Discuss about the Acupuncture-Related Research Literature.
Acupuncture is gaining popularity in the current years as an important modality of complementary and alternative medicine in the western society. It is the insertion of needles for stimulation of specific acupoints present in the body for facilitating recovery. There is increased public attention and acceptance towards scientific exploration of physiological mechanism of acupuncture. When needles are inserted into the body, it goes through multiple layers that include skin, muscles and subcutaneous tissue considered as the beginning of healing process initiated by biophysical, neuronal and biochemical reactions (Action 2009). It has a promising efficacy in the treatment of postoperative pain and beneficial for pain management. Western acupuncture is considered to be a form of alternative medicine that is used for pain relief including shoulder stiffness, low back pain and knee pain (VanderPloeg and Yi 2009). This is possible as it affects afferent nerve signalling and influences the release of endogenous opioids for the promotion of pain relief. Acupuncture has a therapeutic effect that can be augmented by ACTH and cortisol release, down-regulation of the signalling pathways through the pain fibres (Zhu 2014). Western acupuncture is used for chronic back pain and a cost-effective therapy adjunct to clinical care adapted from Chinese acupuncture. It is used for the treatment of musculoskeletal pain that includes myofascial trigger where practitioners choose best points in the body for stimulating nervous system. Therefore, the following assignment involves the understanding of mechanism of action of western acupuncture for the muscular system having therapeutic effects with its benefits and limitations.
Western acupuncture is a translation that modulates imbalances between the sympathetic and parasympathetic activity. It has evolved from Chinese acupuncture where the practitioners does not align to Yin/Yang and qi circulation and regarded as a part of the Chinese conventional medicine designated as “alternative medical system”. This method acts through stimulation of nervous system and mode of action including local antidromic axon reflexes, extrasegmental and segmental neuromodulation (Bai and Lao 2013). Western acupuncture involved fine needles insertion that uses current knowledge of physiology, anatomy and pathology through evidence-based medicine. This form of acupuncture is used for the treatment of symptoms supporting the fact that it supports alleviation of types of pain and nausea. It does not have single mode of action and the main therapeutic effect is achieved through nervous system or sensory stimulation. This results in the production of natural substances inside the body like pain-relieving endomorphins having long-lasting pain relief as compared to single treatment (Vickers et al. 2012). The needle insertion has local effects through antidromic and local axon reflexes, increase in local nutritive blood flow and release of neuropeptides. Western acupuncture has clinical effects on the musculoskeletal pain that can be explained through inhibition of nociceptive pathway at dorsal horn. This can be explained by activation of descend inhibitory pathway having segmental or local effects on the myofascial trigger points (Abdulla et al. 2013). The pain relief mechanism is explained through “gate control theory” where western acupuncture activates peripheral nerves for shutting the gate on the pain signals that travels through spinal cord (Chon and Lee 2013). The interruption of pain signals acting as alterative therapy is called transcutaneous electrical nerve stimulation (TENS). Various adjuncts like electrical acupuncture, heat lamps, injection acupuncture and moxibustion with acupuncture is used for the pain relief and management. In dry needling or trigger point needling technique, needle is inserted at specific trigger points where the needle is dry or solid injection needle (Dunning et al. 2014).
Musculoskeletal pain affects muscles, bones, tendons, ligaments and nerves causing acute or chronic pain either localized or widespread. It is often caused by an injury or jerking movements, falls, accidents, fractures, direct blow to muscle or dislocations. It may also be caused by overuse affecting 33% of adults and lower back pain is the most common work-related injury diagnosed in the Western society (Coggon et al. 2013). The damage to the muscle tissue due to wear and tear can also cause musculoskeletal pain, repetitive movements, postural pain and prolonged immobilization. Low back pain is the most prevalent and common work-related injury that accounts for 29% lost working days (Balagué et al. 2012). Although, the pathophysiology of musculoskeletal pain is not clear, fibrosis, inflammation, tissue degradation, neurosensory and transmitter disturbances have been implicated. The musculoskeletal injury causes increase in mediators and pro-inflammatory cytokines in the affected tissues leading to peripheral nociceptor sensitization. This inflammation can cause fibrotic scarring called fibrosis where there is increase in collagen between and within cells and tissues, reduction in tissue gliding during movement that results in stretch injuries and increased pain (Nijs et al. 2013). Tissue degradation also takes place where there is increase in inflammatory mediators which in turn increases the degradation of extracellular matrices due to increased matrix metalloproteinases enzyme. There is also lowering of tissue load tolerance resulting in further injury and pain. Hypersensitivity, increase in neurotransmitter, cytokines and inflammatory mediator levels cause central pain amplification with nerve compression. Various approaches are present in acupuncture treatment of musculoskeletal pain and trigger point approach is used in western acupuncture where needling of Ah Shi points reduces pain explained by biochemical or neural mechanisms (Dommerholt and de las Penas 2013). The trigger point concept realizes that musculoskeletal pain is located at some distance away from the area where an individual experiences pain (Téllez-García et al. 2015). Therefore, stimulation of trigger points in muscular system by western acupuncture can treat and manage musculoskeletal pain discussed in the subsequent section.
Physiotherapists use acupuncture for treating musculoskeletal pain by following a clinical reasoning process (CRP) for the manual therapy interventions. In western acupuncture, the “layering method” is specifically developed for the physiotherapists for the treatment of musculoskeletal conditions via mechanism-based approach (Patil et al. 2016). It is aimed at targeting the different physiological processes within CNS for providing best effect for each patient diagnosed with musculoskeletal pain. However, it also integrates traditional Chinese acupuncture (TCA) into western clinical reasoning. This method allows physiotherapists to progressively target the pathophysiology of condition of patient while using the effects of acupuncture on CNS. Within western acupuncture, clinical reasoning requires asking series of questions as what the main aim of needling technique is and what is required from it (Chang 2012).
Various mechanisms underpins the layering method where the clinician need to understand the acupuncture points, anatomy knowledge, segmental innervations and peripheral neuroanatomy for the treatment of musculoskeletal pain. Pain mechanisms are understood via various methods of pain classification where western acupuncture is effective for various pain types, diagnosis that also underpin prognosis determination and treatment decisions (Smart et al. 2012). Nociceptive pain results from nociceptor stimulation that relies on nervous system in the peripheral tissues. The mechanisms can be via inflammatory, mechanical or ischaemic associated with tissue injury or acute pain. In the spinal cord, the dorsal horn neurons and peripheral nerve endings become sensitized; however these processes resolve when the tissue is healed and self-limiting (Fornasari 2012). In this mechanism, stimulus-response relationship prevails between pain provocation and experience. Therefore, in this mechanism, nociceptive pain has been illustrated to respond positively to the western acupuncture treatment. Neurogenic pain arises from dorsal root ganglion or nerve segment due to axon damage reacting to sensory inputs and non-noxious inputs sustain or evoke pain resulting in neurogenic pain that is characterized by hyperalgesia and allodynia (Cox 2012). Conventional acupuncture is not effective for neurogenic pain and low-intensity, high-frequency electroacupuncture is applied for activation of non-opioid or noradrenergic pathway in spinal cord.
The yes/no question format is a way of problem-solving method as to presentations in tissue and pain mechanisms, appropriate stimulation points and parameters that can be used to deliver optimum intervention. The questions are asked in terms of peripheral and segmental effects and chronic nociceptive pain. The next layer is segmental sympathetic effects followed by analgesia (supraspinal effects) and sympathetic points (supraspinal motor cortex), supraspinal effects and finally immune effects (Patil et al. 2016).
In the layering method of western acupuncture, a checklist is provided for the treatment of musculoskeletal pain through needling. If the peripheral effect is present, the needle is injected away from the injured tissue and if the answer is yes, the needle is injected directly into tissue that gently maximize stimulation of local effects in the treatment of superficial injuries. A low intensity, high frequency electro-acupuncture is used for blood flow to skin through reduction in sympathetic tone (Yuan et al. 2016). For spinal or segmental effects, if the answer is no, needle tissues is injected away from the damage tissue with different extra segmental or segmental nerve supply. If the answer is yes for needle insertion into damaged tissue, it chooses local points situated nearby or in damaged tissue anatomically. Acute nociceptive pain uses few needles in segmentation (low intensity and high frequency), electroacupuncture for maximizing spinal cord inhibition then progressing towards electroacupuncture or manual acupuncture. For chronic nociceptive pain, more needles are used in segment. In this segment, an extra layer can be added where a spinal point is chosen that influences segment that shares nerve supply at the spinal level where the needle is injected for 10-20 minutes (Yuan et al. 2016).
For supraspinal effects, if the answer is no, moderate stimulation with needle is given for 10-15 minutes on segmental points to damaged tissue and does not take “big points” into consideration. If the answer is yes, extra segmental points are chosen with “big points” of feet and hand, however, these points are considered in TCA. Strong stimulation is given by needle for 20-40 minutes that result in activation of descending inhibitory systems from diffuse noxious inhibitory controls (DNIC) and hypothalamus. When the condition of the patient is not improving via somatic treatment, the question is asked regrading sympathetic outflow. If the answer is no, the clinician treat the patient as per principles of somatic nerve supply. If the answer is yes, segmental tissue level is chosen by the clinician and at the spinal level, needle Bladder Point or Huatuo Jiaj is taken into consideration. Sympathetic outflow to neck (C8 to T4) and head, lower limbs (T10 to L2) and T5 to T9 upper limbs are activated via needling. A distant tissue point is chosen innervated with sympathetic segmental nerve supply as per the clinician’s wish to influence nerve. Strong stimulation by needle for 10 minutes can help in increasing sympathetic outflow or decrease outflow through gentle stimulation. As autonomic nervous system is controlled by hypothalamus, stimulation need to be given in the same manner as it is provided in analgesic supraspinal effects. Large points, feet and hands are chosen where strong stimulation is given for at least 20 to 40 minutes. For immune effects, points are chosen at segmental level of lung, spleen and thymus. General strong points can also be chosen that influence hypothalamus and regulation of autonomic outflow in feet and hands. Strong stimulation and repeated treatments, 30 minutes stimulation on auricular points can also be given that affects activity of vagal efferent nerves (Yuan et al. 2016).
Trigger point approach is used in western acupuncture for the treatment of musculoskeletal pain where it is compared on the basis of distal and local points and determination of Ah Shi points. The method of needling based on location is explained through this approach from the western acupuncture. Other approaches like TCM acupuncture, ear and meridian acupuncture are also used to explain the process of needling and treat musculoskeletal pain. The surface energetic in human body is explored with methods that influence them through these approaches based on parameters like use of palpitation for diagnosis and way in which distal points and Ah Shi or local points are chosen (Quintner et al. 2014). On a contrary, in TCM, relevant Ah Shi points are located distal or proximal, adjacent or local to the pain area. Trigger points are permanent and local contractions in the muscle fibres where on palpitation, nodules or taut bands are experienced that are responsible for pain patterns. The pathology of trigger point is explained through referred pain where it is not necessary that pain need to coincide with the area that patients report. This approach is also known in Chinese medicine, however, in medical literature, referred pain is explained by neural mechanisms where perceptual errors occur in sensory cortex or errors occur in spinal cord. This kind of pain is difficult to localize as it may change or move during disease progression. Initially, the pain is experienced in close proximity to origin of symptoms; however, later it progresses proximally or distally to initial area. This trigger point approach is of paramount importance in the treatment of musculoskeletal pain (Couto et al. 2014).
Trigger point concept has been pioneered by Kellgren in 1938 where it is stated that muscle pathology is the main cause of pain, however clinicians focus on joints, bones, nerves and bursae. The medical explanation pose major problem in explaining trigger point approach as it does not follow nerve pathways nor occur within same myotome, dermatome or sclerotome. However, it is stated that trigger point concept and referred pain follow a well researched and predictable pattern. The main causes for trigger-points activation are trauma to tendons, muscles or joints, chronic stresses on the muscles by bad posture, overuse or involuntary muscle tension as a result of emotional stress. On a contrary, in TCM, it is caused due to exposure to damp weather, cold or drafts or contact with external pathogens (Dommerholt and Fernandez de las Penas 2013).
Various types of trigger points cause pain where all are not actively participating in the pain mechanism and therefore, it is important for a clinician to identify the accurate trigger points that are responsible for pain pattern. A precise and definite pictorial representation of pain is critical for the accurate diagnosis of musculoskeletal pain as verbal descriptions are misleading and imprecise. A blank body form is used for recording patient’s pain routinely. In this approach, it is outlined that details are important like which side of limb hurts, description of pain like concentrated or skipping within a joint. The vague generalizations may lead to misdiagnosis and it is important to find out the exact location of pain to deliver accurate treatment. Once the muscle is identified, clinician locates nodules and taut bands through careful palpitation in muscle fibres that are soft on pressure and may induce referred pain in the patient. Palpitation technique is performed on slight stretched muscle where the practitioner rolls over the muscle skin gently perpendicular to the muscle belly. In this method, initially light pressure is applied for assessing superficial muscles and gradually there is increase in pressure for reaching deeper muscles (Liu et al. 2015).
The distal and local points are located and needling technique for the treatment of trigger points causing musculoskeletal pain. Different possibilities of trigger point treatment are proposed where western acupuncture is considered accurate as in physiotherapy or medical acupuncture, local points or trigger points sites are needled called dry needling (Mejuto-Vázquez et al. 2014). Needles are used according to western acupuncture principles and do not use TCM knowledge of meridians. This needling method is quite effective and accurate, however distal point usage as per meridian theory only increase trigger point needling effectiveness. For an effective treatment of musculoskeletal pain, precise point of trigger point needs to be addressed. Trigger point needling is a precise and acquired art where accurate trigger point is located and stabilize manually. The practitioner uses non-needling thumb and apply firm pressure to tight band side or Kori so that needle reaches trigger and there is no rolling away of muscle fibres. Needling method is performed deeply like TCM which is quite controversial. On a contrary, clinician use superficial needling to 5-10 mm depth and dos not reach trigger point itself. For needles that are left in situ for not more than 30 seconds, also provide equal results with less pain to patient (Rainey and Charles 2013).
Several protocols have been proposed for the treatment of trigger points in musculoskeletal pain where trigger point needling is considered the best approach. In this protocol, the marks are pointed, activation of involved tendino-muscular meridian takes place and finally appropriate treatment is given to spinal segment for addressing the root problem. Finally, needling is done on trigger points superficially with mild needle stimulation and left in place for a short duration and the process is repeated for more positive effects. If any patient does not respond to the mild needling, deeper treatment is applied with vigorous manipulation. Needle can be applied in varied directions covering the entire area of Kori or tight band present around the trigger where muscle attachments may be located and needled (Dunning et al. 2014)
Western acupuncture is an effective and holistic approach in the treatment of pain like musculoskeletal pain. The most important benefit of this method is that it is relatively pain-free and helps in reducing pain in a natural way without any medication and unwanted side effects. This method shows promising results in postoperative and chemotherapy vomiting and nausea and dental pain. The National Institute of Health consider acupuncture safe and it is used for various disease conditions. It helps in the reduction of migraines and headaches as a non-pharmacological tool through “sham” sessions where needles are placed randomly resulting in reduction in pain intensity and symptoms of migraine and headaches (Robinson et al. 2012). Arthritis pain or chronic pain of neck, back and knee is also treated through acupuncture where patients feel less pain and quite reasonable referral option for pain relief and management. Insomnia is also treated through acupuncture where there is decrease in its symptoms adding better effects as compared to herbal treatments or medications used in TCM. According to the National Cancer Institute, western acupuncture helps in boosting immunity and speeding up recovery of patients following cancer treatment (Paley et al. 2015). Platelet count enhancement along with protection of healthy cells is also mediated via acupuncture after patients undergo chemotherapy or radiation therapy. Acupuncture is also effective in the prevention of cognitive decline like in Parkinson’s disease as age-related decline causes neural response in specific areas of brain. There is improvement in symptoms like walking, tremor, slowness, handwriting, depression, sleep, anxiety and pain showing no adverse effects (Liu et al. 2014). Despite of growing popularity for the use of acupuncture, there is lack of evidence for understanding the effectiveness or its efficacy. Moreover, there are certain risks of using acupuncture like it should not be used in patients who take blood thinners or have a bleeding disorder. As needles are inserted, bruising, bleeding and soreness can also occur and one should avoid using unsterilized needles that can result in infection. During insertion, needle can break and damage underlying organs. Therefore, it is advisable that acupuncture should be used along with conventional medical treatments in cases of severe or chronic illness.
From the above discussion, it can be concluded that western acupuncture is one of the popular method stemming from TCM where trained practitioners use thin needles for stimulating specific points in the body. It originated in ancient China and until now, it is used for treating various disease conditions. This method involves the insertion of needles having therapeutic effects on musculoskeletal pain being one of the most common work-related injuries witnessed in the West. For the treatment and pain relief in musculoskeletal disorders, trigger point approach is used where Ah Shi points are needled that eventually reduces pain. This approach recognizes that pain is generated at some point away from the area where pain is experienced. The stimulation of trigger points in the musculoskeletal system helps in the treatment of pain through clinical reasoning process (CRP) used by clinicians. In CRP, layering method is used for the treatment of musculoskeletal pain where a checklist containing questions in yes or no format is used by clinical practitioners so that best intervention is delivered to the patient. The local and distal points are located and needling technique is delivered. Several benefits and limitations of western acupuncture are also outlined in the assignment using needling method. Therefore, it can be concluded that western acupuncture has therapeutic effects on musculoskeletal pain by triggering points in the muscular system.
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