapists Spring 2013, 51–59.
neurological placement from Coventry, Leicester and
other universities since 2005. Diana completed her
Diana Giura graduated as a physiotherapist in 2002. Master’s degree in 2009 and gained a Preparing to
She is a member of the Health and Care Professions Teach in the Lifelong Learning Sector qualification in
Council, the Chartered Society of Physiotherapists, the 2013.

case REPORTS
Acupuncture for pain relief in a patient

following hip arthroscopic surgery
D. Atkinson
English Institute of Sport, Loughborough, UK
Abstract
Acupuncture was used as an alternative modality for pain relief in a patient 8 weeks after
hip arthroscopic surgery. Acupuncture was found to be effective in this case. Further qual-
ity research is required to generalize the findings from this case study and apply it to the
general population.
Keywords: Arthroscopy, hip OA, hip pain, pain relief, post-op
Introduction where this causes symptoms, as it shown that

The management of the ‘young hip pain’ these physiological changes can be present in
patient has seen many advances over the last non-symptomatic patients (Abellan et al. 2011).
15 years, with better access to the specialism These changes may be due to cam morphol-
for the general population as well as advances ogy, pincer morphology or instability, but
in surgical techniques providing excellent are only considered part of the syndrome of
outcomes, particularly with labral pathology femoroacetabular impingement (FAI) if a triad
(Stalzer et al. 2006). This is bolstered by good of factors exist as described in the Warwick
quality evidence supporting the intervention agreement of FAI (Griffin et al. 2016). These
in the sporting field to maintain performance include impingement symptoms (e.g. pain, loss
and assist in speedy return to play (RTP) that of movement), clinical signs (on assessment)
is then maintained up to 5 years post- surgery and diagnostic imaging to view morphology.
(Perets et al. 2018; Menge et al. 2017). While a Surgery can then be considered as an optional
reported 87% of athletes will RTP after surgery management strategy as well as conservative
there can be complications, the presence of and physiotherapy-led rehabilitation.
widespread osteoarthritis (OA) within the joint Once surgery has taken place, effective
at the time of surgery being well documented post-operative care is vital to ensure opti-
(Casartelli et al. 2015a). mal outcomes (Casartelli et al. 2015b) and
Hip arthroscopy is a procedure of choice will involve physiotherapy to guide a staged,
where damage has been caused to the articular goal-
orientated process like that proposed by
structures secondary to physiological changes Bizzini et al. (2007). Initial stages are heavily
apparent around the joint and, more importantly, influenced by the type of surgery completed
in the arthroscopy. For example, where labral
Correspondence: Dan Atkinson, Physiotherapist, repair has occurred a patient may be partial
Multi Sport, English Institute of Sport, EIS/L Boro. weight-bearing for 4–6 weeks and will have limi-
Performance centre, 1st Floor, Loughborough University tations on their ability to actively and passively
LE11 3TU, UK (email: daniel.atkinson@eis2win.co.uk) mobilize the operated joint. This is decided by

Acupuncture for pain relief in a patient following hip arthroscopic surgery
the individual surgeon involved based on best in knee OA. The papers they reviewed with hip
practice models they have created with their OA showed positive results, but there were too
team, in lieu of evidence-based practice, that is few patient numbers and too few accessible
generally based around theory of biomechani- RCTs to provide a definitive answer. Witt et al.
cal models (Grzybowski et al. 2015). This phase (2006) bolstered this opinion but also supported
is described by Casartelli et al. (2015b) as the the use of acupuncture in hip OA with a RCT
protective and early ambulation phase. Progress involving over 3500 patients with knee or hip
through this stage and onto later phases relies OA. This study lacked blinding and statistical
upon achieving goals (strength, neuromuscular difference in a control group (waiting list con-
control, range of movement) without the pres- trol for 3 months) but was able to demonstrate
ence of painful symptoms and is supported by improved outcomes in the population. Haslam
numerous other authors (Wahoff & Ryan 2011). (2001) provides a better quality small RCT
Controlling these symptoms is, therefore, of involving 32 patients. It compared acupuncture
upmost importance to the physiotherapist aim- using mainly the Gall Bladder (GB) meridian, to
ing for optimal rehabilitation. advice and exercise for patients who were wait-
If pain is poorly controlled throughout ing for a hip arthroplasty. Statistically significant
rehabilitation it can delay the progress through improvements in favour of the acupuncture
the goal-orientated programme by reducing the group were found and led to the author advis-
ability to train the relevant muscle groups and ing the use of acupuncture in this patient
mobilize the joint within patient comfort and group.
allowing adequate tissue healing. Patients with
FAI consistently display a weakness in all muscle
groups around the hip and different activation Case report
patterns, particularly in the hip flexors (Casartelli This case report documents the use of acu-
et al. 2011), and again pain is considered a major puncture in a post- operative hip arthroscopy
factor in this inhibition. Kierkegaard et al. (2017) patient struggling to improve his function after
go a step further and report patients often an initial lack of effective physiotherapy.
describing a feeling of an inability to contract
the muscle as well as the non- affected side, Patient profile (Table 1)
suggesting a central protective neural inhibition See Table 1 on opposite page.
over just reduced cross-sectional area.
As a result, it is logical to investigate methods Pain distribution diagram (Fig. 1)
for reducing pain in this patient cohort, yet there See Fig. 1 on p. 100.
is no research available looking into specific
post-hip arthroscopic pain relief strategies. This Clinical opinion
author suggests parallels can be made with hip Ineffective management strategies had led to
OA research, as FAI and OA are often linked fear avoidance to move a pre-operatively stiff
and can present with similar symptoms. One and weak hip, worsening an already chronic
such area of research investigates acupuncture pattern of pain. This was a complex picture of
as effective pain relief. Acupuncture has shown an acute-on-chronic scenario with aspects of
increasing use within the sports physiotherapy pain associated to neurological sensitization as
world with anecdotal evidence of the Western well as inflammation. Even though the patient’s
approach being widely discussed within OA- surgery was more than 8 weeks prior to our
related pain. Kwon et al. (2006) performed a appointment, the patient was still in phase I-II
systematic review into the use of acupuncture in (Grzybowski et al. 2015) and to move forwards,
peripheral joint OA which included 18 random- symptoms needed to be addressed. Adequate
ized controlled trials (RCTs) of varying quality. tissue healing had occurred by this stage so no
They were able to conclude that acupuncture further restrictions on physiotherapy manage-
did have favourable results over sham but only ment remained.

D. Atkinson
Table 1. Patient profile.
Patient profile
35-year-old male. Works in law in an office environment. Plays golf regularly, amateur XC MTB racer, regular user of gym for strength
training.
History of presenting This patient had a progressive worsening of right-sided groin pain that began 12 months ago. During
condition this period, he had increased his general exercise in all areas and had felt improvements in his strength
targets. As he began to increase his lifting he began to have pain in the squat that progressed and
worsened to start to affect his ability to cycle and then to play golf. At this time (approx. 6 months
ago) he stopped exercises for his lower limbs in the gym and stopped cycling due to the pain associated
with these activities. Initial physiotherapy from a private provider proved unsuccessful in reducing pain
or increasing function and so the patient progressed to seeing a consultant who performed an X-ray
and MRI of the hip. The diagnoses of FAI were subsequently given, appropriately fitting within the
agreement of Griffin et al. (2016). Due to severity of symptoms, the surgeon opted for arthroscopic
hip surgery. A cam was debrided, and a labral tear was removed. The surgeon was happy for full weight
bearing and physiotherapy to begin. At a 7-week follow up with the consultant, the patient was still
struggling with significant movement loss and pain. The patient was then referred to the author for a
review and to begin a new period of physiotherapy.
Presenting condition Constant dull ache – VAS 5/10; intermittent sharp pain – VAS 6/10.
Aggravating factors Standing 30 min; reaching to put socks on; driving 20 min; mobility exercises.
Ease Lying prone or on left side for 60 min.
24 hr Morning very stiff but lacks soreness; progressive soreness through day, activity dependent.
Previous medical history Nil relevant.
Drug history Using paracetamol for analgesia but refusing to use higher level pain relief due to nausea.
Patient’s aim To recover from surgery and return to cycling and golf.
Objective examination A full objective assessment of the lower limb and trunk was performed. The following are the key
points:
• wound sites healed; skin cool to touch and even skin tone
• reduced weight bearing through right side in standing; visual loss of muscle bulk through hip
extensors and quads compared to left side
hip PROM – flexion L 120 R 70 (pain)
• IR in flexion L 30 R 0 (pain)
• ER in flexion L 65 R 10 (pain)
• pain inhibited accurate muscle strength testing around the hip but clearly there had been over
6 months of disuse atrophy
• muscle length was reduced in hamstrings and quads on the right side
• gait showed an antalgic pattern with reduced stride length, stance phase and a corrective trunk
posture to cope with reduced lateral hip strength
• palpation demonstrated hypersensitivity through soft touch through the anterior of the right hip
with an over activity at rest also in the anterior musculature.
VAS = visual analogue scale; PROM = passive range of movement; IR = internal rotation; ER = external rotation.
Subjective markers Treatment plan

1. Pain 5–6/10 on the visual analogue scale A combination of treatment was agreed upon
(VAS) with the patient once the above findings
2. Pain on standing for 30 minutes were discussed. The goal- orientated, phased
3. Pain while reaching to put socks on approach (Grzybowski et al. 2015) was intro-
duced to the patient and the initial targets set
Objective markers (Table 2).
1. Right hip flexion passive range of motion
(PROM) 70º Goals
2. Right hip internal rotation in flexion 0º 1. Reduce pain on VAS to 2/10
3. Right hip external rotation in flexion 10º 2. Increase hip flexion PROM to 90º

performed. Although successful in increasing
PROM in the short term the patient would
struggle with pain as an after effect. This created
a need to view alternative treatment modalities.
Acupuncture
The patient’s problem was painful symptoms
distributed anteriorly and laterally in the right hip.
These symptoms were not new and felt very sim-
ilar to the symptoms the patient had pre-surgery.
Evidently there were layers of both acute pain
(8 weeks post-op) and chronic pain (14 months)
and treatment therefore had to be considerate
of these elements. The current evidence base
for treatment of hip pain includes acupuncture
(Haslam 2001; Witt et al. 2006; Kwon et al. 2006)
Figure 1. Pain distribution. and there is a growing body of evidence to sup-
port practitioners in clinical reasoning in the use
Physiotherapy treatment of Western acupuncture (Bradnam 2007; White
In treating to obtain the initial goals a com- et al. 2008a). These papers were used in conjunc-
bination of manual therapy and exercise was tion with the AACP Foundation Course manual
Table 2. Details of treatments.
Treatment
number Selected points Needling technique Dose Treatment effect
1 GB 29 40 mm, p, 2–3 cm depth 10 min, gentle stimulation Generalized De Qi

GB 30 70 mm, p, 3–6 cm depth VAS 3/10
GB 31 40 mm, p, 2–3 cm depth Hip flex PROM 80º
GB 34 25 mm, o, 1–2 cm depth
GB 43 15 mm, p, 0.5 cm depth
ST 44 B/L 25 mm, p, 0.5 cm depth
2 GB 29 40 mm, p, 2–3 cm depth 25 min, gentle stimulation Strong De Qi
3 GB 29 40 mm, p, 2–3 cm depth 25 min, moderate stimulation Moderate De Qi
LI 4 B/L 25 mm, p, 1 cm depth
4 GB 29 40 mm, p, 2–3 cm depth 25 min, moderate stimulation Moderate De Qi
LI 4 B/L 25 mm, p, 1 cm depth
BL 26 40 mm, o, 2 cm depth
GB = Gall Bladder; ST = Stomach; LI = Large Intestine; BL = Bladder; B/L = bilateral; p = perpendicular insertion; o = oblique insertion; PROM =
passive range of movement

D. Atkinson
to guide the acupuncture points used and the As a De Qi response was achieved, this
appropriate dosage. method proved adequate and allowed the thera-
Informed consent was gained prior to acu- pist to continue with manual treatment modali-
puncture treatment. ties that created an increase in the patient’s
PROM in the hip. De Qi, a sensation felt as
Rationale for point selection result of needle insertion, is often desired
Kwon et al. (2006) identified RCTs that used anecdotally by therapists and thought of as nec-
a combination of acupuncture points to treat essary to create the segmental and supraspinal
hip pain, and Haslam (2001) achieved the most effects of acupuncture.
positive results and was included in the system- Notably, the patient’s impression of acu-
atic review. They used a combination of GB puncture improved after the first session. This
points 29, 30, 34 and 43 along with four Ah Shi author believes the effect of acupuncture was
points placed in a north, south, east and west enhanced via increased patient expectation. He
formation around the greater trochanter and believed it worked, and so it did – a theory sup-
then finally Large Intestine (LI) 4 and Stomach ported by Kong et al. (2009).
(ST) 44. The rationale for these points is not This patient’s pain was multifactorial.
well explained other than the comment that Elements of acute and chronic pain were evi-
the author wanted to choose points that passed dent. In such cases, multiple reasons for the
over the hip, and that the GB meridian is said maintenance of pain exist. This creates the
to have influence on muscles and tendons. The need to ensure acupuncture treatment affects
Ah Shi points were used to affect the muscles these multiple reasons through activation of
that stabilize the hip. several mechanisms, dependant on how greatly
In this case, this author felt that to use the the central nervous system is sensitized (White
same dose on this patient would have been et al. 2008a). This was considered in this case
too high. The layering method described by by increasing the dose of acupuncture over
Bradnam (2007) is consistent in advising care- the four sessions by increasing the number of
ful treatment of new patients, and monitoring needles into extrasegmental regions that would
their response and tolerance to acupuncture. also affect the hip region and pain. LI 4 is con-
White et al. (2008a) support this and refer to the sidered to have strong pain- relieving qualities
importance of considering a patient’s personal and was added to support ST 44. Additionally,
reactions when deciding upon the appropriate points used within the hand and foot will create
dose. As a result, only six needles were used for a stronger response thanks to the sensorimotor
a short treatment time and minimal stimulation. homunculus and dense neural innervation, often
They were placed close to the site of pain in the activated through the idea of ‘big points’ in
GB meridian to induce local tissue responses, Western acupuncture.
which occur through modulation of the local As treatment advanced, the patient became
immune system from neuropeptides released more comfortable with acupuncture and an
with stimulation of primary afferent nerve end- increase in the dosage through manipulation of
ings (Lundeberg et al. 1988b, cited in Bradnam number of needles, time and stimulation was
2007). This effect was increased through achieved. This enabled greater use of manual
additional needles along a similar dermatomal therapy and a better compliance with a home
pattern to stimulate segmental analgesia within exercise plan. As shown, PROM increased, and
the spinal cord, a process believed to act on the pain remained consistently low. Functionally,
dorsal horn chemically through neural activation the patient improved and fewer symptoms
from Aδ nerve fibres (White et al. 2008b). Later were provoked in those provocative positions.
in treatment, Bladder (BL) 26 was added to Subjective markers all improved, pain on VAS
directly affect the nerve root at the dermatomal was down to 3/10 and no longer constant, the
level of hip innervation which would logically patient was able to stand for longer periods, and
also work via the same pathway. he was finally able to put his socks and shoes

on. The next phase of treatment involved an this specific case, the best reaction was found
increase in strength work and a plan will be put when points proximal to pain were used and
in place to push strength targets and further stimulated. Peripheral points had less effect.
improve the patient’s long-term picture. Due to this, more needles would be used around
the site of pain in future cases, and could mean
that with hip arthroscopies, local points are
Discussion more effective.
This case has demonstrated the use of acu- Another important question to ask is how
puncture to assist in pain relief during the reha- it worked. As identified through the work of
bilitation of a patient following hip arthroscopy. Adrian White as referenced in this paper, pain
It enabled the patient to tolerate the necessary science is advancing. To clinically reason how
physiotherapy to achieve the early phased acupuncture is working requires this pain sci-
approach now popularized in this area. This ence to improve further still; testing done on
adds to the existing research that acupuncture rat populations needs to be advanced to make
is helpful in dealing with hip pain. To attribute it adaptable to humans. Disappointingly, again
all pain relief to acupuncture directly would there is very little explanation of the ‘how’ in
be unscientific: the well- researched effects of the RCTs available. Discussion is normally
appropriate movement, explanation of symp- directed at if there was a significant result,
toms and positive therapist/patient relationship rather than how it came about. Future research
all had a role in these improvements. needs to involve this element in discussion to
Since writing this paper, the author has assist therapists looking to bring the results into
become aware of a further two studies that are practice.
currently looking into what optimal rehabilita- Limitations within this case study are notice-
tion should look like after hip arthroscopy. The able. The available time to complete this case
details of these are not currently available but study was limited to a 4- week period due to
should shed further light on an under-reviewed work commitments. This undoubtedly will
area, but as often is the case, the research will mean that research had to be very specific and
be stimulated by appropriate questions being did not allow for lateral thinking. It is possible
asked by clinicians. that research exists for other conditions that
Acupuncture was chosen as the modality would answer some of the questions this study
for pain relief in this case due to available has identified but will have been missed.
research supporting its use with hip OA. This To summarize, this study presents a patient
case may not have been directly due to OA, struggling with pain following ineffective
but given the patient’s spread of symptoms, physiotherapy management. Acupuncture was
parallels were made appropriately. It would not found to be an effective tool in managing pain
be time-efficient to research all conditions and which allowed physiotherapy to continue and
their treatment, however further research into increased its effectiveness.
post-operative Western acupuncture in the reha-
bilitation stage would be helpful. References
The acupuncture points used were effec-
Abellan J., Esparza F., Blanco A., et al. (2011) Radiological
tive and chosen in conjunction with the best evidence of femoroacetabular impingement in asymp-
available research. Problematically, the research tomatic athletes. British Journal of Sports Medicine 45 (4),
rarely explains why those points were chosen, 310–384.
so best practice models are selected. This cre- Bizzini M., Notzli H. & Maffiuletti N. (2007)
ated issues when describing to the patient why Femoroacetabular impingement in professional ice
hockey players: a case series of 5 athletes after open
distal points were used. While best practice surgical decompression of the hip. American Journal of
models are helpful, this author feels that all Sports Medicine 35 (11), 1955–1959.
acupuncture research, particularly RCTs, should Bradnam L. (2007) A proposed clinical reasoning model
describe scientifically why points were used. In for Western acupuncture. Journal of the Acupuncture

D. Atkinson
Association of Chartered Physiotherapists Spring 2007, Menge T., Bhatia S., McNamara S., et al. (2017)
21–30. Femoroacetabular impingement in professional football
Casartelli N. C., Maffiuletti N. A., Item-Glatthorn J. F. et al. players, return to play and predictors of career length
(2011) Hip muscle weakness in patients with sympto- after hip arthroscopy. American Journal of Sports Medicine
matic femoroacetabular impingement. Osteoarthritis and 45 (8), 1740–1744.
Cartilage 19 (7), 816–821. Perets I., Craig M. J., Mu B. H., et al. (2018) Midterm out-
Casartelli N. C., Leunig M., Maffiuletti N. A. & Bizzini M. comes and return to sports among athletes undergoing
(2015a) Return to sport after hip surgery for femoro hip arthroscopy. American Journal of Sports Medicine 46
acetabular impingement: a systematic review. British (7), 1661–1667.
Journal of Sports Medicine 49 (12), 819–824. Stalzer S., Wahoff M. & Scalan M. (2006) Rehabilitation
Casartelli N. C., Bizzini, M., Maffiuletti, N. A., et al. following hip arthroscopy. Clinics in Sports Medicine 25
(2015b) Rehabilitation and return to sport after bilat- (2), 337–357.
eral open surgery for femoroacetabular impingement in Wahoff M. & Ryan M. (2011) Rehabilitation after hip
a professional ice hockey player: a case report. Physical femoroacetabular impingement arthroscopy. Clinics in
Therapy in Sport 16 (2), 193–201. Sports Medicine 30 (2), 463–482.
Griffin D. R., Dickenson E. J., O’Donnell J., et al. (2016) White A., Cummings M., Barlas P., et al. (2008a) Defining
The Warwick Agreement on femoroacetabular impinge- an adequate dose of acupuncture using a neurophysio
ment syndrome (FAI syndrome): an international logical approach – a narrative review of the literature.
consensus statement. British Journal of Sports Medicine 50 Acupuncture in Medicine 26 (2), 111–120.
(19), 1169–1176. White A., Cummings M. & Filshie J. (2008b) An
Grzybowski J. S., Malloy P., Stegemann C., et al. (2015) Introduction to Western Medical Acupuncture. Churchill
Rehabilitation following hip arthroscopy – a systematic Livingstone/Elsevier, Edinburgh.
review. Frontiers in Surgery 2 (21). Witt C. M., Jena S., Brinkhaus B., et al. (2006) Acupuncture
Haslam R. (2001) A comparison of acupuncture with in patients with osteoarthritis of the knee or hip: a
advice and exercises on the symptomatic treatment randomized, controlled trial with an additional non-
of osteoarthritis of the hip – a randomised controlled randomized arm. Arthritis and Rheumatism 54 (11),
trial. Acupuncture in Medicine 19 (1), 19–26. 3485–3493.
Kierkegarrd S., Mechlenburg I., Lund B., et al. (2017)
Impaired hip muscle strength in patients with femoro Daniel Atkinson is a physiotherapist working with
acetabular impingement syndrome. Journal of Science and
a sporting population within the English Institute of
Medicine in Sport 20 (12), 1062–1067.
Kong J., Kaptchuk T. J., Polich G., et al. (2009) An fMRI Sport and through physiokinetic at the University of
study on the interaction and dissociation between Birmingham. He graduated with 1st class honours from
expectation of pain relief and acupuncture treatment. Keele University in 2008 and has spent 10 years work-
NeuroImage 47 (3), 1066–1076. ing across elite sport and with the general population.
Kwon Y. D., Pittler M. H. & Ernst E. (2006) Acupuncture
for peripheral joint osteoarthritis: a systematic review
and meta-analysis. Rheumatology 45 (11), 1331–1337.

case reports
Acupuncture for the treatment of whiplash

associated disorder
S. Cronin
South Tees Foundation Trust, The James Cook University Hospital, Middlesbrough, UK
Abstract
The objective of this case report is to discuss the acupuncture treatment of a 37-year-old
female suffering from a case of whiplash associated disorder. The rationale for using
acupuncture alongside other physiotherapy modalities is discussed with regard to recent
evidence and guidelines. Acupuncture was chosen to alleviate pain and facilitate the use
of other physiotherapy techniques to improve movement and function. Outcome measures
implemented included the visual analogue scale for pain, the Oxford scale, neck disability
index (NDI) and range of movement. The client completed six sessions of acupuncture
on a weekly basis in a private physiotherapy setting. The client’s reported pain score fell
from 7/10 to 0/10 from first to final assessment. There was also an improvement in the
NDI score from 8/50 to 2/50. A proposed reasoning for this marked reduction in pain is
discussed. Verbal and written informed consent was obtained from the client.
Keywords: acupuncture, physiotherapy, whiplash associated pain.
Introduction Although acupuncture is commonly used

Whiplash associated disorder (WAD) is a debili- in physiotherapy, there is limited strong evi-
tating condition that accounted for approxi- dence on the most effective physiotherapy
mately 300,000 insurance claims in 2003 (Burton management of WAD, with guidelines advising
2003 in Mercer et al. 2007), a figure which has self-
management strategies and highlighting
no doubt risen since 2003. any psychosocial factors (Verhagan et al. 2007;
WAD results in soft tissues and/or bony Williamson et al. 2009; NICE 2015a). In a
injury following a rapid acceleration-deceleration systematic review conducted by Verhagen et al.
movement of the head and neck and can affect (2007), the researchers concluded the current
other areas of the spine (Moore et al. 2005). evidence does not provide support for the most
WAD can be complicated and worsened by psy- effective treatment for WAD, suggesting active
chosocial factors. Chronic WAD is associated treatments are ‘probably’ more beneficial than a
with the pain lasting more than six months, with more ‘passive’ approach.
research indicating around 14–42% of patients The Chartered Society of Physiotherapists
go on to develop chronic pain (Barnsley 1994) (CSP) has developed guidelines which advise
(Table 1). that patients suffering from a WAD should be
provided with education on posture, use of heat
Correspondence: Suzanne Cronin, South Tees Foundation and exercises to activate the deep neck flexor and
Trust, The James Cook University Hospital, Marton improve range of motion (Moore et al. 2005).
Road, Middlesbrough TS4 3BW, UK (email: suzannec The guidelines report there is weak evidence for
2012@gmail.com). the use of acupuncture to treat this condition

Acupuncture for the treatment of whiplash associated disorder
Table 1. Definition and grading of whiplash-associated disorder (WAD)
A definition and grading of WAD has been provided in guidelines by the Quebec Task Force:
‘Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from a rear-end or side-impact motor
vehicle collision but can also occur during driving or other mishaps. The impact may result in bony or soft tissue injuries (whiplash
injury) which in turn may lead to a variety of clinical manifestations called whiplash associated disorders.’ (Spitzer 1995)
0–No complaint about the neck and no physical sign(s)
1–Neck complaint of pain and no physical sign(s)
2a–Neck complaint and musculoskeletal sign(s). Normal range of motion (ROM)
2b–Neck complaint and musculoskeletal sign(s). Abnormal range of motion (ROM)
2–Neck complaint and neurological sign(s)
3–Neck complaint and fracture or dislocation
(Hartling et al. 2001)
and therefore cannot support or refute its use. (2007) reports: “The origin of all pain is the inflam-
Additionally, researchers White and Ernst (1999) mation and the inflammatory response”. In chronic
in an earlier review found no evidence for acu- conditions such as chronic whiplash, inflam-
puncture in the treatment of neck pain. matory mediators such as bradykinin can add
The NICE guidelines for the management of to the sensitization of tissues; this will lead to
WAD conclude there is weak evidence for the a smaller stimulus triggering a pain response
long-term effectiveness of physiotherapy such as (Chopade & Mulla 2010). It is important we as
exercise and mobilization (NICE 2015a). They therapists recognize the importance of choosing
are not confident physiotherapy would benefit the most effective treatments for WAD at the
patients with WAD; however, this is in direct earliest stage possible to prevent the condition
contradiction to the guidelines by the same becoming chronic.
organization which suggest acupuncture having The evidence for the pain-relieving effect of
a short-term benefit for sub-acute and chronic acupuncture on these systems will be regarded
neck pain as detailed in the NICE guidelines for in the rationale for the acupuncture selection
non-specific neck pain (NICE 2015b). later in this paper. The acupuncture treatment
There is growing support of the use of acu- is justified in this case in order to attempt to
puncture for reducing neck pain (He et al. 2004; alleviate pain and maximise potential for the
White et al. 2004; Vas et al. 2006; Willich et al. client’s rehabilitation.
2006; Witt et al. 2006; Fu et al. 2009; Trinh et al.
2009). It is proposed that acupuncture activates
the body’s own pain-relieving responses locally, Description of the case
segmentally and by having a central effect on The client was assessed in a private physiother-
the nervous system (White et al. 2008). apy practice following authorization from the
It has been suggested that acupuncture can insurance company for six sessions of physio-
modulate inflammatory conditions through therapy (Table 2). The client had not received
an inflammatory effect (White et al. 2008). any previous treatment for her neck pain. As all
Acupuncture has been shown to induce a symptoms appeared consistent with whiplash
phenotypic switch of muscle macrophages; this associated injury (Ferrari et al. 2005), a diagnosis
causes a reduction in pre- inflammatory cells of QUEBEC grading 2b whiplash associated
and an increase in anti-inflammatory cells thus injury – ‘neck pain with point tenderness and
facilitating a healing response (da Silva et al. reduced range of motion’ – was made (Hartling
2015). By treating with acupuncture, it is then et al. 2001).
hypothesized that promoting an inflammatory Acupuncture was discussed with the cli-
cascade will induce a healing response and ent and chosen to treat the client’s pain and
improve the client’s rehabilitation. Omoigui facilitate other physiotherapy modalities. No

S. Cronin
Table 2. Initial assessment
Patient profile
37-year-old female. Mother of two teenagers, works as an administrator full-time; desk-based role. Attends gym twice a week which
involves a Pilates class followed by swimming (breaststroke).
Presenting condition: Neck pain following a road traffic accident 3 weeks ago; diagnosis of whiplash by her GP. Client reports that she
was working at her computer 4 days ago and felt a ‘twinge’ in her neck and since has felt the neck pain has worsened and felt more
‘stiff ’. The client was referred through an insurance company which approved six sessions of physiotherapy.
Mechanism of injury: Client was the passenger in a car in a road traffic accident. Client reports the vehicle was stationary and was hit by
a car from behind at approx. 40 mph. Client describes herself as facing forward with her head thrown forward and backward. The client
was wearing her seatbelt.
No pain felt initially; pain developed later that night. Headaches experienced since the accident. Pain recently increased following being
sat at her desk at work and turned head quickly and felt a ‘twinge’. Intermittent sharp pain = 7/10 at worst, = 5/10 during assessment,
and usually gets worse towards the end of the day. When asked about her psychological status the client reports she suffers occasional
anxiety if her workload is busy.
Past medical history: Hypothyroidism
Drug history: Takes levothyroxine daily, and paracetamol for pain relief
Subjective findings
Pain: Patient reports a bilateral intermittent dull

ache (=5/10) located centrally at the base of her
skull which radiates down her upper trapezius fibres
bilaterally (=7/10) when she turns her head to left
and right. No upper limb pain
Aggravating factors are sitting for long periods,

driving and if she has had a busy day at work
Easing factors are heat and gentle movement. The

client reports her main problem is neck pain. The
patient reports some early morning stiffness in her
neck also, pointing to the levels C5/6
Objective assessment
Observation: forward head position with increased lower cervical flexion and upper extension with protracted girdles, rounded shoulders
On palpation, spasm was detected on palpation of the upper trapezius, scalenes and levator scapular neck muscles. Hypomobility of the
cervicothoracic joint and point tenderness over C5–6
The client presented with reduced deep neck flexor activation, reduced cervical flexion 60%, reduced right and left cervical rotation
80%, and reduced cervical side flexion 75% bilaterally. Pain on all resisted cervical movements = 7/10
No neurological findings were detected upon assessment with upper limb tension tests, myotomal, dermatomal or reflex testing. No red
flags
Problem list
Overall the client’s problems were pain, reduction in movement and function, difficulty functioning at work and activities of daily living.
Goals
Short-term: to reduce pain and improve range of movement

Long-term: to improve muscular control of deep neck flexors, improve flexibility and overall posture

contraindications were noted. Following advice inflammatory mediators which can promote
on possible adverse effects, the client agreed, healing and local pain relief (White et al.
read the patient information leaflet and signed 2008).
an informed consent form. For example, acupuncture needling activates
the body’s Aδ and C fibres in skin and muscles,
causing sensations described as “heaviness, tin-
Treatment plan
gling and soreness,” contributing to the sensa-
Informed consent was obtained prior to each
tion of De Qi (White et al. 2008).
treatment.
• Acupuncture for pain management
• Education – posture, anatomy, pain, pac-
Supporting evidence
ing, diagnosis. This included advice on
Systematic reviews have concluded the evidence
posture throughout the day and while sat at
for acupuncture and WAD is limited and fur-
her desk – a work station assessment was
ther research is required (Moon et al. 2014). In
discussed.
a study of 80 participants with chronic WAD,
• Exercises – given to improve range of
Stirling et al. (2015) found some effectiveness
motion, stability and control.
of dry needling and exercise in a randomized
• Manual techniques and massage.
controlled single blind placebo-controlled trial,
but reported the results were not “clinically
Rationale for point selection worthwhile”.
Three points were chosen during the first Acupuncture may result in pain relief and
session as the client had not had acupuncture increased range of movement (Witt et al. 2006),
before, and the points were increased to seven and may be cost-effective in the management of
during the second session. White et al. (2008) chronic neck pain (Willich 2006). Furthermore,
recommends using six points bilaterally to Ross et al. (1999) found in a large long- term
achieve the observed response. study that patients in primary care respond well
It is proposed that acupuncture activates the to acupuncture.
body’s own pain-relieving responses. The inser- In a study by He et al. (2006), 24 participants
tion of these needles leads to local effects in with muscular neck pain were randomized into
the skin, segmental effects and extrasegmental acupuncture and sham control groups. The
effects in the body. It is due to these effects acupuncture group received electroacupuncture
that acupuncture is used to treat pain in the over 16 body points, however participants
short-and longer-term (Carlsson 2002). self-administered auricular acupuncture over
Small Intestine (SI), Bladder meridian (BL) six points leading to clear flaws in the study’s
and Gall Bladder (GB) points were selected to statistical power. The control group had elec-
allow for a segmental and local approach to the troacupuncture applied with no power turned
client’s pain (White et al. 2008). Additionally, on. The intensity and frequency of pain was
Governor Vessel (GV) 14 was added during significantly lower in the acupuncture group,
the second session as this point can help ease and these improvements were retained in this
postural neck pain (White et al. 2004) (Table 3). group for the following three years compared
GB 20 was used bilaterally as it is deemed to the control group.
to ease occipital headache and relieve pain and In a randomized controlled trial by Vas et al.
stiffness in the neck (White et al. 2008). White (2006), the following points were used and
et al. (2004) state GB 20 and GB 21 should be standardized: GB 20/21, Liver (LR) 3, Large
considered in a clinical setting for the treatment Intestine (LI) 4, GB 34, BL 10, GV 14, SI 3,
of neck pain. BL 62 and GB 39. As in the study by White
The local effects of acupuncture lead to a et al. (2004), the sham transcutaneous electrical
release of a vasodilator calcitonin gene-related nerve stimulation (TENS) was not turned on;
peptide (CGRP) which leads to the release of and statistically significant improvements in

S. Cronin
Table 3. Record of point selection and treatment outcome
Treatment session and Selected points (below
objective of session all bilaterally) Needling technique Dose Effect of treatment
1) Reduce pain from LI 4 30 mm perpendicular, 1 cm depth 10 min as first Nil adverse effects
7/10 treatment Pain = 4/10
No change in ROM
GB 20 25 mm oblique/inferior, 1 cm depth
Neck Disability Index
GB 21 25 mm posterior oblique, 1 cm depth
score = 8
2) Reduce pain from LI 4 30 mm perpendicular, 1 cm depth 20 min Nil adverse effects
7/10; improve ROM Pain 4/10
GB 20 25 mm oblique/inferior, 1 cm depth Improvement in cervical
GB 21 25 mm posterior oblique, 1 cm depth flexion – 75%
BL 10 30 mm oblique, 0.5 cm depth
GV 14 30 mm perpendicular, 1 cm depth
SI 15 30 mm oblique, 1.5 cm depth
BL 60 30 mm perpendicular, 1 cm
3) Reduce pain from LI 4 All as previous 20 min No pain post-treatment
6/10; improve ROM GB 20 Reported has had no
GB 21 further headaches
BL 10 Improvement in cervical
GV 14 rotation 90% bilaterally
SI 15
BL 60
4) Reduce pain from LI 4 All as previous 20 min 2/10 pain
6/10; improve ROM GB 20 post-treatment
GB 21 Cervical flexion full
BL 10
GV 14
SI 15
BL 60
5) Reduce pain from LI 4 All as previous 20 min 2/10 post-treatment
4/10; improve ROM GB 20
GB 21
BL 10
GV 14
SI 15
BL 60
6) Reduce pain from LI 4 All as previous 20 min No pain post-treatment
2/10 GB 20 Neck Disability
GB 21 Index = 2, with client
BL 10 reporting she still gets
GV 14 slight pain if she reads
SI 15 for more than 1 h
BL 60 Cervical rotation 100%
bilaterally
Cervical side flexion
95% bilaterally
LI = Large Intestine; GB = Gall Bladder; BL = Bladder; GV = Governor Vessel; SI = Small Intestine; ROM = range of motion
the acupuncture group compared to the TENS (NICE 2012). Acupuncture has also been
sham were demonstrated. suggested to be more effective than sham acu-
Additionally, Franca et al. (2008) found acupuncture in a systematic review for tension-type
puncture to be more effective when combined headache (Linde et al. 2009).
with physiotherapy for facilitating pain relief When applied to conditions of the neck,
in tension neck syndrome. With regards to the White et al. (2004) in a study with a large sample
client’s headache, the NICE guidelines support size showed a significant effect of acupuncture
the use of acupuncture for chronic headaches for mechanical neck pain when compared to

Table 4. Clinical reasoning for points selected
Points selected Justification for points selected and supporting evidence
LI 4 bilaterally LI 4 covers dermatomes C6/C7 and is a “master point for pain.” It creates a calming response and was
chosen also to create an extra segmental response (White et al. 2008).
Distal points LI 4 were used bilaterally to induce a strong supraspinal pain descending inhibitory effect
(White et al. 2008). Additionally, Wu et al. (1999) found the acupoint LI 4 led to activity in the limbic area
related to pain response and detected in the descending anti-nociceptive pathways.
Haker et al. (2000) found acupuncture to the LI 4 points and an ear point led to a sympathetic response in
the related segment and resulted in pain relief.
GB 20 bilaterally “Master point” for pain and activating the sympathetic nervous system (Hecker et al. 2007)
GB 21 bilaterally GB 21 was chosen bilaterally to achieve a local, segmental and extra segmental effects and subsequently to
target the client’s head and neck pain and stiffness (He et al. 2004; White et al. 2008).
BL 10 bilaterally Vas et al. (2006). Indicated for cervical pain (Hecker et al. 2007)
BL 60 bilaterally Distal point to facilitate the strength of the bladder meridian (White et al. 2004)
GV 14 bilaterally GV 14 during the second session as this point can help with postural neck pain (White et al. 2004)
SI 15 bilaterally (He et al. 2004)
LI = Large Intestine; GB = Gall Bladder; BL = Bladder; GV = Governor Vessel; SI = Small Intestine
sham TENS which was not turned on over the real placebo, as the sham will have a treatment
same acupoints. effect of its own and it has been demonstrated
A large-scale German study (N = 3766) per- that the blunt needle can have profound effects
formed by Witt et al. (2006) found the use of on the limbic system (Pariente et al. 2005). Sham
acupuncture was associated with improvements acupuncture involves needling non-acupuncture
in neck pain and disability when compared to points or using a device whereby the guide tube
routine care alone. In a Cochrane Review with a is pressed against the skin but the needle either
smaller number of participants (N = 661), Trinh penetrates very slightly (superficial tissue) below
et al. (2006) found moderate evidence that acu- the skin or not at all (Lund et al. 2009).
puncture relieves pain better than some sham After reviewing the literature, the evidence
treatments in patients with neck pain. suggests the effectiveness of acupuncture in the
With regards to WAD, the CSP guidelines treatment of neck pain as part of a physiother-
conclude there is not enough clinical evidence apy treatment plan
to support or refute the use of acupuncture
(Moore et al. 2005). However, it is still widely
used in conjunction with other physiotherapy Discussion
modalities. Researchers Fu et al. (2009) in a The client reported no pain following the sixth
systematic review of 14 studies into the effec- treatment session. The NDI score (Appendix
tiveness of acupuncture for neck pain agreed 1) was 8 at initial assessment and reduced to 2
that more long-term follow up in this area was by the final session. The NDI is an outcome
required but reported a short-term benefit of measure which is considered a valid and reliable
acupuncture for neck pain. tool for measuring neck pain (Vernon & Mior
Following a review of the literature, acupunc- 1991; Stratford et al. 1999).
ture seems to have a place in the treatment of Improvements in range of motion were
pain conditions. observed following the third session, and full
The evidence for the effectiveness of acu- rotation was achieved by the final session, but
puncture within physiotherapy is uncertain, the client had some muscular tightness in side
with researchers reporting low quality evidence flexion and was advised to continue with the
produced and using low sample sizes. The big- stretching exercises. Education on posture, use
gest problem with the studies is that the place- of heat, manual techniques and exercises to
bos used, i.e., the sham technique, provide no improve muscular control and improve range

S. Cronin
of motion were used as advised by Moore et al. acupuncture compared to those in the control.
(2005). The pain relief may be a result of the The segmental activation leads to a segmental
pain-relieving mechanisms of the acupuncture analgesia which can last the duration of the
treatment in combination with the other physio- session and days succeeding the initial treatment
therapy modalities used, all of which may have (White et al. 2008). This can explain how acu-
combined to lead to favourable results. puncture can have a cumulative effect on pain
Upon reflection, an alternative treatment for the client.
would have been to use electroacupuncture for Individuals with WAD have been shown to
this case. In a randomized, double-blind study, be hypersensitive to mechanical pressure which
Sator-Katzenschlager et al. (2004) found weekly can lead to changes in the central processing
auricular electroacupuncture reduced pain and of pain (Scott et al. 2005). In the brain, the cer-
therefore proved more effective than manual ebral cortex detects this sensation of needling
acupuncture in the treatment of chronic low and activates an area called the periaqueductal
back pain. gray or ‘PAG’ which is the primary control
Another alternative treatment which could centre for descending pain. The PAG has a
have been adopted was dry- needling trigger high concentration of the cells which produce
point acupuncture. Trigger point acupuncture encephalin (White et al. 2008) and activation via
over SI 15 may be used to manage myofascial the mechanism of acupuncture can lead to the
trigger points common in the area and ease release of noradrenaline and serotonin, leading
muscle spasm in upper trapezius (White et al. to pain relief due to activation of descending
2008). This is supported by Itoh et al. (2007) pain inhibition (White et al. 2008). Furthermore,
who found trigger point acupuncture treatment functional MRI (fMRI) have demonstrated the
was more effective than manual acupuncture, effect of acupuncture on the pain pathways of
resulting in lower intensity neck pain. the brain (Napadow et al. 2009).
It has been proposed that mechanical dis- A pro-inflammatory effect of acupuncture
ruption of connective tissues in the body can may also be responsible for the reduction in the
have an effect on local and global anatomical client’s pain. Wang et al. (2014) when treating
tissues and lead to disturbances in the electri- rats with acupoint GB 30 showed that acupunc-
cal response of tissues and cellular activity ture regulates opioid- containing macrophages
(Langevin & Yandow 2002). In addition to the and anti-nociceptive mediators in inflammatory
pain-relieving responses of acupuncture docu- pain. These studies using animal models have
mented, a structural response has been observed limitations when generalizing the results to
following the manipulation of the acupuncture humans.
needle. In the subcutaneous tissue of a mouse, The client had not had acupuncture before.
a gathering of collagen around the needle and Additionally to the effect on pain, acupuncture
altered fibroblast cellular activity several centi- has an effect on psychological aspects of pain
metres away from the needle was demonstrated and some researchers suggest that positive
by Langevin et al. (2006). This mechanism expectation of pain relief may amplify the
could perhaps explain and have contributed effect of the treatment (Shi et al. 2012; Kong
to the improvement in the client’s range of et al. 2009).
motion. Additionally, the headache the client had
The reduction in pain may have been caused experienced following the injury seemed to have
by the segmental effects of acupuncture which benefited from treatment, however this may
stimulate Aδ and C fibres in skin and type have been a result of an improvement in range
11 and type 111 fibres in muscles, activating of movement and function following the other
the release of encephalin (White et al. 2008). physiotherapy modalities. Other researchers
Clement-Jones et al. (1980) showed that follow- do however advocate acupuncture for tension
ing acupuncture there was an increased level of headaches (Linde et al. 2009) and neurovascular
B-endorphin detected in patients who received headache (Zhao et al. 2011).

Another problem with the studies is the small trial (pilot study). Complementary Therapies in Medicine 16
samples used, which leads to the risk of a type (5), 268–277.
Fu L. M., Li J. T. & Wu W. S. (2009) Randomized con-
two error being made. Furthermore, a limitation
trolled trials of acupuncture for neck pain: systematic
of many of the studies included is that they do review and meta- analysis. Journal of Alternative and
not investigate acute or sub-acute neck pain, Complementary Medicine 15 (2), 133–45.
which is commonly what a patient will present Haker E., Egekvist H. & Bjerring P. (2000) Effect of
to physiotherapy with. sensory stimulation (acupuncture) on sympathetic and
parasympathetic activities in healthy subjects. Journal of
the Autonomic Nervous System 79 (1), 52–59.
Conclusion Hartling L., Brison, R. J., Ardem C. & Pickett W. (2001)
It appears that the segmental, extrasegmental Prognostic value of the Quebec classification of
and central effects proposed with acupuncture whiplash-associated disorders. Spine 26 (1), 36–41.
treatment had a good pain-relieving effect on He D., Veiersted K. B., Høstmark A. T. & Medbø J. I.
the client in this case study. Due to its subjective (2004) Effect of acupuncture treatment on chronic
nature, pain is difficult to study. It seems there neck and shoulder pain in sedentary female workers:
a 6-month and 3-year follow-up study. Pain 109 (3),
is limited strong evidence for the effectiveness
299–307.
of acupuncture for the treatment of WAD, Hecker H.-U., Steveling A., Peuker E., et al. (2007) Colour
leading to contraindications in the guidelines Atlas of Acupuncture, 2nd edn. Thieme Publishing Group,
and frustrations for acupuncturists who see on Stuttgart.
a daily basis the benefit this modality can have Itoh K., Katsumi Y., Hirota S. & Kitakoji H. (2007)
on the individual. Randomized trial of trigger point acupuncture com-
pared with other acupuncture for treatment of chronic
neck pain. Complementary Therapies in Medicine 15 (3),
References 172–179.
Barnsley L., Lord S. & Bogduk N. (1994) Whiplash injury: Kong J., Kaptchuk T. J., Polich G., et al. (2009) An fMRI
clinical review. Pain 58 (3), 283–307. study on the interaction and dissociation between
Burton K. (2003). Treatment guidelines: Is there a expectation of pain relief and acupuncture treatment.
need? In: Proceedings of Whiplash Conference 2003, Bath, NeuroImage 47 (3), 1066–1076.
England, 6–8 May. Lyons Davidson Solicitors, Bristol, Langevin H. M. & Yandow J. A. (2002) Relationship of
as cited in Mercer C., Jackson A. & Moore A. (2007) acupuncture points and meridians to connective tissue
Developing clinical guidelines for the physiotherapy planes. Anatomical Record 269 (6), 257–265.
management of whiplash associated disorder (WAD). Langevin H. M., Bouffard N. A., Badger G. J., et al.
International Journal of Osteopathic Medicine 10, 50–54. (2006) Subcutaneous tissue fibroblast cytoskeletal
Carlsson C. (2002) Acupuncture mechanisms for clini- remodeling induced by acupuncture: evidence for a
cally relevant long-term effects: reconsideration and a mechanotransduction-based mechanism. Journal of
hypothesis. Acupuncture in Medicine 20 (2–3), 82–99. Cellular Physiology 207 (3), 767–774.
Chopade A. R. & Mulla W. A. (2010) Novel strategies for Linde K., Allais G., Brinkhaus B., et al. (2009) Acupuncture
the treatment of inflammatory hyperalgesia. European for tension-type headache. Cochrane Database of Systematic
Journal of Clinical Pharmacology 66 (5), 429–444. Reviews 1: CD007587.
Clement- Jones V., Tomlin S., Rees L. H., et al. (1980) Lund I., Naslund J. & Lundeberg T. (2009) Minimal
Increased ß-endorphin but not met-enkephalin levels acupuncture is not a valid placebo control in random-
in human cerebrospinal fluid after acupuncture for ized controlled trials of acupuncture: a physiologist’s
recurrent pain. Lancet 316 (8201), 946–949. perspective. Chinese Medicine 4 (1).
da Silva M. D., Bobinski F., Sato K. L., et al. (2015) IL-10 Mercer C., Jackson A. & Moore A. (2007) Developing
cytokine released from M2 macrophages is crucial for clinical guidelines for the physiotherapy management
analgesic and anti-inflammatory effects of acupuncture of whiplash associated disorders. International Journal of
in a model of inflammatory muscle pain. Molecular Osteopathic Medicine 10, 50–54.
Neurobiology 51 (1), 19–31. Moon T.- W., Posadzki P., Choi T.- Y., et al. (2014)
Ferrari R., Russell A. S., Carroll L. J. & Cassidy J. D. Acupuncture for treating whiplash associated disorder:
(2005) A re- examination of the whiplash associated a systematic review of randomized clinical trials.
disorders (WAD) as a systemic illness. Annals of the Evidence-based Complementary and Alternative Medicine
Rheumatic Diseases 64 (9), 1337–1342. 2014: 870271.
Franca D. L., Senna- Fernandes V., Cortez C. M., et al. Moore A., Jackson A., Jordan J., et al. (2005) Clinical guide-
(2008) Tension neck syndrome treated by acupuncture lines for the physiotherapy management of whiplash-associated
combined with physiotherapy: a comparative clinical disorder. Chartered Society of Physiotherapy, London.

S. Cronin
Napadow V., Dhond R. P., Kim J., et al. (2009) Brain Verhagen A. P., Scholten-Peeters G. G., van Wijngaarden
encoding of acupuncture sensation – coupling on-line S., et al. (2007) Conservative treatments for whiplash.
rating with fMRI. NeuroImage 47, 1055–1065. Cochrane Database of Systematic Reviews 2: CD003338.
National Institute for Health and Clinical Excellence Vernon H. & Mior S. (1991) The Neck Disability Index:
(NICE) (2012) Clinical guideline CG150. Headaches in a study of reliability and validity. Journal of Manipulative
over 12s: diagnosis and management. [WWW document.] and Physiological Therapeutics 14 (7), 409–415.
http://www.nice.org.uk/guidance/cg150 Wang Y., Gehringer R., Mousa S. A., et al. (2014).
National Institute for Health and Clinical Excellence CXCL10 controls inflammatory pain via opioid
(NICE) (2015a). Neck pain – whiplash injury. Available peptide-containing macrophages in electroacupuncture.
from http://cks.nice.org.uk/neck-pain-whiplash-injury PLoS One 9 (4), e94696.
(last accessed January 2016) White A. R. & Ernst E. (1999) A systematic review of
National Institute for Health and Clinical Excellence randomized controlled trials of acupuncture for neck
(NICE) (2015b) Clinical knowledge summary. Neck pain – pain. Rheumatology 38 (2), 143–147.
non-specific. [WWW document.] http://cks.nice.org.uk/ White A., Cummings M. & Filshie J. (2008) An Introduction
neck-pain-non-specific [Accessed January 2016]. to Western Medical Acupuncture, 1st edn. Churchill
Omoigui S. (2007) The biochemical origin of pain: the Livingstone/Elsevier, Edinburgh.
origin of all pain is inflammation and the inflammatory White P., Lewith G., Prescott P. & Conway J. (2004)
response. Part 2 of 3 – inflammatory profile of pain Acupuncture versus placebo for the treatment of
syndromes. Medical Hypotheses 69 (6), 1169–1178. chronic mechanical neck pain. Annals of Internal Medicine
Pariente J., White P., Frackowiak R. S. & Lewith G. 141 (12), 911–919.
(2005) Expectancy and belief modulate the neuronal Williamson E., Williams M., Hansen Z., et al. (2009).
substrates of pain treated by acupuncture. NeuroImage Development and delivery of a physiotherapy interven-
25 (4), 1161–1167. tion for the early management of whiplash injuries: the
Ross J., White A. & Ernst E. (1999) Western, minimal Managing Injuries of the Neck Trail (MINT) interven-
acupuncture for neck pain: a cohort study. Acupuncture tion. Physiotherapy 95 (1), 15–23.
in Medicine 17 (1), 5–8. Willich S. N., Reinhold T., Selim D., et al. (2006) Cost-
Sator-Katzenschlager S. M., Scharbert G., Kozek- effectiveness of acupuncture treatment in patients with
Langenecker S. A., et al. (2004) The short-and chronic neck pain. Pain 125 (1–2), 107–113.
long- term benefit in chronic low back pain through Witt C. M., Jena S., Brinkhaus B., et al. (2006) Acupuncture
adjuvant electrical versus manual auricular acupuncture. for patients with chronic neck pain. Pain 125 (1–2),
Anesthesia and Analgesia 98 (5), 1359–1364. 98–106.
Scott D., Jull G. & Sterling M. (2005) Widespread sensory Wu M.- T., Hsieh J.- C., Xiong J., et al. (1999) Central
hypersensitivity is a feature of chronic whiplash- nervous pathway for acupuncture stimulation: localiza-
associated disorder but not chronic idiopathic neck tion of processing with functional MRI imaging of
pain. Clinical Journal of Pain 21 (2), 175–181. the brain – preliminary experience. Radiology 212 (1),
Shi G. X., Yang X. M., Liu C. Z. & Wang L. P. (2012) 133–141.
Factors contributing to therapeutic effects evaluated in Zhao L., Guo Y., Wang W. & Yan L.-J. (2011) Systematic
acupuncture clinical trials. Trials 13:42. review on randomized controlled trials of acupuncture
Spitzer W. O., Skovron M. L., Salmi L. R., et al. (1995) for neurovascular headache. Chinese Journal of Integrative
Monograph of the Quebec Task Force on whiplash- Medicine 17 (8), 580–586.
associated disorders: redefining “whiplash” and its
management. Spine 20 (8 Suppl), 1S-73S. Appendix 1
Stirling M., Vicenzino B., Souvlis T. & Connelly L. B. Neck Disability Index
(2015) Dry-needling and exercise for chronic whiplash-
https://www.aaos.org/uploadedFiles/NDI.pdf
associated disorders: a randomized single- blind
Vernon H. (2008) The Neck Disability Index: state-of-the-
placebo-controlled trial. Pain 156 (4), 635–643.
art, 1991–2008. Journal of Manipulative and Physiological
Stratford P. W., Riddle D. L., Binkley J. M., et al. (1999)
Therapies 31 (7), 491–502.
Using the Neck Disability Index to make decisions
concerning individual patients. Physiotherapy Canada 51, Suzanne completed a Sports Therapy BSc in 2009 and
107–112, 119. then a Physiotherapy BSc in 2012, and currently works
Trinh K. V., Graham N., Gross A. R., et al. (2006) as a senior physiotherapist within pulmonary rehabilita-
Acupuncture for neck disorders. Cochrane Database of tion within the South Tees Foundation Trust. Having
Systematic Reviews 3: CD004870.
treated various spinal and peripheral conditions whilst
Vas J., Perea-Milla E., Mendez C., et al. (2006) Efficacy
and safety of acupuncture for chronic uncomplicated working part-time within a private sports physiotherapy
neck pain: a randomized controlled study. Pain 126 clinic, Suzanne felt acupuncture would be a suitable
(1–3), 245–255. adjunct to complement her physiotherapy practice.

opinion
Electricity and electroacupuncture – a quick

overview
L. Pearce
Private Practice, Biggleswade, UK
Abstract
Electricity is good for the body. Attaching it to acupuncture needles can accelerate the
effects we can have on tissue healing, relaxation of both mind and body through stimulating
the release of neurotransmitters, and improving micro-circulation. This article takes a very
brief look at some of the key parameters of electroacupuncture and suggests ways in which
we can add it to our acupuncture-based toolbox.
Keywords: electroacupuncture, high frequency, low frequency.
Introduction Dr Tim Watson reiterates the need for the

Historically, there is an intimate link between body to have current with this comment from
electricity and health. Too much of it (like Electrotherapy: Evidence Based Practice:
being struck by lightning) – well, that’s not very “ . . . there is a concept that biological tissues
healthy at all, especially if you don’t survive; not demonstrate electrical characteristics and that this
enough of it and our biology cannot function bio-electrical activity is . . . integral to their form and
as it should, which can lead to illness. function. It would appear that without this activity,
We live on a huge magnet which throws out characteristics, behaviour and response to adverse
electrical fields, we are affected by electricity events, the body would not be able to deal with the
in the atmosphere, and we are surrounded by environment as efficiently as it does.” (Watson
and interact with many different wavelengths 2008).
in the electromagnetic spectrum. Every cell is
like a mini-magnet and generator, and there is a As physiotherapists, we are used to using elec-
constant flux of electric current and physiology trotherapy and may have a vestigial memory of
trying to keep some sort of homeostasis in our our theory from college as to what works on
bodies. the tissues, and how. The main aim, with what-
Dan Keown’s enlightening book The Spark in ever outside force we are using, is to stimulate
the Machine (2014) provides an overview of how physiology into a different state from the one in
current may drive biological function and be which we find it.
linked to embryological development. There is In terms of tissue healing, we know tissue
an elegant correlation with the concept of the needs blood flow and chemistry in order to heal.
meridian network in here too – a must read. This precipitates a cascade of other events such
as tissue laydown and remodelling. If we can
Correspondence: Lynn Pearce, The Courtyard Centre stimulate this with our needles, how much more
for Health and Wellbeing, Biggleswade, Bedfordshire can we achieve with the addition of electro
SG18 0JA, UK (lynn.p.pearce@gmail.com). acupuncture? And what kind of frequencies do

Electricity and electroacupuncture – a quick overview
what kind of job? In short, is it worth adding Taking this as a baseline, we can see that the
current to the needle in order to gain a more lower frequencies have greater effect on tissue
enhanced effect? healing – anything between 2–20 Hz seems to
In general terms, electricity applied to the cover most of our patients’ needs!
tissues has one of three effects: When we compare the effect that electro
• chemical acupuncture has over manual acupuncture, we
• physical (or stimulatory) see we can achieve a lot more with the addition
• thermal. of electroacupuncture (Table 2).
In summary, the application of low frequency
These can influence the body at different levels:
(between 2–15 Hz) is more useful in helping
• cellular
chronic pain, having a vascular effect due to
• tissue
an active muscle twitch. It has a longer lasting
• segmental
effect but may take longer to start having that
• systemic.
effect. The physiology of endorphin produc-
It is important to remember that two points tion starts from 2–4 h post- treatment up to
connected together electrically in the lumbar 48 h, with patients often reporting an increasing
spine, for example, will not just affect the local sense of tiredness and relaxation after this time
area. There will be segmental blocking, as per as opposed to immediately after or during a
transcutaneous electrical nerve stimulation treatment session (Duan 2016a; Duan 2016b).
(TENS), and a global chemical effect which A 20–30 min stimulation is required.
occurs after the treatment session and can con- Applying high frequency (between 80–
tribute to increased endorphin production with 120 Hz) is more helpful in affecting acute pain
an improvement in sleep and/or wellbeing (Han or for more immediate relief, since relief is
2004; Lundburg 2005). quicker but does not last as long. High frequen-
Likewise, certain tissues respond to certain fre- cies tend to have a predominantly segmental
quencies and so if we can manipulate the internal and short- term effect (Mayor 2007). There is
environment more effectively by applying these an associated release of dynorphin at the spinal
frequencies, which we cannot do with manual cord level. A 10–20 min stimulation should give
acupuncture alone, then perhaps the treatment an anaesthetic effect.
will be even more effective (Qi 2016) (Table 1). Oschman (2000 p.179) claims that in general,
“organisms are poised to respond to minute ‘whispers’ in
Table 1. Relationship between the range of ELF and the clini- the electromagnetic environment ”. What is significant
cal results identified by Siskin & Walker (in Oschman 2000).
about these results is the known relationship of
2 Hz Nerve regeneration
using extremely low frequency (ELF) biomag-
7 Hz Bone regrowth
10 Hz Ligament healing netic fields to promote healing. For example,
15, 20, 72 Hz Decreased skin death, stimulation of capillary in 1995 Siskin & Walker (Oschman 2000 p.87)
formation and fibroblast proliferation noted that an ELF of 2 Hz stimulated nerve
25 and 50 Hz Enhances nerve growth factor activity
regeneration, and that a frequency of 7 Hz can
Table 2. Comparing manual acupuncture with electroacupuncture.
Manual acupuncture Electroacupuncture
Needle manipulation is brief and intermittent Stimulation is continued for the duration of treatment
Only ‘low frequency’ is possible (twirling or lifting-thrusting) No limitation to frequency of stimulus (frequency-specific and tissue-
specific effects can occur)
Strong manipulation risks tissue damage Strength of stimulation only limited by patient tolerance
Mostly central mechanism with De Qi More reaction around needle (2 Hz) – calcitonin gene-related peptide,
vaso-intestinal peptide and noradrenaline, greater vasodilation, and
increased segmental effects, alteration of sympathetic tone – segmental
and visceral organs
Local effects-trigger points e.g. some local tissue response Best effect re-creates exercise = melatonin production = better sleep

L. Pearce
References
Barlas P., Ting S. L., Chesterton L. S. et al. (2006) Effects
of intensity of electroacupuncture upon experimental
pain in healthy human volunteers: a randomized,
double-blind, placebo-controlled study. Pain 122 (1–2),
81–89.
Duan D., Tu Y., Yang X. & Liu P. (2016a) Electro
acupuncture restores 5- HT system deficit in chronic
mild stress- induced depressed rats. Evidence-Based
Complementary and Alternative Medicine 2016:7950635.
Duan D. M., Tu Y., Liu P. & Jiao S. (2016b) Antidepressant
effect of electroacupuncture regulates signal targeting
in the brain and increases brain-derived neurotrophic
Figure 1. The key components (after Mayor 2007).
factor levels. Neural Regeneration Research 11 (10),
1595–1602.
be used to stimulate bone growth. A frequency Han J. S. (2004) Acupuncture and endorphins. Neuroscience
of 10 Hz promotes ligament healing, and 15, Letters 361 (1–3), 258–61.
20, and 72 Hz may be used to decrease skin Keown D. (2014) The Spark in the Machine. Singing Dragon.
necrosis and stimulate capillary formation Lundburg T. (2005) Conference presentation, BMAS
Electroacupuncture Study Day, 30 November 2005.
(Table 1).
Mayor D. (ed) (2007) Electroacupuncture: A practical manual
Key factors in getting the optimum dose and resource. Churchill Livingstone, Edinburgh.
are time, frequency and intensity (Fig 1). Oschman J. L. (2000) Energy Medicine: The Scientific Basis.
Establishing a correct dose is probably one of Churchill Livingstone, Edinburgh.
the most difficult things to do in acupuncture, as Qi L., Tang Y., You Y., et al. (2016) Comparing the effec-
there are so many variables. However, that said, tiveness of electroacupuncture with different grades
of knee osteoarthritis: a prospective study. Cellular
the time needs to be between 20–40 min for a
Physiology and Biochemistry 39 (6), 2331–2340.
low frequency effect to reach its optimum, and Watson T. (ed) (2008) Electrotherapy: Evidence Based Practice,
the intensity needs to be such that the patient is 12th edn. Churchill Livingstone, Edinburgh.
in charge of the current and that it is as high as
they can stand without it being uncomfortable Lynn Pearce qualified from Addenbrookes School of
(Barlas 2006). Strong tapping is the order of the Physiotherapy in 1982. She has worked clinically since
day. High frequency is faster acting, and actually that time within several fields and is now working in
does not need to be as strong – milder levels an outpatient private practice setting at the Courtyard
will bring segmental effects. Centre for Health and Wellbeing in Biggleswade,
Certain conditions seem to respond particu- Bedfordshire. Her initial acupuncture training in
larly well – osteoarthritic (OA) knees, really tight 1989 was followed by a Traditional Chinese Medicine
chronically stiff spinal issues where the tissue is course in 1993 at the British College of Acupuncture,
thick and blood flow is compromised, shoulder London. She regularly uses electroacupuncture alongside
issues involving tension in the protective muscle manual therapy and physiotherapy practice. She is also
splint, and many more. David Mayor’s book a tutor for the AACP and a qualified Clinical Canine
Electroacupuncture (2007) is the definitive text but Massage Practitioner and works at DogzAligned for
applying the outline above for low and high our canine friends (www.dogzaligned.com).
frequency will give tissue and chemical specific
effects that can dramatically speed up treatment
for our clients.
So – is it worth applying current to the
needles?
Absolutely – yes.

Reviews
The Handy Cure S device – a applications). Protective eyewear is supplied.

brief personal review Output combines 905 nm (‘Class 1M’) LILT,
Although trained as a purist in ‘traditional’ acu- infrared (875 nm, 30–90 mW), visible red light
puncture, I have always had an interest in things (635 nm, 2–10 mW) and a static magnetic field
electrical, and six years after completing my (25–45 mT, although stated to be 25–45 MT in
initial training began to use electroacupuncture the Scientific Evidence printout supplied!). That’s
in my clinical practice. As a side interest, I took an innovative and clever combination, with
courses in low intensity (low-level) laser therapy claimed synergistic effects (Friedmann et al.
(LILT, or LLLT), but was always put off using 2009) and a supposed penetration depth of up
it in practice by the relatively high price of the to 8–10 cm. The case studies included in the
equipment. Over the years, however, I dab- printout included some for non-musculoskeletal
bled with low- cost versions, such as Amcor’s conditions such as thrombophlebitis, shingles
Biobeam units from Israel (Mayor 1996) or the and non-healing ulcers.
intriguing Chinese method of intranasal low- The user manual emphasizes the synergistic
intensity laser therapy (iLILT) (Mayor 2014). effects of the device on inflammation and tis-
So Gudaro Med-Tech’s full-page colour advert sue repair and describes the three programmes
for another such Israeli device, the ‘Handy Cure that can be used: variable frequency pulsation
S,’ manufactured by Medical Quant, slap bang (1–250 Hz/sec) for initial treatment), 50 Hz
opposite the Editorial in the Spring 2018 edition (50 Hz/sec) for acute pain, and 5 Hz (5 Hz/
of Acupuncture in Physiotherapy, caught my atten- sec) for chronic pain. Recommended treatment
tion. The advert was full of alluring references is for five minutes at each location (timed
to acute or chronic musculoskeletal conditions automatically), once or twice daily, for 21 days,
that might respond to treatment using the with variable frequency applied during the first
device, with a number of ringing endorsements week and then either 5 or 50 Hz in subsequent
from practitioners (chiropractor, acupuncturist, weeks. For acute conditions this is somewhat
massage and sports injury therapists). I was puzzling, as the appropriate programme would
hooked! not be used until the second week of treat-
The Handy Cure S has been available in ment, when – hopefully – the condition would
Israel since at least 2009 (Friedmann et al. 2009). no longer be so acute. Also puzzling is the
Although there is of course a voluminous lit- suggestion that penetration depth is greater
erature on LILT/LLLT and laser acupuncture at the lower frequency (i.e. for chronic condi-
(over 5,700 studies listed in PubMed currently), tions), whereas the textbooks – as well as other
and at least one publication on a different device promotional material about the Handy Cure
providing combinations of laser and LED light S – state that it is dependent on the wavelength
at different wavelengths and frequencies (Leal- of the light applied, not the frequency at which
Junior et al. 2014), I have not been able to locate it is pulsed.
other published studies that explicitly used the Feeling somewhat cautious when faced with
Handy Cure S. This is particularly surprising, these inconsistencies, and in the best traditions
given its low price and ready availability. of ‘romantic’ (rather than hard-headed) science,
The device is comfortable to hold, not too I decided to have a go at ‘handy curing’ myself
heavy if rested on the area to be treated, and before trying it out on my patients. First off,
easy to use (additional probes/‘nozzles’ can my incipient bilateral Dupuytrens, with variable
be attached for acupuncture point and other frequency twice daily for one week, followed by

Reviews
5 Hz for the following two weeks. By the end if protocols did not require daily use for three
of three weeks, I could possibly imagine some weeks. As I wrote about LILT over 20 years ago
softening of the cords in my hands, although a in this journal: “From these rather rough and ready
critic might comment that such an improvement results, it is clear that a patient has to be well moti-
could as well be attributable to taking a break vated to take on this particular form of ‘homework.’”
from work and endless keyboard bashing, and (Mayor 1996).
instead performing regular self-massage by rub- Over the years I have seen many therapy
bing the device over my hands. The condition devices come and go, and perhaps have become
certainly got little better, and may have even got too sceptical, less open, as a result. As we all
worse, during the subsequent very hot weather. are, I am also well aware that expectation –
I also tried it on a mild ankle sprain (with ice positive or negative – can affect the results of
and elevation – improved by the next day), a treatment (Mayor et al. 2017). To really test the
stubbed toe (ditto), some venous eczema (pos- benefits or otherwise of equipment like the
sible improvement – although I have noticed in Handy Cure S will require some well conducted
the past that this may happen with hotter, drier studies where practitioner bias can be reduced,
weather and less sitting about), holiday heat or perhaps even counterbalanced, with both
rash and insect bites (possible slowing down of sceptics and enthusiasts involved. For now,
recovery compared to untreated areas?), and an though, my own Handy Cure S will probably
inadvertent but uncomfortable self-injury from join the other devices in my well-stocked cup-
stupidly biting the inside of my own cheek board of those currently out of favour, while I
(healing no quicker than usual). get on with using my hands and needles – and
I then ventured to try it in conjunction with electroacupuncture, of course!
acupuncture on a patient with longstanding
groin pain (‘some improvement’ – but he always David Mayor
says this improves after acupuncture treatment), Visiting Fellow (Physiotherapy)
and on a close relative with chronic peroneal Department of Allied Health Professions
tendonitis (pain worsened and changed charac- Midwifery and Social Work
ter, becoming more intrusive). Another patient University of Hertfordshire
has been using the device for a painful shoulder UK
injury and does report benefit from using it
consistently on a daily basis, in combination with References
regular but less frequent acupuncture treatment! Friedmann H., Lipovsky A., Nitzan Y. & Lubart R. (2009)
Combined magnetic and pulsed laser fields produce
These few results from my own somewhat synergistic acceleration of cellular electron transfer.
subjective and non- rigorous investigations Laser Therapy 18 (3), 137–141.
are clearly inconclusive. A closer look at the Leal-Junior E. C., Johnson D. S., Saltmarche A. &
testimonials supplied – in addition to those Demchak T. (2014) Adjunctive use of combination
included in the Acupuncture in Physiotherapy of super-pulsed laser and light-emitting diodes photo
advertisement – gave me the impression that therapy on nonspecific knee pain: double- blinded
randomized placebo- controlled trial. Lasers in Medical
the Handy Cure S is often recommended as an Science 29 (6), 1839–1847.
adjunctive rather than stand- alone treatment, Mayor D. (1996) Light, light . . . and more light: on LEDs,
which begs the question of which interven- lasers and lunacy. Journal of the Acupuncture Association of
tion is really responsible for the improvements Chartered Physiotherapists (March), 19–22.
experienced – as so often when more than one Mayor D. (2014) Intranasal Low Intensity Laser Therapy
treatment is involved. I have to say that I would [Book review]. Journal of the Acupuncture Association of
Chartered Physiotherapists 26 (2), 113–116.
have felt more like continuing with my own Mayor D. F., McClure L. S. & McClure J. H. C. (2017)
experiments if I understood the justification Nonspecific feelings expected and experienced during
for the frequencies used in the three different or immediately after electroacupuncture: a pilot study
programmes offered by the Handy Cure S, and in a teaching situation. Medicines 4 (2), 19.

Book reviews
Pocket Atlas of Acupuncture and three informative parts: “Body Acupuncture

Trigger Points Points,” “Ear Acupuncture Points” and “Trigger
By Hans-Ulrich Hecker, Angelika Steveling, Points.” Part 4 contains the appendices.
Elmar T. Peuker and Kay Liebchen Although each section was colour-coded in the
Thieme Medical Publishers, 2017, 392 pages, previous version, this has now been improved
paperback, £40 so that each section can be distinctly seen on
ISBN 978–3132416031 the outer edges of the pages.
Part 1 is divided into 16 sections containing
The previous edition of this book, published in a formal introduction, information on the 12
2001, was one of my favourite points manuals main channels, information on the Conception
for a number of years. I used it so much that Vessel and Governing Vessel, and ending with
it eventually fell apart and it sadly now resides a short section on Extra points. Pleasingly, the
in a small A3 folder. As a result of this, I was nomenclature of the channels aligns with the
intrigued to see what improvements had been World Health Organization advice, but the
made in the updated version and was pleasantly book contains only the important and use-
surprised at the content. The newer version ful points rather than every point along every
has increased by over 150 pages and the book channel. This may be considered a flaw by
appears to be well organized in terms of the some professionals but, for the novice Western
medical practitioner, this book contains ample
information for effective practice. One of the
positive aspects is that some point descriptions
contain safety notes and practical anatomical
tips which will be useful in the early stages of
acupuncture practice. There is also reference to
traditional Chinese medical concepts, with some
points having been described classically, for
example source points, connecting points, mu
points, tonification/sedation points and open-
ing points. This may, however, be confusing to
some practitioners.
The second part, “Ear Acupuncture,” is
divided into 22 short sections describing points
mainly from the perspective of two different
philosophies, Chinese and Nogier, although
a short reference to Bahr is also included. It
also contains practical hints and tips along with
safety advice. There are plenty of other auricu-
lar acupuncture books on the market but this
will be sufficient for any novice practitioner.
By far the most expansive section is Part 3
relating to trigger points. The section begins
with a short definition of trigger points with
the references arranged in the Vancouver style.

Book reviews
Oddly, this is different referencing to those in
Part 1 in that only authors are mentioned. One
example is Bischko, who has three different
citations in the reference list contained in the
appendices but it is unclear to which article
the information is referring. There are 34 short
chapters each discussing a separate muscle or
group of muscles which is a big increase on the
19 chapters of the 2001 version. Again, these
sections also contain hints and safety tips and
also relate these points to local acupuncture
points. This information, although not as in-
depth as is in some other trigger point manuals
available, still covers enough material, such as
location and pain projection patterns, that it is
likely to be of value to all physiotherapists and
not just novice practitioners.
Overall, I was pleased with the range of
content in the book and would recommend
it as a study aid for trainees on Foundation
Acupuncture courses as well as a handy aide-
memoire for more experienced practitioners.
Lesley Pattenden
AACP Tutor and Board Director
the book does not adhere to World Health
Organization nomenclature (although, oddly, the
The Fundamentals of Acupuncture reference for this does appear in the reference
By Nigel Ching list), and none of the tables/boxes are titled
Singing Dragon, London, 2017, 752 pages, so it is not always easy to relate information in
hardback, £60 these to the relevant text.
ISBN 978–1848193130 There are six parts, with Parts 1–3 explain-
ing “Basic Principles,” “The Vital Substances”
From the introduction, Nigel Ching appears to and “The Internal Organs.” There were some
be a well-renowned acupuncturist and author of interesting viewpoints within Part 1: the author
many acupuncture-related books, with this one describes yin and yang as relative and not abso-
being a translation of a book previously written lute, and gives some useful examples of this
in Danish. His hardback book was the third particularly relating to physiological processes.
points manual to be reviewed by myself and He also describes the Five Phases not as ele-
was of a completely different style compared to ments but as energies that are dynamic and are
Hecker et al. (2017) and Bouratinos and Jarmey under constant change, and briefly describes the
(2018), with it being principally aimed at stu- influences of the Ko and Shen cycles in terms
dents of traditional Chinese medicine (TCM). which can be easily understood by the most
This large tome of over 700 pages is his cur- novice of acupuncturists.
rent interpretation of TCM principles as well In the introduction to “Vital Substances,” the
as a manual for acupuncture points, although author tries to describe Qi as an overall concept
much of the information is based on the work with his definition being: “Qi is that which makes
of other well-known authors such as Giovanni us alive whilst at the same time all matter is Qi”
Maciocia, Larre and Rochat de la Vallée, and (p. 70), which is probably the most thought
Peter Deadman. From a practical viewpoint, provoking one- line definition that I have

Book reviews
encountered. He then goes on to describe basic understanding of TCM theories but there
the different forms and functions of Qi, Jing are other books on the market with similar
(essence), Xue (blood), Jinye (fluids) and Shen information so this one did not stand out as
(spirit/mind) in greater detail. a “must buy” book to have in your personal
Part 3 (“The Internal Organs”) is divided into library.
Zang Fu and Fu organs and then each organ is
described in more detail in a manner similar to Lesley Pattenden
that of Maciocia (2006) but without the useful AACP Tutor and Board Director
summary boxes and coloured highlighting con-
tained within that book. References
Interestingly, in Part 4, in addition to the Hecker H.- U., Steveling A., Peuker E. T. & Liebchen
information on the 12 regular channels, he K. (2017) Pocket Atlas of Acupuncture and Trigger Points.
includes a more expansive section on the Eight Thieme Medical Publishers.
Extraordinary Vessels compared to other texts Bouratinos I. & Jarmey C. (2018) A Practical Guide to
Acupoints, 2nd edn. Lotus Publishing.
which was pleasing to read.
Maciocia G. (2006) The Foundations of Chinese Medicine, 2nd
Part 5 introduces the reader to points along edn. Churchill Livingstone, Edinburgh.
the channels starting with a general TCM clas-
sification of points. He also provides a handy
quick reference box depicting a list of points A Practical Guide to Acupoints,
for each category including Ghost points and 2nd edn.
Heavenly Star points as well as the usual source By Ilaira Bouratinos and Chris Jarmey
and transporting points. The book then provides Lotus Publishing, 2018, 416 pages, paperback,
a list of actions and indications with a list of £29.99
explanations for some of the terms used in later ISBN 978–1905367801
descriptions such as “expel, disperse, activate,
anchor” before reviewing every point on every There have been a number of updated points
meridian which could be useful for physiother- manuals appearing on the market in recent
apists wanting to understand more TCM. months and this is another that fits the brief.
It is always useful to select a commonly-used The previous version appeared 10 years ago
point and compare between texts to ascertain so it was interesting to see what additional
the level and quality of the information pro- information has been included in this version.
vided to ascertain if the book will have some Interestingly, the introduction notes that Chris
value to the reader. For Large Intestine (LI) 4, Jarmey died suddenly in 2008 and therefore the
there were no practical safety hints, precautions update appears mainly to be the work of the
or precise locations noted as the information other author and her associates.
given related to indications for use such as The introduction to this updated book clari-
“stops pain,” “induces labour” and “headaches,” fies the audiences at which this book is aimed,
with some limited commentary on each of the and there has been an effort to include infor-
indications. mation relevant to complementary health practi-
The final section is on the use of needle tioners such as those practising Shiatsu, magnet
techniques to affect Qi such as Xu ji (fast-slow therapy and Guasha. Consequently, some of
insertion), Nian zhuan (rotation of the needle) the information is irrelevant to the majority of
and Hu xi (breathing), all of which were inter- physiotherapists practising acupuncture and this
esting to read and useful for effective practice. new information accounts for most of the extra
In summary, this was not a manual for 50 pages of this version.
point locations even though every point was The book has already been reviewed by an
described, but an introduction to TCM theory eminent acupuncturist who extolled the quality
related to some aspects of practice. It would be of drawings, the depth of information pre-
an interesting read for those wishing to gain a sented and other useful information. Personally,

Book reviews
are difficult to distinguish quickly when trying
to find a point location on these meridians.
One of the positive aspects of the book is
that it now contains information on every point
on every meridian rather than selected points
only, although most of the expanded infor-
mation pertains to other professionals rather
than physiotherapists. On the negative side,
the book does not use standard World Health
Organization (WHO) nomenclature which is a
shame.
In the meridian chapters, there are 43 Extra
points described, and the addition of these
changes the page layout compared to the first
edition. As a result, there is a noticeable amount
of “empty space” at the end of pages and
chapters.
Given that the nomenclature for Extra points
is confusing anyway, Chapter 24 describing these
does not add any further clarity to the situation
because it does not use WHO guidance. For
example, it describes M-BW-1A/1B which do
I found that the drawings lacked colour and not exist in WHO, and the authors have added
definition; that some of the information was three “new” points for lumbar pain (located
not useful; and that, as a resource, it was not as near metacarpals 2/3/4) that I have not seen
user-friendly as it could have been. written in other texts.
The first nine chapters review the process of At the beginning of the book there appears
needling safely with precautions and contrain- to be an opportunity to download supple-
dications (colour-coded yellow and red respec- mentary information, however after a number
tively), but also include chapters on moxibustion of attempts via email to do this, no further
and cupping. In terms of point selection, some information has been forthcoming. The author
general principles are given in Chapter 7, but states that, overall, she wants the manual
the classification of points (Chapter 6) is purely to be useful to the lay person as well as for
from a traditional Chinese medical perspective health professionals, and it does align to this
which may be confusing to those familiar with a aspiration. Therefore, it is suitable as a points
more Westernized approach, although interest- manual resource for physiotherapists practising
ing to read. acupuncture but it purposely does not include
Chapters 10–24 cover each meridian individu- any evidence base and only gives a nod to the
ally with the page corners coloured appropriately concept of Western medicine.
for each pairing of meridians. The light grey
colour used for Large Intestine/Lung and the Lesley Pattenden
light purple for Governor/Conception Vessels AACP Tutor and Board Director

News, views and interviews
Clinical efficacy of acupuncture reduce the expression of TLR4, thus leading

on rheumatoid arthritis to anti-inflammatory effects. Another possible
Chou and Chu (2018) have reviewed 43 stud- mechanism could be attributed to the anti-
ies on the clinical efficacy of acupuncture on oxidative effect (such as inducing the increased
rheumatoid arthritis (RA) published between activities of super oxide dismutase and catalase
1974 and 2018 – of which all but one reported in the serum of RA), alleviating oxidative stress
positive benefits. and inflammation, and improving antioxidant
According to traditional Chinese medicine and energy metabolic status.
(TCM), RA is categorized as belonging to bi or Acupuncture has its root in TCM; tradition-
impediment diseases. This is a group of diseases ally, TCM does not seek the specific pathogen
caused by the invasion of wind, cold, dampness and pathological changes in a specific organ or
or heat pathogen on the meridians, involving individual, but seeks the disturbances among the
muscles, sinews, bones and joints, manifested self-controlled systems by analyzing all symp-
by local pain, soreness, heaviness, hotness, and toms and signs. The TCM therapeutics work by
even articular swelling, stiffness and deformities. activating and improving system connection and
An estimated 60–90% of arthritis patients enhancing human resistance. The mechanism in
are reported to use complementary and alter- TCM is not like modern medicine that seeks
native medicine, including acupuncture. When the mechanism from cellular or molecular per-
taking study design into consideration, TCM spectives. In light of this, to accomplish a well-
theory was adapted substantially in most of the designed randomized controlled trial (RCT) that
investigations. The authors found an interesting has every possible variable controlled and takes
fact that acupoint Zu San Li Stomach (ST 36) TCM theory into account is extremely difficult
was used in almost every research, followed Each investigation, with the exception of one
by Yang Ling Quan Gall Bladder (GB 34) and trial, found that any kind of acupuncture as the
Hegu Large Intestine (LI 4). main treatment or adjuvant treatment tool could
Measurements of quality of life have gained benefit clinical conditions of RA in human or
more interest among RA patients than other animal subjects. There were no adverse effects
disease-related parameters such as inflammatory of acupuncture reported. However, the authors
biomarkers or joint counts. Some studies in note that there is still inconsistency regarding
this review have adopted related questionnaires. the clinical efficacy and lack of well-designed
Acupuncture was found to be able to improve human/animal double- blinded RCTs. They
the quality of life in all but one of the studies suggest that future discussion for further agree-
reviewed. ment on taking TCM theory into consideration
An anti-inflammatory effect has been the most as much as possible is a top priority.
well- known mechanism of how acupuncture
works for RA; many studies in this review used Rosemary Lillie
inflammatory biomarkers for comparison such News Editor
as erythrocyte sedimentation rate, C- reactive
protein, rheumatoid factor, interleukins, nuclear Reference
factor-κB, and tumor necrosis factor- α. Dong
Chou P. -C. & Chu H. -Y. (2018) Clinical efficacy of acu-
et al. indicated that a toll-like receptor (TLR) sig- puncture on rheumatoid arthritis and associated mech-
nalling pathway contributed to the development anisms: a systemic review. Evidence-based Complementary
and progression of RA and acupuncture could and Alternative Medicine 2018, Article ID 8596918.

News, views and interviews
Helene Langevin named Helene has published many influential papers
as Director of the National on the physical and physiological effects of acu-
puncture. She has lectured in the past at AACP
Center for Complementary and
annual conferences, and has a particular interest
Integrative Health in the behaviour of fascia.
Dr Helene Langevin – familiar to many AACP
If you are interested in exploring her
members as AACP President – has been
research, the feature article highlighted in the
announced as the new Director of the National
reference below will give a good overview, as
Center for Complementary and Integrative
well as providing further references to articles
Health (NCCIH) in the US.
she has written.
The NCCIH is the Federal government’s lead
Everyone at AACP congratulates Helene, and
agency for scientific research on the diverse
we wish her every success in this new role.
medical and health care systems, practices, and
products that are not generally considered part Rosemary Lillie
of conventional medicine.
News Editor
“Helene’s distinguished career and leadership
in the integrative health community, along with
her research on the role of non-pharmacological Reference
treatment for pain, makes her ideally suited to Langevin, H (2013) The science of stretch. The Scientist
lead NCCIH,” said Dr. Francis Collins, National May 2013 [WWW document.] URL https://www.the-
Institutes of Health (NIH) Director. “We are scientist.com/features/the-science-of-stretch-39407
so pleased to have her join the NIH leadership
team.”

Guidelines for authors
Introduction Preparation of manuscripts

Always refer to a recent edition of Acupuncture Authors should submit material by email or on
in Physiotherapy. Please follow the style and layout CD-ROM. All articles must be typed with wide
of an article or item that is similar to your own (3-cm) margins and the pages should be num-
contribution. If something is submitted for bered consecutively. Articles should be a maxi-
publication, then it is implied that it has not been mum of 7500 words (excluding the abstract,
simultaneously submitted to another journal or references and tables).
any other type of publication. Reprints may be Papers should be arranged as follows:
considered, but these must be clearly identified
as such and permission must be obtained from Title
the original publisher. The title of the article should be in sentence case,
Templates for clinical papers and case reports bold and ranged left, as in the main title above:
are available on the AACP website (www.aacp. note that there is no full stop and no underlining.
org.uk), or by email on request. These templates The author’s name(s) and institutional affilia
should not be deviated from if used. Manuscripts tion(s) should run consecutively below the title.
may be returned to authors if they have not Again, there are no full stops.
adhered to the guidelines. If necessary, the clini-
cal editor should be consulted in the initial stages
for clarification. Abstract
Authors may submit clinical papers, literature A summary of not more than 250 words outlin-
reviews, clinical commentaries, case reports, ing the purpose, scope and conclusions of the
book reviews, course reports, news items, letters paper should be submitted. This should be
or photographs for consideration for inclu- followed by a minimum of three and a maximum
sion in the journal. Academic and clinical
of five keywords that best represent the contents.
papers are subject to review by the editorial
committee and may require revision before Text
being accepted. The layout of the journal is that the main heading
A Portable Document Format (PDF) file of of each section is in sentence case and bold.
the final version of any academic article is Notice that, again, there are no full stops and no
available free of charge if notice is given to the underlining.
clinical editor when the article is submitted. The first paragraph is left-justified; subsequent
All published material becomes the copyright paragraphs in the same section are indented, as is
of the Association. this part of the guidelines. When including dia-
All submissions should be sent directly to the grams and photographs, these should be num-
clinical editor: bered in the order in which they appear in the
text, and should be submitted in separate files
Dr Val Hopwood FCSP (do not embed images in the text). Any figure
18 Woodlands Close captions should be left-justified and run after the
Dibden Purlieu author’s biography at the end of the text. Any
Southampton SO45 4JG tables should come after the figure legends, if
UK there are any. Please indicate placement in the
text (e.g. “Fig. 1’’ and “Table 1’’). All figures and
Email: val.hopwood@btinternet.com tables must be referred to in the text.

When using numbers in the text, these should Bekkering R. & van Bussel R. (1998) Segmental acupunc
be written out in words up to and including nine ture. In: Medical Acupuncture: A Western Scientific Approach
(eds J. Filshie & A. White), pp. 105–135. Churchill
unless these are measurements, numbers in
Livingstone, Edinburgh.
tables or units of time. Always use the Inter
national System of Units (SI).
For references to documents on the World
Wide Web (WWW), give the author’s surname
Clinical papers: referencing followed by all initials, the year of publication in
All clinical papers must be fully referenced and brackets, the document title in italics, an indica
the citations verified by the author. No exception that it is a WWW document in square
tions will be made. The reference list must be brackets and the complete Uniform Resource
arranged alphabetically by the name of the first Locator (URL):
author or editor, following the Harvard style. In
the text, give the author(s) and date of publica- List D. (2004) Maximum Variation Sampling for Surveys and
tion in brackets [e.g. “(Smith 1998)’’], or if the Consensus Groups. [WWW document.] URL http://
main author’s name is part of a sentence, then www.audiencedialogue.net/maxvar.html
only the year is in brackets [e.g. “as described by
Smith (1998)’’]. For more than one author, Please adhere strictly to this style of referencing
reference can be made in the text to “Smith et al. in any contribution to the journal.
(1998)’’ (note the italics). However, when writ-
ing the reference list, the convention is as fol Acknowledgements
lows: for up to five authors, write all the authors’ Please state any funding sources, or companies
names; for six or more authors, write the first providing technical or equipment support.
three authors’ names, followed by “et al.”
For journals, give the author’s surname and
Photographs
initials, the year of publication, the title of the
Photographs may be submitted in colour or
paper, the full name of the journal, the volume
black-and-white, but will be printed in mono
number, the issue number in brackets, and the
chrome. Images must be in sharp focus. Photo
first and last page numbers of the article (note
graphs should be numbered and their placing
the correct use of italic, bold, commas and full
indicated in the text. Digital photographs should
stops):
be of high resolution (i.e. a minimum of 300 dots
Ceccherelli F., Rigoni M. T., Gagliardi G. & Ruzzante L. per inch).
(2002) Comparison of superficial and deep acupuncture
in the treatment of lumbar myofascial pain: a double-
blind randomized controlled study. Clinical Journal of Pain Line illustrations
18 (3), 149–153. These should follow the style used in the journal,
i.e. any labelling text should be in sentence case
For books, give the author’s/editor’s surname (10-point, Arial font), graphs should be two-
and initials, the year of publication, the book dimensional and all images must be mono-
title in italics, and the publisher and city of chrome. As with photographs, line illustrations
publication: should be numbered and their placement indi
cated in the text. All images should be of high
Williams P. L. & Warwick R. (eds) (1986) Gray’s Anatomy, resolution (i.e. a minimum of 1200 dots per
36th edn. Churchill Livingstone, Edinburgh. inch).
For a chapter or section in a book by a named
author (who may be one of several contributors), Case reports
both chapter and book title should be given, The journal welcomes case reports of up to
along with the editor’s name(s), and the first and 3000 words. These should be structured as
last page numbers of the chapter: follows: title, abstract and keywords, a brief

introduction, a concise description of the patient no more than 500 words in length; query for
and condition, and an explanation of the assess- longer.
ment, treatment and progress, followed finally by Please contact the book review editor before
a discussion and evaluation of the implications writing a review.
for practice. The study must be referenced
throughout. Further guidance is available upon
request.
General points to note
Please enclose your home, work and email
addresses, and telephone number.
It is the author’s responsibility to obtain and
Book reviews acknowledge permission to reproduce any
At the beginning of the review, give all details of material that has appeared in another journal or
the book including the title in bold, the author/ textbook.
editor’s full name(s), publisher, city and year of A brief biographical note about the author(s)
publication, price, whether hardback or paper- should be included at the end of a clinical paper
back, number of pages, and ISBN number. The in italics.
reviewer’s name should appear at the end of the All notes and news should have clinical rel-
review in bold, right-justified, followed by their evance to AACP. Please refer at all times to the
title and place of work in italics. Reviews of style and layout of previous issues of the journal
DVDs and DVD-ROMs should follow the same for whatever you are writing. Using these guide-
format. Book reviews and reports are normally lines will save the editorial team time.

DDZ^ >K'/E
hƐĞƌŶĂŵĞ
WĂƐƐǁŽƌĚ
,ĞůƉ͊Ͳ /͛ǀĞ ĨŽƌŐŽƩĞŶ ŵǇ ĚĞƚĂŝůƐ͊

>ŽŐ /Ŷ
,KDKhdd,Wt,d/^hWhEdhZ͍Et^dZ/E/E'ΘKE&ZE^d,W:KhZE>:K/Ed,W
Dz ^,KZ Dz /^KhEd^ W >'> ^hWWKZd Et^ KhDEd^ Dz sEd^ Z^Z, >K' Khd
KhZD/EWZdEZ
tĞůĐŽŵĞ ƚŽ ƚŚĞ ĐƵƉƵŶĐƚƵƌĞ ƐƐŽĐŝĂƟŽŶ
ŽĨŚĂƌƚĞƌĞĚWŚǇƐŝŽƚŚĞƌĂƉŝƐƚƐ;WͿ
dŚĞWŝƐĂůǁĂǇƐůŽŽŬŝŶŐƚŽŵĂŬĞǇŽƵƌĞǆƉĞƌŝĞŶĐĞĂƐĂŵĞŵďĞƌĂƐ
ŝŶĨŽƌŵĂƟǀĞ ĂŶĚ ƵƐĞƌͲĨƌŝĞŶĚůǇ ĂƐ ƉŽƐƐŝďůĞ͘ dŚĞ ŵĞŵďĞƌƐ͛ ĂƌĞĂ ŽĨ ƚŚĞ W
ǁĞďƐŝƚĞ ŚĂƐ ďĞĞŶ ĚĞǀĞůŽƉĞĚ ŝŶ ƌĞĐĞŶƚ ǇĞĂƌƐ ƚŽ ƉƌŽǀŝĚĞ Ă ƉĞƌƐŽŶĂůŝƐĞĚ
ĞǆƉĞƌŝĞŶĐĞ ĨŽƌ ĞĂĐŚ ŝŶĚŝǀŝĚƵĂů ŵĞŵďĞƌ͕ ŽīĞƌŝŶŐ ǇŽƵ ŵŽƌĞ ĐŽŶƚƌŽů ŽǀĞƌ ǇŽƵƌ ŵĞŵďĞƌƐŚŝƉ ĂŶĚ ƉƌŽǀŝĚŝŶŐ
Ă ǁĞĂůƚŚ ŽĨ ĂĐƵƉƵŶĐƚƵƌĞͲƌĞůĂƚĞĚ ŝŶĨŽƌŵĂƟŽŶ ĂŶĚ ƌĞƐŽƵƌĐĞƐ͘ ŝƐĐŽƵŶƚ ĐŽĚĞƐ ĂŶĚ ĂĐĐĞƐƐ ƚŽ ŵĂŶǇ ŽĨ ƚŚĞ
W ŵĞŵďĞƌƐŚŝƉ ďĞŶĞĮƚƐ ĐĂŶ ďĞ ĨŽƵŶĚ ǁŝƚŚŝŶ ƚŚĞ ŵĞŵďĞƌƐ͛ ĂƌĞĂ͘
/Ĩ ǇŽƵ ĂƌĞ ƵŶƐƵƌĞ ŽĨ ǇŽƵƌ ůŽŐŝŶ ĚĞƚĂŝůƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ W ŵĞŵďĞƌƐŚŝƉ ƚĞĂŵ ǀŝĂ ƚŚĞ ĐŽŶƚĂĐƚ ĚĞƚĂŝůƐ
ďĞůŽǁ ĂŶĚ ƚŚĞǇ ǁŝůů ĂƐƐŝƐƚ ŝŶ ŐĞƫŶŐ ǇŽƵ ůŽŐŐĞĚ ŝŶ͘
KŶĐĞ ůŽŐŐĞĚ ŝŶ͕ Ă ŶĞǁ ŵĞŶƵ ǁŝůů ĂƉƉĞĂƌ ƵŶĚĞƌŶĞĂƚŚ ƚŚĞ ŵĂŝŶ ŵĞŶƵ͘ hƐĞ ƚŚŝƐ ŵĞŶƵ ƚŽ ŶĂǀŝŐĂƚĞ ĂƌŽƵŶĚ
ƚŚĞ ŵĞŵďĞƌƐ͛ ĐŽŶƚĞŶƚ͘ zŽƵ ĐĂŶ ĐŚĞĐŬ ĂŶĚ ƵƉĚĂƚĞ ǇŽƵƌ ƉĞƌƐŽŶĂů ĚĞƚĂŝůƐ͕ ƉƌŽĨĞƐƐŝŽŶĂů ŝŶĨŽƌŵĂƟŽŶ͕
ĂĐƟǀŝƟĞƐͬŝŶƚĞƌĞƐƚƐ ĂŶĚ ƌĞĐŽƌĚ ǇŽƵƌ W͘ zŽƵ ĂƌĞ ĂůƐŽ ĂďůĞ ƚŽ ƐĞĞ ǇŽƵƌ ƐƵďƐĐƌŝƉƟŽŶ ŝŶĨŽƌŵĂƟŽŶ ĂŶĚ
ŚŝƐƚŽƌǇ ŽĨ ƉĂǇŵĞŶƚƐ ŵĂĚĞ ƚŽ ƚŚĞ W͕ ǁŝƚŚ ĚŽǁŶůŽĂĚĂďůĞ ƌĞĐĞŝƉƚƐ ĨŽƌ ǇŽƵƌ ƌĞĐŽƌĚƐ͘ ͚DǇ ǀĞŶƚƐ͛ ĂůůŽǁƐ
ǇŽƵ ƚŽ ŬĞĞƉ ƚƌĂĐŬ ŽĨ W ĐŽƵƌƐĞƐ ĂŶĚ ĐŽŶĨĞƌĞŶĐĞƐ ǇŽƵ ĂƌĞ ďŽŽŬĞĚ ŽŶ ƚŽ ĂƐ ǁĞůů ĂƐ ĂĐĐĞƐƐ ƚŽ Ăůů ƌĞůĞǀĂŶƚ
ĚŽĐƵŵĞŶƚƐ ĨŽƌ ďŽŽŬĞĚ ĐŽƵƌƐĞƐ͘ dŚĞ ͚ŽĐƵŵĞŶƚƐ͛ ƐĞĐƟŽŶ ĐŽŶƚĂŝŶƐ Ă ǁĞĂůƚŚ ŽĨ ƌĞƐĞĂƌĐŚ͕ ĐĂƐĞ ƐƚƵĚŝĞƐ͕
ŐƵŝĚĂŶĐĞ ĚŽĐƵŵĞŶƚƐ͕ ŵĂƌŬĞƟŶŐ ƌĞƐŽƵƌĐĞƐ ĂŶĚ ŵŽƌĞ͘
dŚĞWKŶůŝŶĞ^ŚŽƉ ŝƐ ĂůƐŽ ŶŽǁ ĂĐĐĞƐƐŝďůĞ ŽŶůǇ ďǇ ůŽŐŐŝŶŐ ŝŶ ƚŽ ƚŚĞ ŵĞŵďĞƌƐ͛ ƐŝĚĞ ŽĨ ƚŚĞ W
ǁĞďƐŝƚĞ͘
ĚĚŝƟŽŶĂůůǇ͕ ǇŽƵ ĂƌĞ ŶŽǁ ĂďůĞ ƚŽ ĚŽǁŶůŽĂĚ ǇŽƵƌ ŵĞŵďĞƌƐŚŝƉ ĐĞƌƟĮĐĂƚĞ ĨƌŽŵ ƚŚĞ ǁĞďƐŝƚĞ͘ /Ĩ ǇŽƵ
ƌĞƋƵŝƌĞ Ă ĨŽƌŵĂů ĐĞƌƟĮĐĂƚĞ ŽŶ W ŚĞĂĚĞĚ ƉĂƉĞƌ͕ Žƌ ŚĂǀĞ ĂŶǇ ŵĞŵďĞƌƐŚŝƉ ƋƵĞƌŝĞƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ
ŵĞŵďĞƌƐŚŝƉƚĞĂŵŽŶϬϭϳϯϯϯϵϬϬϬϳηϭ Žƌ ǀŝĂ ƐĞĐΛĂĂĐƉ͘ƵŬ͘ĐŽŵ͘
AACP ANNUAL
CONFERENCE
2019 Save The Date!
:ŽŝŶƚŚĞW
^ŽĐŝĂůDĞĚŝĂ
Celebrating our...
DATE: Saturday 18th May 2019

TIME: 9:00am - 5:00pm
DoubleTree by Hilton,
London Docklands,
London,
ŽŵŵƵŶŝƚǇ
SE16 5HW
dŚĞW
4-for-3 GROUP DISCOUNTS
Join us in London for our biggest conference yet. We will also be celebrating our 35th anniversary on Friday
17th May with an evening of fun, food and festivities...with a few surprises! We are offering complimentary ΛWͺWŚǇƐŝŽ
tickets to the anniversary celebrations for a limited number of conference delegates. Full speaker line-up to be
announced soon. Join us on Facebook, Twitter and LinkedIn to make sure you don’t miss any announcements.
ĐƵƉƵŶĐƚƵƌĞ ƐƐŽĐŝĂƟŽŶ ŽĨ
www.aacp.org.uk ŚĂƌƚĞƌĞĚWŚǇƐŝŽƚŚĞƌĂƉŝƐƚƐ>ƚĚ͘
#AACP35
Acupuncture in PhysiotherapyTM
Acupuncture in Physiotherapy TM
Journal of the Acupuncture Association

of Chartered Physiotherapists
Sports & Physical Therapies
Autumn 2018
including Acupuncture, Moxibustion
Volume 30, Number 2
Cupping, Magnetic and much more...
ACUPUNCTURE & MOXA TREATMENT ROOM TAPING MASSAGE

© Martinmark | Dreamstime
Volume 30, Number 2, Autumn 2018
REHAB & EXERCISE CUPPING SPORT SUPPORTS & BRACES
www.harmonymedical.co.uk
ISSN 2058-3281
t: +44 (0)208 5187337 e: admin@harmonymedical.co.uk

Aip Autumn 2018

Uploaded by

Copyright:

Available Formats

Aip Autumn 2018

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Aip Autumn 2018

Uploaded by

Copyright:

Available Formats

Acupuncture in PhysiotherapyTM

Journal of the Acupuncture Association

ACUPUNCTURE & MOXA TREATMENT ROOM TAPING MASSAGE

Volume 30, Number 2, Autumn 2018

REHAB & EXERCISE CUPPING SPORT SUPPORTS & BRACES

DATE: Saturday 18th May 2019

KE>z&KZWDDZ^ >Kt^dWZ/^'hZEd d,^dYh>/dzWZKhd^

y>h^/s>z&KZ WZ/Dd, WZKhd^KhZ/E'

EŽƚ ĨŽƵŶĚ ǁŚĂƚ ǇŽƵ͛ƌĞ ůŽŽŬŝŶŐ

© 2018 Acupuncture Association of Chartered Physiotherapists 3

Prices per year UK Europe

Welcome to the Autumn 2018 edition of

Chief Executive Officer: Caspar van Dongen

© 2018 Acupuncture Association of Chartered Physiotherapists 5

6 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 7

8 © 2018 Acupuncture Association of Chartered Physiotherapists

Chief Executive Officer’s report

Musings on membership a clear majority of board members are drawn

© 2018 Acupuncture Association of Chartered Physiotherapists 9

AACP Annual Conference, 19 May 2018

Introduction compared three groups of pregnant women

© 2018 Acupuncture Association of Chartered Physiotherapists 11

12 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 13

14 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 15

Mechanisms and dose parameters of electric

Correspondence: Thomas Perreault, Physical Therapy Introduction

© 2018 Acupuncture Association of Chartered Physiotherapists 17

18 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 19

20 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 21

22 © 2018 Acupuncture Association of Chartered Physiotherapists

Figure 1. Diagram showing primary mechanisms of ENS-­induced analgesia.

© 2018 Acupuncture Association of Chartered Physiotherapists 23

24 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 25

26 © 2018 Acupuncture Association of Chartered Physiotherapists

The interaction and outcomes of acupuncture,

Introduction (semiconductor); the adhesive electrodes as

© 2018 Acupuncture Association of Chartered Physiotherapists 27

28 © 2018 Acupuncture Association of Chartered Physiotherapists

Question: Do you use Deep Oscillation®

Deep Oscillation® therapy and

© 2018 Acupuncture Association of Chartered Physiotherapists 29

MSK presentation Treatment

an arthritic setting 160 Hz × 10 min followed by 85 Hz × 5 min

Table 3. The effect of different Deep Oscillation® frequencies.

high frequencies (80–250 Hz) • pain significantly reduced

Question: What do you feel DOT does to Case studies

30 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 31

32 © 2018 Acupuncture Association of Chartered Physiotherapists

© 2018 Acupuncture Association of Chartered Physiotherapists 33

34 © 2018 Acupuncture Association of Chartered Physiotherapists

Practical applications of meridian theory in pain

Authors’ note and accuracy, which help to convey the practical

KE>z&KZWDDZ^ >Kt^dWZ/^'hZEd d,^dYh>/dzWZKhd^

y>h^/s>z&KZ WZ/Dd, WZKhd^KhZ/E'

Figure 1. Diagram showing primary mechanisms of ENS-induced analgesia.

Nontreatment control intervention-insertion shams were inconclusive

Aggravating factors: Easing factors: 24-hour pattern: