Needling and spasticity

Inspired by Sánchez-Mila Acupunct Med 2018 [1]

I have been curious about the potential effect of acupuncture needling in muscles with high tone since witnessing the rapid relief of lumbar muscle spasm following insertion of acupuncture needles whilst serving as a medical officer in the British military.

Subsequently I have tried the technique (combined with immediate passive stretch) with success in localised contractures, and for restoring upper limb joint range in hemiplegic stroke. It takes multiple sessions in these latter cases, and I guess that makes it hard to compete with botulinum toxin injection, although the latter does have some limitations (eg cost, excess weakness, allergic reactions).

I have tried both direct dry needling into the muscles exhibiting high tone as well as electroacupuncture (EA) to either high tone agonist or weaker antagonist muscles. The latter seems to be the most convenient and palatable approach in my practice. So I was interested to see that recent systematic reviews now tentatively support the use of EA in post-stroke spasticity [2,3].

This paper uses the more direct approach of dry needling into the affected muscles. They choose a very specific subgroup of stroke patients with their first episode of unilateral hemiplegia and spasticity resulting in an equinovarus foot – that is a foot forced into dorsiflexion and inversion by tibialis posterior and triceps surae (soleus and gastrocnemius). The intervention involved multimodal rehabilitation (Bobath concept) with or without the addition of a single session of dry needling to the affected tibialis posterior under ultrasound (US) guidance. The outcomes were functional scales (Ashworth and Fugl-Meyer) plus computerised dynamic posturography – something rather like the Nintendo wii fit balance board.

Ultrasound-guided dry needling of tibialis posterior – Figure 1 from Sánchez-Mila Acupunct Med 2018 [1]

The needling involved relatively gentle movement of the needle (4-5mm lift and thrust at 1Hz) for 25-30 seconds within tibialis anterior. US guidance was used to ensure accurate positioning and presumably to avoid penetration of the posterior tibial artery that lies between soleus and tibialis posterior. A 0.3x50mm needle was used, and whilst it is not easy to see such a fine needle on US, it is easy to see movement of fascial planes as they are indented, and therefore be reasonably confident of the needle position.

26 patients were randomised, and the single session of needling for half a minute resulted in a significant improvement in spasticity and balance. Further research will be needed, but this does seem to support the idea we have had for some years that physical rehabilitation can be improved by adding needling.

There are still lots of questions of course. Do we need to needle tibialis posterior directly? A standard technique without US guidance would be easier in practice, so would more superficial needling be as effective? Tibialis posterior can be reached with a relatively deep insertion at around SP7 or SP8, without particular risk of hitting the posterior tibial artery. So this might be a possible approach when US is not available, and a handheld stimulator can be used to confirm the position in the muscle. Finally, I have found to my surprise (guided by a stroke patient with prior experience) that EA to antagonists can be just as good if not better (the patient felt it was better) than EA into the spastic muscles directly. With this in mind, perhaps we could achieve the same results with very much more convenience by my favourite approach of EA to ST36 and zongping?

…EA to ST36 and zongping 😉

References

  1. Sánchez-Mila Z, Salom-Moreno J, Fernández-de-Las-Peñas C. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupunct Med 2018; acupmed-2017-011568. doi:10.1136/acupmed-2017-011568
  2. Zhu Y, Yang Y, Li J. Does acupuncture help patients with spasticity? A narrative review. Ann Phys Rehabil Med Published Online First: 5 November 2018. doi:10.1016/j.rehab.2018.09.010
  3. Cai Y, Zhang CS, Liu S, et al. Electroacupuncture for Poststroke Spasticity: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2017;98:2578–2589.e4. doi:10.1016/j.apmr.2017.03.023

Declaration of interests MC