Observation on Clinical Effect of Superficial Needling for Intractable Humeral Epicondylitis

Zhang Dong-yun, Song Hai-yun

Taihe Hospital Affiliated to Hubei Medical College, Shiyan 442000, China

Observation on Clinical Effect of Superficial Needling for Intractable Humeral Epicondylitis

Zhang Dong-yun, Song Hai-yun

Taihe Hospital Affiliated to Hubei Medical College, Shiyan 442000, China

Objective: To observe the clinical effect of superficial needling for intractable humeral epicondylitis.

Methods: Sixty cases in conformity with the inclusion criteria of intractable humeral epicondylitis were randomly divided into two groups, 30 cases in each. The cases in the superficial needling group were treated by superficial needling plus moxibustion, while those in the electroacupuncture (EA) group were treated by EA plus moxibustion. After treatment, the improvement of the clinical symptoms and signs were compared between the two groups.

Results: The curative rate was 80.0% and the total effective rate was 96.7% in the superficial needling group. The curative rate was 60.0% and the total effective rate was 83.3% in the EA group. The differences in the clinical effects between the two groups were statistically significant (P＜0.05).

Conclusion: The therapeutic effect of superficial needling plus moxibustion for intractable humeral epicondylitis is better than that of EA plus moxibustion.

Tennis Elbow; Superficial Needling; Electroacupuncture; Acupuncture Therapy; Moxibustion Therapy; Suspended Moxibustion

Humeral epicondylitis, also termed tennis elbow, is caused by mild tear and minor bleeding of the tendons attached to the carpal extensor muscle, common extensor muscle of the fingers, and supinator muscle due to accumulated chronic strain, producing adhesion and scars during self-repairing, and leading to chronic aseptic inflammation. It often occurs in jobs with large load of activity of the forearm, mostly in the middle-aged and elderly people. Currently, acupuncture, physiotherapy, topical application of herbal drugs, block therapy and acupotomy are mostly adopted in clinic and can work at different extent[1-4]. But, some intractable cases repeatedly reoccur and are difficult to cure. Between January of 2011 and January of 2013, 30 cases of intractable humeral epicondylitis were treated with superficial puncture plus moxibustion in our clinic. Now, the report is given as follows.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnostic criteria were stipulated in accordance with theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[5]and theDiagnostic Classification and Standard ofFunctional Evaluation of Damage and Diseases of Bone and Joint[6]. Generally, there is no obvious traumatic history, but it is often seen in workers frequently using the forearm, such as masons, carpenters, heavy object carriers, sweater knitters, and mahjong players. The rotating activity of the elbow joint is limited, with sensitive tenderness on the external epicondyle of the humerus, and positive extensor tendon stretch test (Mills sign) or positive extensor extension test (Cozen test).

1.2 Inclusion criteria

Those in conformity with the above diagnostic criteria, with the age ranging from 20-65 years old; no traumatic history in the sick elbow joint recently; no improvement after 1-3 different types of treatment, or with reoccurrence after three times of block therapy or acupotomy; having signed informed consent.

1.3 Exclusion criteria

Those not in conformity with the above inclusion criteria, or complicated with cardiovascular diseases, infectious disease and mental disorders; and those giving up or not cooperating with the treatment due to various reasons.

1.4 General data

Totally, 60 cases of the recruited patients all came from the Acupuncture Department of our hospital. Before treatment, the patients failed after receiving 1-3 different types of physiotherapy, medications or acupotomy, or reoccurred after three times of block therapy or acupotomy. The above patients were divided by random digital table into a superficial needling group and an electroacupuncture (EA) group. In 30 cases of the superficial needling group, there were 12 males and 18 females, with the age ranging from 35-60 years old, at the average age of (44.5±6.5) years; with the duration ranging from 19 to 35 months, at the average duration of (15.6±11.0) months, including 9 cases with problem in the left elbow and 21 cases in the right elbow. In 30 cases of the EA group, there were 14 males and 16 females, with the age ranging from 36-63 years old, at the average age of (45.5±7) years; with the duration ranging from 20 to 30 months, at the average duration of (14.8±12.0) months, including 11 cases with problem in the left elbow and 19 cases in the right elbow. In comparison of gender, duration and pathological situation between the two groups, the differences were not statistically significant (P＞0.05), indicating that the two groups were comparable.

2 Therapeutic Methods

2.1 Superficial needling group

2.1.1 Superficial needling

Acupoint: Ashi point.

Operation: After the patient took a sitting or supine position, doctor looked for the tenderness in the local area of the humeral epicondyle and fix on the inserting spot 6-8 cm away from the tenderness. After the doctor’s fingers and the inserting spot of the patient were disinfected, Fu’s superficial needle of 0.6 mm in diameter and 32 mm in length was used. By holding the needle handle with the thumb, index and middle finger, the doctor inserted the needle toward the tenderness with a 15°-35° angle between needle body and skin, and then inserted it quickly about 5 mm with proper strength. Then, the needle was slightly lifted and pulled away from the muscle to the underneath of the skin, and with the needle tip in the shallow fasciae directly toward the tenderness. In the whole process, the patient did not have aching, distending, numb and painful sensation. Otherwise, the depth of the needle insertion should be adjusted. Then, with the inserting spot as a fulcrum, the doctor held the needle base and shook the needle leftward and rightward in a fan movement, gently and softly in rhythm, not upward or downward suddenly. The needle was manipulated for 2-3 min each time, till the patient’s pain disappeared completely or was not relieved any more. The needle was retained for 10 min and then manipulated in the above way for 2-3 min. In the whole treatment, the operation would be repeated for three times. The needle was retained for 40-50 min and then taken out.

2.1.2 Moxibustion

Acupoints: Ashi point, Quchi (LI 11), and Zhouliao (LI 12).

Operation: Moxa roll of 2 cm in length was inserted into the moxibustion board and ignited. Then, the moxibustion board was put on the above acupoints for treatment, with a distance of 2-3 cm between the moxa roll and the skin. The patient felt warm but without pain in the local area. Generally, moxibustion was applied to each acupoint for 10-15 min.

2.2 EA group

2.2.1 EA

Acupoints: Ashi point, Quchi (LI 11), Zhouliao (LI 12), and Shousanli (LI 10)[2].

Operation: After the patient took a sitting or supine position, with the arm flexed, the filiform needles of 0.3 mm in diameter and 40 mm in length were used. After the arriving of the needling sensation, the needle handles were connected with G6805-2 EA apparatus with continuous wave and 2.2-3.0 Hz frequency. The stimulating intensity should be within the patient’s tolerance. The needle was retained for 30 min.

2.2.2 Moxibustion

The acupoints and operation were as same as those in the superficial needling group.

Both groups were treated once every day, and a continuous 7-day as one course. One-day rest was givenbetween two courses. After three courses, the therapeutic effects were assessed by one certain person.

3 Observation of Therapeutic Effects

3.1 Observed Indexes

3.1.1 Improvement of pain

The scores were recorded by four grades of pain degrees: no pain 30 points; mild pain 20 points; moderate pain 10 points; and severe pain 0 point.

3.1.2 Scores of activity function of the elbow joint

The motor arc above 100° was 20 points; the motor arc between 50°-100° was 15 points; and the motor arc below 50° was 5 points.

3.1.3 Scores of activities of daily living (ADL)

Including the eight items of combing hair, washing face, brushing teeth, lifting object, twisting towel, unbuttoning, and fastening the belt, the completion of every movement was divided into five grades: unable to complete 0 point; complete under help of other people 1 point; complete partially 2 points; complete in long time 3 points; complete normally 4 points; and full mark 32 points.

The lower the scores were, the worse the pathological situation was.

3.2 Criteria of therapeutic effects

Cured: Pain disappears, without pain in lifting object, normal activity in the elbow.

Remarkable effect: Pain is relieved, basically normal in the activity of the elbow joint.

Effect: After the treatment, the above indexes are improved.

Failure: No obvious change in the symptoms and signs after treatment.

3.3 Therapeutic results

3.3.1 Comparison of therapeutic effects

After treatment, the curative rate and total effective rate were obviously higher in the superficial needling group than those in the EA group, and the differences between the two groups were statistically significant (P＜0.05), indicating that the therapeutic effect was better in the superficial needling group than that in the EA group (table 1).

Table 1. Comparison of clinical effects after treatment between the two groups (case)

3.3.2 Changes of pain scores before and after treatment

Before treatment, there was no statistical difference between the two groups (P＜0.01), and after treatment the superficial needling group was obviously better than the EA group. The differences between the two groups were statistically significant (P＜0.05), indicating that the superficial needling plus moxibustion should be helpful to relieve the patient’s pain (table 2).

3.3.3 Score changes in ADL and the activity function of the elbow joint

After treatment, scores in ADL and the activity function of the elbow joint were obviously increased, with statistical differences in comparison with the same group before treatment (P＜0.01 orP＜0.05). The differences between the two groups after treatment were statistically significant (P＜0.05), indicating that the superficial needling plus moxibustion can obviously enhance the ADL and activity of the elbow joints of the patients (table 3).

Table 2. Comparison of pain before and after treatment between the two groups (, point）

Table 2. Comparison of pain before and after treatment between the two groups (, point）

Note: Compared with the same group before treatment, 1)P＜0.01; compared with the EA group after treatment, 2)P＜0.05

Superficial needling307.92±1.10 23.95±1.741)2)EA 307.54±1.51 14.79±1.541)

Table 3. Comparison of ADL scores before and after treatment between the two groups (, point)

Table 3. Comparison of ADL scores before and after treatment between the two groups (, point)

Note: Compared with the same group before treatment, 1)P＜0.01, 2)P＜0.05; compared with the EA group after treatment, 3)P＜0.05

GroupsnADL score Score of elbow activity Before treatment After treatment Before treatment After treatment Superficial needling 30 11.54±1.52 25.01±2.001)3)8.91±1.43 18.05±1.011)3)EA 30 12.01±1.01 18.98±0.881)9.02±1.31 13.14±1.132)

4 Discussion

Humeral epicondylitis belongs to the scope of‘tendon Bi-Impediment syndrome’, ‘injury of tendon’and ‘elbow pain’ in Chinese medicine, and is mostly caused by inappropriate use of the strength, leading to obstruction of the meridians and poor circulation of qi and blood, and hence presenting pain and motor impairment. The superficial needling originated from the theories of traditional acupuncture, Ashi points and wrist-ankle acupuncture, and is obviously effective to localized pain with obvious tenderness[7]. It is believed in modern medicine that superficial needling functions underneath the skin, producing the piezoelectric effect and converse piezoelectric effect by the interaction of the loose connective tissues. By the information transmission, pain threshold can be instantly elevated, so pain can instantly disappear or obviously be relieved. At the same time, the sweeping and dispersing action is a special feature of the superficial acupuncture. The repeated sweeping action of the superficial needling can quickly change the microcosmic electrophysiology of the cell tissues, relieve spasm and contraction of muscles and other soft tissues, and enhance local blood circulation and repair inflammation[8-9].

Moxibustion can warm up the body, disperse cold, support yang and correct prostration, dissolve blood stasis, disperse masses, prevent disease for healthcare. Some scholars believe that moxibustion has two major functions: local temperature increase by heat energy via direct transmitting effect of the body tissues, and the reaction of the body to the heat stimulation, leading to the circulatory temperature-increasing phenomenon along the longitudinal axis tissues of the body. The foundation of moxibustion in the treatment of disease is heat stimulation and drug permeation[10-11]. Moxibustion can realize the local temperature increase to relieve pain and can also permeate the medicinal components of moxa leaves to the acupoints by the heat stimulation to the meridians and acupoints, so as to lead to temperature increase along the meridians, to realize the triple effect of heating, herbal drug and acupoints for the treatment of diseases.

It is indicated by the results from this study that the superficial needling (without retaining the needle) plus moxibustion for intractable tennis elbow is better than the EA plus moxibustion in the therapeutic effect. The author thinks that its key is to use the sweeping and dispersing effect of superficial acupuncture. In the treatment, it is necessary for the practitioner to remember two elements: first to be patient, and do sweeping and dispersing action no less than 3 min, and secondly do sweeping and dispersing action repeatedly, no less than 3 times in each treatment. This method is simple in operation, definite in the clinical effect, fast in stopping pain, and easy to be accepted by the patients and is worthy of further practice and study.

[1] Cai YM, Huang WY, Zheng JF. Clinical study on the treatment of lateral humeral epicondylitis by wheat-grain moxibustion plus acupuncture. Shanghai Zhenjiu Zazhi, 2012, 31(10): 746-747.

[2] Zheng ZJ. Clinical observation on Ashi point injection of ozone for tennis elbow. J Acupunct Tuina Sci, 2009, 7(6): 347-348.

[3] Zhang RX, Yu Z. Observation on the efficacy of auricular point plaster therapy plus acupuncture and moxibustion in treating external humeral epicondylitis. Shanghai Zhenjiu Zazhi, 2013, 32(2): 126-127.

[4] Ye MZ. Contralateral needling method and its applications in treating upper-limb pain. J Acupunct Tuina Sci, 2012, 10(1): 58-61.

[5] State Administration of Traditional Chinese Medicine. Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine. Nanjing: Nanjing University Press, 1994: 189-190.

[6] Liu YP, Liu Y. Diagnostic Classification and Standard of Functional Evaluation of Damage and Diseases of Bone and Joint. Beijing: Tsinghua University Press, 2002: 204.

[7] Liu ZL, Pan QJ. Observations on the efficacy of superficial needling therapy for tennis elbow. Shanghai Zhenjiu Zazhi, 2011, 30(10): 693-694.

[8] Shen DG. Introduction of a good method for treating painful diseases: electric superficial acupuncture. Shanghai Zhenjiu Zazhi, 2006, 25(2): 32-33.

[9] Xu RZ, Wang MP. Study on the traditional Chinese medicine theory of floating acupuncture therapy. Zhonghua Zhongyiyao Zazhi, 2009, 24(9): 1171-1173.

[10] Wu HG, Yan J, Yu SG, Xu B, Chang XR, Ma XP, Mu JP, Liu HR. Research current situation and development trend of moxibustion therapy. Shanghai Zhenjiu Zazhi, 2009, 28(1): 1-6.

[11] Chen XH, Zhang GY, Zhou MQ, Zheng J. Analysis and study on modern pharmacy and pharmacology of moxibustion. Zhongguo Zhenjiu, 2009, 29(5): 428-430.

Translator: Huang Guo-qi

R246.2

A

Date: May 20, 2013

Author: Zhang Dong-yun, deputy superintendent nurse

Song Hai-yun, bachelor, deputy superintendent nurse.

E-mail: 2330320069@qq.com