Stimulated by Lee et al 2020, and Yamamoto et al 2021.
SR – systematic reviewkey to acronyms
MSK – musculoskeletal
DOMS – delayed onset muscle soreness
YIPS – York Incontinence Perceptions Scale
YIPS – Yale Interpersonal Stressor
Lee et al is a systematic review (SR) that I have been wanting to highlight for a while. My opportunity arrived with the publication of a case report of an acupuncture related adverse event in an athlete.
The SR focusses on acupuncture for the treatment of sports injuries in athletes and it includes 22 papers: 10 single case reports and 12 case series including from 2 to 42 cases in each. It makes a welcome change to see a review without a whole stack of forest plots to scrutinise.
This is a descriptive review including a total 211 athletes, 56.4% men, with a mean age of 24.8 years (range 8 to 77). Eight countries were represented, with the most reports coming from the US (7); followed by Canada (4); the UK (3); China, Israel and Japan (2 each); and Brazil and Puerto Rico (1 each).
The sports included basketball (4 papers, 9 cases); running, skiing, volleyball (3 papers each); field hockey, ice hockey, soccer, football, swimming, athletics (2 papers each); rugby, cycling, rowing, lacrosse, table tennis and golf (1 paper each).
Unsurprisingly, the musculoskeletal system and connective tissue diseases accounted for the highest proportion of complaints, coming in at 98 cases (46.4%), followed by DOMS and fatigue. The most injured body region was the knee, followed by the elbow and the shoulder.
Most papers involved the use of MA or EA, but there was one each using TENS, laser or catgut embedding at acupuncture points.
There are a couple of large tables outlining each of the reports and giving details of the acupuncture and co-interventions. Acupuncture was only used alone in two cases: golfer’s yips and runner’s stitch syndrome. Most of you will have experience of the latter from childhood, but the former – ‘the yips’, may be less familiar. I remember the term because this report was sent to me to review as editor of Acupuncture in Medicine in 2005. Prior to that I had not heard of the yips.
The yips or golfer’s cramp is a motor phenomenon of involuntary movements affecting golfers, making certain strokes, especially putting, all but impossible.[3-5]
In this case, a veteran BMAS member, Palle Rosted, reported complete resolution of ‘the yips’ after a single treatment with acupuncture, but questioned whether or not this was simply coincidence. Since the yips adds an average of 4.7 strokes to a round of golf and affects about 28% of golfers; if acupuncture can work miracles in this condition, I’m surprised we haven’t heard more about it.
I quite like the term yips. It is short and almost onomatopoeic. But unfortunately, YIPS has also been used as an acronym for a couple of completely unrelated things: a outcome measure from York – the York Incontinence Perceptions Scale; and a psychological test procedure from Yale that sounds unnecessarily cruel – the Yale Interpersonal Stressor.
Getting back to athletes, the second paper I want to highlight should be a cautionary tale to those of us who engage in the more vigorous needling approaches in big muscles.
A 26-year-old athlete had acupuncture needling to his left hip with a long needle. A 40mm long portion of the needle broke off in his gluteal muscles and the acupuncturist could not retrieve the retained fragment. As the patient felt no pain he continued training, and did not present to hospital until hip flexion started to become painful 6 days later. The needle fragment had presumably migrated, and it was retrieved from the inside of the pelvis via laparoscopy, where it was just piercing the peritoneum.
The needles pictured in the report look very fine, but the fragment retrieved appears to be thicker than the sample needles placed beside it. This case report comes from Japan where the use of fine needles is common, but unfortunately they do not state the diameter of the fragment.
This reminds me of a case of a needle fragment in the neck that migrated as a result of attempts to retrieve it, and it almost ended up in the brainstem. This case report was highlighted on the blog in October 2018: Needle migration in the neck. We have also covered laparoscopic removal of needle fragments previously: Laparoscopic needle fragment removal 2019. In this case the needle fragment had been retained for 2 years. But that’s not the record, is it! All those of you who have completed the BMAS Foundation Course will know that the record for the longest time interval from needling to an adverse event is 50 years. This was a pneumothorax presenting in a 92-year-old woman in Japan. She also had needle fragments in her liver and spleen.
The frequency of broken needles, in the absence of deliberately snipping them off (as was a popular practice in the past), is very low. Looking at the various reports, it seems that the anatomical areas concerned are linked by having a significant thickness of muscle and multiple muscle layers. My guess is we can reduce the risk in these areas by avoiding strong voluntary muscle contractions and by using the best quality needles of an appropriate gauge.
1 Lee J-W, Lee J-H, Kim S-Y. Use of Acupuncture for the Treatment of Sports-Related Injuries in Athletes: A Systematic Review of Case Reports. Int J Environ Res Public Health 2020;17:8226. doi:10.3390/ijerph17218226
2 Yamamoto A, Hiro J, Omura Y, et al. Laparoscopic removal of an aberrant acupuncture needle in the gluteus that reached the pelvic cavity: a case report. Surg Case Rep 2021;7:51. doi:10.1186/s40792-020-01065-8
3 Rosted P. Acupuncture for treatment of the yips? – a case report. Acupunct Med 2005;23:188–9. doi:10.1136/aim.23.4.188
4 McDaniel KD, Cummings JL, Shain S. The “yips”: a focal dystonia of golfers. Neurology 1989;39:192–5. doi:10.1212/wnl.39.2.192
5 Smith AM, Adler CH, Crews D, et al. The “yips” in golf: a continuum between a focal dystonia and choking. Sports Med Auckl NZ 2003;33:13–31. doi:10.2165/00007256-200333010-00002
6 Smith AM, Malo SA, Laskowski ER, et al. A multidisciplinary study of the “yips” phenomenon in golf: An exploratory analysis. Sports Med Auckl NZ 2000;30:423–37. doi:10.2165/00007256-200030060-00004
7 Lee PS, Reid DW, Saltmarche A, et al. Measuring the psychosocial impact of urinary incontinence: the York Incontinence Perceptions Scale (YIPS). J Am Geriatr Soc 1995;43:1275–8. doi:10.1111/j.1532-5415.1995.tb07406.x
8 Stroud LR, Tanofsky-Kraff M, Wilfley DE, et al. The Yale Interpersonal Stressor (YIPS): affective, physiological, and behavioral responses to a novel interpersonal rejection paradigm. Ann Behav Med Publ Soc Behav Med 2000;22:204–13. doi:10.1007/BF02895115
9 Yamaya M, Sekizawa K, Sasaki H. Case Report [Minerva]. BMJ 1998;317:1536.
10 Witt CM, Pach D, Brinkhaus B, et al. Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form. Forsch Komplementmed 2009;16:91–7. doi:10.1159/000209315