Elbow pain and acupuncture

Elbow pain and acupuncture

Palle Rosted MD & Annette Jørgensen MD

Introduction.

Tennis elbow is probably the most common cause of pain in the elbow in general practice. It is typically caused by inflammation of the attachment of the tendons of extensor carpi radialis brevis muscle, but the supinator muscle is also important. The less frequent golfer’s elbow is usually caused by inflammation in flexor communis muscle.

The present range of available treatments are less than adequate for the management of all cases; one study has shown that two weeks of treatment with NSAIDs was no more effective than a placebo, and steriod injections appear to give a shortlived effect with the risk of undesirable morbidity. Acupuncture is frequently proposed as a treatment for these conditions (Hay et al. 1999).

Scientific research

A range of research considers the use of acupuncture in the management of tennis elbow. This is summarised below; from this one might argue that acupuncture, has, at least, a shortlived effect on tennis elbow. Further research on the long term effects is still needed.

In a meta-analysis by Bisset et al. 2005, based on 4 RCTs, it was shown that acupuncture appears to have a duration of the effect for at least 2-8 weeks.

In another systematic review by Trith et al. 2004, the authors found strong evidence for treating lateral epicondylitis, with acupuncture.

In a placebo controlled trial by Fink et al. 2002, 45 patients were allocated to either acupuncture in classical points, such as LI-10, LI-11,and LU-5. As distal point was either LI-4 or TE-5 used. In the placebo group, points several centimeters from the classical acupuncture points were used. Otherwise all procedures in the two groups were similar. Initially there was a significant difference between the two groups, but this had dissappeared at 2 and 12 months follow up, with no clear difference between the groups. However, both groups showed a clear reduction of the pain intensity by the 12 month followup, compared to the initial value.

In another study by same author Fink et al. 2002, it was concluded, that acupuncture in classical acupuncture points, was significantly better than acupuncture in non classical points. However, it needs to be emphasised that 71 % of triggerpoints are situated in classical acupuncture points. This study also demonstrated no significant difference in outcomes between the two groups at 12 month followup, but that the level of pain was significantly reduced in both groups compared to the initial value.

However, in both studies, interpretation of the results may be complex, as a result of the selected placebo procedure. In the first study, classical acupuncture points were used in the test group compared to non-classical points in the placebo group. These points – whether classical or palcebo - are all located within the same spinal segments.

It is well known that acupuncture is a nociceptive stimulus, that induces an inflammatory process locally, that stimulates the peripheral nervous system and thus we register pain. Any nociceptive stimulus, irrespective of the site on the body, will have an influence upon the peripheral nervous system, and therefore an effect on the patients pain. Considering that the procedures of both groups were identical, it is not surprising that an effect was reported in both groups.

In the second study, the authors try to analyze the problem further, by comparing classical acupuncture points with deep needling in muscles against superficial needling. Initially, there was a difference between the two groups. It is accepted that both deep and superficial acupuncture activates the A-delta nerve fibers of the peripheral nervous system. The A-delta fibers from both superficial and deep needling terminate primarily in the second layer in the dorsal horn where the pain is inhibited through a release of enkephalin. However, the A-delta fibers from deep acupuncture, continue via synapse with a second order interneurone to the fifth layer of the dorsal horn, where the fibres crossover and contine via the spinothalamic tract to the midbrain, thalamus etc. As a consequence deep needling will have both a segmental and a central effect.

In contrast the A-delta fibers from superficial needling, does not continue to the fifth layer of the dorsal horn, does not pass to the spinothalamic tracts, and as a consequence superficial stimulation will have a segmental effect only.

It is known that endorphin is released from superior centers in the brain and it is expected that this is the reason for the initial difference between the two groups in the second study of Fink.

In a study by Tsui et al. 2002, the difference between manual acupuncture and electroacupuncture was investigated in 20 patients suffering from elbow pain.

The acupuncture points GB-34 and ST-38 were used in both groups. In the group receiving ectroacupuncture points a frequenzy of 4 HZ was used. The patients were evaluated by grabsize and on a VAS scale for pain.

After 6 treatments, an improvement on 32% was found on the VAS scale, in the manual acupuncture group. In the electropuncture group an improvement of 50% was reported. Equal values were found in the grabsize-scale.* Se artiklen

The explanation for the poor result in the manual acupuncture group, effectively no greater than that explainable with a placebo response, can easily be explained by the choice of acupuncture points. These are remote to the site of problems. It seems more logical to use points within the segments and muscles involved.

A cochrane review by Green et a. 2003 concludes that the present number of studies is too small to either recommend or reject acupuncture. However, the review did conclude that acupuncture appears to have at the very least, a temporary effect.

In a study by Molsberger et al 1994, 48 patients recieved either acupuncture in the point GB-34 or placebo acupuncture, without penetration of the skin on the point BL-13 for the treatment of elbow pain. In the true treatment group there was an improvement of the pain on 55.8 %, compared to 15% in the placebogroup. The pain relief lasted 20 hours in the treatment-group, compared to 1.4 hours in the placebo group.

One might speculate for the reason for the points chosen (extrasegmentary), but at least it probably illustrates that penetration by a needle, anywhere in the body, results in an increase of the endorphine concentration in the blood. One must expect that a better and more lasting effect would have been achieved if a segmental treatment had been used.

The treatment of 82 patients with tennis elbow is described by Haker et al.1990.

The patients were allocated to either deep needling or superficial needling. LU-5, LI-10, LI-11 and LI-12 were used in the treatment group. TE-5 was used as the distant point.

After 10 treatments, a clear improvement was found in the group with deep needling. However, this difference was not found at the follow up after three and twelve months, nor at end of treatment.

However, at the one year follow up, a significant improvement was found in both groups, compared to the start value. That there was no difference between the two groups can easily be explained by the fact that the points used were the same.

In a study by Brattberg 1983, 50 patients who suffered from treatment resistant tennis elbow, were either treated with acupuncture or steroid injections. 61.8% of the group treated with acupuncture showed a significant improvement, compared to the group recieving steroid injections, where an improvement of only 30.8% was found. The patients recieved 6 acupuncture treatments, in 4 weeks. The usual local points were used and as distant point, LI-4 was used.

Possible mode of action

The cause of tennis elbow is always a result of overuse of the extensores muscles around the elbow. This sometimes causes a local imflammatory proces, that, probably secondarily, contributes by either creating new triggerpoints, or activating a latent triggerpoint in the regional muscles.

It is presumed that an active triggerpoint causes a shortening of the muscle as a result of a contraction in the muscle, which in the long term will cause ischaemia in the muscle. This decreased circulation locally, will as a consequence cause a accumulation of waste products, such as lactid acid, which will contribute to a chemical reaction with release of, among other things, potasium ions. Traval et al 1982,1983.

It is proven that acupuncture increases the local blood supply, probably through a decrease in the sympaticus tonus, Kuo et al 2004, Green 2003, leading to vasodialtion, and thus reestablishing the normal hæmodynamic relations in the affected muscle/muscles.

However, the pain is not simply as a result of ischaemia alone. It has been shown that muscular ischaemia does not cause muscular pain during rest. However, use of an ischaemic muscle will lead to the onset of pain. It is belived that this muscular pain during work is initiated by the release of bradykinin, potasium ions and prostaglandins, that then sensitises the nociceptors, Jensen et al 2003.

Practical recommendations for treating tennis elbow.

Like all other diseases treated by acupuncture, a combination of classical acupuncture points and trigger points is often essential for obtaining the best result. Moreover, a biomechanical analysis of the problem is of vital importance to understand the cause of the disease.

The cause for tennis elbow is an overuse in the extensor muscles on the forearm and subsequent activation or development of triggerpoints in the involved muscles.

The extensor muscle is quoted the most important muscles in development of tennis elbow. However, in particular, the supinator muscle seems to be involved in nearly all patients suffering from tennis elbow.

Supinator muscle

Most textbooks recommend the following combination of points LI-10, LI-11 as the most important. As a distant point LI-4 is often recomended. However, one might speculate about the relevance of using the point LI-4. Everyone will agree, that the point LI-4 is located in the adductor pollicis muscle, and one might question the logic in using the point LI-4 for this condition. After all tennis elbow is a localised phenomen, involving muscles around the elbow, and it would be logical to use points in this region only.

The selection of points should be guided by the examination of the forearm, in particular on the radial site. However, muscles are always working in groups, so it is remended to palpate the ulnar site as well.

Standard treatment for tennis elbow

Local pointsLU-5½, LI-10, LI-11 and I-12

Distant pointsNone

Supplementary triggerpoints

NB. the main function of the triceps muscle is on the elbow, and the region needs to be examined in all patients suffering from tennis elbow.

Referencer

Bisset L, Paungmali A, VicenzinoB, Beller E, A systemic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005; 39: 411-22.

Trinh KV, Phillips SD, Ho E, Damsma K. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology 2004; 43: 1085-90.

Kuo TC. Lin CW. Ho FM. The soreness and numbness effect of acupuncture on the skin blood flow. Am J Chin Med. 2004; 32(1): 117-29.

Green S. Buchbinder R. Barnsley L. Hall S. White M. Smidt N. Assendelft W. Acupuncture for lateral elbow pain. The Cochrane Library. Issue 2. 2003. CD003527.

Jensen TS, Dahl JB. Arendt-Nielsen L. Smerter – en lærebog. 2003. FADL’S Forlag, p141-51

Tsui P. Leung M.C.P. Comparison of the effictiveness between manual acupuncture and electro-acupuncture on patients with tennis elbow. Acupun Electrother Res. 2002; 27: 107-17.

Fink M. Wolkenstein E. Luennemann M. Gutenbrunner C. Gehrke A. Karst M. Chronic epicondylitis: Effects of real and sham acupuncture treatment: A randomised controlled patient- and examiner-blinded long term trial.Forschende Komplementärmedizin - Klassische Naturheilkunde. 2002; 9: 210-5.

Fink M. Wolkenstein E. Karst M. Gehrke A. Acupuncture in chronic epicondylitis: a randomised controlled trial. Rhematol. 2002; 41: 205-9.

Hay E.M. Paterson S.M. Lewis M. Hosie G. Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naprroxen for treatment of lateral epicondylitis of elbow in primary care. 1999. BMJ; 319(7215): 964-8.

Molsberger A. Hille E. The analgesic effect of acupuncture in chronic tennis elbow pain. Br. J. Rgeumatol. 1994;33: 1162-5.

Travell JG, Simons DG. Myofascial pain and dysfunction II. The trigger point manual. Williams & Wilkins, Baltimore;1992.

Haker E. Lundeberg T. Acupuncture treatment in epicondylagia: A compartive study of two acupuncture techniques. Clinical J. Pain. 1990; 6: 221-6.

Brattberg G. 1983. Acupuncture therapy for tennis elbow. Pain; 16: 285-8.

Travell JG, Simons DG. Myofascial pain and dysfunction I.The trigger point manual. Williams & Wilkins, Baltimore; 1883.

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