A Tale of two Fridays

The following story was reported to me by a colleague from general practice. The details are altered somewhat to preserve anonymity, including the name of the teller, but regular readers will recognise some characteristic use of language and style.

Dear Mike

This is a little story that illustrates the problems people have with acupuncture, or at least with what it means, or the perception of acupuncture.

One Friday some weeks ago, as part of routine primary care, I saw woman in her 30’s with unexplained left sided loin pain. She had suffered from an episode of pyelonephritis and subsequently developed persisting loin pain. Technically ‘chronic pain’, lasting for more than three months etc. She had undergone ultrasound scans, blood tests and two colleagues saw her. One had tried manual medicine within the osteopathic paradigm. “It aggravated it, and it stayed” she said, and she was frustrated and a bit scared. I examined and looked at the results and thought it could be myofascial pain, possibly secondary to the pyelonephritis following Maria Adele Giamberardino’s heuristics. I said that I could offer acupuncture, but first I would suggest stretching etc, all directed towards quadratus lumborum. I sensed apprehensiveness, and did not want to needle into apprehensiveness and preconceptions. She said that her husband was sceptical and he considered that acupuncture was mumbo jumbo.

I said my offer is there, no pressure, less work is good for me. She said “Come on, then”. I needled her in side lying as we teach on the course. Just one needle towards the lumbar transverse process, it could have been lateral part of erector spinae or quadratus lumborum, I am not so sure, but I am confident that the needle tip hit the target, the appropriate place. She confirmed that it was the pain she was experiencing. I stretched the muscle afterwards and whilst I was tidying up and typing the notes, she was wiggling her hip, searching for ‘her pain’, and the pain had disappeared. She asked how long will it last? I replied I don’t know, ideally forever, but what in life is ideal? Sceptical optimism, sceptical hope – I said please phone me on Monday. She never did.

…the pain had disappeared.

Friday afternoon one week later. I called a patient in. My heart sank: she had a tripod multifunction-cane, was tattooed all-over, smelled of nicotine, hopelessness and fed-up-ness, and took ages to make it to my door. The way from the waiting room to my room is a parcour with a flight of stairs up and a flight of stairs down. The Inca trail. A functional assessment strip. With a firm handshake plus the parcour I have a good understanding of the frailty score. She was frail. Her opener was “Do you do acupuncture?” Nobody in this town knows that I do acupuncture. I am a normal GP and use needling as part of my routine services but I do not attract sufferers of all countries to unite in my consultation room.

I do not attract sufferers of all countries to unite in my consultation room.

“Who told you?” I asked.

“A woman I know, she was so much better after your acupuncture.”

“Does her name start with…?”

“Yes”

The friends and family test! She recommended me.

She recommended acupuncture for pain that does not go away!

And here is where the parallel stops.

The ‘fed-up’ lady had a long medication list, was tearful and disabled. She came to get treatment for her coccydynia. I decided to do as little damage as possible and needled two points at gluteus maximus insertion at sacrum as anchor points for hope and a different conversation. Whilst she was lying down I asked her to tell me about her life. She told me about her multiple blood clots, the pulmonary embolus, that she nearly died, that she had three kids and three grandchildren, that she was a fighter, but that now she felt like giving up, that her tattoos were an idea of wanting change, like a makeover, she told me that she grieved for what she had lost and that she struggled with breathlessness and pain. 

Whilst she was lying down I asked her to tell me about her life.

For pain clinic purposes she ticked all the criteria of multimorbidity, polypharmacy, depression etc and at a point pain started creeping in and settling somewhere in her body.

I know that acupuncture rarely works to get these emergent demons out.

Needling works extremely well for isolated myofascial pain, as it did for her neighbour, but not in isolation for multi-morbidity, hopelessness and all forms of demons.

In a way these two women seemed to have the same limited way of understanding acupuncture, just like the helicopter view looking at classification terms in systematic reviews.

Does acupuncture work for chronic pain/loin pain?

The answer is that it depends on the context and the label itself: ‘acupuncture for chronic pain/loin pain’ is probably too simplistic a question to answer.


Declaration of interests MC

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