PROPOSED MODEL FOR THE STUDY OF THE EFFICACY OF MEDICAL ACUPUNCTURE IN THE MANAGEMENT OF MUSCULO-SKELETAL PAIN

DOMINIC S. CHU, M.D.

ABSTRACT - The study of the efficacy of medical acupuncture has been often criticized as non-scientific and uncontrolled, and as not having rigid diagnostic criteria. Most of the human studies involving medical acupuncture depend on the patient's questionnaire and survey. Musculo-skeletal pain offers a good model for the study of acupuncture while using objective measurements of range of motion and strength according to standardized testing protocols. The diagnosis can also be clinically made by using acceptable sets of criteria in orthopedic practice. Lateral epicondylitis and subacromion bursitis of the shoulder are good examples to use in a study protocol.

     Dr. James Rotchford proposed a pilot study survey of medical acupuncture in a recent publication (1). The method of the study used questionnaires and follow-up telephone calls to the patients about whether their prior condition was better or resolved. This method has been criticized by skeptics of medical acupuncture as non-controlled and subject to psychosocial bias, arguing that patients seeking acupuncture treatment tend to self-select themselves.
     Recently in the Journal of Pain, Dr. Chu-Andrews commented about the effectiveness of using Dr. Chan Gunn's intramuscular nerve stimulation for the treatment of the myofascial-fibromyalgia syndrome. In her letter, she comments about an article written by a Dr. McCain about the pathophysiology of fibromyalgia. Dr. McCain rebutted Dr. Chu-Andrews on the grounds that Dr. Chan Gunn's method had not been studied with sufficient scientific rigor in a controlled blind fashion and using appropriate control groups fulfilling acceptable criteria for diagnosis(2).
     Such skepticism is not unusual and it does have some reasonable logic from a medical research standpoint. Aside from animal studies, most of the parameters used to test the efficacy of acupuncture are patient surveys recording subjective reports on their pain or well being.
     There seems to be a fairly large group of Physical Medicine specialists who are beginning to use acupuncture for the management of musculo-skeletal pain in the office. Reported here is a case study, in which appropriate measurements were made to follow treatment response. Such a format may serve as a model for a future study of the efficacy of medical acupuncture in musculo-skeletal problems. It is not, by any means, a complete case report, but should rather be viewed as an example of clinical evaluation methodology.

CASE REPORT
    J.L. is a 32-year-old man who works for the mobile home construction business around the Marshfield area. His work requires repetitive movements and lifting involving the upper extremities on both sides. He injured his left elbow ten days prior to his visit to the clinic by lifting a heavy truss, which is a piece of wood used in mobile home construction. He had pain in the lateral aspect of the elbow and found it difficult to extend his arm. He continued to work until one week prior to his visit, noticing worsening of his pain and occasional numbness down the forearm, with loss of range of motion. Eventually the pain impeded elbow extension and disabled him from continuing his daily work.
     Examination showed tenderness in the lateral epicondyle and over the insertion of the extensor digitorum communis. There was some puffiness just behind the olecranon. Range of motion of the elbow was significantly decreased. The range of motion was measured with the Cybex, electronic ergonometer (model EDI 320). His range of motion flexion/extension was limited to 45/140 degrees.
     There was no crepitus on range of motion of the elbow, yet the patient experienced severe pain when contracting the left forearm extensor against resistance, which was felt mostly in the lateral epicondyle. The patient, however, had full range of motion of the wrist in extension and flexion, although his hand grip was weak, as measured with the Jammer type of dynamometer with an infrared hookup (Dynatron 320). The protocol according to the American Society of Hand Therapists was used(3). On the first position of the Jammer dynamometer the output was 30 pounds, the third position 38, and at the fifth position 28 pounds. He had normal 2+ biceps jerks and triceps jerks. Sensation was intact to touch and pinprick except for decreased sensation along the lateral epicondyle and over the insertion of the extensor digitorum communis. X-rays done on that day revealed no fracture or dislocation and there was no soft tissue swelling or effusion on the areas examined.
     The diagnosis of epicondylitis was therefore made on clinical grounds and negative X-ray findings. The treatment proposed was that of injection of DepoMedrol and Xylocaine as well as a course of physical therapy. A non-steroidal agent was also recommended.
     The patient was opposed to any form of steroid injection. Therefore, medical acupuncture was offered as a therapeutic option. The treatment program and rationale were explained to the patient and he was given patient education material to read prior to receiving treatment.
     The needles used in this treatment program were disposable stainless steel needles with copper handles, size no. 5, which measure 14 mm. in length and 0.25 mm. in diameter. After the puncture site was cleansed with betadine and alcohol, the needles were inserted into acupuncture points LI 4, LI 10, LI 11, LI12 and TH5. After the needles were inserted, they were twirled until the patient felt some numbness or aching sensation, which translates into eliciting a De Chi sensation. Depth of insertion varied between 1.5 and 3 cm. Needles were connected to an electrical stimulator producing square waves with a frequency of 5-6 Hertz at about 250-300 microamps. The microampere was controlled to have the patient get a feeling of tapping with some twitching of the muscle or vibration, but no real pain. After twenty-five minutes of treatment, the electrical wires were disconnected and the needles were removed.
     Immediately after the treatment, the patient noticed reduction of pain in the elbow. Examination showed no tenderness on palpation of the lateral epicondyle. Range of motion testing was done using the Cybex ergonometer. This time he had full range of motion of the elbow. Hand grip testing was done with the Jammer dynamometer. In the first position his output was about 60 pounds, on the third position 98 pounds, and the fifth position 89 pounds. He was instructed in a range of motion exercise program and, since the patient preferred not to take any medications, non-steroidal antiinflammatory agents were not prescribed.
     He was seen again one week later, reporting that he felt no pain in the elbow after the treatment, and it was not until he mowed the lawn and did some remodeling work around his house over the weekend, that some soreness in the elbow returned. Examination on that day revealed that he had full range of motion from 45 degrees to 180 degrees on the left elbow. The range of motion testing was done again using the Cybex ergonometer (EDI 320).

DISCUSSION
     This case report indicates a very good measurable result of using acupuncture for the management of musculo-skeletal pain. Significant ergonometric and dynamometric changes were obtained immediately after, and one week following only one treatment. Many bursitis and tendinitis cases seen in practice respond to corticosteroid injection and this remains one of the effective choices of treatment for these conditions in orthopedic practice(4). However, with the awareness of steroid abuse, more and more patients refuse the use of steroids, especially done in the injectable form. Indeed there are questions regarding the longterm value and complications associated with the use of intra-articular injection of steroid(5). Medical acupuncture in this setting offers an effective alternative without the side effects associated with corticosteroid injections.
     The treatment of musculo-skeletal pain as well as bursitis/tendinitis involving the joints offers a very good model for the investigation of the effectiveness of medical acupuncture. There is a growing number of Board certified Physical Medicine specialists who use medical acupuncture for management of musculo-skeletal pain, and this trend will most likely result in a larger number of research contributions.
     Conditions like low back pain, of course, are very difficult to diagnose specifically without the use of expensive testing. However, musculoskeletal conditions such as bursitis/tendinitis, particularly of the upper extremities and the shoulder and elbow, can be accurately diagnosed by history and physical examination only. Subacromion bursitis and lateral epicondylitis are good examples of when a verifiable diagnosis can be made exclusively on clinical grounds in an office clinical setting.
     The efficacy of the treatment of acupuncture for these conditions can also be verified by objective, reproducible measurements of range of motion and strength. There are standardized methods and instruments for measuring these parameters. The case presented here is a good example of using a highly prevalent condition in Family Practice, Physiatry and Orthopedics, to conduct a study which could be carried out with minimal funding.
     The effectiveness of treatment, either with injection, medication or physical therapy, can be measured by the subjective scales evaluating degree of pain, tightness, numbness. More objective measurements, however, can be made with range of motion and strength testing. Strength testing, traditionally done manually by grading the muscle strength, is subject to inter/intra examiner bias and should probably not be used for research purposes. The dynamometer testing described above does include statistical and graphic analyses to insure reliability of the findings. Both the equipment and methodology can be reproduced and verified by following a standardized procedure. This case illustrates how the efficacy of medical acupuncture can be measured in the management of a common condition such as lateral epicondylitis.
     The following protocol for measurement of efficacy of medical acupuncture, specifically for acute and subacute musculo-skeletal pain syndromes is proposed:

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