Case Study: Acupuncture in the Management of Shoulder and Lateral Elbow Pain

By KW

Introduction

Acupuncture is the insertion of fine needles into predetermined specific points in the body along specific channels named meridians. It has been practised for centuries, with origins in the Eastern community; predominantly China. Practice of acupuncture has been growing in popularity and has become widely utilised in the western community over the course of decades. Since acupuncture has become more widely accepted (Green et al., 2008) and evidence has been published to support its use, several healthcare professions have started to practice acupuncture to complement their repertoire of treatment that they may offer patients. Acupuncture within physiotherapy has been used for its analgesic effects (Green et al., 2008a) and evidence is starting to prove its efficacy in treating painful syndromes (Green et al., 2008a, Green et al., 2008b). The proposed mechanism of action can be described in using western and eastern philosophies: Eastern philosophies define good health as a balance between two opposing forces of Yin and Yang. Our health and well-being relies on these forces maintaining balance. Qi, the vital energy or life source, in health flows freely through pathways called meridians. If there is an imbalance then the flow will be disturbed causing an imbalance between Yin and Yang. Needles inserted into the specific points along the meridians are taught to readdress imbalance and restore health and well being (Filshie and White, 1998). The Chinese proposed that there were approximately 100 blood vessels in the body, which intersect at specific points and this causes stagnation of blood. We now know that this is not the case, and that blood will only stagnate once the muscle pump (heart) has stopped. Pyne and Skenker (2008) noted that the traditional Chinese explanation has no scientific basis; Western philosophies have proposed that acupuncture induces pain relief via physiological mechanisms that include the theory that the analgesic effect is due to the release of B-endorphins in the lumbar spine and increased 5-Hydroxytryptophan level in the cerebrum (Viola, 1998); whereas Eastern philosophies would suggest that the application of acupuncture is used to free energy flow, named Qi or reduce the stagnation, or pooling, of blood.

History

The patient was a 47 year old male presenting with neck pain extending down to the left shoulder and distal to the elbow with focal area of pain around the common extensor origin. Mechanism of injury was a front end road traffic accident while stationary, with a direct acceleration-deceleration injury to the cervical spine. He had previously experienced some diffuse paraesthesia but this had resolved at time of contact. Range of movement at the cervical spine revealed 10% loss of left rotation and lateral flexion; with combined movements causing severe discomfort into extension, left lateral flexion and left rotation. Shoulder, elbow and wrist were full range. Neurological tests revealed no abnormalities. Upper limb tension test 1 was positive for pain and decreased range. On palpation, there was localised pain at the common extensor origin, lateral epicondyle and the distal aspect of the radial groove.

Clinical Hypothesis

The patient was hypothesised to have Whiplash-Associated Disorder including irritation of the lower cervical nerve roots, and lateral epicondylalgia The patient was classified as Grade IIb on the Quebec Scoring System for Whiplash developed by the Quebec Task Force (Spitzer et al., 1995).

Intervention

Initial intervention followed CSP and locally agreed guidelines for the treatment of Whiplash-Associated Disorder and consisted of joint mobilisation, soft tissue mobilisation, trigger point release, neural mobilisation, advice, education and active exercise. This was effective at increasing the patients active range of movement, but he was profoundly irritable. On discussion with the patient, we agreed to commence a trial of acupuncture specifically for pain relief. The aim of acupuncture in this case was to achieve better control of pain, without the use of pharmacology, in order to achieve full painless range of movement and allow full return to normal daily living activities, including running and cricket. The selection of acupuncture points relied on understanding concepts of Traditional Chinese Medicine. The theories of Yin-Yang and the five elements were two interpretations of natural phenomena that originated in ancient China (Xinnang, 1997). The philosophy if Yin-Yang holds that all things have two equal forces that oppose each other, Yin and Yang. Our health and well being relied on these two forces maintaining balance and harmony. Both are necessary for a whole to exist. If there is an imbalance then the physiological balance of the body is disturbed, the Yang may be more dominant than Yin which subsequently may lead to a variety of symptoms. The sum of these forces is the flow of Qi or life energy. Qi flows along pathways or channels which are referred to as meridians. Meridians refer to the route that transport Qi and blood, regulate Yin and Yang, connect the Zang organs with the Fu organs, and associate the external with the internal and the upper with the lower. These meridians are paired according to this philosophy with Yin meridians situated on the flexor aspect of the body and deeper than Yang meridians situated on the extensor aspect. The meridians are named after internal organs of the body and along there channels various acupuncture points can be found (Filshie, 1998). Acupuncture points are found where Qi and blood form the viscera, and meridians effuse and infuse in the body surface (Yanfu, 2000). There are numerous local acupuncture points available for use around the elbow, Including Lung (LU) 5, Large Intestine (LI) 10, 11, 12, 13 and Small Intestine (SI) 8.

LI 11 and LU 5 are located in different meridians but lie anatomically very close together. They are considered sandwich points which when are combined during treatment can be very effective (Xinnong, 1997). LI 4 is known as the universal point for pain relief, the great exterminator, although situated distal to the elbow this may also be utilized. LI4 is also the Yaun (Source) point of the LI (Yang) meridian. The point at which the original Qi is stored (Houchi, 2004).

The main symptoms are located on the extensor (Yang) aspect of the tissues. LI points are most dominant in this area therefore this meridian was chosen as the primary one to use to treat the pain. Treatment 1 Points used: LI 11 & LI 4 bilaterally Length of time: 20 minutes (DeQi achieved) The patient was reviewed 3 days following the treatment and he reported a great reduction in pain, and increase in function. He was keen to continue to utilise the effects of acupuncture. Treatment 2 Points used: LI 14, LI 11, LI 4 & SI 14 bilaterally Length of time: 20 minutes (Restimulated x 2, DeQi achieved) The patient reported continual improvement in symptoms at next visit, to the extent that symptoms were becoming latent and he was at full capacity to complete activities of daily living. Treatment 3 Points used: LI 15, LI 11, LI 4 & TE 14 bilaterally Length of time: 20 minutes (Restimulated x 2, DeQi achieved) Following this session, the patient only reported latent episodes of pain when gripping objects, with pain on palpation of the common extensor origin. A graded loading programme in combination with deep transverse friction massage was utilised to strategically load the affected tissues until symptom resolution.

Justification The first chosen points were LI 11 and LI 4. LI 11 was chosen as the He-sea point. This represents, the confluence of rivers in the sea where the Qi is most flourishing (Ceniceros, 1998). By using this point it is thought that energy can be brought to the surface and thus correct any imbalance. As LI 4, is the most distal point it was chosen as a drainage point to allow any excess energy to drain out and for its pain relieving properties. To use a minimal number of points with minimal stimulation allowed me to identify how the patient would react to acupuncture treatment and identify any possible difficulties at the earliest opportunity. As the initial treatment was effective, further points along the meridian were chosen in order to maximise the effectiveness. Further local points were identified in accordance with the patients individual presentation (SI 14 for levator scapulae trigger point, TE 14 for posterior shoulder pain) to high efficacy.

Conclusion

In this case of management of lateral elbow and shoulder pain, acupuncture as a treatment modality was very effective. The pain relieving properties allowed the patient to return to function as soon as possible and even though he continued with some latent symptoms, the unique combination of acupuncture and physiotherapy allowed him to undertake a graded loading programme to determine symptom resolution. Further experiential intervention will allow me to develop my point prescription to an optimal level and will allow me to identify patients in which acupuncture can be utilised to have a positive effect also.