11/7/2007
Objectives
Acupuncture In
Sports
Medicine:
Getting Right to
the Point!
Michael Krafczyk, MD, FAAFP, DABMA
St. Luke’s Family Practice/Sports Medicine
Bethlehem, PA
What is acupuncture?
• Insertion of needles
therapeutically in
various combinations
and patterns
• Dates as far back as
4000 BC
• Earliest major text was
2nd century BC
• Introduced into Europe
in 19th century
• Increased popularity in
U.S in 1970’s with
James Reston’s
landmark article
What is medical acupuncture?
• Acupuncture integrated
into Western medical or
allied health practices
• Derived from Asian and
European sources
• Choice of needle
patterns based on:
– Traditional principles
– Modern concepts
– Combination
• Used to complement
Western medicine
• Introduce acupuncture and acupuncture
terminology
• Discuss acupuncture’s role in sports medicine
• Introduce the pathophysiology of acupuncture
• Apply
A l pathophysiologic
th h i l i mechanisms
h i
tto
practical application to sports injuries
• Give overview of the literature supporting
acupuncture in sports medicine
• Review cases that would benefit from
acupuncture treatment
What is acupuncture?
•
•
Many different styles of:
Chinese, Japanese, Korean
Hand, auricular, etc.
In hands of trained
acupuncturist very safe
– Most common complications
are bruising, reaction to
metal, bleeding, vasovagal
response.
– More serious, but rare,
complications: pneumothorax
or puncture of other organs,
infection, puncture of larger
vessels, retained needle.
•
•
Generally treatments take
about 20 minutes
Minimal discomfort
Acupuncture Terminology
• Electroacupuncture (EA) –
acupuncture in which the
needles are stimulated with
electrical boxes, can alter
frequency and intensity to
modify pain
• Moxibustion – dried herbal
preparation of Artemisia
vulgaris (mugwort) that is
ignited and used to warm
needles
• Meridians – “channels” that
go from feet to hands and
then back to feet
1
11/7/2007
Does Acupuncture Play a Role in
Sports Medicine?
• Used in ancient China
on the battlefield
• Many countries have
acupuncturists on
staff for their Olympic
teams
• One Olympic athlete
stated that about 90%
of Olympic athletes
use acupuncture
Does Acupuncture Play a Role in
Sports Medicine?
• David Cone used
acupuncture to stay
healthy
• Matt Hasselbeck
featured numerous
times on ESPN.com
as using
acupuncture to
come back from
quad contusion
Does Acupuncture Play a Role in
Sports Medicine?
• Used very
commonly in dance
• Canadian
Gymnastic team has
acupuncturist that
travels with them
Does Acupuncture Play a Role in
Sports Medicine?
• NY Giants Michael
Strahan was
featured on MNF
and
d showed
h
d hi
him
getting acupuncture
• Pete Sampras and
Venus Williams both
had acupuncture for
injuries
Does Acupuncture Play a Role in
Sports Medicine?
• Other sports figures
known to use or have
used acupuncture:
–
–
–
–
–
–
–
–
Jeremy Shockey
Patrick Kerney
Bill Romanowski
Jim McMahon
Mark McGwire
Jaromir Jagr
Tyler Hamilton (biker)
Dwayne Wade
Pathophysiology
• Proposed
mechanisms:
– Local effects:
•
•
•
•
Vascular
Lymphatic
Nervous system
Musculotendinous
– Central effects:
• Analgesic
• Nervous system
• Anti-inflammatory
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11/7/2007
Pathophysiology
Pathophysiology – Pain Response
• Physiology of pain
– Various afferent nerve fibers are involved in
transmitting pain impulses
•
• Large myelinated nerves
– A- Beta (skin) carry touch
– Type I (muscle) carry proprioception
• Small myelinated nerves carry pain
– A-delta (skin)
– Type II and III (muscle)
•
•
•
• Type II, III, IV and C carry nonpainful messages
•
Electroacupuncture’s Effect:
Low frequency/high intensity
•
•
•
•
Acupuncture needle activates a
Type II or III small afferent
nerve from a sensory receptor
in the muscle
This cell synapses in spinal cord
and affects:
– spinal cord
– midbrain
– pituitary-hypothalamus
complex
Inhibitory response in spinal
cord causes blocks original
painful stimulus both locally and
segmentally
Centrally response transmitted
to pituitary/hypothalmus
resulting in release of
endorphins and ACTH
Pathophysiology of Pain Summary
• When using local points can recruit segmental and central
pain inhibition
• When using distal sites mainly recruiting central pain
response
• Clinically ideal to use both together
• The low frequency stimulation produces analgesia of
slower
l
onsett and
d llong d
duration,
ti
with
ith a 20 minute
i t
stimulation effecting 30-120 minutes of analgesia
– The effects are cumulative in repeat sessions
– may be due to observed increase in m-RNA for endorphins seen for 48
hours after stimulation
• The high frequency stimulation is rapid but short duration
and no cumulative effects
An injury to the skin activates
the sensory receptors
(squares) of small afferent Adelta and C-fibers (#1)
These synapse onto the
p
Tract in the
Spinothalamic
spinal cord (#2)
The Spinothalamic Tract cell
projects its axon to the
Thalamus (#3)
Here it synapses with a cell
that sends impulses to
activate the primary sensory
cortex (#4)
Dark triangles are excitatory
synapses, white are inhibitory
Electroacupuncture’s Effect:
High frequency/low Intensity
• Stimulates only the
spinal cord and
midbrain, but bypasses
endorphin synapses
there
• High frequency EA has
a strong spinal
segmental effect
• Mediated by:
– Monoamine transmitters
• Serotonin
• Norepinephrine
– Dynorphins
Proposed & Validated Mechanisms
for Acupuncture’s Effect
• Needles cause their
effect thru
bioelectrical, and/or
neurohumeral
mechanisms
• Different levels
affected
• Some mechanisms
supported by
research other is
speculation
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11/7/2007
Proposed & Validated Mechanisms
for Acupuncture’s Effect
Proposed & Validated Mechanisms
for Acupuncture’s Effect
• Unique properties of
acupuncture points
• Unique properties of
meridians
– Electrical conduction &
physiologic response to
electricity differs from
non-acupuncture
non
acupuncture points1
– Electron micrographs
show loose connective
tissue with high
concentration of nerves
and vessels – 80% of
known points illustrate
this2
– Correlate with
peripheral endings of
spinal/cranial nerves3
1Niboyet
JE, Mery A. Experimental Research of the Meridians. Internation Journal of Acupuncture. 1957: 47-51
R, Auziech O. Histophysiology of Acupuncture Points. Acupuncture and Traditional Chinese Medicine. 1989
anatomy department of Shanghai Medical University. A relationship between points of meridian and peripheral nerves. Acupuncture Anaesthetic Theory
Study. 1973: 251-264
2Senelar
3Human
PathophysiologyProposed & Validated
Mechanisms for Acupuncture’s Effect
•
Vascular effects
– Thermographic scans show
manual acupuncture induces a
nonsegmental warming
effect(1)
– Plethysmography shows
increased blood flow with
electroacupuncture(2)
•
Antiinflammatory
– EA has been shown to increase
cortisol levels
– Proposed that local needles
placed without stimulation
decreases inflammation
•
•
1Ernst
Immune – some evidence that
acupuncture can stimulate IgA
as well as other immune effects
Has been shown to modulate
autonomic nervous system and
decrease hear rate(3)
M, et al. Sympathetic vasomotor changes induced by manual and electrical acupuncture…Visualized by thermography. Orthopedic Review 21
1985:25-33
2Looney GL, et al. A neurologic basis for acupuncture. Acupuncture Electrotherapeutic Research. 1(1976): 210.
3 Knardahl JP,Elam M,et al. Sympathetic nerve activity after acupuncture in humans. Pain 75:19-25, 1998.
Proposed & Validated Mechanisms for
Acupuncture’s Effect
• Cutaneovisceral reflex
– Diseased organs will
refer pain superficially
(splanchnotomal
distribution)
– Needling
N dli th
these points
i t iis
proposed to affect the
involved organ
• Can improve fatigue by
increasing beta
endorphins and cortisol
– Technetium99 injected at
acupuncture point
diffused along meridian
vs nonacupuncture
points diffused
centrifugally.
Stimulation of the points
increased migration
rate1
– Resistance between 2
acupuncture points on
same meridian
consistently less than 2
random points2
1Darras JC, et al. Nuclear medicine investigation of transmission of acupuncture information. Acupuncture in Medicine. 11(1993): 2228.
2Reichmanis M, et al. Skin conductance variation at acupuncture loci. Journal of Chinese Medicine, 4(1976): 69-72.
Proposed & Validated Mechanisms for
Acupuncture’s Effect
• Can also use similar to
trigger point injections
– Dry needling to release
muscle spasm
– Attempt to needle motor unit
and cause stretch reflex
– This is similar to testing
reflexes – get rapid
contraction followed by
relaxation
– Study showed 71%
correlation between trigger
points and acupuncture
points*
*Melzack R, et al. Trigger points and acupuncture points for pain. Correlations and implications. Pain, 3 (1977): 3-23.
Application In Sports Injuries
• 20 yo soccer player
injures back during soccer
match
• Presents prior to next
game with continued back
pain
• Exam reveals tight muscle
spasm in lumbar
paraspinals with trigger
points
• Treatment: High
frequency/low intensity EA
at site of trigger points
along with meridian
treatment for more central
pain response
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11/7/2007
Application In Sports Injuries
• Lacrosse player sustained
grade II ankle sprain during
game
• Next week is league
championship
• Exam: Swollen ankle with
erythema, tender over ATFL,
min laxity on drawer
• Use local needles around
swelling and leave in
dispersion (not stimulating
needle)
• Do this daily until swelling
down
Application In Sports Injuries
•
•
•
17 yo high school field hockey
and track runner who presents
with persistent shin splints
unresponsive to conservative tx
Exam: tenderness over mid to
distal tibia medial border; bone
scan negative
ti
Treatment:
Application In Sports Injuries
•
•
•
•
– Consist of specific peripheral
points that would have a
central effect releasing
endorphins and cortisol
– Could also use points geared
towards the autonomic
system
Application In Sports Injuries
• NFL quarterback sustains
quad contusion
• Exam reveals significant
ecchymosis and swelling
q
over lateral quad
• Treatment:
– Standard tx
– Initially local needles around
quad left in dispersion
– As swelling decreases over
several days begin to
needle into tender area with
high frequency stim
– Local myofascial needling
– Needle trigger points and put
mid to high frequency stim
– Use nonlocal points (meridians)
– Superficial needles over tibia
– Needles along tibial border with
EA
•
Patient does well and competes
pain free with acupuncture q3
weeks
Application In Sports Injuries
• 21 yo college basketball
player develops acute
gastroenteritis
manifested by
abdominal pain and
nausea the day before
a big tournament
• Exam is c/w VGE
• Treatment:
– Use meridian points
which help control
nausea
– Find splanchnotomal
reflex points on abdomen
and back and needle
19 yo NCAA 800 meter runner
at a invitational track meet
Ran 800 semifinals and
4X800 meter relay and has to
run both again tomorrow
C/o fatigue and is worried
about being tired tomorrow
Treatment:
Application In Sports Injuries
•
•
•
•
•
32 yo triathlete presents with
persistent ITB pain and
tightness
Stretching and PT have not
helped
Exam:
– Tender along length of ITB
– Tight ITB’s by palpation and
Ober test
Treatment:
– Continue stretching
– Acupuncture needles placed
along ITB
Results:
– Patient continued to have
relaxation of the ITB with
less pain and tightness
– 4 months later completed
ironman triathlon
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11/7/2007
Table 1: World Health Organization Indications for Acupuncture
Respiratory Diseases
Acute sinusitis
Acute rhinitis
Common cold
Acute tonsillitis
Bronchopulmonary
Diseases
Acute bronchitis
Bronchial asthma
Eye Disorders
Acute conjunctivitis
Cataract(without
complications)
Myopia
Central retinitis
Orthopedic Disorders
Periarthritis humeroscapularis
Tennis elbow
Sciatica
Low back pain
Rheumatoid arthritis
Gastrointestinal Disorders
Spasm of the esophagus and cardia
Hiccups
Gastroptosis
Acute and chronic gastritis
Gastric hyperaciditt
Chronic duodenal ulcer
Acute and chronic colitis
Acute bacterial dysentery
Constipation
Diarrhea
Paralytic ileus
Neurologic Disorders
Headache
Migraine
Trigeminal neuralgia
Facial paralysis
Paralysis after apoplectic fit
Peripheral neuropathy
Paralysis caused by polio
Meniere’s syndrome
Neurogenic bladder
Nocturnal enuresis
Intercoastal neuralgia
Disorders of the Mouth Cavity
Toothache
Pain after tooth extraction
Gingivitis
Pharyngitis
Table 2. NIH Consensus Statement: Efficacy for Specific Disorders
Clear Evidence
Adult post-op nausea and vomiting
Adult chemotherapy nausea and vomiting
Nausea of pregnancy
Reasonable Evidence
Pain relief in: menstrual cramps,
tennis elbow, fibromyalgia
Evidence
Post-op dental pain
Does not demonstrate efficacy
Smoking cessation
Acupuncture. NIH Consensus Statement 1997 November 3-5;15(5)
Bannerman R. Acupuncture: the WHO view. World Health December 1979;12:27-28.
What’s The Evidence?
•
•
What’s The Evidence?
Not much!!!
Problems with acupuncture
research:
• Lateral epicondylitis
– Multiple studies
showing benefit
– Mostly short term
improvement*
– Can not do double blind
placebo controlled trials
– Hard to blind patient to
treatment
– Can not blind acupuncturist to
tx
– Many different forms of
acupuncture
– Individualized treatments, ie
not formula driven
•
•
Much of the research comes
out of Europe and China
Some of the Chinese literature
is questionable
*Trinh KV, et al. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumtalogy 2004 Sep;43(9):1085-90.
What’s the evidence?
• Patellofemoral Pain
– Systematic review in
Journal of Orthopaedic &
Sports Physical Therapy
concluded that
acupuncture was
effective in tx PFPS
– Based on study by
Jensen in 1999
– This study was given the
highest methodologic
quality score in this
review
What’s The Evidence?
• Back pain
– Cochrane review suggests
acupuncture may be useful adjunct
for chronic low back pain
– 2 recent meta-analysis reviewed
RCT’s using acupuncture for any
type of LBP1,2
• Showed acupuncture superior
to various sham interventions
• No evidence to suggest
acupuncture better than other
interventions for chronic LBP
• Insufficient evidence for use in
acute LBP
– Recent clinical guidelines from
ACP and APS recommends
acupuncture as option for patients
who fail self-care for 3
subacute/chronic LBP
1Manheimer
E, et al. Meta-analysis: Acupuncture for low back pain. Ann Intern Med. 2005;142:651-663.
et al. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration.
Spine. 2005;30:911.
R, et al. Diagnosis and Trreatment of LBP: A joint clnical practice guideline from the American College of Physicians and the American Pain
Society.. Ann Intern Med. 2007;147:478-491.
2Furlan AD,
3Chou
6
11/7/2007
What’s The Evidence?
• Neck pain
What’s The Evidence?
• Osteoarthritis
– Cochrane Database review in 2006 found1:
– Systematic review1 concluded
in most rigorous studies,
acupuncture not superior to
sham but both alleviated sxs,
so either:
• Sham effective tx
• Strong placebo effect
– RCT comparing acupuncture
and hydrotherapy to control in
patients with hip OA2
• Tx groups had improved:
– Pain control
– Function
– Quality of life
• Electroacupuncture pain
and function benefits lasted
at least 3 months longer
than hydrotherapy
• Moderate evidence that acupuncture relieves pain better than some
sham tx
• Moderate evidence that acupuncture patients had less pain at short term
follow-up compared to wait listed patients
• Moderate evidence that acupuncture more effective than inactive tx for
relieving pain and this is maintained at short follow-up
– RCT in patients with chronic neck and shoulder pain showed
reduced neck and shoulder pain up to 3 years after tx compared
to placebo group (sham)2
– RCT showed acupuncture added to routine care in patients with
chronic neck pain improved pain and disability compared to tx with
routine care.3
1Trinh
KV, et al. Acupuncture for Neck disorders. Cochrane Database Syst. Rev. 2006 Jul 19;3:CD004870. Review
D, et al. Effect of acupuncture treatment on chronic neck & shoulder pain in sedentary female workers: a 6 month and 3-year follow-up study.
Pain. 2004 Jun;109(3):299-307.
et al. Acupuncture for patients with chronic neck pain. Pain. 2006 Jun 13.
2He
1Ezzo J, et al. Is acupuncture effective for the treatment of chronic pain? A systematic review. Pain. 2000;86:217
2Stener-Victorin E, et al. Comparison between electro-acupuncture and hydrotherapy, both in combination with patient education and patient education alone, on the sx tx of
OA of the hip. Clin J Pain. 2004;20:179.
3Witt CM,
What’s The Evidence?
• OA of the knee
– Systematic review1 in
2001 revealed:
• Strong evidence that
more effective than
sham
• Evidence limited
whether better than
usual care
– Subsequent systematic
review2 in 2002 should
marked placebo effect
– 3 RCT’s3-5 since have
shown improvements in
pain and function over
placebo and 2 over
control
1Ezzo
J, et al. Acupuncture for Osteoarthritis of the knee.: A systematic review. Arthritis Rheum. 2001;44: 819
I, et al. Effectiveness of acupuncture in the treatment of pain from osteoarthritis of the knee. Aten Primaria 2002;30:602
BM, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a RCT. Ann Int Med 2004;141:901.
J, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: RCT. BMJ 2004;329:1216/
c, et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet. 2005;366:136
2Ferrandez
3Berman
4Vas
5Witt
What’s The Evidence?
What’s The Evidence?
• Acupuncture more
effective than U/S in
shoulder
impingement1
• A recent study
showed auricular
acupuncture
decreased the need
for ibuprofen in
patients after
ambulatory knee
surgery2
1Johansson
2Usichenko
KM, et al. Effects of acupuncture versus ultrasound in patients with impingement syndrome: A RCT. Phys Ther. 2006 Jan;86(1):143-144.
T, et al. Auricular acupuncture for pain relief after ambulatory knee surgery: A randomized trial. CMAJ. 2007;176(2):179-83.
What’s The Evidence?
• Performance
– “The Effect of Acupuncture and Moxibustion on Physical
Performance by Sedentary Subjects Submitted to Ergospirometric
Test on the Treadmill” in The Journal of Sports Medicine and
Physical Fitness 2005
• Found decrease in heart rate compared to controls
threshold, velocity in anaerobic threshold and
• O2 uptake in anaerobic threshold
caloric consumption increased significantly
– “Influence of acupuncture on physical performance capacity and
hemodynamic parameters” in American Journal of Acupuncture
1993
• Treatment group had higher maximal exercise capacity
• Treatment group were able to perform higher workloads at onset of
blood lactate accumulation compared to placebo
• “Acupuncture and
Responses of Immunologic
and Endocrine Markers
during Competition” in
Medicine and Science in
Sports and Exercise 2003
– Looked at elite female
soccer players during a
multiday tournament
– Found
• Exercise induced decrease
in salivary IgA and increase
of salivary cortisol were
inhibited by acupuncture
• Acupunture improved
subjective rating of muscle
tension and fatigue
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11/7/2007
Who is an appropriate
acupuncture patient
• Acute injuries:
– Used in conjunction with
conventional tx
– Trying to speed up RTP
– Failing conventional tx
– Not a surgical problem
– Ex: ankle/MCL sprain, LBP
• Chronic conditions
– Failing conservative tx and
not a surgical candidate
– Ex: LBP, neck pain, OA,
tennis elbow, plantar fasciitis,
shin splints, PFPS, etc…
• Preventative
– Athletes with lack of flexibility
– Help recovery
– Ex: athlete with tight ITB,
generalized pain/fatigue after
competition
• Medical problems
–
–
–
–
Virall ill
Vi
illness
Nausea
Fatigue
Make sure conventional eval
and tx done first or in
conjunction with tx
– Ex: viral gastroenteritis,
common cold, chronic fatigue
syndrome, nausea of
pregnancy, etc..
Conclusions
• There are some physiologic models for explaining
acupunctures affects
– Some backed by science
– Others hypothesized
• Many athletes utilize acupuncture including elite
athletes with perceived benefits
• Athletes with many different types of
injuries/illness could potentially benefit from
acupuncture
• The evidence behind acupuncture is scant but is
starting to increase
8