Randomized Trial of Trigger Point Acupuncture Treatment

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60 K Itoh et al, 1 Introduction shoulder pain lasting for 6 months 2 no neurological. disorders causing shoulder pain 3 an average pain score. Shoulder pain is an important medical and socioeconomic of 50 mm or on a 100 mm visual analogue scale VAS in the. problem in the western world with between 7 and 26 of pre month 4 age between 40 years and 70 years 5 no. the population reporting shoulder problems at any one time referred pain from the cervical spine 6 no osteoarthritis. 1 The presence of pain and stiffness in the shoulder can of the glenohumeral joint or systemic bone and joint dis. lead to an inability to work and or to carry out domestic order e g rheumatoid arthritis 7 no history of shoulder. and recreational activities thus creating a high burden of surgery 8 no other current therapy involving analgesics. disease for both the individual and society 2 9 had not received acupuncture in the last 6 months and. Pain and stiffness of the shoulder is commonly caused by 10 insufficient response to the medications prescribed by. rotator cuff disorders including tendonitis and bursitis by their orthopedic specialist. adhesive capsulitis and by osteoarthrosis of the gleno The patient could continue to use their medications as. humeral joint 3 The normal course of the disease consists they had before enrolment Exclusion criteria were major. of a gradual or sudden onset accompanied by night pain trauma or systemic disease and other conflicting or. and pain on moving the affected joint The mobility of the ongoing treatments. shoulder joint then becomes progressively more limited Patients who gave written informed consent were. until in many cases a frozen or stiff shoulder is the result enrolled and randomly allocated using a computerized. The process according to most of the literature is gener randomization program to the trigger point acupuncture. ally self limiting lasting for about 1e3 years Neverthe TrP or SH treatment groups Each patient received a. less a significant number of patients suffer from a residual total of five treatments one per week each lasting 30. clinically detectable restriction of movement beyond 3 minutes and was followed up for 20 weeks from the first. years 4 The common treatments for shoulder pain are treatment. NSAIDs physiotherapy injections and conservative wait Patients were blinded to their treatment They were. and see 5 Unfortunately none of these treatments is told before randomization that they would be allocated to. clearly proven to be effective for chronic shoulder pain in one of two groups The measurements were performed by. the long run calling for new treatment strategies to an independent investigator who was not informed about. improve the situation of chronic shoulder pain sufferers the treatment sequence or the treatment the patient. 4 5 received before each measurement Patients were asked to. Worldwide chronic shoulder pain is considered one of cover their eyes with an eye mask to blindfold them and to. the indications most amenable to treatment with ensure that they avoided being aware of the SH procedure. acupuncture 6e10 A small number of clinical and meth Ethical approval for this study was given by the ethics. odologically diverse trials have been published recently committee of the Meiji University of Integrative Medicine. that show little evidence to support or refute the use of. acupuncture for chronic shoulder pain 11 However 2 1 Trigger point acupuncture group. whether the effect varies depending on the difference in. the acupuncture technique has not clearly been The trigger point acupuncture TrP group received. demonstrated acupuncture treatment at trigger points The correct. It is generally accepted that the acupuncture treatment application of the technique requires experience in palpa. administered in the studies conducted so far have been tion and localization of taut muscle bands and myofascial. based on clinical practice rather than empirical evidence trigger points Precise needling of active myofascial trigger. The method of point selection in published trials seems to points provokes a brief contraction of muscle fibers This. be more simple and formulaic than that used in the stan local twitch response should be elicited for successful. dard acupuncture practice at our clinic We believe that therapy but it may be painful and posttreatment soreness. the response to acupuncture and therefore the success of is frequent 12 13 In this study the most important mus. a trial depend substantially on the choice of and the cles of the neck and superior limb were examined for. number of points treated myofascial trigger points Table 1. The main aim of this study was to determine if Disposable stainless steel needles 0 2 mm 50 mm. acupuncture at trigger points is an effective treatment for Seirin Sizuoka Japan were inserted into the skin over the. chronic shoulder pain when compared with sham SH trigger point to a depth of 5e15 mm appropriate to the. treatment at trigger points muscle targeted attempting to elicit a local muscle twitch. response using the so called sparrow pecking technique. 2 Materials and methods After the local twitch response was elicited or a reason. able attempt made the needle was retained for a further. 10 minutes The mean number of insertions was 4 1, The design of this study was a blinded SH controlled. randomized clinical trial in which one group received. acupuncture treatment and the other SH acupuncture 2 2 Sham acupuncture group. treatment Patients aged 40 years with a history of. shoulder pain were recruited from the Meiji University of The sham SH group received SH treatment at trigger. Integrative Medicine Hospital specifically for the study The points The methods of choosing trigger points were the. patients were outpatients in whom chronic shoulder pain same For the SH group similar stainless steel needles. had been clinically diagnosed Inclusion criteria were 1 0 2 mm 50 mm were used but the tips had been cut off. RCT of trigger point acupuncture for chronic shoulder pain 61. Table 1 Muscles treated in the two trigger point,acupuncture groups. Muscle Trigger point group Sham group,Musculus trapezius 3 4. M supraspinatus 4 6,M infraspinatus 6 6,M teres minor 4 3.
M teres major 2 2,M subscapularis 5 6,M latissimus dorsi 1 2. M pectoralis major 2 2,M pectoralis minor 2 1,M biceps brachii 2 3. to prevent the needle from penetrating the skin The cut Figure 1 Participation flow in the study One patient was. ends were smoothed with sandpaper manually under clean excluded after she dropped out. conditions 14 The acupuncturist pretended to insert and. manipulate the needle place the needle with a guide tube applied to detect significant changes within each group To. over the designated point and tap the top of the needle compare the results of two groups the area under the. handle and then remove the tube while holding the needle curve AUC of the pain VAS was calculated from the sum. tip with the thumb and the forefinger of the left hand and mation of the timeeresponse curves for individual patients. thrust and withdraw the needle with the right hand which The AUC data arbitrary units for each group were used for. holds the needle handle sparrow pecking technique A group comparison by a one way analysis of variance. simulation of needle extraction was performed after 10 ANOVA followed by post hoc multiple comparisons using. minutes by touching the patient and noisily dropping the Bonferroni correction. needles into a metal case Assessment of the success of blinding was analyzed using. To facilitate blinding we used an eye mask The mean a c2 test SPSS software for Windows version 11 0 SPSS. number of insertions was 4 4 The treatments were per Japan Inc Shibuya Tokyo Japan or Systat 11 Systat. formed by two acupuncturists who had 4 years of Software Washington Chicago USA was used for the. acupuncture training and 3 or 10 years of clinical statistical analysis A p value 0 050 was considered as. experience statistically significant,2 3 Evaluation. Primary outcome measures were pain intensity quantified. using a 100 mm VAS and pain disability 15 measured 3 1 Patient characteristics. using the ConstanteMurley Score CMS 15 16 The total. CMS consists of nine questions range 0e100 points the Eighteen patients 15 women 3 men aged 42e65 years. worst condition being 100 were randomized to two groups and administered treat. The VAS measures were assessed immediately before the ment Fig 2 No differences were found the between the. first treatment and 1 2 3 4 5 10 and 20 weeks after the two groups in the variables measured at baseline including. first treatment The CMS measures were assessed before age disease pain duration VAS and drug use Table 2. the first treatment and 5 10 and 20 weeks after the first Patient progress through the trial is shown in Fig 2 One. treatment The VAS and SMS measures were completed by patient in the SH group dropped out as they had no. participants immediately before each treatment Fig 1 response to treatment The drop out rate was not different. To examine the efficacy of the blinding technique of the among the groups p Z 0 31 ManneWhitney U test The. study the participants were asked to select an answer for analyses were performed on the 17 patients who completed. the question How did you feel when the acupuncture the study. needle was inserted at the end of the first phases The. available answers were 1 needles were inserted into. 3 2 VAS score, muscle 2 needles did not penetrate the skin and 3 I. could not discriminate the difference, Pain intensity decreased at weeks 4e5 in the TrP group.
when compared with pretreatment levels These improve. 2 4 Statistical analysis ments persisted for 10 weeks after cessation of the treat. ment in the TrP group The mean VAS score decreased. The data are reported as mean standard deviation significantly in the TrP group p 0 001 in the TrP by. mean SD Dunnett s multiple comparison test was repeated measures ANOVA Fig 2. 62 K Itoh et al, Figure 3 The columns indicate the area under the curve. AUC arbitrary units for changes in the pain visual analogue. Figure 2 This shows the effect of acupuncture on visual. scale VAS score in the two groups During the observation. analogue scale VAS score for chronic shoulder pain The pain. period improvement was greater in the TrP group than the SH. intensity was lower at weeks 4e5 in the trigger point. group p Z 0 024 p 0 01, acupuncture TrP group when compared to pretreatment. scores TrP group n Z 8 A sham acupuncture group,n Z 7 p 0 05 p 0 01 4 Discussion. The AUCs for pain intensity VAS score are shown in In the present study there was a statistically significant. Fig 3 The score was significantly lower in the TrP group difference between the TrP and SH acupuncture treat. than in the SH group p Z 0 024 ments 5 weeks after the first treatment These results. suggest that TrP treatment is more effective than SH. acupuncture treatment for chronic shoulder pain, 3 3 Functional impairment In many cases chronic shoulder pain is correlated with. deformation of the shoulder joint and muscle tension. The reduction in the CMS score was higher at week 5 in the around the joint 17 A wide range of treatments are used. TrP group when compared with that at pretreatment including drugs physical medicine methods and manual. These improvements persisted for 1 month after cessation treatments 4 5 Acupuncture treatment has been used for. of the treatment The mean CMS score showed a significant pain relief for a long time Several studies have examined. reduction in the TrP group p 0 001 in the TrP Fig 4 the efficacy of acupuncture treatment for shoulder pain. The AUCs for functional impairment CMS score are however the results have been mixed 11 17. shown in Fig 5 The score was not significantly higher in the In evaluating the efficacy of acupuncture three impor. TrP group than in the SH group p Z 0 311 tant parameters are the site mode and intensity of the. stimulation For assessing the stimulation site parameter. one can define the number of stimulation sites and their. 3 4 Assessment of the blinding technique location traditional acupoint or tender trigger point In. In the present procedure 77 8 in the TrP group and 75 0. in the SH group stated that they received the needle. insertion to the muscle whereas 22 2 in the TrP group and. 25 0 in the SH group stated they received no penetration. of the needle There was no significant difference between. the two treatment types c2 Z 0 18 p Z 0 89, Table 2 Characteristics and baseline values of patients in.
the two groups,Trigger point group Sham group,Sample size 8 8. Age y 55 0 12 6 59 3 15 6,Pain duration y 2 1 1 6 2 2 1 6. Visual analogue 67 3 18 2 66 9 10 1, scale mm Figure 4 The effect of acupuncture on ConstanteMurley. ConstanteMurley 57 0 9 9 57 6 8 0 Score CMS score indicating shoulder function The CMS score. Score was lower at weeks 5e10 in the trigger point acupuncture TrP. Drug user 0 0 group when compared to pretreatment scores TrP group. n Z 9 A sham acupuncture group n Z 8 p 0 05, RCT of trigger point acupuncture for chronic shoulder pain 63. pain or referred tenderness and local twitch response. 12 13 Acupuncture or dry needling of a myofascial trigger. point appears to provide immediate relief of pain related to. that myofascial trigger point 21 33 34 However the ef. fects of TrP on chronic shoulder pain remain unclear. 2 1 Trigger point acupuncture group The trigger point acupuncture TrP group received acupuncture treatment at trigger points The correct application of the technique requires experience in palpa tion and localization of taut muscle bands and myofascial trigger points Precise needling of active myofascial trigger points provokes a brief

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