Study on the therapeutic effect of external application of Shounian powder combined with acupuncture at Zhitong acupoint on intercostobrachial nerve syndrome after breast cancer operation

Ning Mao,Yin-Hai Dai,Zhi-Yong Shao,Mao Wang,Jun-Yi Bai,Qian-Qian Liang*

1The Second Affiliated Hospital,Shanxi University of Traditional Chinese Medicine,Shanxi 710000,China; 2Xi’an Municipal Hospital of Traditional Chinese Medicine,Shanxi 710000,China.

Abstract Background:To explore the clinical effect of external application of Shounian powder combined with acupuncture at Zhitong acupoint in the treatment of intercostobrachial nerve syndrome (ICBNs) after breast cancer operation.Methods:A total of 80 patients with ICBNs who underwent modified radical mastectomy in our hospital from July 2014 to July 2016 were collected and divided into control group and study group according to the different treatment methods of ICBNs.Forty patients in the control group were treated with symptomatic analgesia and 40 patients in the study group were treated with external application of Shounian powder combined with acupuncture at Zhitong acupoint to compare and analyze the pain relief,quality of life and analgesic recurrence rate of ICBNs between the two groups.Results:Compared with the control group,the pain relief rate of ICBNs in the study group was higher.The patient satisfaction and long-term quality of life in the study group were better than those in the control group.However,there was no significant difference in postoperative pain recurrence rate.Conclusion:External application of Shounian powder combined with acupuncture at Zhitong acupoint can effectively relieve pain and improve quality of life for patients with ICBNs after breast cancer operation,which has a certain popularizing significance in clinical practice.

Key words:Intercostobrachial nerve syndrome,Shounian powder,Zhitong acupoint,Acupuncture,Relieve pain,Clinical effect

Background

The annual increasing rate of breast cancer is as high as 3%.Judging from the current rising rate of breast cancer incidence,breast cancer will be the highest incidence of malignant tumor in China [1].At present,surgery is still the main treatment method for breast cancer,and modified radical mastectomy is the first choice.In traditional axillary dissection,the retention of intercostobrachial nerve (ICBN) is ignored,resulting in severe intercostobrachial nerve syndrome(ICBNs) [2],which is mainly characterized by sensory disturbance on the medial side of the upper arm,such as numbness,pain,burning sensation or dull sensation of pain temperature.With the deepening of ICBN research in recent years,its reservation has been widely recognized and supported.However,if the tumor has a certain degree of infiltration of ICBN,we will still choose to disconnect ICBN.Therefore,some patients still have postoperative ICBNs,which seriously affects the quality of life of patients.At present,the treatment of ICBNs is mostly limited to pain relief and symptomatic treatment.Although ICBN block can achieve good results,it has not been widely carried out in clinic because of the complexity of operation and low acceptance of patients [3].

Shounian powder,composed of Yanhusuo(Rhizoma corydalis),Xiangfu (Rhizoma cyperi),Chenxiang (Lignum aquilariae sinensis),Wulingzhi(Faeces trogopterori),Moyao (Myrrha) are applied externally to the upper limb of the patient,which can play the function of activating Qi and promoting blood circulation,dispelling cold and relieving pain.Acupuncture is one of the widely recognized analgesic treatments both in China and in other countries.Modern studies have proved that acupuncture can promote the secretion of opioid peptides in the human brain to produce analgesic effect and reduce the intensity of pain.The operation of the combination of external application of Shounian powder and acupuncture at Zhitong acupoint is relatively simple and is more easily accepted by patients.

In this paper,we collected 80 patients with ICBNs caused by amputation of ICBN due to tumor infiltration of ICBN during modified radical mastectomy in our hospital from July 2014 to July 2016.A total of 80 patients were treated with external application of Shounian powder combined with acupuncture at Zhitong acupoint and symptomatic analgesia,respectively.The relevant indexes were followed up for 12 months.We found that the combination of Shounian powder and acupuncture can effectively relieve pain and improve quality of life for patients with ICBNs after breast cancer operation.

Materials and methods

General information

A total of 132 patients with breast cancer were collected from the Department of Surgical Oncology of the Second Affiliated Hospital of Shanxi University of Traditional Chinese Medicine from July 2014 to July 2016.Among them,80 patients with ICBNs were the objects of this study.The corresponding treatments were given to patients immediately after the diagnosis of ICBNs.Among them,40 patients were treated with external application of ShinNian Powder combined with acupuncture at Zhitong acupoint,and the other 40 patients were treated with oral dihydrocodeine.The general data of patients are shown in Table 1.

Treatment method

Research group.External application with Shounian powder combined with acupuncture Zhitong acupoint therapy.The drug composition of Shounian powder are [4]:Yanhusuo (Rhizoma corydalis) 15 g,Xiangfu(Rhizoma cyperi) 15 g,Chenxiang (Lignum aquilariae sinensis) 15 g,Wulingzhi (Faeces trogopterori) 15 g,Moyao (Myrrha) 15 g.Grinding the above herbs into fine powder and the powder was adjusted into paste by vinegar and then applied at the pain site.The application area exceeds the edge of the pain area 0.3–0.5 cm.The appropriate thickness of the powder paste was 2–4 mm,covered with gauze and fixed with adhesive tape.The application of Shounian powder is once a day for 4–6 h each time.After applying the drug,please pay attention to observe the skin for allergic reactions such as itching,redness and swelling.If an allergic reaction occurs,immediately stop the application and give anti-allergic treatment.Acupuncture at Zhitong acupoint (Figure 1) [5],located in the depression of the third and fourth metacarpal bone of the back of the hand,with 0.3 mm × 50 mm filiform needle,flat tonifying and purging,retaining the needle for 25 minutes.Acupuncture at Zhitong acupoint is once a day,10 days as a course of treatment,and once a month for a total of 6 months.

Control group.Simple symptomatic treatment,that is,when the patients felt the most obvious pain,oral paracetamol and dihydrocodeine tablets [6],10 mg/time.

Observation index

Observation of pain in patients.The degree,location and type of postoperative pain were recorded and the degree of pain relief was also recorded.The degree of pain was evaluated according to the World Health Organization Pain Grading Standard [7].

Table 1 The general data of the included patients

Observation of other conditions on the affected side.The abnormal sensation of the affected side was mainly characterized by hypoesthesia,numbness,ant sensation and burning sensation,and the scope of abnormal sensation was judged by acupuncture.The edema of the upper limb was mainly characterized by the change of the circumference of the affected side,which was different from that of the healthy side.At the same time,the duration and regression time of edema were recorded.Dyskinesia was referred as limitation of the movement of the shoulder joint in the process of limb lifting and abduction,and fatigue and fine motor difficulties after movement [8].

Statistics of quality of life score after treatment.The FACT-B scale was used to evaluate the quality of life of patients with breast cancer after treatment,which was composed of the General scale (FACT-G)and the Breast Cancer Specificity Scale [9].

Pain recurrence rate.The recurrence of pain was recorded in detail by telephone follow-up at 1 month,3 months,6 months and 12 months after treatment.The appearance of the same symptoms and signs was referred as the standard of recurrence during the follow-up period.

Statistical analysis

SPSS 19.0 software was used for statistical analysis,The percentage is used to represent a rate.The comparison between the two groups was analyzed by Chi-square Test.P< 0.05 was considered to indicate statistical significance.

Results

Pain relief

The pain situations including pain grading,site and types of patients in each group are shown in Table 2.There is no significant difference in pain grade,location and type between the study group and the control group (P> 0.05).After different treatment methods,the degree of pain relief in the study group was better than that in the control group.The pain relied rate after 12 month follow-up was 92.5% in the research group,which is much better than 22.5%in the control group.The pain relied rate in different time was shown in Table 3.

Other index

It can be seen from Table 4 that compared with the control group,the recovery of sensory abnormalities and motor disorders in the study group was better than that in the control group (P< 0.05),but there was no statistical significance in the degree of upper limb edema relief between the two groups (P> 0.05).

Quality of life score after treatment

Compared with the control group,the score of quality of life in the study group was higher than that in the control group (P< 0.05) (Table 5).

Pain recurrence rate

There was no significant difference in recurrence rate between the two groups within 12 months after operation (P> 0.05) (Table 6).

Table 2 The pain situations of 80 patients (n (%))

Table 3 The degree of pain relief after treatment (n (%))

Table 4 Number of patients associated with other conditions after treatment (n (%))

Table 5 Quality of life rating scale after treatment (x±s,score)

Table 6 Pain recurrence rate after treatment (n (%))

Discussion

The incidence of breast cancer is increasing year by year,but the fatality rate is gradually decreasing,which is due to the continuous maturity of treatment in recent years.At present,surgery is still the main treatment for breast cancer.With the gradual broadening of breast-conserving surgery indications,the way of breast cancer surgery has experienced a series of evolution from small to large,and from large to small.On the premise of prolonging the survival time of patients,we should reduce the surgical trauma as much as possible to reduce the occurrence of postoperative complications,so as to improve the quality of life.Therefore,breast-conserving surgery and corresponding breast reconstruction have gradually become the first choice for breast surgeons [10].Of course,for patients with a certain stage,modified radical mastectomy has to be the first treatment.

In traditional axillary lymph node dissection,considering that it will increase the difficulty of the operation,violate the tumor-free principle and increase the risk of local recurrence of breast cancer,we often choose to cut off the ICBN [11].However,as the anatomical study of the ICBN becomes more and more detailed,breast surgeons realize that retaining ICBN will not increase the difficulty of operation,nor will it increase the risk of recurrence and metastasis,so they usually choose to retain ICBN [12].Of course,the preoperative pathological evaluation is only one aspect,and we also need to adapt to the situation during the operation.If the enlarged axillary lymph nodes cause infiltration of the ICBN below the axillary vein,we will choose to cut off the ICBN.

Resection of ICBN will affect the sensory function of the affected upper limb to a certain extent.A large number of patients show persistent pain in the breast area,chest wall,upper arm and other areas caused by the operation itself or other reasons,which is called ICBNs [13].The corresponding symptoms usually occur immediately or 3 months after operation.The postoperative literature analysis considers that after the amputation of ICBN,the stump forms a neuroma,resulting in intractable sensory abnormalities [14].The surgical resection of intercostal neuroma is a treatment choice to relieve pain.Wastson et al.used capsaicin externally in the pain area and get a certain therapeutic effect [15].Although preventing the occurrence of ICBNs is more meaningful than treatment,the postoperative ICBNs still needs an effective treatment to reduce the pain of patients in order to improve the quality of life of patients [16].

According to traditional Chinese medicine theories,there are two aspects of pain.One is that obstruction will cause pain and the other is that the lack of nourishment will cause pain.Among the two aspects,the first one is more common and often results from Qi stagnation,blood stasis and cold coagulation.[17].

Shounian powder is from Cheng Guopeng’sYixuexinwu(Medical Mind) in the Qing dynasty.Foshou (Fructus citri sarcodactylis) fragrance but not strong,mild but not steep,and has the function of activating Qi and relieving pain.Chenxiang (Lignum aquilariae sinensis) warms stagnation of cold pathogen and regulates Qi and relieves pain.Yanhusuo (Rhizoma corydalis) can treat Qi stagnation in blood and blood stagnation in Qi,and specialize in treating all kinds of pain in the whole body.Yujin (Radix curcumae) soothes the liver and relieves depression and relieves Qi and relieves pain.Baishao (Radix paeo) nourishes the blood and softens the liver and relieves pain [18].

Modern studies also provide the antalgic evidences of herbs in Shounian powder.Hotta et al found that the volatile oil of bergamot contains carvanol,which can competitively block the peroxidase value-added activated receptor and inhibit the expression of cyclooxygenase 2,thus reducing pain and hyperalgesia [19].Tetrahydropalmatine can inhibit the ectopic spontaneous discharge of neurons in a dose-dependent manner,and can inhibit the peripheral nervous system by suppressing spontaneous discharge [20].The part of incense n-butanol has a good analgesic effect and can effectively relieve the degree of pain caused by peripheral action [21].Most of the postoperative pain occurred in the axilla or the medial side of the upper limb,with less subcutaneous adipose tissue and more subcutaneous venous network,which provided a good anatomical environment for drug absorption and utilization.Therefore,we used Shounian powder externally.

Acupuncture is one of the widely recognized analgesic treatments worldwide.Modern studies have proved that acupuncture can promote the secretion of opioid peptides in the human brain to produce analgesic effect and reduce the intensity of pain.The Zhitong acupoint selected in this study were first reported by the 175 Hospital of the Chinese people’s Liberation Army [22].This Zhitong acupoint was used for many kinds of pain treatment in many parts and systems of the body,and the analgesic effect is fast and effective.

Conclusion

This study compared the therapeutic effect of external application of Shounian powder combined with acupuncture at Zhitong acupointfor ICBNs patients.The results showed that the combination of Shounian powder and acupuncture has a positive effect on the treatment of ICBNs including pain relief and improvement of quality of life.Therefore,this combination method has potential application value in clinic,and whether it is effective for other type pain still need further studied.