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Acupuncture in Physiotherapy TM

Journal of the Acupuncture Association

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ŵĞŵďĞƌƐŚŝƉƚĞĂŵŽŶϬϭϳϯϯϯϵϬϬϬϳηϭ Žƌ ǀŝĂ ƐĞĐΛĂĂĐƉ͘ƵŬ͘ĐŽŵ͘

Acupuncture in Physiotherapy
www.aacp.org.uk
Acupuncture in Physiotherapy is printed twice a year
for the membership of AACP. It aims to provide
information for members that is correct at the time
of going to press. Articles for inclusion should be
submitted to the clinical editor at the address below
or by e-mail. All articles are reviewed by the clinical
editor, and while every effort is made to ensure
validity, views given by contributors are not
necessarily those of the Association, which thus
accepts no responsibility.
Editorial address
Dr Val Hopwood
18 Woodlands Close
Dibden Purlieu
Southampton SO45 4JG
UK
E-mail: val.hopwood@btinternet.com
The Association
The British association for the practice of Western
research-based acupuncture in physiotherapy,
AACP is a professional network affiliated with the
Chartered Society of Physiotherapy. It is a
member-led organization, and with around 6500
subscribers, the largest professional body for
acupuncture in the UK. We represent our members
with lawmakers, the public, the National Health
Service and private health insurers. The organization
facilitates and evaluates postgraduate education. The
development of professional awareness and clinical
skills in acupuncture are founded on research-based
evidence and the audit of clinical outcomes.
AACP Ltd
Sefton House, Adam Court, Newark Road,
Peterborough PE1 5PP, UK
Tel: 01733 390007
Printed in the UK by Henry Ling Ltd
at the Dorset Press, Dorchester DT1 1HD
© 2017 Acupuncture Association of Chartered Physiotherapists
Contents
Summer 2017
Editorial..........................................................................3
Chairman’s report.........................................................5
Chief Executive Officer’s report...............................7
Paradigms
Countering the sceptics and respecting patient
preferences: making the case for acupuncture
by K. Coleman-­Rooney......................................................9
Original research
Scientific Evaluation and Review of Claims in
Health Care (SEaRCH): a streamlined, systematic,
phased approach for determining “what works”
in healthcare by W. B. Jonas, C. Crawford,
P. Elfenbaum & L. Hilton...........................................17
Meridian masterclass
The Spleen meridian: the foot Tai Yin channel
by R. Lillie.....................................................................29
Case reports
Acupuncture for the treatment of whiplash-­
associated disorder by S. Cronin ..............................39
Acupuncture for the management of pain in a
woman with muscular sclerosis by K. Biss..............49
Acupuncture treatment for a 50-­year-­old female
with fibromyalgia suffering from a whiplash
injury following a road traffic accident by
C. Hamer.......................................................................59
Electroacupuncture in the treatment of
patellar tendinopathy in a 52-­year-­old male
by B. Bradford................................................................67
Use of acupuncture to treat an academy
football player with ankle impingement
by G. Parry ..................................................................75
Acupuncture as an adjunct to standard
physiotherapy in the management of adhesive
capsulitis by L. Bennett ...............................................83
Myofascial pain masquerading as neuropathic
pain by C. Waldock .....................................................91
Good practice statement
Acupuncture for pregnancy-­related low back
pain and pelvic girdle pain ......................................95
Reviews
Book reviews ..............................................................99
News, views and interviews................................... 103
Guidelines for authors............................................ 109
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 Editorial

Welcome to the latest edition of Acupuncture in

Physiotherapy. As ever, we have a wide-­ ranging
selection of original research, opinion, case
reports, news and reviews.
Kaye Coleman-­ Rooney (pp. 9–15) provides
some good general information about acupunc-
ture that you can offer to your friendly local
general practitioners, who may well become
Acupuncture in more inclined to refer their patients to you. The
serious science in this issue is covered by Wayne
Physiotherapy Jonas et al. (pp. 17–27), who take a close look at
how we evaluate our service and “what works”
in healthcare.
www.aacp.org.uk The latest in our series of meridian master­
classes is provided by Rosemary Lillie, who
Journal Committee
discusses the Spleen meridian (pp. 29–38). This
Clinical Editor continuing feature has provided members with
Dr Val Hopwood FCSP
a great deal of additional information, and the
Corporate Editor whole collection will soon be brought together
Andrew J. Wilson in an exclusive AACP publication. Watch this
(e-mail: ajwpublishing@gmail.com)
space!
Book Review Editor Our case studies are very interesting: pain in
Wendy Rarity
(e-mail: Wendy.Rarity@hotmail.com) multiple sclerosis from Kay Biss (pp. 49–57);
adhesive capsulitis from Louisa Bennett
News Editor
Rosemary Lillie (pp. 83–89); and electroacupuncture in the
(e-mail: wimbledonphysio@tiscali.co.uk) treatment of patellar tendinopathy from Ben
Public Relations and Marketing Officer
Bradford (pp. 95–98).
Jennifer Clarkson We also have two variations on whiplash
(e-mail: jennifer@aacp.uk.com) injury from Suzanne Cronin (pp. 39–47) and
AACP Office Manager Charlotte Hamer (pp. 59–66). It’s always inter-
Lisa Stephenson esting to compare and contrast treatments,
(e-mail: lisa@aacp.uk.com)
bearing in mind that we all know that every
patient is different anyway.
AACP Ltd Board Members Then we have an academy football player
Chairman: Jon Hobbs with an ankle impingement from Gemma Parry,
Lesley Pattenden and finally, an intriguing view of myofascial
Paul Battersby
Diana Lacraru
pain from Colin Waldock (pp. 91–93).
George Chia We also have an interesting selection of book
Christopher Hall reviews (pp. 98–101) and acupuncture news
Wendy Rarity
Caspar van Dongen (pp. 103–108), including some information
from Beverley de Valois about her recent, highly
Chief Executive Officer: Caspar van Dongen commended work with moxa and oncology
Auditor: Rawlinsons, Peterborough
Company Secretary: Michael Tolond research (pp. 103–105).
Val Hopwood
Clinical Editor

© 2017 Acupuncture Association of Chartered Physiotherapists 3

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Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 5–6
Chairman’s report
Welcome to the Summer 2017 edition of
Acupuncture in Physiotherapy. As ever, there has
been a lot of activity since the last edition of
the journal.
This year saw the trial of a 1-­ day Annual
Conference, which was held on Saturday 13 May
2017 in Coventry. In an effort to reach out to
members across the UK, the AACP has organ-
ized three, 1-­day events this year: the others will
take place in Bristol and Edinburgh.
The 1-­day Annual Conference format, which
featured talks covering a range of special inter-
est areas within acupuncture and physiotherapy,
was well received. Among the guest speakers
were: Dr Kien Trinh, who flew in from Canada
to discuss an evaluation of the National Institute
for Health and Care Excellence guidelines for
low back pain (LBP) (NICE 2016); and Sinead
McCarthy, who reviewed the evidence for the
safety and effectiveness of acupuncture for
pregnancy-­related LBP and pelvic girdle pain.
Sinead will also attend AACP’s Bristol
Conference on 23 September 2017, where
she will talk about the use of acupuncture in
men’s health. This event will also feature: Dr
Val Hopwood, who will deliver an enlightening
overview of acupuncture in the UK from both
a political and historical perspective; Professor
Tianjun Wang, who will discuss an innovative
approach to scalp acupuncture; Dr Elisa Rossi,
who will cover acupuncture in paediatrics; and
Tom van Callister, who will outline the role and
importance of acupuncture in musculoskeletal
problems, and perform a practical demonstra-
tion of his approach to the treatment of neck
pain.
The previous success of the AACP Ireland
and Scotland conferences sees this year’s event
brought to Edinburgh on 21 October 2017,
where a variety of topics will again be covered.
Amos Ziv from Israel will present his meridian
wave acupuncture theory, and include a practical
demonstration. John R. Cross will discuss the
use of acupressure for neurological conditions.
© 2017 Acupuncture Association of Chartered Physiotherapists
Johnny Wilson, who is head of sports medicine
at Notts County Football Club, will discuss
the use of acupuncture within the realm of
professional football. He can be seen treating
Notts County striker Jon Stead in a video on
our website (Austin 2017). Also look out for a
forthcoming longer video from AACP featuring
Johnny and players from Notts County pro-
moting the use of acupuncture in professional
football.
On the subject of promotion, the
Association’s media and public relations
officer, Jennifer Clarkson, née Hodges (e-­mail:
jennifer@aacp.uk.com), has been working tire-
lessly along with the rest of the team at Sefton
House to develop a variety of media projects.
To date, we have now promoted the benefits of
receiving acupuncture from a AACP-­registered
chartered physiotherapist in several print media
titles, including but not exclusively, Ask the Doctor,
Balance, Calibre, Athletics Weekly, The Guardian and
The Mail on Sunday, reaching a total readership of
more than 5 million. Jennifer also continues to
produce guidance on how to promote ourselves
effectively via social media, and has created a
selection of ready-­made tweets, Facebook posts
and electronic images to help members get
started. As always, may I encourage members
to engage with the AACP administration team
in order to take full advantage of this facility,
and see how we can support members in the
promotion of their own services to the general
public. The team also includes AACP clinical
adviser Christopher Ireland (e-­mail: chris@aacp.
uk.com), who is on hand to support members
with queries about subjects ranging from indi-
vidual treatments to policy, management and
commissioning issues related to the integration
of acupuncture within physiotherapy.
The new website format has also given the
Association’s public interface a facelift. This is
not only designed to be more user-­friendly, but
now offers more features than ever, including
online booking for conferences, journal article
5
Chairman’s report
and conference presentation archives, news
articles, and an online shop.
The new online shop offers members exclu-
sive deals on a wide variety of products, and
makes a guaranteed price-­ match promise. As
a not-­for-­profit organization, AACP can offer
a huge discount on needles and other clinical
supplies to members, providing another valu-
able membership benefit. The benefits of the
online shop, combined with significant savings
in sharps and contaminated waste management
from B Hygienic, and clinical supplies from
Economed offer real cash value to all members
in addition to the professional standing associ-
ated with being a member.
The website also lists forthcoming training
events and courses, and these can be booked
online. However, if you do not see a course
listed that you would like to have run in your
area, please feel free to contact AACP training
and education coordinator Claire Buckingham,
née Brough (e-­mail: claire@aacp.uk.com), who
will be happy to discuss the option of you
hosting courses of your choice in your region.
The Association can support you in marketing
and advertising, and there are also two free
6 © 2017 Acupuncture Association of Chartered Physiotherapists
places available on each course or the monetary
equivalent for the host. Check out the new
website for events soon to take place in your
area.
There are always a variety of projects in
the pipeline that the AACP team are work-
ing on, but if you think that there are other
things that we need to look at or you have
any ideas on how you would like to see the
Association develop, then please feel free to get
in touch with the Office or me directly (e-­mail:
chair@aacp.uk.com). As ever, I look forward to
catching up with you at an AACP event some-
where soon.
Jonathan Hobbs
Chairman
Reference
Austin S. (2017) Inside the Treatment Room: Watch Jon Stead’s
Acupuncture Session. [WWW document.] URL https://
www.aacp.org.uk/news/16/inside-­the-­treatment-­room-­
watch-­jon-­steads-­acupuncture-­session
National Institute for Health and Care Excellence (NICE)
(2016) Low Back Pain and Sciatica in Over 16s: Assessment
and Management. NICE Clinical Guideline 59. National
Institute for Health and Care Excellence, London.
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 7–8
Chief Executive Officer’s report
AACP: your professional
organization
A professional organization is generally defined
as “an organization of and for professional
people” (TFD 2017).
Since its inception in 1984, AACP has cer-
tainly been an organization for professionals,
i.e. chartered physiotherapists who practise
acupuncture. The Association has also always
been run by professionals, which has resulted
in it becoming by far the largest acupuncture
organization in the UK.
In recent years, AACP has increasingly
become a fully-­fledged professional organization
in the sense defined above. The services pro-
vided by the AACP Office, which is profession-
ally administered by our office manager, cover
a varied and wide-­ranging number of activities
and services that will support you in your day-­
to-­day acupuncture physiotherapy work.
The AACP membership department is
available to answer any questions that you
may have about your subscription. A member
management system contains all the informa-
tion needed to help us deal efficiently with your
queries. Failing that, the vast experience of the
staff at the department will certainly be able to
help you further.
Booking continuing professional development
(CPD) courses or Acupuncture Foundation
Courses (for new members) is an easy online
process, and all our courses effectively managed
by our education and training coordinator.
Many of you have put questions to our
clinical advisor, who also participates in the
development of our clinical and medical leaflets
and documents. He and several AACP directors
represent you by getting involved in the various
issues concerning Western medical acupuncture
addressed by the National Institute for Health
and Care Excellence and regulatory bodies.
Our public relations and marketing officer
has made great inroads in realizing very
© 2017 Acupuncture Association of Chartered Physiotherapists
cost-­effective insertions in many patient-­
oriented publications. These have reached mil-
lions and encouraged them to search for their
acupuncture physiotherapist via our website
(www.aacp.org.uk/search). Together with our
office manager, she is also involved in the
organization of three well-­attended AACP con-
ferences across the country each year.
The Association runs a legal service for you
that is accessible through the website. Free
advice can be obtained on human resources,
health and safety, employment, and tax issues,
among other things.
Lastly, our new AACP online shop, exclusively
for members, is now up and running. This is
a one-­stop shop for your all acupuncture and
physiotherapy needs, offered at the best prices
possible.
An organization of and for professional people;
that’s your AACP.
Conferences and Annual General
Meeting
Another very successful AACP Conference was
held at the Hilton Hotel Coventry in May. Like
our other conferences, it was a gathering with
a real buzz, and afterwards, we received a lot
of compliments about the organization and the
quality of the event from delegates, speakers
and trade representatives alike. Our conferences
are ideal opportunities to: hear the latest about
acupuncture in physiotherapy from both speak-
ers and trade representatives; add some useful
CPD hours; and network with colleagues. You
can find more details of our upcoming confer-
ences in Bristol and Edinburgh on our website
(www.aacp.org.uk/events/conferences).
During our Conference in May, the AACP
Annual General Meeting accepted all the pro-
posals put before it with substantial majorities.
The Board’s overall strategy remains focus-
ing on improving communication with our
7
Chief Executive Officer’s report
membership, the public and the authorities, and
enhancing the quality and number of benefits
for our members.
The 2016 AACP financial year was summa-
rized as one in which earlier years’ membership
growth started to materialize into increased rev-
enue, and the first steps were taken to reach out
to the media in a more professional and targeted
way. The new public relations and marketing
function within the organization has managed
to spread the AACP message to an audience
of millions in the UK for the first time, while
its in-­
house design function has reduced the
cost of developing promotional and support
materials.
The 2016 financial result was achieved
through maintaining a carefully managed bal-
ance between income and costs during the year.
The aim was to achieve a close-­to-­break-­even
situation in which as much as possible of the
8 © 2017 Acupuncture Association of Chartered Physiotherapists
Association’s income was redeployed for the
benefit of its members, an objective that was
achieved. After a small deficit in 2015, we ended
2016 with a small surplus. The two main sources
of income remain membership subscriptions
and course provision. At the end of the year,
the total membership of AACP stood at over
6000.
As always, we are your Association, and if you
have suggestions for positive changes, or adding
any services or benefits, please don’t hesitate to
contact me directly at the AACP Office (e-­mail:
ceo@aacp.uk.com).
Caspar van Dongen
Chief Executive Officer
Reference
TheFreeDictionary (TFD) (2017) Professional Organization.
[WWW document.] URL http://www.thefreedictionary.
com/professional+organization
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 9–15

PARADIGMS

Countering the sceptics and respecting patient

preferences: making the case for acupuncture
K. Coleman-­Rooney
The Acupuncture Academy, Leamington Spa, UK

Abstract
The argument that acupuncture is a placebo performed by the irresponsible on the gullible
is one that is familiar to most practitioners. Sceptics describe acupuncture as pre-­scientific,
challenge its fundamental theories, specifically the existence of Qi and the meridians, and
dismiss research as of no clinical relevance. However, biomedical research in fields as diverse
as stem cell and genomic theory, embryology, and neurophysiology now offers a more con-
structive framework for interdisciplinary discussion around the different physiological and
neurological models involved in an understanding of acupuncture. Quantitative and qualita-
tive research into acupuncture treatment and the setting in which it is offered is effectively
reframing the placebo and “real versus sham” debate, as well as demonstrating the efficacy
of acupuncture as a treatment and management tool across a wide range of conditions.
Healthcare policy researchers increasingly argue for the development of best-­practice models
that, in line with the UK National Health Service Constitution, prioritize patient prefer-
ences for alternative, safe and low-­technology treatment options as ethical and economic
imperatives.
Keywords: acupuncture, healthcare policy, patient preference, placebo effect, real versus sham
needling.

Introduction is little or no more than a theatrical placebo”

When readers search for the term “acupunc-
ture” on The Guardian website (www.theguardian.
com), an article dating from 2013 still tops the
list. “Why acupuncture is giving sceptics the
needle” (Derbyshire 2013) was prompted by a
vehement opinion piece by David Colquhoun
and Steven Novella in the journal Anesthesia and
Analgesia (Colquhoun & Novella 2013). Their
editorial attacks the principles underlying tradi-
tional Chinese medicine (TCM) as “bizarre” and
“prescientific”, contending that “acupuncture
Correspondence: Kaye Coleman-­
Rooney, The Acu­
puncture Academy, 54 High Street, Leamington Spa
CV31 1LW, UK (e-­mail: kaye.rooney@gmail.com).
(Colquhoun & Novella 2013, p. 1360).
These and similar accusations regularly circu-
late online, and express doubts familiar to every
practitioner of acupuncture from discussions
with healthcare providers and professional col-
leagues trained in other disciplines. While many
patients are enthusiastic about the benefits that
they have experienced as a result of acupunc-
ture, the sceptics’ arguments would appear
to reflect the reservations of many potential
patients. Therefore, it is worthwhile reviewing
the evidence base for acupuncture in the light
of the sceptics’ specific claims and objections.
Those dubious about complementary tradi-
tions and approaches characterize patients who

© 2017 Acupuncture Association of Chartered Physiotherapists 9

Making the case for acupuncture
seek out alternatives to the biomedical and
pharmacological approaches as gullible and
desperate (Colquhoun & Novella 2013). Since
respect for patient preferences is now enshrined
in principle in the National Health Service
(NHS) Constitution for England (DH 2015),
the present paper also discusses the ethical and
economic arguments for facilitating informed
patient choice.
Journalist David Derbyshire’s (2013) article
for The Guardian explores three aspects of the
argument in some detail:
(1) Qi, which is fundamental to TCM and
acupuncture theory, is “meaningless in the
context of medical science”.
(2) Research does not meet the required
standards for randomized controlled tri-
als (RCTs), while recent meta-­ analyses
show “barely clinically significant” results,
according to David Colquhoun, who is
quoted in the article.
(3) “Real” acupuncture offers no significant
benefits over sham acupuncture, and there-
fore, is little better than a placebo.
Sceptics who, like Colquhoun & Novella (2013,
p. 1361), claim that the flow of Qi through
meridians in the body is “purely imaginary” are
ignoring significant advances in current bio-
medical research. The work of leading research-
ers in fields as diverse as stem cell and genomic
theory, embryology, and neurophysiology is
providing robust support for acupuncture’s
theoretical principles (Keown 2014). Qualitative
research also increasingly provides evidence
of acupuncture’s relevance to, and efficacy in,
clinical settings where individualized treatments
by trained practitioners make valuable contribu-
tions to improved health (Paterson & Britten
1999; Hopton et al. 2013: MacPherson et al.
2014).
Considering the evidence
Medical science can explain Qi
In the mid-­1970s, as acupuncture first started
to become more widely known in the West,
biomedicine made use of then-­current endor-
phin release and gate control theories of pain
10
modulation in its first attempts to understand
how acupuncture might work simply as analge-
sia (Birch & Felt 1999; Stux & Hammerschlag
2001).
However, the clinical applications of acu-
puncture and its benefits to patients extend sig-
nificantly beyond pain control, with the primary
physiological focus being on regulating and bal-
ancing the homeostatic processes of the body
(Kaptchuk 2000; Maciocia 2015). Therefore,
research that is limited to analgesic enquiry is
clearly inadequate for any real understanding of
acupuncture, the concept of Qi or the creation
of a meaningful evidence base for its efficacy
(Birch & Felt 1999; Stux & Hammerschlag 2001;
Keown 2014). It is little wonder that Colquhoun
& Novella (2013) found explanations based on
this area of research unconvincing: it is only
part of the story. In the 4 decades since the
endorphin and gate control theories were pinned
to acupuncture, new biomedical disciplines have
emerged that not only extend the frontiers
of conventional medicine, but provide new
conceptual frameworks of intelligent, dynamic
physiological organization and communication.
In the West, we typically translate “Qi” as
“energy”, and view it as something that we
should be able to quantify. A medical doctor and
trained acupuncture practitioner, Daniel Keown
argues that it is more helpful to think of Qi as
shorthand for, or a metaphor expressing the
idea of, an “intelligent and organised metabo-
lism” (Keown 2014, p. 26). The discovery in the
1990s of a number of neuropeptides linking the
immune, endocrine and nervous systems (Pert
1999) allowed neurophysicists for the first time
to conceive and map the signalling, receptor and
regulatory mechanisms of the body in terms of
information theory. They characterized peptides
and their individual receptors as facilitators of
homeostasis, and described the body as a series
of “internal conversations” (Pert 1999, p. 263).
This new understanding provided a significantly
different biomedical model of somatic and
psychological interdependence. It corresponds
more closely with and contributes to a more-­
appropriate framework for understanding the
different physiological and neurological models
that TCM encapsulates as Qi, and the meridians
© 2017 Acupuncture Association of Chartered Physiotherapists

through which it flows (Pert 1999; Keown
2014).
The work of American academic, Dr Charles
Shang (2001, 2009, 2011) updated a considerable
body of research, synthesizing neurophysiology,
stem cell theory, genetics and embryology (Birch
& Felt 1999; Keown 2014). Shang’s growth
control theory describes and evidences an
integrated theory of acupuncture, defining Qi
in biomedical terms as “morphogens and electrical
currents running in connective tissue planes” (Keown
2014, p. 85). Acupuncture points are mapped to
the organizing centres fundamental to embryol-
ogy, and acupuncture meridians to planes of
the fascia (Keown 2014). Meridians derive from
growth control folds in the embryo in utero,
where associated gap junctions form discrete
communication departments that continue to
develop after birth, creating an interconnected
network of bioelectric currents – correspond-
ing to Qi – navigating the borders of the fascia
and connective tissue.
The conduct and conclusions of research
In addition to basic research focused on con-
ventional biomedicine, and despite the difficul-
ties of securing funding for research into inter-
ventions outside conventional pharmacological
and surgical approaches (Birch & Felt 1999),
there is now a considerable body of research
centred on the meaningful evaluation of acu-
puncture. Colquhoun & Novella (2013) claimed
that generally inconclusive results typically force
researchers to conclude that “more research is
needed” (Derbyshire 2013).
Their view sidelines robust programmes
of evaluation and integration at some of
the world’s leading healthcare and health
policy institutions – including the World Health
Organization (WHO 2013) – producing and
evaluating research on acupuncture’s efficacy
and value in clinical applications as diverse as
the management of cancer-­ related symptoms
(Javdan & Cassileth 2015) and chronic pain
(MacPherson et al. 2014).
However, acupuncture is a complex interven-
tion, presenting researchers and reviewers with
considerable challenges when adjusting for
© 2017 Acupuncture Association of Chartered Physiotherapists
K. Coleman-­Rooney
multiple variables, and controversial approaches
to controls, allocation and blinding. As
Derbyshire’s (2013) article concedes, the use
of sham needling techniques used to provide
a third control group between acupuncture
and no acupuncture/usual care controls “con-
tinues to muddy the waters of research into
acupuncture”.
Problematic enough in single-­ focus RCTs,
it is unsurprising that these issues are ampli-
fied in the meta-­analysis of RCTs. Derbyshire
(2013) highlighted the controversy around the
Vickers et al. (2012) meta-­ analysis, stemming
from Colquhoun & Novella’s (2013) charge that
the apparently positive conclusions are unwar-
ranted, and that the improvements noted lack
clinical significance. The present author will
now discuss these claims before examining the
charge that “real” acupuncture offers no signifi-
cant benefits over sham needling.
Using data from 29 high-­quality RCTs involv-
ing 17 922 patients, Andrew J. Vickers and his
fellow researchers found that acupuncture is
“superior to both no-­acupuncture control and
sham acupuncture for the treatment of chronic
pain”, and concluded that “acupuncture is a
reasonable referral option” (Vickers et al. 2012,
p. 1450). Colquhoun & Novella (2013) disputed
Vickers et al.’s (2012) endorsement of acupunc-
ture’s efficacy, comparing its methodology unfa-
vourably with a study that had a similar intent
(Madsen et al. 2009), but smaller scope (13 trials
with 3025 patients). The Madsen et al. (2009)
study came to a conclusion more in line with
Colquhoun & Novella’s (2013) own opinion, i.e.
that any slight analgesic effect of acupuncture
had no clinical relevance and was vulnerable to
bias.
However, contrary to Colquhoun & Novella’s
(2013) claim, Vickers et al.’s (2012) meta-­analysis
supports its important conclusions with a robust
and thorough methodology. The research team
went to considerable lengths to exclude and
adjust as appropriate for, inter alia:
• clinical and methodological heterogeneity;
• statistical variance at baseline and follow-­up;
• the type and delivery of genuine treatment;
and
• varieties of sham treatment.
11
Making the case for acupuncture
In addition, RCTs with a high likelihood of
bias from unblinding were excluded. Crucially,
Vickers et al. (2012) also prioritized individual
patient data meta-­ analysis, obtaining raw data
from the studies under review to ensure greater
precision and reliability.
By contrast, the Madsen et al. (2009) study
demonstrates considerable shortcomings in its
methodology. In stark contrast to the Vickers
et al. (2012) review, Madsen et al. (2009) under-
took no raw data analysis. Instead, data were
pooled, aggregated and standardized to mean
outcomes. This was done despite Madsen et al.’s
(2009) admission of considerable heterogene-
ity between the studies under review, with the
researchers noting more variation than could be
expected by chance.
Assessing sham versus “real”
acupuncture and the placebo effect
Colquhoun & Novella (2013) substantiated
their dismissal of acupuncture as an elaborate
placebo by reference to the apparent scant dif-
ference in benefit between sham acupuncture
and “real” needling techniques.
Research results (MacPherson 2014) do show
that patients receiving sham acupuncture typi-
cally report improvements over patients receiv-
ing no or usual treatment. Leading practitioner
and researcher Hugh MacPherson (2014), for
example, cites Vickers et al.’s (2012) estimate
that 60% of reported benefits could be ascribed
to sham needling techniques and other factors,
such as the patient–practitioner relationship.
The remaining 40% improvement is the addi-
tional effect of “true” acupuncture. As the
debate rages around sham and “real” needling,
it is easy to lose sight of patients’ perceptions
of worthwhile benefit (Paterson & Britten
1999; Paterson et al. 2011; Hopton et al. 2013),
and that sham or “real” is, anyway, an artificial
difference (MacPherson 2014): no general prac-
titioner (GP) will offer patients sham treatment.
Relevance to the individual patient in the
clinical setting is key to understanding many
of the limitations of the biomedical research
model when assessing treatments predicated on
a rationale that is fundamentally different from
12
that of conventional medicine. In contrast to
Western normative traditions, where treatment
protocols are specific to the disease, acupuncture
tailors treatment specifically to the individual
(Kaptchuk 2000). Therefore, the acupuncture
treatment offered to individual patients follow-
ing standardized research protocols is generally
suboptimal for the majority of patients (Birch
& Felt 1999; Birch 2004; MacPherson 2014).
However, although a research methodology
evaluating the impact of individual, more-­
optimal treatment is challenging to design
(Paterson et al. 2011), recent qualitative and
quantitative research in the general practice set-
ting has robustly demonstrated that the addition
of 12 sessions of Five Element acupuncture
to normal GP care brought sustained improve-
ments in health and well-­being to patients over
a 12-­month period (Paterson et al. 2011).
It is clear that there are significant shortcom-
ings associated with using sham acupuncture as
an apparent placebo control (Birch & Felt 1999;
Birch 2004). While a sugar pill is clearly an inac-
tive placebo, needling or intense pressure at any
point on the body causes a measurable physi-
ological response (Birch & Felt 1999; Keown
2014). The validity of a sham control is further
compromised because many points selected as
inert by researchers are, in fact, recognized by
qualified practitioners as more or less powerful
points on the acupuncture meridians (Birch &
Felt 1999; Birch 2004; MacPherson 2014).
Therefore, the measurement of real against
sham is not the comparison of optimal, con-
sidered treatment with a demonstrably inert
placebo. In effect, in studies where sham
acupuncture is involved, researchers are actu-
ally noting the difference between two active,
albeit suboptimal, treatments and their impact
on the patient (Birch & Felt 1999; Birch 2004;
MacPherson 2014).
The patient’s perspective
In its current National Institute for Health and
Care Excellence (NICE) best practice guidelines
on improving the experience of care in adult
NHS services (NICE 2012, 2013), the NHS
advises practitioners to take into account not
© 2017 Acupuncture Association of Chartered Physiotherapists

only the needs of patients, but also the require-
ment to offer services that reflect patients’
preferences and values. This extends to providing
alternative options for the treatment and man-
agement of their health and emotional well-­
being, and includes support to optimize quality
of life.
Furthermore, while the majority of patients
may still be unaware of its existence, the NHS
Constitution for England (DH 2015) explicitly
prioritizes patient preferences in the design of
NHS services. Its statement of principles is clear
and unambiguous: “NHS services must reflect,
and should be coordinated around and tailored
to, the needs and preferences of patients, their
families and their carers” (DH 2015).
A growing body of qualitative research
(Paterson & Britten 1999, 2003; Luff & Thomas
2000; Hopton et al. 2012; Mulley et al. 2012;
Hopton et al. 2013) supports the NICE advice,
and underpins this fundamental principle of
NHS service design. Findings suggest that con-
ventional treatment options increasingly fail to
reflect the diversity of values that patients bring
with them to the surgery. There is also evidence
that sufferers of many chronic conditions are
frustrated by, and disappointed in, conventional
treatment (Paterson & Britten 1999; Mulley et al.
2012), particularly when they perceive or experi-
ence adverse effects from prescribed medication
or surgical intervention (Mulley et al. 2012).
In their 1999 report, “‘Doctors can’t help
much’: the search for an alternative”, Paterson &
Britten (1999) observed that many patients are
wary of the risks of pharmaceutical and surgical
interventions to the extent that they welcome,
and prefer, alternative options, including acu-
puncture. These authors commented that:
“[H]ealth professionals make value judge-
ments on what constitutes acceptable risks
from side-­ effects of drugs. This study
reminds us that many patients make their
own judgements about risk.” (Paterson &
Britten 1999, p. 629)
Their conclusion – that patients find much of
modern high-­ technology medicine irrelevant
and/or inappropriate to their needs – is sup-
ported by their own, more-­ recent studies
© 2017 Acupuncture Association of Chartered Physiotherapists
K. Coleman-­Rooney
(Paterson & Britten 2003; Paterson et al. 2011),
and those of other researchers (Luff & Thomas
2000; Hopton et al. 2012; Mulley et al. 2012).
A recent and wide-­ranging attitudinal survey,
from influential healthcare think-­ tank The
King’s Fund, goes further, arguing the ethical
case for patient preference. In Patients Preferences
Matter: Stop the Silent Misdiagnosis (Mulley et al.
2012), authors Al Mulley, Chris Trimble and
Glyn Elwyn argue that doctors are, in a signifi-
cant number of cases, offering pharmacologi-
cal and surgical approaches that patients find
inappropriate and/or irrelevant. Contending
that “there are breathtaking gaps between what
patients want and what doctors think they
want” (Mulley et al. 2012, p. 5), they make a case
for the development of best-­ practice models
that prioritize patient preferences for alternative
treatment options as an ethical imperative.
Cost and service efficiency benefits
Sensitivity to preferences can also deliver ben-
efits to the NHS budget. Making reference to
a wide range of diseases, including the chronic
and long-­ term conditions GPs and primary
care providers find particularly intractable, and
for which many patients welcome alternative
interventions such as acupuncture (Hopton
et al. 2012, 2013), Mulley et al. (2012) pointed
to the potential for considerable cost savings.
In particular, they cited research by Wennberg
et al. (2010) demonstrating that options that
help patients manage their own conditions satis-
factorily can deliver, for example, reductions in
hospital admissions, and attendance at accident
and emergency departments.
In another example, MacPherson & Thomas’
(2007) RCT of acupuncture for low back pain
in a primary care setting went further than
reporting continued health improvements at 12
and 24 months. They also rated the treatment as
a “highly cost-­effective” option when measured
against quality-­adjusted life-­year criteria.
Similarly, in an evaluation of the Beating Back
Pain Service (Cheshire et al. 2013), research into
patient outcomes, and experiences of an acu-
puncture and self-­care service for persistent low
back pain in an NHS primary care setting in
13
Making the case for acupuncture
central London, found that more than one-­third
of patients experienced a clinically significant
improvement in their pain at the 3-­ month
time point. The researchers also found statisti-
cally and clinically significant improvements
in a wider range of health and quality of life
indicators, including improved physical activity,
reductions in the use of prescription painkillers,
psychological well-­being and self-­efficacy. They
concluded that the provision of acupuncture
contributed to an “effective and valuable”
(Cheshire et al. 2013, pp. 1 & 11) service for
patients managing long-­term chronic back pain.
Safety
Contrary to the sceptics’ charge of irresponsi-
bility, the safety of acupuncture procedures is
of primary concern (BAcC 2016), and when
carried out by fully trained practitioners, is
well evidenced. In 2001, a prospective survey
(MacPherson et al. 2001) of 34 407 treatments
by fully trained practitioner members of the
British Acupuncture Council (BAcC) that
was published in the BMJ, Hugh MacPherson
and his team found no (zero) serious adverse
events (defined as problems requiring hospital
admission, or leading to permanent disability or
death).
This equates to an underlying serious adverse
event rate of between 0 and 1.1 per 10 000
treatments by BAcC members, and resulted in
a BMJ editorial recommending acupuncture as
“safe in the hands of competent practitioners”
(Vincent 2001, p. 467).
Conclusion
Acupuncture is a beneficial, valued, safe and
cost-­effective treatment option. Notwithstanding
its considerable limitations as a paradigm for
the understanding of acupuncture, quantitative
biomedical research increasingly offers an evi-
dence base that facilitates a science-­led discus-
sion of the fundamental concepts of Qi and
the meridians, and demonstrates the efficacy of
acupuncture across a range of conditions.
Qualitative research shows that the provi-
sion of acupuncture in the primary care setting
makes a significant contribution to the sustained
14
well-­
being of patients, particularly those with
chronic, hard-­to-­manage conditions. Offering
acupuncture also conforms to NHS principles
and NICE guidelines on reflecting patients’
preferences and values. Last, but not least, it
has been shown that acupuncture should be
considered as a cost-­effective option that can
potentially contribute to overall cost savings.
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K. Coleman-­Rooney
Paterson C., Taylor R. S., Griffiths P., et al. (2011)
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much”: the search for an alternative. British Journal of
General Practice 49 (445), 626–629.
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with chronic illness: combining qualitative and quanti-
tative outcome assessment. The Journal of Alternative and
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You Feel. Pocket Books, London.
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acupuncture. Evidence-­Based Complementary and Alternative
Medicine 6 (1), 31–39.
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Neurohumoral Theory. [WWW document.] URL https://
medicalacupuncture.wordpress.com
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Acupuncture: Scientific Basis. Springer-­Verlag, Berlin.
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Acupuncture for chronic pain: individual patient data
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1444–1453.
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Kaye Coleman-­Rooney is a student practitioner at The
Acupuncture Academy in Leamington Spa. She is also
a student member of the British Acupuncture Council.
15
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 17–27

ORIGINAL RESEARCH

Scientific Evaluation and Review of Claims

in Health Care (SEaRCH): a streamlined,
systematic, phased approach for determining
“what works” in healthcare
W. B. Jonas,* C. Crawford & P. Elfenbaum
Samueli Institute, Alexandria, VA, USA

L. Hilton
Samueli Institute, Alexandria, VA, and RAND Corporation, Santa Monica, CA, USA

Abstract
Answering the question of “what works” in healthcare can be complex, and requires the
careful design and sequential application of systematic methodologies. Over the past decade,
the Samueli Institute has, along with multiple partners, developed a streamlined, system-
atic, phased approach to this process called the Scientific Evaluation and Review of Claims
in Health Care (SEaRCH™). The SEaRCH process provides an approach for rigorously,
efficiently and transparently making evidence-­ based decisions about healthcare claims in
research and practice with minimal bias. SEaRCH uses three methods combined in a coordi-
nated fashion to help determine what works in healthcare. The first, the Claims Assessment
Profile (CAP), seeks to clarify the healthcare claim and question, and its ability to be evalu-
ated in the context of its delivery. The second method, the Rapid Evidence Assessment of
the Literature (REAL©), is a streamlined, systematic review process conducted to determine
the quantity, quality and strength of evidence, and risk/benefit for the treatment. The third
method involves the structured use of expert panels (EPs). There are several types of EPs,
depending on the purpose and need. Together, these three methods – CAP, REAL and
EP – can be integrated into a strategic approach to help answer the question “What works
in healthcare?” and what it means in a comprehensive way. SEaRCH is a systematic, rigorous
approach for evaluating healthcare claims of therapies, practices, programmes or products
in an efficient and stepwise fashion. It provides an iterative, protocol-­driven process that
is customized to the intervention, consumer and context. Multiple communities, including
those involved in health service and policy, can benefit from this organized framework,
assuring that evidence-­based principles determine which healthcare practices with the great-
est promise are used for improving the public’s health and wellness.
Keywords: decision-­making, evidence-­based medicine, expert panel, patient-­centred care, policy,
systematic review.

*Correspondence and present affiliation: Wayne
B. Jonas MD, H&S Ventures, 1800 Diagonal
Road, Suite 617, Alexandria, VA 22314, USA
(e-­mail: wayne@hsventures.org).
Introduction
Consumers, practitioners, insurance companies
and governments spend billions of dollars
annually on therapies that have limited or no
solid medical evidence, and which may interact

© 2017 Wayne B. Jonas, et al. 17

Scientific Evaluation and Review of Claims in Health Care
adversely with existing treatments or produce
direct adverse effects of their own, and even
exacerbate existing medical conditions (Berwick
2013). Ideally, any type of treatment should
only be offered to the public when it has
known mechanisms of action, and clinically
relevant safety and efficacy data from definitive
Phase III, controlled, randomized clinical trials
(RCTs). While such an ideal is not possible,
more streamlined and systematic steps can at
least be provided that are organized in a way to
allow the most appropriate interventions to be
based on best current evidence at the time.
In addition to the extensive use of conven-
tional practices that are not evidence-­based, the
public uses many practices from outside the
conventional healthcare system, usually without
supervision or knowledge of their effectiveness.
These are often called complementary and alter-
native medicine (CAM). When the two systems
(conventional and CAM) are integrated into the
mainstream health system, the term comple-
mentary and integrative medicine (CIM) or just
integrative medicine (IM) is often used (Coulter
et al. 2013). The 2007 National Health Interview
Survey of more than 30 000 US adults found
that 38% of American adults had used some
form of CAM within the past year, spending
nearly $36 billion on these practices and prod-
ucts, mostly out of their own pocket (Nahin et al.
2009). In addition, it was recently shown that
44% of military members use CAM therapies
(Goertz et al. 2013). Despite widespread use and
dramatic claims of benefit for serious disease,
relatively little has been definitively established
regarding the efficacy, effectiveness and safety
of the majority of IM practices (Coulter et al.
2010).
In order to select the most appropriate
interventions from any practice, whether con-
ventional, CAM or IM, the first question is
often “What works?” when deciding what to
do, pay for or avoid. As simple as this ques-
tion is to ask, attempts to answer it for any
particular treatment are often complex. This
is true whether the question is applied to a
product, practice, programme or policy, and for
any particular outcome, be it cure, enhanced
well-­being, satisfaction or cost. Because of this
18
complexity, answering this question requires a
careful design and the sequenced application of
a set of methodologies.
This article describes a streamlined, system-
atic, phased process for determining “what
works” for any treatment – be it a programme,
practice or product – by breaking down the
process into a subset of corollary questions
designed to piece together the overall picture
of the treatment and its outcomes (Crawford
et al. 2015; Coulter et al. 2016; Hilton & Jonas
2017). The approach is called the Scientific
Evaluation and Review of Claims in Health
Care (SEaRCH™), and uses three methods
combined in a coordinated fashion to help
determine what works in healthcare. The first
method is the Claims Assessment Profile (CAP)
(Hilton & Jonas 2017), which seeks to clarify
the healthcare claim and question. The second
method is the Rapid Evidence Assessment of
the Literature (REAL©), which uses streamlined
systematic review methods to determine the
current state of the evidence (Crawford et al.
2015). The third method involves the structured
use of expert panels (EPs) (Coulter et al. 2016)
in order to deliver evidence-­informed decisions
to the end user in a transparent fashion.
SEaRCH has been developed over a number
of years with input from scientists, practitioners,
healthcare administrators and policy-­makers, and
it has been “field tested” on multiple treatments
and claims (Buckenmaier et al. 2014; Costello
et al. 2014; Attipoe et al. 2015; Crawford et al.
2015, 2016a, 2017; Boyd et al. 2016a, b; Coulter
et al. 2016). This validation testing has been
done on existing practices in areas of behav-
ioural medicine, self-­ care, nutrition, lifestyle
programmes and CIM. However, the principles
of this framework are drawn from general
scientific evaluation methods, and are applicable
to any healthcare claim, whether about a pro-
gramme, practice or product already in use. Its
value is demonstrated not so much in examining
new theories, but in analysing existing practices
that have not been fully evaluated or validated.
This article describes the evolution of SEaRCH
as an organized framework, the sequences of
corollary questions and methodologies that
make it up, and the approaches developed to
© 2017 Wayne B. Jonas, et al.

answer these questions and synthesize their
information for determining “what works” in
healthcare. Through collaboration and partner-
ships, it is hoped that this organized framework
can be improved and implemented more widely
to deliver evidence-­ informed knowledge of
what works in healthcare.
Evolution and development of
SEaRCH
Typically, the scientific process begins in the
laboratory or with a new technology, and then
moves forward through Phase I, Phase II, and
finally, Phase III clinical trials. This process can
take many years and cost hundreds of millions
of dollars. Thus, many promising practices
(even perhaps the best practices) never make it
through this process. In recognition of this fact,
researchers and funding agencies have taken
the pragmatic approach of occasionally mov-
ing into Phase II and III trials before perfect
information regarding mechanisms of action is
available. These trials can still often take 5 years
or more to complete, and cost tens of millions
of dollars. Many of the most promising CIM
practices (perhaps even the best practices) are
not commercially profitable, and so will never
be supported at such levels or delivered to the
public. In addition, a number of such trials have
been performed, and the results have been nega-
tive (Jonas et al. 2013). It is, therefore, impera-
tive that the best choices possible are made
regarding specific treatment protocols, including
dosing, duration and frequency of treatment.
In the past, funding agencies such as the US
National Institutes of Health (NIH) and the
Department of Defense have relied upon infor-
mation derived from evidence-­based reviews, as
well as public health significance and best case
series, to develop Phase III clinical trial initia-
tives (NCCAM 2011). The latter, however, are
risky and expensive without adequate pilot data
and systematic review evidence. Clinical trials of
a more modest size help to develop preliminary
tools and information on appropriate outcomes
measures, feasibility of data collection, patient
burden and effect size. Prospective studies with
appropriate control groups collect preliminary
© 2017 Wayne B. Jonas, et al.
W. B. Jonas et al.
data, and assist in the development of both
mechanistic/preclinical studies and larger-­ scale
RCTs.
SEaRCH was developed over a number of
years with the support of the NIH, the Centers
for Disease Control and Prevention (CDC), and
the US military. These methods included field
investigations and the Prospective Outcomes
Evaluation Monitoring System (POEMS)
system used by the National Cancer Institute.
What was needed was an organized way to
move the CIM field forward through rigorous
evaluation of actual clinical practice. SEaRCH
development has grown through public–private
partnerships over the past decade. The original
concept was conceived in 1996, through a
governmental mandate to the NIH, to docu-
ment and evaluate alternative therapies and
practices. Through collaboration with the CDC,
the Office of Alternative Medicine (OAM)
at the NIH developed the Field Investigation
and Practice Assessment (FIPA) programme in
1997, and conducted evaluations of dozens of
CAM practices around the world.
The concept of conducting CAM research
within the practice setting is not unique. From
1995 to 1999, the NIH OAM sponsored the
FIPA programme, under which OAM con-
ducted 33 site visits of CAM practices. The
major goals of this programme were to: (1)
contact CAM and/or CIM and conventional
practices that offered promising therapies for
specific diseases; (2) assess the feasibility of
conducting a practice outcomes assessment/
monitoring programme or an RCT; and (3)
screen unusual cases to see if sufficient data
existed to engage in retrospective and/or pro-
spective outcomes studies. The OAM followed
up on initial site visits by contracting with the
CDC to conduct formal field study investiga-
tions of promising CAM clinical practices. An
example of this work is a field investigation
on naturopathy in the treatment of menopause
symptoms by Cramer et al. (2003). In addition,
OAM, in conjunction with the National Cancer
Institute, established the Cancer Advisory
Panel for Complementary and Alternative
Medicine to advise them on conducting a Best
Case Series programme (IMCUCAMAP 2005).
19
Scientific Evaluation and Review of Claims in Health Care
This programme led to the development of
large-­scale RCTs to study therapies that offered
promise for cancer outcomes, and evolved into
using the Best Case Series design to screen
other therapies making claims of benefit for
cancer patients. While case series have been
conducted by investigators in a number of
countries on local treatments for serious dis-
ease, the research methodology used in these
studies is often inadequate for supporting
objective conclusions. SEaRCH addresses this
inadequacy by pulling from and organizing
the best of these methods, and gathering the
research expertise necessary at the local and
international levels to collect sound data on
these practices.
A variation of the NIH FIPA programme
was extended in 2003 under the congression-
ally mandated CAM Research for Military
Operations and Health Care programme
run by the Samueli Institute. It was further
developed under the name Epidemiological
Documentation Service (EDS) through a
subcontract to the National Foundation of
Alternative Medicine. The EDS was later taken
over by the Samueli Institute, where it was
further developed, redesigned and renamed
SEaRCH. The goal of this latter redesign was
to enable more rapid and complete throughput
and assessment of not only CAM practices, but
any practice, conventional or unconventional,
already in use and claiming a particular benefit.
Part of the improvement in SEaRCH was done
in collaboration with the RAND Corporation,
which houses a Samueli/RAND programme
on policy research in integrative health. This
collaboration enhanced the descriptive and
qualitative section of SEaRCH (Hilton et al.
2016). In addition, the Institute has begun to
incorporate EP methodology, adapted from
RAND’s “appropriateness” process to complete
the SEaRCH design described here (Shekelle
et al. 1991; Coulter et al. 2016).
Prospective outcomes studies
One method not incorporated into SEaRCH
in its current version is the prospective clinical
trial. Walach (2001) has developed a cogent
20
argument for the value of prospective out-
comes studies. He cautions against rushing
to placebo-­controlled RCTs without sufficient
information on critical issues such as healing
rates, diseases that might respond best to the
therapy, time to initial improvement, dose and
so on. To address this, an approach was pro-
posed called the prospective outcomes docu-
mentation system (PODS) for getting informa-
tion on practice delivery and effectiveness in
real-­world settings. Unlike most prospective
studies, PODS (and the similar method
developed by NCI called POEMS) captures
prospective data without interfering or altering
the clinical practice as a whole. Examples can
be found in prospective outcomes studies in
the chiropractic literature. Hayden et al. (2003)
conducted a prospective cohort study of chi-
ropractic treatment for paediatric patients with
low back pain (LBP) and concluded they had
a favourable response to chiropractic manage-
ment. Nyiendo and colleagues reported a series
of positive findings from their practice-­based
study of chiropractic for medical patients with
LBP (Nyiendo et al. 2001; Haas et al. 2002;
Stano et al. 2002).
Perhaps the best examples of prospective
outcomes evaluations have occurred in the area
of CAM treatments for cancer. Richardson
et al. (2000, 2001) collected prospective out-
comes data from several oncology clinics that
take a CAM approach to cancer therapy. They
reported on both the feasibility and challenges
of conducting outcomes research of CAM
therapies in cancer clinics. Pfeifer & Jonas
(2003) used a PODS approach to investigate
immuno-­ augmentative therapy (IAT), a CAM
therapy used by thousands of cancer patients
that had not been previously evaluated in a
systematic fashion for either safety or effi-
cacy. This PODS demonstrated no significant
improvement in cancer survival following IAT
over expected outcomes when all patients were
followed up. A previous best case series had
reported positive outcomes for IAT (Shekelle
et al. 2003). Often a PODS or RCT is recom-
mended by a research panel after a claim is
assessed by SEaRCH. That will be demon-
strated later in this article.
© 2017 Wayne B. Jonas, et al.
 W. B. Jonas et al.
SEaRCH process and
frameworks
The SEaRCH process is drawn from two
primary scientific methods for evaluation of
therapeutic claims in medicine and healthcare.
The first, called the Evidence House (Jonas
2001; Jonas & Guerrera 2015), is a modi-
fication of the standard evidence hierarchy
used by multiple groups, including clinical
trialists, systematic reviewers, clinical guide-
line developers and federal agencies dealing
with product regulation (e.g. the Food and
Drug Administration), comparative effective- Figure 1. The Evidence House.
ness research (e.g. the Agency for Healthcare
Research and Quality) or patient-­ centred
research (e.g. the Patient-­Centered Outcomes
Research Institute) (Fig. 1).
In the Evidence House framework, knowl-
edge elements are matched to particular meth-
ods, and then these methods are matched to the
goals of stakeholders and decision-­makers, such
as patients, practitioners, researchers or regula-
tors. These are placed in a semi-­ hierarchical
arrangement, with laboratory and qualitative
research as the foundational methods seeking
to collect new information, with the goals of
moving them toward determining their “reality”
and “relevance”, respectively. Evidence is then
added vertically through four other, more com-
plex approaches needed to build on these two
types of knowledge. Since SEaRCH is focused Figure 2. Research Methodology Mandala©.
on existing practices or products, it draws from
qualitative, observational, controlled trial and
systematic review approaches to construct a the evaluation of methods beginning at the top
“mixed-­method” sequence specifically designed of the mandala through practice descriptions in
for the central question of interest: “What order to answer “What is it and how is it being
works in healthcare?” applied?” through a method called the CAP, and
The second framework that was used in then uses systematic review methods to answer
the design of SEaRCH is the Methodology “What is the current state of the evidence?”
Mandala© illustrated in Fig. 2. Created primarily through a streamlined process called the REAL.
to facilitate better management of compara- Then it selects application and implementa-
tive effectiveness research, the Methodology tion methodologies to answer the question
Mandala uses a circle of questions (inner “How can the practice be translated to other
ring) with a matching set of methods (outer settings?” using structured, evidence-­informed
ring), each integrated into a set of coordinated EPs. Together, these methods, which are all
approaches to the questions asked in each aimed to answer specific questions about what
knowledge domain. Specifically, the current works, are arranged into a simplified, phased
SEaRCH design draws from and streamlines methodological process (Table 1). In other

© 2017 Wayne B. Jonas, et al. 21

Scientific Evaluation and Review of Claims in Health Care
Table 1. Scientific Evaluation and Review of Claims in Health Care (SEaRCH) framework
Query SEaRCH method
What is it? How is it applied? Claims Assessment Profiles and stakeholder
engagement
What is the current evidence? Systematic reviews
How can the practice be utilized? Expert panels
words, each method is designed to answer the
particular sub-­questions needed to complete
the knowledge necessary to achieve the “What
works in healthcare?” goal. The outcome of this
process can be applied to decisions about the
appropriateness of a practice, policies for pay-
ment and implementation, and/or in building
a logical research agenda. The use of SEaRCH
methodology may point to the use of other
methods listed around the mandala, such as the
PODS or randomized trials, and ultimately, the
translation of the evidence into public value.
SEaRCH methods
The current version of SEaRCH consists of
three primary methods: the CAP, REAL and
EP processes. The CAP methodology seeks
to describe the practice and clarify the health-
care claim/question. It does this by accurately
describing the practice, precisely defining what
it claims to do, and determining readiness,
capacity and the resources involved in further
research or evaluation (Hilton & Jonas 2017).
The second method is the REAL, which is a
streamlined, efficient systematic review process
conducted to determine the quantity, quality
and strength of evidence, and risk/benefit for
the treatment, as reflected in current research.
The REAL provides the evidence base of a
healthcare claim, so that groups can identify the
gaps and next steps needed in a field (Crawford
et al. 2015). The final method involves the struc-
tured management of EPs for making value
judgements about the use of current evidence
(Coulter et al. 2016). There are several types
of EPs, depending on the purpose and need.
A clinical EP focuses expert opinion on the
appropriateness of a given clinical practice or
product for clinical use. A research EP focuses
22
Outcome
Detailed description of practice, process and
reported outcomes
Summary of the evidence supporting practice
or product
Detailed outline for next steps in research or
clinical application
expert opinion on research directions for a
practice or product. A policy EP focuses on
making the evidence-­ based policy judgements
needed to direct implementation of a practice
claim. Patients can be incorporated into the
panel process for making more patient-­centred
decisions, which is called a patient EP.
Method for addressing the sub-­
questions
Describing the intervention
Each of the above methods is designed to pro-
vide the types of information needed to answer
“What works in healthcare?” These are posed as
a series of sub-­questions that must be addressed
in order to have a full evidence base for the
answer. The first sub-­question involves defining
and describing what the intervention is for any
claim. If the intervention is a single chemical
agent, this becomes relatively simple, includ-
ing standardization and quality control of the
product, and isolation of its effects in random-
ized, placebo-­controlled trials. If the product is
a combination of chemicals, such as a herb or
supplement, quality control and the issues of
synergy of product components multiply the
complexity logarithmically. If the intervention
is a practice, then variation in the practice adds
increased complexity to the description. For
example, a surgical procedure may be described
in uniform terms, but delivered in a variety of
ways. A procedure such as acupuncture, where
different philosophies and individualization of
treatment occur, also adds complexity. If an
intervention involves a combination of practices
customized to the particular patient involving,
for example, a product for delivery, a method of
education and a behavioural change (such as a
© 2017 Wayne B. Jonas, et al.

lifestyle change), this further increases variations
in delivery. If the intervention requires the com-
pliance of the patient or participant, behavioural
changes, or changes in attitude and expectation,
the key components of the “it” (the interven-
tion or treatment) may be difficult to measure,
and so may be missed in an evaluation. Multiply
this complexity again if there are multiples of
interventions in a policy guideline attempting
to optimize and coordinate various approaches.
These types of interventions – product, prac-
tice, programme and policy – layer on each
other, and rapidly increase the complexity
and variability of delivery, measurement and
analysis. The first methodological segment in
SEaRCH – the CAP – is designed to address
this complexity. The CAP provides an approach
to determine what the “it” is for answering the
question of “What works?” A full description
and examples of the CAP method can be found
in detail elsewhere (Hilton & Jonas 2017). The
outcome of a CAP is a full description of the
intervention, and its hypothesized outcome and
impact on the claim.
Describing the outcomes
In addition to answering the question of what
the “it” of the intervention is, the question
of what impact “it” has becomes another
sub-­question the CAP addresses. This is the
question of “It works for what?” or “What is
(are) the claimed or hypothesized outcome(s)
from the treatment?” An outcome might be
a defined change in a biochemical parameter,
such as cholesterol, or it might be the elimi-
nation of pathology, such as a tumour, or it
might be the alleviation or elimination of an
illness, as defined by a complex experience
of symptoms or a functional ability. If the
outcome falls into a more elusive or subjec-
tive category, such as wellness or prevention,
it becomes more complex and difficult to
measure. For example, consider how wellness
is defined: “Who wants it, in what context and
over what time period?” Depending on the
stakeholder, the outcome may have nothing
to do with individual health at all. Common
outcome questions include “What is the cost?”,
© 2017 Wayne B. Jonas, et al.
W. B. Jonas et al.
“How many people are getting the service?”
or “How does it compare with some other
intervention?” Some of these outcomes may or
may not be of particular interest to a patient
or their family. The involvement of key stake-
holders throughout each segment of SEaRCH,
not only the CAP, but also the REAL and EP,
frames the outcomes to ensure relevance for
the end user (Crawford et al. 2015; Coulter et al.
2016; Hilton & Jonas 2017).
Describing the population
Another corollary question is “What works for
whom?” Is the outcome something that will be
used by or for a specific group? For example,
cancer survival and a longer life might be the
main goal of the medical profession for cancer
patients. However, in an elderly population or
those undergoing a serious intervention with
many side effects, this may not be the outcome
of most interest to a patient. Patients may be
more interested in quality of life, or achieving
specific lifeline goals.
Describing the comparisons
Finally, the most complex corollary question of
all may be “How does it work when compared
to what?” To determine if an intervention
is producing a value relative to other inter-
ventions requires that they be compared on
outcome, adverse effects, feasibility, preference
and cost, both human and economic. That is,
what is the overall cost-­value of two different
interventions? A rational approach to such a
comparison can only be conducted when the
primary intervention is fully described in the
CAP (Hilton & Jonas 2017). For example, if the
intervention is a chemical, it means comparing it
to the same treatment without the chemical. If
the intervention is a practice or a programme,
it means comparing it to a patient receiving a
different practice or programme, or receiving
no practice or programme. The first of these
comparisons is called “efficacy,” and the second
of these comparisons is called “comparative
effectiveness”. These are very different types of
evidence, and working with key stakeholders to
decide what is the most meaningful and useful
23
Scientific Evaluation and Review of Claims in Health Care
evidence needed is essential in framing research
questions and agendas.
Design of SEaRCH
Given the complexity of answering the primary
question of “What works?”, and the sub-­
questions of “What is it, for what, for whom
and compared to what?” that are essential for
ensuring useful evidence, it is little wonder that
so few existing interventions (conventional
or complementary) are adequately evaluated.
Often, some of the sub-­questions are answered,
but without the full picture of evidence needed
to answer the primary question of “What
works?” The CAP helps to define clearly with
the stakeholders involved the answers to those
essential questions. The REAL comes into play
for determining “What is the current evidence?”
to support the “it”, and clarifying the “What,
for whom and compared to what?” issues. This
clarification is called Population, Intervention,
Control/Comparator and Outcomes (i.e.
the PICO framework for systematic review)
(Richardson et al. 1995), where the evidence of
interest is clearly defined with the key stakehold-
ers upfront, and a streamlined process applied to
determine the evidence base for the claim rigor-
ously and objectively. Finally, the EP process
allows decision-­makers in healthcare – policy-­
makers, researchers, clinicians and patients – to
weigh in on making complex decisions, but with
good evidence as a basis.
Aligning the components of SEaRCH
There is currently no systematic, streamlined
and inexpensive way of going from one sub-­
question to another in an organized manner in
healthcare decisions. SEaRCH is designed to
do that. SEaRCH creates a linear, phased set
of methods to answer each sub-­ question. To
preserve rigour, each method is applied using
current standards of evidence quality.
Streamlining judgement, managing bias
and enhancing rigour
In order to achieve a streamlined process for
incorporating judgements about relevance,
24
SEaRCH uses two important systems. First,
it uses a structured EP process for the judge-
ment process. That process can focus on which
research approaches are needed (research EP),
what is appropriate for clinical practice based
on existing evidence (clinical EP) or which
implementation guidelines are needed (policy
EP), or determine patient needs, preferences
and perspectives (patient EP). Whatever its
composition, the EP uses a semi-­ quantitative
Delphi method. The method involves extracting
judgement from the stakeholders (e.g. clini-
cians, researchers, policy-­makers and patients)
in a way that allows for independent, blinded
opinions from diverse perspectives about the
relevance and use of the evidence presented.
This reduces the bias that is often introduced
when EPs are employed, and at the same time,
accesses the best expert judgement grounded in
evidence. Secondly, SEaRCH uses an informa-
tion technology platform throughout its design
that increases efficiency and reliability, and
ensures complete transparency. Through the
use of an online technology platform designed
specifically for this process, SEaRCH is able to
deliver results faster with improved accuracy
and reliability, and provides a complete audit
trail of all changes made during each step of
the process. Samueli has applied this system to
integrate across the SEaRCH steps so that all
data can be captured remotely in the system, and
the reports shared across the three steps. The
technology alone can reduce the cost and time
by threefold. Figure 3 graphically illustrates the
design of SEaRCH, and how the sub-­questions
are answered in each step.
Each of these methods (the CAP, REAL and
EP) have been described in detail in previous
publications (Crawford et al. 2015; Coulter et al.
2016; Hilton & Jonas 2017). The approach is
designed for practices that are already being
used and delivered, such as those in primary
care, traditional (indigenous) practices, market-­
derived products and procedures, military medi-
cine, and CAM/CIM. It is especially useful in
controversial areas where independent analysis,
bias reduction, transparency and balanced input
from diverse stakeholders are needed. In addi-
tion, SEaRCH is useful for the evaluation of
© 2017 Wayne B. Jonas, et al.

Figure 3. Scientific Evaluation and Review of Claims in
Health Care (SEaRCH™) overview.
self-­care practices such as weight loss, dietary
supplements, and stress and pain management
programmes that people adopt and use for
self-­care (Buckenmaier et al. 2014; Costello et al.
2014; Attipoe et al. 2015; Boyd et al. 2016a, b;
Crawford et al. 2016a, b). The approach has
been presented at national and international
conferences, in research methodology forums,
and through workshops and online training. The
goal is to be able to use this method in any area
of healthcare when confronted with the chal-
lenging question of “what works” in healthcare.
Conclusions
This article describes the overall SEaRCH
process and its components. These include the
CAP, the REAL and the EP. The CAP process
provides a detailed description of the treat-
ment and claim. The REAL process provides a
rigorous assessment of the current literature to
support making evidence-­based decisions. The
EPs are the final method used for gaining struc-
tured insight into what experts believe about
the implications of the evidence for a given
treatment or approach. Together, these methods
can be used to address the question of “what
works” in healthcare in a rigorous yet efficient
and stepwise manner. In summary, SEaRCH is
a series of methodologies for evaluating claims
about the prevention or treatment of disease,
and/or for improving health. Through its sys-
tematic, streamlined, protocol-­
driven process,
© 2017 Wayne B. Jonas, et al.
W. B. Jonas et al.
it can critically evaluate claims for healthcare.
Consumers, medical and healthcare communi-
ties, and researchers can benefit from SEaRCH
by using it to evaluate healthcare claims to
determine those with the greatest promise for
treating disease and improving health.
Acknowledgments
The authors would like to acknowledge Mr
Avi Walter for his assistance with the overall
SEaRCH process developed at the Samueli
Institute, and Ms Viviane Enslein for her assis-
tance with manuscript preparation. In addition,
the authors would like to acknowledge all
partners who were involved in the evolution
and development of the SEaRCH framework.
This project was partially supported by award
number W81XWH-­08-­1-­0615-­P00001 (United
States Army Medical Research Acquisition
Activity). The views expressed in this article
are those of the authors and do not neces-
sarily represent the official policy or position
of the US Army Medical Command or the
Department of Defense, or those of the
National Institutes of Health, Public Health
Service, or the Department of Health and
Human Services.
Author disclosure statement
No competing financial interests exist.
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Wayne B. Jonas MD, Cindy Crawford BA, Lara
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27
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 29–38

MERIDIAN MASTERCLASS

The Spleen meridian: the foot Tai Yin channel

R. Lillie
Private Practitioner, London, UK

Abstract
This article presents an overview of the Spleen meridian, and its potential clinical uses for
the physiotherapist. The channel theory is introduced, and an outline of the functions of the
Spleen according to principles of traditional Chinese medicine (TCM) is given. The course
of the Spleen meridian is explained, and key points are examined in depth. The principles
of TCM are examined in conjunction with Western concepts in order to demonstrate the
clinical reasoning behind the selection of points along the course of the channel.
Keywords: acupuncture, Spleen meridian, traditional Chinese medicine.

Introduction This organ controls the digestion of food,

According to traditional Chinese medicine
(TCM), vital energy (Qi) flows through a sys-
tem of 12 channels or meridians, regulating
bodily functions. Each meridian is associated
with an organ or function. The 12 organs are
divided into six pairs, one being yin (Zang) and
the other yang (Fu). The Spleen (Pi) is a Zang
organ and is paired with the Stomach (Fu). In
Five Element Theory, these organs belong to
Earth. Each organ is kept in check by another
one: the Spleen is controlled by the Liver, and
in turn, it controls the Kidneys. The Stomach
and Spleen are the root of Post-­ Heaven Qi,
which derives from the nourishment that food
and fluids take into the body, and also the origin
of Qi and Blood. Therefore, the Stomach and
Spleen nourish and indirectly tonify all the other
organs.
In TCM, the functions of the Spleen are
held to be transformation and transportation.
Correspondence: Rosemary Lillie, West Wimbledon
Physiotherapy Clinic, 532 Kingston Road, Raynes
Park, London SW20 8DT, UK (e-­mail: rosemary@
westwimbledonphysio.co.uk).
and is responsible for the intake of fluid. It
takes the output from the Stomach, transforms
this into Blood (by providing the Heart with
energy), fluids and Qi, and moves these around
the body. The Spleen assimilates the Qi from
nutrition, and nourishes and moves the Blood.
If it fails to control Blood, excessive bleeding
can occur. It also controls the ascension of
Qi. If Qi cannot ascend, things are not held in
place, giving rise to varicose veins, prolapse or
poor muscle tone. The Spleen also governs the
connective tissue, and holds the organs in place.
It controls Blood, muscles and limbs, providing
vigour and bulk to the muscles. It also houses
the intellect, i.e. how we process information
and think things through. The Spleen produces
Blood, which the heart depends upon, and with
the Stomach, is the main support for the Heart.
It opens to the mouth, controls the sense of
taste and is manifested in the lips. It controls
saliva. In cases of Spleen Qi stagnation, typi-
cal signs are chewing or picking the lips. The
external climatic influence is Dampness, and the
internal emotional influence is depression.

© 2017 Acupuncture Association of Chartered Physiotherapists 29

The Spleen meridian
In cases of perverse energy invasion, typical
symptoms include abdominal distension with
flatus, vomiting after meals and stiffness at the
root of the tongue, and internal causes result in
diarrhoea, pain in the cardiac area, a generalized
feeling of stiffness and pain at the root of the
tongue.
Abdominal symptoms of excess in the Spleen
channel result in shooting pains in the abdomen,
and deficiency results in distension of the belly.
Factors that affect the Spleen include over-
thinking, poor diet (e.g. consuming too many
dairy products or fried foods), external Damp
and problems with the Liver, especially Liver Qi
stagnation. Remember, the Liver controls the
Spleen.
Pathological conditions associated with this
organ include full/excess (e.g. Damp Heat or
Damp Cold invasion), or empty/deficiency
(e.g. Spleen Qi deficiency or descent, Spleen
blood deficiency, Spleen yang deficiency,
Spleen yin deficiency, Spleen and heart defi-
ciency, or Spleen and lung deficiency with
lung phlegm).
Problems with the Spleen (Zang) are gener-
ally treated using the coupled Stomach (Fu)
meridian. This follows the general rule of basic
yin–yang theory. Yin is the solid material basis
for the yang function of moving Qi. Again, in
general, yin is better for tonifying, and yang
for draining. Therefore, it is most appropriate
to treat Spleen excess, Heat and stasis by using
the Stomach meridian. Conversely, for deficient-­
type digestive disorders that may also involve
Cold in the Stomach channel, the Spleen merid-
ian is most effective channel to use in treatment
(Wang & Robertson 2008).
The sources for the acupuncture points and
their functions included in this masterclass
have been taken from the books and websites
listed in the reference section (Deadman et al.
1998; Ellis 1999; Maciocia 2005, 2007; Betts
2006; Wang & Robertson 2008; Woodley
2009; Dorfman 2017; Oriental Medicine 2017).
Because of the present author’s special interest
in women’s health, she has highlighted those
taken from Betts (2006), since these are specific
to the use of acupuncture during pregnancy
and childbirth.
30
The course of the Spleen
meridian
The primary channel of the Spleen meridian
begins on the medial side of the tip of the
big toe, runs along the medial border of the
foot and ascends behind the medial malleolus
(Fig. 1). It then travels up the medial aspect
of the leg into the lower abdomen, where
it ascends again, terminating in the seventh
intercostal space. A branch travels across the
diaphragm, along the oesophagus and ends in
the middle of the tongue. Another branch goes
through the diaphragm and links with the heart
(Fig. 2).
Clinical application of the
meridian and acupuncture points
The connections of the primary channel of the
Spleen meridian are as follows:
• It connects with the following Zang Fu
organs – the Spleen, the Stomach and the
Heart.
• At Spleen (SP) 4 (Gong Sun), the connecting
channel links with the Stomach meridian.
• It meets the Lung meridian at Lung 1 (Zhong
Fu).
• It connects with the Conception Vessel (Ren
Mai) meridian at Conception Vessel (CV)
3 (Zhong Ji), CV4 (Guan Yuan) and CV10
(Xia Wan).
• It passes through the lateral costal region.
• It connects with the Heart Zang.
• The Spleen meridian sinew channel con-
verges at the external genitalia, and binds at
the umbilicus.
Spleen 1: Yin Bai, “Hidden White”
Location: The point is located 0.1 cun proximal
to the corner of the nail of the big toe.
Innervation: On the anastomosis of the dorsal
digital nerve derived from the superficial pero-
neal nerve, and the proper digital branch of the
medial plantar nerve. The significance of this
is that this point has rich innervation from the
nervous system, and consequently, responds
well to stimulation.
© 2017 Acupuncture Association of Chartered Physiotherapists

Figure 1. Course of the Spleen (SP) meridian, the foot Tai Yin channel: lower limb
(AACP 2015).
Dermatome segment: L5.
Notes: Spleen 1 is the Jing-­ Well point of the
Spleen meridian. Jing-­Well points are the most
distal Shu or transporting points of a channel,
and are where Qi emanates from, like water
in a well. This is one of the major points for
strengthening the Spleen’s function of holding
Blood in its proper place. Therefore, it is very
useful for controlling bleeding, especially in
the Lower Jiao. Examples of this include any
uterine bleeding, or blood in the urine or stools.
© 2017 Acupuncture Association of Chartered Physiotherapists
R. Lillie
Spleen 1 is also useful for treating such prob-
lems in the Upper Jiao, such as nosebleeds or
vomiting blood. The technique of “pricking to
bleed” is often used to control bleeding caused
by Spleen deficiency.
The Spleen also controls dampness, and
in turn, swelling. Abdominal distension and
swelling in the limbs can occur in Spleen
deficiency. Because the Jing-­Well point is the
most dynamic point in the channel, stimulating
it can be particularly effective when treating
oedema, including oedema that is secondary
31
The Spleen meridian
Figure 2. Course of the Spleen (SP) meridian, the foot Tai Yin channel: trunk
(AACP 2015).
to steroid use, and also that caused by system
failures.
As a Jing-­Well point and because of the Spleen
meridian’s links with the Heart, SP1 can also be
used to treat heart agitation, manic depression
and insomnia. It can also be used for loss of con­-
sciousness, like Governor Vessel 26 (Shui Gou).
Good combinations include: SP1 with Bladder
(BL) 40 (Wei Zhong) for severe nosebleeds; SP1
with Stomach (ST) 45 (Li Dui) for nightmares;
and SP1 with Liver (LR) 1 (Da Dun) for loss of
consciousness.
32
In the present author’s experience, Jing-­Well
points are not used very often because of
where these are located and the intense reac-
tions produced by needling. Therefore, the
beneficial effects of stimulating these points are
not utilized sufficiently.
Spleen 2: Da Du, “Great Metropolis”
Location: Spleen 2 is found on the medial side
of the great toe, anterior and inferior to the
first metatarsophalangeal joint.
© 2017 Acupuncture Association of Chartered Physiotherapists

Innervation: On the proper plantar digital nerve
arising from the medial plantar nerve.
Dermatome segment: L5.
Notes: This is the Ying-­Spring and Fire point
of the Spleen meridian. These points are the
principal ones for clearing Heat in the channel.
Hence, SP2 is used in cases of Damp or in
chronic conditions. Its primary use is to reduce
excess patterns.
This is a particularly useful point for treating
swelling and a feeling of heaviness, and also
abdominal distension and insomnia. It is also a
useful distal point in the treatment of lumbar
pain.
Spleen 2 is used in combination with SP3
(Tai Bai) in local treatment for arthritis of  the
first metatarsophalangeal joint, which is a com-
mon condition seen in most physiotherapy
clinics.
Spleen 3: Tai Bai, “Supreme White”
Location: The point is located posterior and
inferior to the head of the first metatarsal
bone.
Innervation: At the branches of the saphenous
and superficial peroneal nerves. Purely sensory
in function, the saphenous nerve is the largest
cutaneous branch of the femoral nerve.
Dermatome segment: L4.
Notes: Spleen 3 is the Shu-­Stream, Yuan-­Source
and Earth point of the meridian, and it connects
with ST40 (Feng long). The Shu-­Stream is the
point in the channel where flow is stronger and
deeper, and the movement of Qi can transport
things; for example, external pathogens can be
carried into the interior. However, to counteract
this, defensive (Wei) Qi gathers here. The Shu-­
Stream point in yin organs is also referred to
as the Yuan-­ Source point. This is where the
source Qi of the Spleen is stored in the merid-
ian. Consequently, stimulation of this point can
© 2017 Acupuncture Association of Chartered Physiotherapists
R. Lillie
build strength and energy in its related meridian
or organ system.
Spleen 3 has a very powerful action on
regulating the Qi of the Spleen and Stomach,
particularly when there is a deficiency. It har-
monizes the flow of Qi in the Middle Jiao, and
regulates both the Lower and Middle Jiao.
General conditions that SP3 can be used for
include abdominal pain and distension, diar-
rhoea, vomiting, vertigo, chronic fatigue, and
pain and tension in the thorax and epigastric
region. It can also help in cases of constipation
in which Qi is insufficient to move and activate
the bowels. If Dampness or Damp Heat invade
the body, which is common when there is under-
lying Spleen deficiency, SP3 is indicated in the
treatment of heaviness of the body with pain
in the knees or lumbar pain. Avoid using Yuan-­
Source points in pregnancy, because original Qi
should be directed to the foetus (Betts 2006).
Useful combinations include: SP3 and ST36
(Zu San Li) for tonifying the Spleen and Qi;
and SP3 and ST40 for eliminating Dampness
and phlegm.
Spleen 3 is a very useful distal channel point,
and the present author finds that it can be effec-
tive when treating back pain, especially if L4 is
the source of the pathology since it lies within
the L4 dermatome. Take care when needling
because this is another sensitive point. The pre-
sent author usually employs a smaller and finer
needle to avoid causing too much discomfort
for the patient (15 × 0.18 mm).
Spleen 4: Gong Sun, “Grandfather
Grandson”
Location: The point is found on the medial
border of the foot, in a depression immediately
distal to the base of the first metatarsal bone.
Innervation: At the saphenous nerve and the
branch of the superficial peroneal nerve.
Dermatome segment: L4.
Notes: This is the Luo-­ Connecting point
of the Spleen meridian, linking with ST42
33
The Spleen meridian
(Chong Yang), and the confluence point of Spleen 5: Shang Qiu, “Shang Mound”
the Penetrating Vessel. The Penetrating Vessel Location: Spleen 5 is found in the hollow anterior
(Chong Mai) originates in the lower abdo- and inferior to the medial malleolus.
men (the uterus in women). It ascends along
the spine, by way of the Kidney channel, up
Innervation: In the medial crural cutaneous nerve,
the throat and around the lips to the eye; it
a branch of the saphenous nerve, and the
descends along the medial side of the lower
branch of the superficial peroneal nerve.
leg, and also to the big toe. The Penetrating
Vessel links the Stomach and Kidney merid-
ians, and is known as the Sea of Blood. It Dermatome segment: L4
acts as a reservoir for excess Qi and Blood,
and also circulates the defensive (Wei) Qi and
Notes: This is the Jing-­ River and Metal point
protects against external pathogens. It has
of the Spleen meridian. The Jing-­ Well is a
no acupuncture points, but shares coalescent
place through which Qi flows, and SP5 can
points on the meridians. Hence, Spleen 4 is an
be used to treat coughs and asthma caused by
important regulator of the Penetrating Vessel,
pathogenic Cold and Heat. The Metal point on
and helps to calm the spirit and regulate Qi in
a meridian is also known as the sedation point,
the Middle Jiao.
This point can be effective following and it is used in cases of excess energy within
abdominal surgery. It is also used to treat loss the meridian, i.e. hot, acute conditions. Needling
of appetite, indigestion with thin bowel move- SP5 particularly benefits the sinews and bones.
ments, dysmenorrhea, abdominal distension It is a good local point for treating ankle joint
and vomiting, and to relieve lower abdominal problems.
pain.
Spleen 4 regulates the Spleen, Stomach and
Penetrating Vessel, and therefore, it is used to
Spleen 6: San Yin Jiao, “Three Yin
treat nausea in pregnancy (Betts 2006).
Meeting”
Good combinations include:
Location: This point is found 3 cun above the
• SP4, Pericardium (PC) 6 (Nei Guan) and
medial malleolus, just posterior to the tibial
CV12 (Zhong Wan) for abdominal problems,
border.
nausea and vomiting;
• SP4, ST36 and SP10 (Xue Hai) for Blood
stagnation; and Innervation: Superficially, this is the medial crural
• SP4, CV6 (Qi Hai) and CV3 for stagnation cutaneous nerve; deeper, in the posterior aspect,
of Qi and Blood, dysmenorrhea, and dif- this is the tibial nerve.
ficult menstruation.
Dermatome segment: L4.
The significance of this point is the link with the
Penetrating Vessel. This is important in the field
of gynaecology. Spleen 4 is particularly useful Notes: Spleen 6 is reputedly the third most com-
in cases of blood pathology. With Blood stasis, monly used point in acupuncture treatments. It
the result is dysmenorrhea, i.e. painful periods. is the royal point for gynaecological problems.
With Blood Heat, the result is menorrhagia, i.e. It is also the meeting point of the three yin
heavy periods. With blood deficiency, the result channels of the leg, i.e. the Spleen, Liver and
is amenorrhea, i.e. a lack of or scanty periods. Kidney meridians, which are all influenced by it.
All these conditions can be effectively treated by Spleen 6 traditionally balances the yin and yang
stimulation of the opening and coupled points energy of the Kidney. It supports the abdomi-
SP4 and PC6, together with Kidney 14 (Si Man) nal viscera, and therefore, is a master point
and SP10. for urogenital disorders including enuresis, and

34 © 2017 Acupuncture Association of Chartered Physiotherapists


difficulty with urination. Stress incontinence is
often the result of uterine collapse, and can be
treated by reinforcing Qi at SP6.
This point is used to treat menstrual prob-
lems, including irregular menstruation, uterine
bleeding, menorrhagia, amenorrhoea, dysmen-
orrhoea and leucorrhoea. Spleen 6 is a general
tonification point for the body, and it can be
stimulated to speed up uterine contractions
during labour and relieve pain. It can be used
for gastrointestinal problems (e.g. diarrhoea and
abdominal distension), urogenital problems (e.g.
impotence, frigidity and dysmenorrhea), allergic
and immunological diseases, and skin disorders.
Spleen 6 is a valuable point for insomnia because
it helps to calm the mind (Shen). It can resolve
Dampness, particularly in the Lower Jiao, includ-
ing oedema and heaviness of the body.
Spleen 6 should be avoided in pregnancy,
especially in combination with Large Intestine
(LI) 4 (Hegu), LR3 (Tai Chong) and BL60 (Kun
Lun) (Betts 2006).
Good combinations are:
• SP6 and SP9 (Yin Lin Quan) to eliminate
dampness; and
• SP6 and CV12 to support the digestive
system.
Any physiotherapist working in women’s health
will find that SP6 is an invaluable point. It is
very useful for treating any problems associated
with menstruation, and is a good point to use
in combination with LI4 for the promotion of
labour. This is usually done by using chopsticks
to apply acupressure at these points (Betts 2006).
It is also very useful when treating incontinence,
and a major point for oedema.
Spleen 8: Di Ji, “Earth Pivot”
Location: Spleen 8 is found on the medial side
of the leg, 3 cun below SP9 (Yin Ling Quan),
at the posterior border of the tibia.
Innervation: This is the saphenous nerve, a branch
of the femoral nerve (L2–4).
Dermatome segment: L4.
© 2017 Acupuncture Association of Chartered Physiotherapists
R. Lillie
Notes: Spleen 8 is the Xi-­ Cleft point of the
meridian, and the Spleen Qi accumulates most
deeply in this area. For this reason, Xi-­ Cleft
points are very effective in the treatment of
diseases affecting their own meridian systems in
which pain or bleeding is involved. Spleen 8 is
effective in acute Spleen problems.
It is indicated for lumbago, menorrhagia, dys-
menorrhoea and abdominal distension. Spleen 8
is not a point that the present author uses very
often, but her research suggests that it is of
value and perhaps she should make more use
of it.
A good combination for acute dysmenorrhea
is SP8 and LI4 with the addition of electroacu-
puncture (Deadman 1998).
Spleen 9: Yin Ling Quan, “Yin Mound
Spring”
Location: This point is found in a depression just
below the medial condyle of the tibia on a level
with the tuberosity of the tibia.
Innervation: Superficially, different sources indi-
cate either the medial crural cutaneous nerve or
the saphenous nerve, a branch of the femoral
nerve (L2–4); deeper, this is the tibial nerve.
Dermatome segment: L4.
Notes: This is the He-­Sea and Water point of
the Spleen meridian. He-­ Sea points represent
places where rivers merge and enter the sea, and
therefore, the flow of Qi is deeper and stronger
here.
Spleen 9 is the main point for treating
Dampness accumulating in the body because
of a Spleen dysfunction. It is a good point for
treating oedema, particularly swelling in the legs.
Spleen 9 can also be used for abdominal pain
and distension. If there is Damp Heat in the
intestines leading to fresh blood in the stools,
or if there are haemorrhoids, SP9 can help to
resolve this. As a He-­Sea point, it is indicated
for perverse Qi flow, i.e. Qi flowing in the
wrong direction (e.g. diarrhoea).
35
The Spleen meridian
Spleen 9 also opens the Water passages, moves
Water and aids urination. Therefore, it is very
useful for treating urinary problems, including
enuresis (i.e. bed-­wetting), urinary retention and
painful urination. In cases of Spleen and Kidney
yang deficiency presenting as nephritis, both
SP9 and SP6 can help to eliminate Dampness
and oedema. Spleen 9 clears Heat and resolves
Dampness from the Lower Jiao, and therefore,
it can be effective in the treatment of urinary
tract infections.
This point can also treat vaginal discharge
and itching, which are signs of Dampness in
the genitals (Betts 2006).
As a local point to the knee, SP9 can be
used in cases of Bi syndrome. In acupuncture
terminology, Bi means obstruction; it may
be wandering, painful, fixed or febrile. Most
musculoskeletal disorders are grouped into one
of the several Bi syndromes as a guide to the
selection of acupuncture points. Spleen 9 can
also be used to treat swelling in the knee.
It also can be used as a remote point when
other points on the Spleen meridian are being
treated.
The fact that SP9 is the Water point on this
channel makes it particularly useful for treating
Water problems, and it can be an invaluable
body point for physiotherapists who treat con-
tinence issues.
Spleen 10: Xue Hai, “Sea of Blood”
Location: This point is found 2 cun proximal to
the upper border of the patella at the highest
point of vastus medialis muscle.
Innervation: This is the anterior femoral cutane-
ous nerve, and the muscular branch of the
femoral nerve.
Dermatome segment: L3.
Notes: The translation of the Chinese name
indicates one of the major uses of SP10, which
is in the treatment of Blood disorders. It can
nourish, hold, cool and invigorate Blood. It also
helps to stop bleeding and regulate menstruation.
36
Spleen 10 is good for painful periods because it
invigorates Blood in the uterus.
This point is very useful for treating urticaria
and skin rashes because it cools Blood in the
skin. It is used for skin disorders that are hot
and irritating.
Spleen 12: Chong Men, “Surging Gate”
Location: Spleen 12 is located on the inguinal
groove, in the depression of the saphenous
hiatus, just lateral to the femoral artery. The
point is slightly more than one hand’s width
lateral to the anterior midline. Furthermore, it is
about one finger’s width lateral to the palpable
femoral artery and approximately 1 cun lateral
to LR12.
Innervation: Superficially, this involves the femoral
branches of the genitofemoral nerve from L1.
Dermatome segment: L1.
Notes: Spleen 12 is the place where the Spleen
and Liver meridians meet, and the point of
the yin linking vessel (Yin Wei Mai). It is con-
nected to the Penetrating Vessel, and hence, it
invigorates Blood and moves Qi. It also helps
to subdue Chong Mai rebellious Qi, and can be
used to treat foetus Qi rushing upwards to har-
ass the Heart. Spleen 12 resolves Dampness in
the bladder, and is particularly useful for treat-
ing urination problems including retention, and
painful and difficult urination. It is a good local
point for treating the hip joint, and traditionally,
can be used to treat inguinal hernias.
Spleen 15: Da Heng, “Great Horizontal”
Location: This point is found 4 cun lateral to the
umbilicus and level with ST25 (Tian Shu).
Innervation: Superficially, this is the lateral cuta-
neous thoracic nerve from T11.
Dermatome Segment: T11.
Notes: Spleen 15 is an important point for treat-
ing abdominal complaints. Because it regulates
© 2017 Acupuncture Association of Chartered Physiotherapists

the Qi in the abdomen, it is useful for alleviating
abdominal pain. It is also employed for chronic
constipation caused by Spleen Qi deficiency.
However, paradoxically, because SP15 can
resolve dampness in the intestines, it can also
be used to treat chronic diarrhoea with mucus
in the stools.
Because this point strengthens the Spleen, it
can be used to treat tiredness and sadness. By
strengthening the Spleen, SP15 transports food
essence to the limbs, and therefore, it can be
used to treat cold and weak limbs.
Spleen 21: Da Bao, “Great Wrapping”
Location: Spleen 21 is found on the mid-­axillary
line in the seventh intercostal space.
Innervation: This is the lateral cutaneous thoracic
nerve from T6 or T7.
Dermatome segment: T6–7.
Notes: Spleen 21 is the great Luo-­ Connecting
channel of the Spleen meridian. This is the
point where a meridian splits off and links with
its interiorly or exteriorly related meridian or
organ system.
It helps to regulate the Qi in the chest, and
therefore, is useful in treating breathlessness,
chest and rib pain, and coughs.
It acts to invigorate the Blood in the Blood-­
Connecting channels via the Penetrating Vessel.
Therefore, SP21 is useful in the treatment of
pain across the whole body.
Finally, it benefits the sinews, and can be used
to treat weak or flaccid limbs, or weak joints.
This is the final point on the Spleen meridian.
Points excluded
The following points have been excluded from
the main body of the present article because
these have more-­limited uses, and hence, are not
employed as frequently in clinical practice. The
present author might use the points listed below
occasionally, but these are more useful in TCM
practice. Physiotherapists who are involved with
© 2017 Acupuncture Association of Chartered Physiotherapists
R. Lillie
chest therapy would probably find SP18, SP19
and SP20 to be of value.
Spleen 7: Luo Gu, “Dripping Valley”
This point is not commonly used in clinical
practice, but it can resolve Dampness and pro-
mote urination.
Spleen 11: Ji Men, “Winnowing Gate”
Spleen 11 can be used for urinary problems
including retention and enuresis.
Spleen 13: Fu She, “Abode of the Fu”
This point can be used for abdominal pain, and
pain in the thigh.
Spleen 14: Fu Jie, “Abdomen Knot”
Spleen 14 can be used for stagnant or rebellious
Qi in the abdomen.
Spleen 16: Fu Ai, “Abdomen Sorrow”
This point is used to regulate the intestines.
Spleen 17: Shi Dou, “Food cavity”
Spleen 17 is mainly used for local pain, and for
treating food stagnation.
Spleen 18: Tian Xi, “Heavenly Stream”
This point is used to treat problems of the
breast, shortness of breath and hiccups.
Spleen 19: Xiong Xiang, “Chest Village”
Spleen 19 is used for coughing and shortness
of breath.
Spleen 20: Zhou Rong, “Encircling Glory”
This point is used for chest problems including
coughing, phlegm and shortness of breath.
Discussion
It is unusual to find research papers that only
examine a single acupuncture point, although
there are exceptions such as PC6 and LI4.
However, there is a good overview of SP9 by
Li Shi Zhen (1991) that goes into great depth
about the conditions that can be treated by
using this point.
37
The Spleen meridian
There are two articles that look at SP6:
Kashefi et al. (2011) describe the use of this
point to improve women’s general health; and
Wong et al. (2010) examine its use in treating
dysmenorrhoea.
The majority of research articles discuss
Spleen meridian points in combination with
others since this would be normal clinical prac-
tice. Therefore, the most expedient method of
researching the use of different acupuncture
points would be to select a specific condition
or pathology, and direct a search in this manner.
Conclusion
The Spleen meridian is extremely useful for
any physiotherapist working in women’s health
because of the influence of the Spleen on both
Blood and Water. This makes it invaluable in
treating menstrual problems, incontinence and
swelling. It also has one of the key points used
in treating hot and itchy skin conditions, and
can be very effective for insomnia. The Spleen
meridian is useful for treating musculoskeletal
conditions in the legs and lower back, and this
links well with the direct nervous innervation and
dermatome distribution demonstrated above.
References
Acupuncture Association of Chartered Physiotherapists
(2015) Acupuncture Foundation Course Manual, Version
2.4. Acupuncture Association of Chartered
Physiotherapists, Peterborough.
Betts D. (2006) The Essential Guide to Acupuncture in
Pregnancy and Childbirth. The Journal of Chinese
Medicine Publications, Hove.
Deadman P., Al-­Khafaji M. & Baker K. (1998) A Manual
of Acupuncture. The Journal of Chinese Medicine
Publications, Hove.
Dorfman B. (2017) Seattle Acupuncture – the
Spleen Meridian. [WWW document.] URL
h t t p : / / s e a t t l e a c u p u n c t u r e a n d c o a ch i n g. c o m /
seattle-­acupuncture-­the-­spleen-­meridian/
Ellis N. (1999) Acupuncture in Clinical Practice: A Guide for
Health Professionals, 2nd edn. Nelson Thornes, Cheltenham.
Kashefi F., Khajehei M., Ashraf A. R. & Jafari P. (2011)
The efficacy of acupressure at the Sanyinjiao point
38
in the improvement of women’s general health. The
Journal of Alternative and Complementary Medicine 17 (12),
1141–7.
Maciocia G. (2005) The Foundations of Chinese Medicine: A
Comprehensive Text for Acupuncturists and Herbalists, 2nd
edn. Churchill Livingstone, Edinburgh.
Maciocia G. (2007) The Practice of Chinese Medicine: The
Treatment of Diseases with Acupuncture and Chinese Herbs,
2nd edn. Churchill Livingstone, Edinburgh.
Oriental Medicine (2017) Point Theory. [WWW document.]
URL http://www.orientalmedicine.com/point-­theory
Wang J.-­Y. & Robertson J. D. (2008) Applied Channel
Theory in Chinese Medicine: Wang Ju-­Yi’s Lectures on Channel
Therapeutics. Eastland Press, Seattle, WA.
Wong C. L., Lai K.-­Y. & Tse H.-­M. (2010) Effects of SP6
acupressure on pain and menstrual distress in young
women with dysmenorrhea. Complementary Therapies in
Clinical Practice 16 (2), 64–69.
Woodley S. (2009) Points Database. [WWW document.] URL
http://www.steve-­woodley.co.uk/?content=pointsearch
Zhen L. S. (1991) Yinlingquan: SP-­9. The Journal of Chinese
Medicine 36 (May), 5–9.
Rosemary Lillie BSc(Hons) MCSP is an advanced
member of AACP who combines acupuncture with tra-
ditional physiotherapy at her private clinic in London.
She is also currently training in the practice of Chinese
herbal medicine, which she believes will augment her
approach to treatment.
Rosemary is a member of the Pelvic, Obstetric and
Gynaecological Physiotherapy professional network, and
has a special interest in pelvic pain in both men and
women. She treats infertility and supports her patients
throughout all aspects of pregnancy. Rosemary also
treats incontinence, and finds that acupuncture is an
important treatment modality for this group of patients.
The Spleen meridian is particularly useful for women’s
health issues.
She is a sponsor of Sutton United Football Club,
and also has a particular interest in sports medicine and
football injuries. Again, acupuncture plays an important
part in her treatment.
Rosemary is the news editor of Acupuncture in
Physiotherapy, and is always interested in hearing
about any interesting information that members may
come across.
© 2017 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 39–48

CASE REPORT

Acupuncture for the treatment of whiplash-­

associated disorder
S. Cronin
Rehabilitation Centre, The James Cook University Hospital, South Tees Hospitals NHS
Foundation Trust, Middlesbrough, UK

Abstract
This case report describes the acupuncture treatment of a 37-­year-­old female suffering from
whiplash-­associated disorder. The rationale for using acupuncture alongside other physio-
therapy modalities is discussed with reference to recent evidence and guidelines. Acupuncture
was chosen to alleviate pain, and to facilitate the use of other physiotherapy techniques in
order to improve movement and function. The outcome measures implemented included a
visual analogue scale (VAS) for pain, the Oxford Scale, the Neck Disability Index (NDI) and
range of motion. The subject completed six sessions of acupuncture on a weekly basis in a
private physiotherapy setting. Her reported pain score fell from 7/10 to 0/10 on the VAS
between the first and final assessments. There was also an improvement in the NDI score
from 8/50 to 2/50. The proposed reasoning for this marked reduction in pain is discussed.
Keywords: acupuncture, pain, whiplash-­associated disorder.

Introduction A definition of the condition is contained

Whiplash-­associated disorder (WAD) is a debili-
tating condition that accounted for approxi-
mately 300 000 insurance claims in 2003 (Burton
2003, cited in Mercer et al. 2007), a figure that
has no doubt risen since then.
This disorder results in soft-­ tissue and/or
bony injuries following a rapid acceleration-­
deceleration movement of the head and neck,
and can affect other areas of the spine (Moore
et al. 2005). It can be complicated and worsened
by psychosocial factors. Chronic WAD is asso-
ciated with pain lasting for more than 6 months,
and research has indicated that around 14–42%
of sufferers go on to develop chronic pain
(Barnsley et al. 1994).
Correspondence: Ms Suzanne Cronin, Rehabilitation
Centre, The James Cook University Hospital, South
Tees Hospitals NHS Foundation Trust, Marton Road,
Middlesbrough TS4 3BW, UK (e-­ mail: suzannec
2012@gmail.com).
in the guidelines produced by the Quebec
Task Force on Whiplash-­Associated Disorders
(Spitzer et al. 1995, p. 22S):
“Whiplash is an acceleration-­ deceleration
mechanism of energy transfer to the neck.
It may result from a rear-­end or side-­impact
motor vehicle collisions, but can also occur
during diving or other mishaps. The impact
may result in bony or soft-­ tissue injuries
(whiplash injury), which in turn may lead
to a variety of clinical manifestations called
Whiplash-­Associated Disorders.”
Hartling et al. (2001) graded the categories of
WAD as follows:
(0) no complaint about the neck and no physi-
cal sign(s);
(1) neck complaint of pain and no physical
sign(s);
(2a) neck complaint and musculoskeletal
sign(s);

© 2017 Acupuncture Association of Chartered Physiotherapists 39

Treatment of whiplash-­associated disorder
(2b) neck complaint, musculoskeletal sign(s) and
neurological sign(s); and
(3) neck complaint, and fracture or dislocation.
Although acupuncture is commonly used in
physiotherapy, there is a limited amount of
strong evidence for the most effective physio-
therapy management of WAD, with guidelines
recommending self-­management strategies and
highlighting any psychosocial factors (Verhagen
et al. 2007; Williamson et al. 2009; NICE 2015a).
In a systematic review, Verhagen et al. (2007)
concluded that the then-­ current evidence did
not provide confirmation of the most effective
treatment for WAD, and suggested that active
treatments are “probably” more beneficial than
a more “passive” approach.
The Chartered Society of Physiotherapy
(CSP) developed guidelines that recommend
that individuals who are suffering from WAD
should be provided with education on posture,
the use of heat, and exercises to activate the
deep neck flexor muscles and improve range of
motion (ROM) (Moore et al. 2005). The authors
of the guidelines reported that there was weak
evidence for the use of acupuncture to treat
this condition, and therefore, that they could
not support or oppose its use. Additionally, an
earlier review by White & Ernst (1999) found
no evidence for the efficacy of acupuncture in
the treatment of neck pain.
The National Institute for Health and Care
Excellence (NICE) guidelines for the manage-
ment of WAD concluded that there is weak
evidence for the long-­ term effectiveness of
physiotherapy treatments such as exercise and
mobilization (NICE 2015a). Although the
authors of this clinical knowledge summary
were not confident that physiotherapy is of
benefit for patients with WAD, this was in direct
contradiction to other recommendations issued
by the same organization, which suggested that
acupuncture treatment is of short-­term benefit
for subacute and chronic neck pain. This evi-
dence is detailed in the NICE guidelines for
the treatment of non-­specific neck pain (NICE
2015b) and low back pain (LBP) (NICE 2009).
There is growing support of the use of
acupuncture in the reduction of neck pain (He
40
et al. 2004; White et al. 2004; Vas et al. 2006;
Trinh et al. 2006; Willich et al. 2006; Witt et al.
2006; Fu et al. 2009). It has been proposed that
needling activates the body’s own pain-­relieving
responses both locally and segmentally, and by
having a central effect on the nervous system
(White et al. 2008).
It has been suggested that acupuncture can
modulate inflammatory conditions through an
inflammatory effect (White et al. 2008). Needling
has been shown to induce a phenotypic switch
of muscle macrophages. This causes a reduction
in pre-­inflammatory cells and an increase in anti-­
inflammatory cells, and thus, facilitates a healing
response (da Silva et al. 2015). Therefore, it has
been hypothesized that promoting an inflam-
matory cascade with acupuncture will induce
a healing response and improve patient reha-
bilitation. Omoigui (2007, p. 1169) stated that:
“The origin of all pain is inflammation and the
inflammatory response.” In chronic conditions
like chronic whiplash, inflammatory mediators
such as bradykinin can add to the sensitization
of tissues, which will lead to a smaller stimulus
triggering a pain response (Chopade & Mulla
2010). It is important that physiotherapists
recognize the necessity of choosing the most
effective treatments for WAD at the earliest
stage possible in order to prevent the condition
becoming chronic.
The evidence for the pain-­ relieving effect
of acupuncture on these systems will be con-
sidered in the rationale for the acupuncture
point selection described later in the present
paper. Acupuncture treatment was justified in
this case in order to attempt to alleviate pain
and maximize the potential for the subject’s
rehabilitation.
Case report
Background
The present subject was a 37-­ year-­
old female
who was the mother of two teenage children.
She worked full time as a desk-­based admin-
istrator, and attended Pilates classes and went
swimming twice a week.
Three weeks before presentation, the subject
had been involved a road traffic accident, during
© 2017 Acupuncture Association of Chartered Physiotherapists

which her stationary vehicle was hit from behind
by a car travelling at around 64 km h−1. She was
wearing her seatbelt at the time, but her head
was thrown backwards and forwards by the
impact. The subject had felt no pain at first, but
its onset began later that night and headaches
followed. While working at her computer 4 days
before presenting, she moved her head suddenly
and felt a “twinge” in her neck, after which the
pain had grown worse and her neck felt “stiff ”.
Since then, the pain had increased (particularly
at the end of the day), with the subject report-
ing the intermittent sharp pain to be 7/10 on
a visual analogue scale (VAS), and 5/10 during
the assessment.
Her general practitioner had diagnosed whip-
lash, and her insurance company had approved
six sessions of physiotherapy.
Besides pain, the subject reported a reduction
in movement and function, and difficulty per-
forming work and activities of daily living. She
described occasional anxiety when her workload
was heavy. The subject had a previous medical
history of hypothyroidism, for which she took
levothyroxine daily. She also took paracetamol
for pain relief.
Clinical impression
The subject’s head was in a forward position,
and she exhibited increased lower cervical flex-
ion and upper extension with protracted girdles.
She had rounded shoulders. The subject pre-
sented with reduced deep neck flexor activation,
reduced cervical flexion (60%), reduced right
and left cervical rotation (80%), and reduced
cervical side flexion (75%) bilaterally. She rated
her pain on all resisted cervical movements as
7/10 on the VAS.
No neurological findings were detected upon
assessment with upper limb tension tests, and
myotomal, dermatomal and reflex testing. There
were no red flags.
Treatment
The subject had not received any previous treat-
ment for her neck pain. Because all her symp-
toms appeared consistent with WAD (Ferrari
et al. 2005), a diagnosis of Quebec grading 2a
© 2017 Acupuncture Association of Chartered Physiotherapists
S. Cronin
was made: “Neck pain with point tenderness
and reduced range of motion” (Hartling et al.
2001).
Acupuncture treatment was discussed with
the subject, and was chosen to treat her pain
and facilitate other physiotherapy modalities.
No contraindications were noted. Following
advice about possible adverse effects, the sub-
ject agreed, read the patient information leaflet
and signed an informed consent form.
Treatment plan
Informed consent was obtained from the
subject prior to each treatment session, which
involved the following approaches:
• acupuncture for pain management;
• education about posture, anatomy, pain,
pacing and diagnosis (including advice about
her posture throughout the day and while sat
at her desk – a workstation assessment was
discussed);
• exercises intended to improve ROM, stability
and control; and
• manual techniques and massage.
The acupuncture point selections and treatment
outcomes, and the clinical reasoning for the
points selected are described in Tables 1 and 2,
respectively.
The outcome measures implemented included
a VAS for pain, the Oxford Scale, the Neck
Disability Index (NDI) and ROM.
Rationale for acupuncture point selection
Only three acupuncture points were chosen
during the first session because the client had
not had acupuncture before. This was increased
to seven points during the second session. White
et al. (2008) recommend using six points bilater-
ally in order to achieve the desired response.
It has been proposed that acupuncture acti-
vates the body’s own pain-­relieving responses.
The insertion of the needles leads to local
effects in the skin, and segmental and extra­
segmental effects in the body. It is because of
these effects that acupuncture is used to treat
pain in the shorter and longer terms (Carlsson
2002).
41
Treatment of whiplash-­associated disorder
Table 1. Acupuncture point selection and treatment outcome: (ROM) range of motion; (LI) Large Intestine; (GB) Gall Bladder; (BL)
Bladder; (GV) Governor Vessel; (SI) Small Intestine; (VAS) visual analogue scale; and (NDI) Neck Disability Index

Acupuncture
Objective of treatment* points† Needling technique Dose (min) Acupuncture response

Session 1
Reduce pain from 7/10 LI4 30 mm perpendicular, 1 cm depth 10‡ No adverse effects
GB20 25 mm oblique/inferior, 1 cm depth Pain: VAS = 4/10
GB21 25 mm posterior oblique, 1 cm depth No change in ROM
NDI = 8

Session 2
Reduce pain from 7/10 LI4 30 mm perpendicular, 1 cm depth 20 No adverse effects
Improve ROM GB20 25 mm oblique/inferior, 1 cm depth Pain: VAS = 4/10
GB21 25 mm posterior oblique, 1 cm depth Improvement in cervical flexion to
BL10 30 mm oblique, 0.5 cm depth 75%
GV14 30 mm perpendicular, 1 cm depth
SI15 30 mm oblique, 1.5 cm depth
BL60 30 mm perpendicular, 1 cm depth

Session 3
Reduce pain from 6/10 LI4 All as above 20 No pain after treatment
Improve ROM GB20 Subject reported that she has had no
GB21 further headaches
BL10 Improvement in cervical rotation to
GV14 90% bilaterally
SI15
BL60

Session 4
Reduce pain from 6/10 LI4 All as above 20 Pain: VAS = 2/10 after treatment
Improve ROM GB20 Cervical flexion full
GB21
BL10
GV14
SI15
BL60

Session 5
Reduce pain from 4/10 LI4 All as above 20 Pain: VAS = 2/10 after treatment
Improve ROM GB20
GB21
BL10
GV14
SI15
BL60

Session 6
Reduce pain from 2/10 LI4 All as above 20 No pain after treatment
GB20 NDI = 2
GB21 Subject reported that she still gets
BL10 a slight pain if she reads for more
GV14 than 1 h
SI15 Cervical rotation now 100%
BL60 bilaterally
Cervical side flexion now 95%
bilaterally
*Visual analogue scale scores.
†All points needled bilaterally.
‡Because first treatment.

42 © 2017 Acupuncture Association of Chartered Physiotherapists

 S. Cronin
Table 2. Clinical reasoning for acupuncture point selection: (LI) Large Intestine; (GB) Gall Bladder; (BL) Bladder; (GV) Governor Vessel;
and (SI) Small Intestine

Points selected* Justification for the points selected and supporting evidence

LI4 LI4 covers the C6–7 dermatomes, and is considered to be a “master point for pain”
It creates a calming response, and was also chosen to induce an extrasegmental effect (White et al. 2008)
When needled bilaterally, LI4 is a distal point that has a strong descending inhibitory effect on supraspinal pain
(White et al. 2008)
Additionally, Wu et al. (1999) found that LI4 promotes activity in the limbic area that is related to pain responses,
and activates the descending anti-­nociceptive pathways
Haker et al. (2000) found that needling LI4 bilaterally and an ear point led to a sympathetic response in the related
segment, resulting in pain relief
GB20 GB20 is another “master point for pain” that activates the sympathetic nervous system (Hecker et al. 2007)
GB21 GB21 was chosen bilaterally to achieve local, segmental and extrasegmental effects, and subsequently, to target the
subject’s head and neck pain, and stiffness (He et al. 2004; White et al. 2008)
BL10 BL10 is effective in the treatment of neck pain (Vas et al. 2006)
BL10 is indicated for cervical pain (Hecker et al. 2007)
BL60 BL60 is a distal point that amplifies the strength of the Bladder meridian (White et al. 2004)
GV14 GV14 was employed during the second treatment session because it can relieve postural neck pain (White et al.
2004)
SI15 SI15 is effective in the treatment of neck pain (He et al. 2004)

*All points needled bilaterally.

Small Intestine (SI), Bladder (BL) and Gall
Bladder (GB) points were selected to allow for
a segmental and local approach to the subject’s
pain (White et al. 2008). Additionally, Governor
Vessel (GV) 14 was added during the second
session since this point can help to ease postural
neck pain (White et al. 2004).
Gall Bladder 20 was used bilaterally because
it is believed to ease occipital headache, and
relieve pain and stiffness in the neck (White
et al. 2008). White et al. (2004) stated that GB20
and GB21 should be considered for the treat-
ment of neck pain in a clinical setting.
The local effects of acupuncture lead to
a release of calcitonin gene-­ related peptide
(CGRP), a vasodilator that causes the release
of inflammatory mediators that can promote
healing and local pain relief (White et al. 2008).
For example, needling activates Aδ and
C-­fibres in the skin and muscles, causing the
sensations of heaviness, tingling and soreness
that contribute to the sensation of De Qi
(White et al. 2008).
Supporting evidence
Systematic reviews have concluded that the
evidence to support acupuncture treatment for
WAD is limited and further research is required
(Moon et al. 2014). In a randomized single-­blind
placebo-controlled trail involving 80 participants
with chronic WAD, Sterling et al. (2015) found
that dry needling and exercise demonstrated
some efficacy, but reported that the results were
not “clinically worthwhile”.
Acupuncture may result in pain relief and
increased ROM (Witt et al. 2006), and be cost-­
effective in the management of chronic neck
pain (Willich et al. 2006). Furthermore, in a
large long-­term study, Ross et al. (1999) found
that patients in primary care respond well to
acupuncture.
In a study by He et al. (2004), 24 participants
with muscular neck pain were randomized into
acupuncture and sham control groups. The
acupuncture group received electroacupuncture
(EA) over 16 body points. However, the partici-
pants also self-­administered auricular acupunc-
ture over six points, clearly undermining the
statistical power of the study. The control group
received sham EA, which was applied without
any current. The intensity and frequency of
pain was significantly lower in the acupuncture
group, improvements that were retained 3 years
later in comparison to the control subjects.

© 2017 Acupuncture Association of Chartered Physiotherapists 43

Treatment of whiplash-­associated disorder
In a randomized controlled trail by Vas et al.
(2006), the following points were used and stand-
ardized: GB20, GB21, Liver 3, Large Intestine
4, GB34, BL10, GV14, SI3, BL62 and GB39.
However, as in the study by White et al. (2004),
the sham transcutaneous electrical nerve stimula-
tion (TENS) was not turned on, and statistically
significant improvements were demonstrated in
the acupuncture group when compared to the
participants receiving sham TENS.
Additionally, França et al. (2008) found that
acupuncture was more effective when combined
with physiotherapy for facilitating pain relief
in tension neck syndrome. With regard to the
present subject’s headache, the NICE guidelines
support the use of acupuncture for chronic
headaches (NICE 2012). Furthermore, a sys-
tematic review of acupuncture for tension type
headache suggested that needling is more effec-
tive than sham acupuncture (Linde et al. 2009).
In a study with a large sample size, White et al.
(2004) demonstrated that acupuncture treatment
for mechanical neck pain has a significant effect
in comparison to sham TENS over the same
acupoints.
In a large-­ scale German study (n = 3766),
Witt et al. (2006) found that the use of acupunc-
ture was associated with improvements in neck
pain and disability when compared to routine
care alone. In a Cochrane Review with a smaller
number of participants (n = 661), Trinh et al.
(2006) found moderate evidence that acupunc-
ture was more effective at relieving patients’
neck pain than some sham treatments.
With regard to WAD, the CSP guidelines con-
clude that there is not enough clinical evidence
to support or refute the use of acupuncture
(Moore et al. 2005). However, it is still widely
employed in conjunction with other physio-
therapy modalities. In a systematic review of 14
studies of the effectiveness of acupuncture for
neck pain, Fu et al. (2009) agreed that longer-­
term follow-­up was required in this area, but
reported that it provided short-­term benefit.
The NICE clinical guidelines have previously
recommended acupuncture for the treatment of
LBP (NICE 2009). Additionally, a systematic
review conducted by Furlan et al. (2005) sug-
gested that this modality may be a useful adjunct
44
in the treatment of chronic LBP, but stated that
more high-­quality research is required. A review
of the literature by the present author suggests
that acupuncture has a place in the treatment of
pain conditions.
The evidence for the effectiveness of acu-
puncture within physiotherapy is uncertain, and
researchers have reported a preponderance of
low-­quality evidence and small sample sizes. The
biggest problem with the majority of studies
is that the placebos used (i.e. the “sham” tech-
nique employed) are not genuine controls. Sham
acupuncture also produces a treatment effect,
and it has been demonstrated that a blunt needle
can have profound effects on the limbic system
(Pariente et al. 2005). Sham acupuncture involves
needling non-­ acupuncture points, or using a
device that presses a guide tube against the skin
(Lund et al. 2009). In the latter case, the needle
either penetrates the skin very slightly (i.e. it only
pierces the superficial tissue), or not at all.
Following a review of the literature, the evi-
dence suggests that acupuncture is effective in
the alleviation of neck pain as part of a physio-
therapy treatment plan.
Discussion
The present subject reported no pain following
the sixth and final treatment session. Her NDI
score, which was 8 at the initial assessment, was
reduced to 2 by the final session. The NDI is
an outcome measure that is considered to be a
valid and reliable tool for measuring neck pain
(Vernon & Mior 1991; Stratford et al. 1999).
Improvements in ROM were observed follow-
ing the third session. Full rotation was achieved
by the final session, but because the subject still
had some muscular tightness in side flexion,
she was advised to continue with the stretch-
ing exercises. As recommended by Moore et al.
(2005), education was provided on posture, the
use of heat, manual techniques, and exercises
to improve muscular control and ROM. The
favourable results that the subject experienced
may have been a result of a combination of the
pain-­relieving mechanisms of the acupuncture
treatment and the other physiotherapy modali-
ties that were used.
© 2017 Acupuncture Association of Chartered Physiotherapists

Upon reflection, EA could have been used as
an alternative treatment in this case. In a random-
ized, double-­ blind study, Sator-­Katzenschlager
et al. (2004) found that weekly auricular EA
reduced pain, and therefore, proved more effec-
tive than manual acupuncture in the treatment
of chronic LBP.
Dry needling trigger point acupuncture
could have been another possible approach
to treatment. Trigger point acupuncture over
SI15 can be used to manage myofascial trigger
points, which are common in this area, and
to ease muscle spasms in the upper trapezius
muscle (White et al. 2008). This approach was
supported by Itoh et al. (2007), who found that
trigger point acupuncture treatment was more
effective than manual acupuncture, and reduced
the intensity of neck pain.
It has been proposed that mechanical dis-
ruption of connective tissues in the body can
have an effect on local and global anatomical
tissues, and lead to disturbances in the electri-
cal response of tissues and cellular activity
(Langevin & Yandow 2002). In addition to the
documented pain-­relieving effects of acupunc-
ture, a structural response has been observed
following needle manipulation. Langevin et al.
(2006) demonstrated that collagen gathered
around a needle inserted into the subcutaneous
tissue of a mouse, and found alterations in the
cellular activity of fibroblasts several centimetres
away from the site of acupuncture. This mecha-
nism could explain and may have contributed to
the improvement in the present subject’s ROM.
The reduction in pain may have been caused
by the segmental effects of acupuncture. These
stimulate Aδ and C-­fibres in the skin, and type
II and type III fibres in the muscles, triggering
the release of enkephalin (White et al. 2008).
Clement-­Jones et al. (1980) showed that an
increased level of β-­ endorphin was detected
after treatment in patients who received acu-
puncture compared to controls. The segmental
activation leads to an analgesic effect that can
last not only for the duration of the session but
for days after the initial treatment (White et al.
2008). This may explain how repeated acupunc-
ture treatments can have a cumulative effect on
pain.
© 2017 Acupuncture Association of Chartered Physiotherapists
S. Cronin
Individuals with WAD have been shown to
be hypersensitive to mechanical pressure, which
can lead to changes in the central processing
of pain (Scott et al. 2005). The brain’s cerebral
cortex detects this sensation of needling, and
activates the periaqueductal grey (PAG) matter,
which is the primary control centre for descend-
ing pain. The PAG has a high concentration of
the cells that produce enkephalin (White et al.
2008), and when these are activated via the
mechanism of acupuncture, this can lead to the
release of the noradrenaline and serotonin, lead-
ing to pain relief as a result of the activation of
descending pain inhibition (White et al. 2008).
Furthermore, functional magnetic resonance
imaging studies have demonstrated the effect of
acupuncture on the pain pathways of the brain
(Napadow et al. 2009).
The pro-­inflammatory effect of acupuncture
may also have been responsible for the reduction
in the present subject’s pain. When treating rats
with acupoint GB30, Wang et al. (2014) showed
that acupuncture regulates the opioid-­containing
macrophages and anti-­ nociceptive mediators
associated with in inflammatory pain. However,
studies using animal models have limitations
when generalizing the results to human beings.
The present subject had not undergone acu-
puncture before, and in addition to its effect on
physical pain, needling influences the psycho-
logical aspects of pain. Some researchers have
suggested that a positive expectation of pain
relief may amplify the results of the treatment
(Kong et al. 2009; Shi et al. 2012).
Additionally, the headache that the present
subject had experienced since suffering from
the injury seemed to have benefited from treat-
ment. However, this may have been a result of
improvements in ROM and function that were
achieved after the other physiotherapy modali-
ties were employed. However, other researchers
have advocated acupuncture for tension-­ type
(Linde et al. 2009) and neurovascular headaches
(Zhao et al. 2011).
Another problem with the studies described
above is the small sample sizes used, which
lead to the risk of a type II error being made.
Furthermore, the limitations of many of
these reports means that the authors did not
45
Treatment of whiplash-­associated disorder
investigate acute or subacute neck pain, which
is commonly what a patient will present with
when attending physiotherapy.
Conclusions
It appears that the segmental, extrasegmental
and central effects that are associated with acu-
puncture treatment had a good pain-­ relieving
effect on the present subject. Because of its
subjective nature, pain is difficult to study. There
is only a limited amount of strong evidence for
the effectiveness of acupuncture for the treat-
ment of WAD, leading to contradictions in the
guidelines, and frustrations for acupuncturists
who see the benefit that this modality can have
on a daily basis.
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and Physiological Therapeutics 14 (7), 409–415.
Wang Y., Gehringer R., Mousa S. A., et al. (2014)
CXCL10 controls inflammatory pain via opioid
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Acupuncture versus placebo for the treatment of
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47
service at South Tees Hospitals NHS Foundation lung conditions. Suzanne also has a keen interest in
Trust. She is passionate about promoting patient inde- chronic pain and musculoskeletal conditions, and works
pendence, and helping individuals to self-manage their in a private physiotherapy setting.
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 49–57

CASE REPORT

Acupuncture for the management of pain in a

woman with multiple sclerosis
K. Biss
Physiotherapy Outpatients, Birmingham City Hospital, Sandwell and West Birmingham
Hospitals NHS Trust, Birmingham, UK

Abstract
Multiple sclerosis (MS) is a neurological condition affecting the central nervous system that
damages the myelin sheath of nerve fibres. Pain is one of the symptoms associated with this
disorder. Since it is a long-­term, progressive condition, MS pain must be managed in order
to allow patients to have a decent quality of life, and to continue with their normal activities
and hobbies. Acupuncture was used to treat a 36-­year-­old woman with MS since previous
traditional physiotherapy treatments had been unsuccessful. This case report highlights the
lack of previous research into the effects of acupuncture on MS pain, and indicates that
there may be a place for its use. More research is needed to increase the evidence base for
the treatment of MS pain with acupuncture.
Keywords: acupuncture, multiple sclerosis, neurology, pain.

Introduction The symptoms of MS vary, and each indi-

Multiple sclerosis (MS) is a neurological condi-
tion affecting the central nervous system that
damages the myelin sheath of nerve fibres. It
affects more than 100 000 people in the UK, and
almost three times as many women are affected
than men; symptoms start between 20 and
40 years of age (MacLean 2011). There are four
main types of MS: relapsing-­remitting, second-
ary progressive, primary progressive and benign.
The exact aetiology of MS is unknown, but it is
thought to be caused by a T-­cell-­mediated auto-
immune response against the central nervous
system (CNS) that is triggered by environmental
exposure in an individual who is genetically sus-
ceptible (Goodin 2009; Goverman 2009).
Correspondence: Mrs Kay Biss, Physiotherapy
Outpatients, Birmingham City Hospital, Sandwell
and West Birmingham Hospitals NHS Trust, Dudley
Road, Birmingham, West Midlands B18 7QH, UK
(e-­mail: kay.biss@nhs.net).
vidual’s experience will be different. Some
common symptoms include: balance problems;
bladder and bowel disturbances; cognition
changes; weakness; spasticity; depression; pain;
fatigue; tremor; difficulty with speech and
swallowing; visual disturbances; and dizziness
(Webster & Whittam 2013). At present, there
is no cure, but research is ongoing. There have
been recent developments in the use of immu-
noablation followed by immune-­ cell-­
depleted
autologous haemopoietic stem cell transplanta-
tion, which has been shown to stop all detect-
able inflammatory activity in the CNS and
result in a “substantial recovery of neurological
function” (Atkins et al. 2016, p. 576). However,
while research is still in progress, the symptoms
of MS must be managed as effectively as pos-
sible, and this can be done in a wide variety
of ways, such as disease-­modifying treatments,
complementary medicines, exercise and lifestyle
changes (MacLean 2011).

© 2017 Acupuncture Association of Chartered Physiotherapists 49

Management of pain in a woman with multiple sclerosis
The symptom of pain in MS could be man- and insomnia. A review of the evidence of the
aged with acupuncture. This modality has been effects of acupuncture on MS by Karpatkin
found to relieve pain in several different ways. et al. (2014) found that, although there is much
Locally, acupuncture increases blood flow to the to recommend the extensive use of acupuncture
area being needled, and triggers an inflamma- in the treatment of MS, there is only a small
tory response (Sandberg et al. 2003). In turn, amount of literature describing its efficacy, and
this leads to the secretion of endorphins and much of this is methodologically flawed. The
increased synthesis of endorphin receptors above authors go on to state that “practition-
(Stein et al. 2001; Carlsson 2002). Acupuncture ers should not assume that acupuncture is not
also works segmentally by stimulating the Aδ effective in this population but rather that the
fibres in the skin and muscle that help to block literature is insufficient to make claims either for
nociceptive messages from the C-­ fibres, and or against its use” (Karpatkin et al. 2014, p. 8).
thus, closes the pain gate (White et al. 2008).
More globally, in the spinal cord and brain,
acupuncture has been shown to relieve pain by Case report
causing the release of opioid peptides and sero-
Background
tonin (Han & Terenius 1982). Segmental acu-
The present subject was a 36-­ year-­
old female
puncture may be able to influence the neurons
who was referred with chronic bilateral mid-­
in the lateral spinal cord, which contain the cell
back pain around her scapulae that radiated
bodies of the autonomic nervous system (ANS)
upwards to her neck. She also had low back
efferent fibres (Bradnam 2003, 2007). The ANS
pain, but although she had previously received
is also under central control, via the vasomotor
physiotherapy for this, she reported no improve-
centre in the medulla and the hypothalamus. It
ment. Her current pain was sharp and intermit-
is believed that low-­intensity input may reduce
tent, and more pronounced on her right than
sympathetic outflow from that segment (Sato
her left. Aggravating factors included thoracic
et al. 1997), and high-­ intensity, low-­frequency
rotation and standing, and rest eased her dis-
may be most beneficial for supraspinal effects.
comfort. The subject’s pain was worse towards
At present, there are no Cochrane Reviews
the end of the day and after sustained activity.
of the use of acupuncture for MS; although
Her other problems included fatigue. There was
one was proposed in 2010 (Cui et al. 2010), no
no record of previous X-­rays or other investi-
results have been published to date. There is no
gations. The subject’s main problems were pain
specific reference to the use of acupuncture in
and fatigue, and the main aim of the treatment
the treatment of MS in the National Institute
was to reduce her pain levels and increase her
for Health and Care Excellence guidelines
level of function.
(NICE 2014), although these do state that
The subject lived with her husband and three
musculoskeletal pain should be assessed and
children, who were aged 4, 5 and 11 years. She
treatment offered. Despite the lack of overarch-
was a housewife who had last worked 6 years
ing protocols, there is some evidence to suggest
ago. Her husband assists with all heavy lifting
that the use of acupuncture in the management
activities, but she is otherwise independent.
of MS may be beneficial. A survey by Wang
Her drug history included dimethyl fumarate,
et al. (1999) found that approximately two-­thirds
gabapentin, amoxicillin and aspirin.
of respondents experienced short-­ term relief
from many symptoms, including pain, spastic-
ity, bladder and bowel problems, problems with Clinical impression
coordination, and sleep disorders. Bowling & The subject had a slumped posture with
Stewart (2002) reported that 20% of respond- pseudo-­winging of her scapulae bilaterally. She
ents had used acupuncture for pain and anxiety had: full cervical range of motion (ROM); full
management, and about half of these described thoracic ROM with pain at end-­of-­range exten-
improvements in fatigue, depression, spasticity sion, left rotation and left side flexion; and full

50 © 2017 Acupuncture Association of Chartered Physiotherapists

 K. Biss
shoulder ROM with discomfort at end-­of-­range physiotherapy; these had included education,
abduction. strengthening exercises, and general advice
No neurological findings were detected upon regarding pacing and a gradual increase in nor-
assessment with upper-­limb tension tests, and mal activity levels. Subjectively, she reported no
myotomal, dermatomal and reflex testing. There changes in overall function; however, objectively,
were no red flags. there had been some increase in functional out-
comes. Because of the lack of improvements in
her symptoms, the subject was keen to explore
Treatment
other options in the management of her pain.
The subject was given information about her
Therefore, it was agreed that acupuncture would
symptoms and their management. She was also
be used in an attempt to reduce her symptoms
provided with education regarding chronic pain
and allow her to increase her function in a
management, and a paced increase in general
paced way, so as to improve her quality of life
exercises, such as walking and swimming,
in the long term.
to manage fatigue. She was given literature
The subject had previously undergone acu-
produced by the MS Society relating to MS
puncture for low back pain, and had found
and fatigue, muscle spasms and pain. A home
this to be beneficial in the short term. There
exercise plan of paced functional exercises and
is a great deal of evidence to support the use
specific strengthening exercises for scapular
of acupuncture to treat chronic pain. A study
control was devised. She was also given postural
by Witt et al. (2006) found that acupuncture
re-­education.
combined with usual care (where this includes
Before treatment began, the subject was pro-
physiotherapy and exercise) produces a clinically
vided with an information leaflet regarding the
relevant reduction in symptoms. In a review of
use of acupuncture, and its effects, side effects,
the evidence, Dorsher (2011) found that there
precautions and contraindications. A consent
is considerable evidence to support the clini-
form was completed during the session prior to
cal efficacy of the use of acupuncture to treat
the commencement of acupuncture treatment,
chronic pain in a variety of conditions, and
as per department policy, and valid, verbal con-
although there are limited findings to demon-
sent was obtained at each subsequent session.
strate the effectiveness of acupuncture in MS,
It was ensured that the subject was suitably
the principles of chronic pain management can
clad and in a comfortable position, and that
still be applied.
the therapist had clean hands prior to needling.
In the present case, there were two main
Sterile, single-­use needles were employed, and
considerations to be taken into account prior to
these were inserted using a guide tube.
commencing acupuncture treatment.
The acupuncture point selections and treat-
First, one of the subject’s main problems
ment outcomes are shown in Tables 1 and 2,
was fatigue caused by the MS. Although there
respectively. The outcome measures included
is evidence to suggest that acupuncture can
a visual analogue scale (Boonstra et al. 2008),
be used as an effective treatment for chronic
functional outcomes (i.e. sit-­ stands, arm
fatigue syndrome (Wang et al. 2009), increased
raises and step-­ups), and the EuroQol – Five
fatigue is a common side effect if an incorrect
Dimensions – Five Levels questionnaire
dosage is used (AACP 2015). Therefore, only
(EuroQol Group 1990; Brooks 1996; Öster
four needles were used in the first session, and
2009; Herdman et al. 2011; van Hout et al. 2012;
these were applied for no more than 10 min.
Janssen et al. 2013).
This was done in order to gauge the subject’s
response and minimize the potential for adverse
Rationale for acupuncture point selection reactions. White et al. (2008) suggested that the
The subject’s main problems were pain and treatment dose should be adjusted depending
fatigue. There had been no change in her on the degree to which the nervous system is
symptoms after four sessions of standard sensitized in each individual, and therefore, a

© 2017 Acupuncture Association of Chartered Physiotherapists 51

52
Table 1. Acupuncture point selection and technique: (BL) Bladder; (SI) Small Intestine; (LI) Large Intestine; (GV) Governor Vessel; (GB) Gall Bladder; and (+) strong De Qi
Needle size Depth
Acupuncture points (mm) Needling technique (mm) Restimulation De Qi Time (min) Adverse effects Advice given

Session 1
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Once at 5 min Yes 10 None General advice in case of adverse
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Once at 5 min Yes effects; advised to continue with home
exercise plan
Session 2
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 None Yes 20 None Advised to continue with home
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 None Yes exercise plan
SI9 (bilateral) 0.25 × 40 Perpendicular 20 Once at 10 min Yes

Session 3
Management of pain in a woman with multiple sclerosis

BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Once at 10 min Yes 20 None Advised to continue with home
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Once at 10 min Yes exercise plan
LI4 (bilateral) 0.25 × 25 Perpendicular 10 Once at 10 min Yes+

Session 4
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Once at 10 min Yes 20 None Advised to continue with home
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Once at 10 min Yes exercise plan
LI4 (bilateral) 0.25 × 25 Perpendicular 10 Once at 10 min Yes

Session 5
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes 20 Minimal dizziness, General advice in case of adverse
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes eased after 2 min effects; advised to continue with home
LI4 (bilateral) 0.25 × 25 Perpendicular 10 Every 5 min Yes when needles exercise plan and to rest on return
GV14 0.25 × 25 Oblique in a cephalic direction 10 Every 5 min Yes removed home
GB34 (bilateral) 0.25 × 40 Perpendicular 10–20 Every 5 min Yes
GB20 (bilateral) 0.25 × 40 Oblique towards opposite eye 10 Every 5 min Yes
Continued/

© 2017 Acupuncture Association of Chartered Physiotherapists

 Table 1. (Continued)
Needle size Depth
Acupuncture points (mm) Needling technique (mm) Restimulation De Qi Time (min) Adverse effects Advice given
Session 6
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes 20 None Advised to continue with home
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes exercise plan
LI4 (bilateral) 0.25 × 25 Perpendicular 10 Every 5 min Yes
GV14 0.25 × 25 Oblique in a cephalic direction 10 Every 5 min Yes
GB34 (bilateral) 0.25 × 40 Perpendicular 10–20 Every 5 min Yes
GB20 (bilateral) 0.25 × 40 Oblique towards opposite eye 10 Every 5 min Yes

Session 7
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes, muscle 20 Minimal dizziness, Advised to continue with home
twitch on eased after 2 min exercise plan and to rest on return

© 2017 Acupuncture Association of Chartered Physiotherapists

right when needles home
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes removed
LI4 (bilateral) 0.25 × 25 Perpendicular 10 Every 5 min Yes
GV14 0.25 × 25 Oblique in a cephalic direction 10 Every 5 min Yes
GB34 (bilateral) 0.25 × 40 Perpendicular 10–20 Every 5 min Yes
GB20 (bilateral) 0.25 × 40 Oblique towards opposite eye 10 Every 5 min Yes, muscle
twitch
Session 8
BL11 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes 20 Minimal dizziness, Advised to continue with home
BL14 (bilateral) 0.25 × 25 Oblique towards spine 10 Every 5 min Yes, muscle eased after 2 mins exercise plan and to rest on return
twitch when needles home
LI4 (bilateral) 0.25 × 25 Perpendicular 10 Every 5 min Yes+ removed
GV14 0.25 × 25 Oblique in a cephalic direction 10 Every 5 min Yes
GB34 (bilateral) 0.25 × 40 Perpendicular 10–20 Every 5 min Yes
GB20 (bilateral) 0.25 × 40 Oblique towards opposite eye 10 Every 5 min Yes

53
K. Biss
Management of pain in a woman with multiple sclerosis
Table 2. Treatment outcomes
Outcome measure
Visual analogue scale
Functional outcomes (1 min each):
sit-­stands
arm raises
step-­ups
EuroQol – Five Dimensions – Five Levels questionnaire:
mobility
self-­care
usual activities
pain/discomfort
anxiety/depression
index value
low dose was chosen to minimize any adverse
response. Witt et al. (2011) stated that an
increased acupuncture effect can be found in
patients with chronic pain, and attributes such
as being a female and the failure of other previ-
ous therapies, and therefore, the initial dose
was also limited because of this. In the second
session, when it was certain that the subject
had experienced no adverse reactions, the dos-
age was increased to 20 min, which has been
reported to be an adequate length of treatment
(White et al. 2007).
Secondly, the subject was taking aspirin to
help with the management of her MS-­related
fatigue. Aspirin is a drug that thins the blood;
however, unlike warfarin, it is classed as an
antiplatelet medication rather than an anti­
coagulant, and therefore, does not carry the
same associated risk when acupuncture is
employed (NHS Choices 2016). She reported
no problems with blood clotting or bleeding dis­
orders, and so it was decided that it was safe to
continue.
Points local to the subject’s pain were chosen
for the first session because her symptoms were
thought to be primarily myofascial in origin.
Elements of the layering method proposed by
Bradnam (2003, 2007), in which treatment is
individualized depending on the underlying pain
mechanism were used, in deciding which points
to use. According to Bradnam (2003, 2007,
p. 24), “fewer needles should be used in cases
of intense acute nociceptive pain, since the seg-
ment will already be sensitized by the painful
afferent input from the injury”. Therefore, only
four points were chosen.
54
Initial assessment Final treatment Improvement
 6/10  4/10 2/10
 9 15 6
15 20 5
11 14 3
 1  1
 1  1
 2  1
 3  2
 1  2
 0.767  0.768 0.001
At the second session, the subject reported
that she had experienced some reduction in her
symptoms, and so two additional needles were
added, although these were still local to the
area of her pain. Since De Qi was maintained
at both Bladder points bilaterally, only the
Small Intestine (SI) points were re-­ stimulated
at 10 min. Overstimulation was avoided in an
attempt to avoid aggravating her fatigue.
Since there had been no adverse reactions,
Large Intestine 4 was added at the third ses-
sion. This was intended to increase the supra­
spinal effects, and therefore, boost pain relief;
the activation of descending pain inhibitory
systems is thought to give pain relief that has
longer-­lasting effects (Lundeberg et al. 1988).
When the pain is centrally evoked, it is recom-
mended that the activation of these pathways
is done extrasegmentally “to avoid overloading
the sensitized segment” (Bradnam 2003, 2007,
p. 25). The use of these “big points” has also
been recommended in order to effectively
activate central autonomic responses. Because
of patient positioning and comfort, SI9 was
not used during this session. All points were
stimulated at 10 min so as to maintain De Qi.
The same points and timings were used in the
fourth session.
Since there had been no change in the sub-
ject’s symptoms and she had experienced no
adverse reactions, the number of needles was
increased for the fifth session, as was the level
of stimulation. Governor Vessel 14 was added
as an additional local point because it is believed
to be beneficial in the treatment of postural,
cervicothoracic junction problems. Gall Bladder
© 2017 Acupuncture Association of Chartered Physiotherapists

(GB) 34 was added bilaterally as an additional
“big point”. In traditional Chinese medicine,
GB34 is said to be an influential point for
muscles and tendons that restores homeostasis,
and a strong relaxation point (Norris 2011). On
arrival at this session, the subject reported that
she had experienced a flare-­up in her upper neck
pain, and therefore, GB20 was added bilaterally.
When the needles were removed at the end
of treatment, she reported increased dizziness;
however, this side effect was short-­lived and no
other adverse effects occurred.
At the three subsequent sessions, the nee-
dles, times and stimulation were kept the same
because the subject reported a reduction in her
pain levels with no adverse reactions, apart from
minimal dizziness at the end of each treatment.
Discussion
As mentioned above, the evidence for the use
of acupuncture in MS is limited, and therefore,
the present case report is interesting because it
demonstrates a reduction in pain and an increase
in function when acupuncture is used in combi-
nation with standard physiotherapy treatment.
The subject presented with pain and fatigue as
a result of a chronic, progressive condition, but
she also had several biopsychosocial issues such
as a poor understanding and acceptance of her
diagnosis, which may have contributed to her
symptoms.
However, as with any study, there are some
limitations. First, the improvement in the
subject’s symptoms may have been limited by
the slow increase in the dosage used because
of concerns about causing an increase in her
fatigue levels. Acupuncture has been found to
increase nocturnal melatonin secretion, and
reduce insomnia and anxiety (Spence et al. 2004).
However, the exact level of insomnia reduc-
tion and, thus, increased drowsiness is unclear,
and will vary for each individual. Therefore, to
prevent a worsening of the subject’s symptoms,
the dosage was increased very slowly. Secondly,
because of patient and clinician holidays, there
was a break of almost 3 weeks between the
fourth and fifth treatments. White et al. (2007,
p. 384) stated that acupuncture was “‘adequate’
© 2017 Acupuncture Association of Chartered Physiotherapists
K. Biss
if it consisted of at least six treatments, at least
one per week”. Repeated electroacupuncture
(EA) has been found to have a cumulative effect
on chronic pain by relieving spinal spasticity
and creating “a plastic change in the release
and metabolic rate of spinal opioid peptides”
(Luo 1996, p. 241). The longer period between
acupuncture treatments that occurred in the
present study might have meant that this cumu-
lative effect could have been reduced, leading
to slower progress. A study by Luo (1996) also
suggests that the present subject might have
experienced better results if EA had been used
rather than standard acupuncture.
The reduction in the subject’s symptoms
and the increase in function are believed to be
the result of the combination of needling, and
the functional exercises and education that she
was given. Acupuncture has been shown to be
most beneficial when combined with usual care
(Witt et al. 2006), and its effects may enhance
physiotherapy performance in musculoskeletal
rehabilitation (França et al. 2008). The reduction
in her pain levels may have allowed the subject
to increase her function, and this would have
led to a further lessening of her symptoms. It
is hoped that this will continue, aiding the long-­
term management of her symptoms.
Since a variety of both local and extra­
segmental points were used as the treatment
progressed, this suggests that several different
mechanisms of action produced the overall
result. These mechanisms are outlined in the
introduction above.
When the dosage was increased in the later
sessions, the subject reported some dizziness
for a few minutes following the removal of
the needles. Dizziness is a recognized adverse
reaction associated with the use of acupuncture,
but it is generally transient and mild (Yamashita
2004). It could be a result of the effect that acu-
puncture is believed to have on the autonomic
system (Sakai et al. 2007). Because this adverse
reaction was short-­ lived and had no lasting
detrimental effect on the subject, treatment was
continued at the same dosage.
A more rapid increase in the dosage might
have led to a stronger overall response with
respect to the symptoms. Another approach
55
Management of pain in a woman with multiple sclerosis
to acupuncture treatment could have been to
needle more myofascial trigger points. However,
because the subject had MS, this was thought to
be risky since it could have reduced the muscle
tone that she relied on to maintain her posture.
Needling trigger points is believed to evoke
segmental anti-­nociceptive effects (Srbely et al.
2010).
Future sessions with this subject may involve
a similar number of needles in comparable posi-
tions if her symptoms continue to improve, or
these might feature an increase in the number
of needles locally if her symptoms persist, with
the potential to add further “big points” if no
increase in adverse reactions occurs.
The present study shows that acupuncture
has some degree of a positive effect on pain in
a patient with MS, although further research is
needed to demonstrate a stronger relationship
between these two factors.
Acknowledgements
I would like to thank the subject of the present
study, my fellow coursemates and my tutor for
helping me to begin practising acupuncture.
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57
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 59–66

CASE REPORT

Acupuncture treatment for a 50-­year-­old female

with fibromyalgia suffering from a whiplash
injury following a road traffic accident
C. Hamer
Assessment and Rehabilitation Centre, Blackpool Teaching Hospitals NHS Foundation
Trust, Blackpool, UK

Abstract
This case study describes the treatment of a 50-­year-­old female with fibromyalgia who suf-
fered from a whiplash injury following a road traffic accident. Current evidence, guidelines
and assessment findings informed the choice to include acupuncture within the physiotherapy
treatment plan. The primary aims of the acupuncture treatment were to produce analgesic
effects, and to enable training to begin for the subject’s upcoming goal of completing the
Inca Trail to Machu Picchu in Peru. Massage, heat therapy, lumbar and cervical spine range
of motion (ROM) exercises, and core-­strengthening exercises were included to improve her
symptoms over six weekly sessions. The outcome measures included lumbar and cervical
spine ROM, a Numerical Rating Scale to measure subjective pain, and the EuroQol – Five
Dimensions – Five Levels questionnaire about quality of life. Improvement was demon-
strated in all outcomes after treatment, and the subject was able to return to her hobby of
spinning classes and begin hiking practice for the Inca Trail.
Keywords: acupuncture, fibromyalgia, road traffic accident, whiplash injury.

Introduction 1988). The result is pain and stiffness in the

Stux & Pomeranz (1995) reported that acupunc-
ture can be used to treat musculoskeletal (MSK)
pain, and stated that neck pain is one of the
three most commonly reported complaints of
the MSK system.
A whiplash injury is defined as a musculo­
ligamental sprain or strain of the cervical spine
caused by hyperextension and/or hyperflexion
(Radanov et al. 1995). This occurs when people
are not prepared for sudden trauma, and it
causes soft-­
tissue damage, muscle strain and
trauma to the joint capsule (Greenwood et al.
Correspondence and present address: Charlotte Hamer,
Physiotherapy Department, Blackpool Victoria Hospital,
Blackpool Teaching Hospitals NHS Foundation Trust,
Whinney Heys Road, Blackpool FY3 8NR, UK
(e-mail: charlottehamer18@gmail.com).
neck, shoulder and back, and possible head-
aches and nerve-­root pain extending down one
or both arms.
According to Hurtig et al. (2001), the major-
ity of patients with fibromyalgia report pain
and stiffness in their neck and shoulder mus-
cles, a lower threshold for mechanical pain (i.e.
allodynia), and exaggerated pain responses to
noxious stimuli (i.e. hyperalgesia). Both indi-
viduals with chronic pain after whiplash injury
and those with fibromyalgia have been found
to display exaggerated pain after sensory stim-
ulation. This amplified perception of pain has
been attributed to possible hyperexcitability of
the central nervous system (CNS). Banic et al.
(2004) tested the hypothesis that patients with
chronic whiplash pain and those with fibro­
myalgia display a facilitated withdrawal reflex,

© 2017 Acupuncture Association of Chartered Physiotherapists 59

Whiplash injury following a road traffic accident
and therefore, spinal cord hypersensitivity. The
nociceptive withdrawal reflex is a spinal reflex
of the lower extremities that can be elicited by
painful stimulation of a sensory nerve (Willer
et al. 1979). Central hypersensitivity could
explain the amplification of the nociceptive
signal by the hyperexcitable neurons.
Peripheral injury and inflammation cause
plasticity changes in the CNS that result in
neur­ onal hyperexcitability (Woolf & Salter
2000). Inflammation produces the release
of cyclooxygenase-­ 2 (COX-­ 2) in the spinal
cord, leading to prostaglandin production and
neuronal hyper­excitability (Ichitani et al. 1997).
Pharmacological inhibition of COX-­2 can pro-
vide relief from the symptoms of inflammation
and pain. Non-­ steroidal anti-­ inflammatory
drugs exert their effects through inhibition
of COX-­ 2. Elevated levels of substance P
and excitatory amino acids have been found
in the cerebro­ spinal fluid of individuals with
fibromyalgia, raising the possibility that these
substances can cause generalized spinal cord
hypersensitivity (Larson et al. 2000). It is not
known whether similar biochemical changes
occur in the cerebrospinal fluid of the victims
of whiplash.
Dubner & Ren (1999) suggested that spinal
cord hyperexcitability elicited by trauma or
inflammation is influenced by the descend-
ing facilitatory and inhibitory pathways. The
involvement of serotonin in descending modu-
lation suggests that genetic factors account for
the imbalance of descending pain modulation
that leads to enhanced pain reactivity (Li &
Zhuo 2001). Peripheral inflammation induces
gene expression in the dorsal root ganglion,
resulting in an increased synthesis of peripheral
receptors. This causes a reduced threshold for
pain within the injured area.
The nociceptive withdrawal reflex was elec-
trophysically measured to quantify the excit-
ability of spinal neurons in a study of patients
with fibromyalgia by Banic et al. (2004). These
authors found that the electrical stimulation
bypassed the peripheral receptors and activated
the nerve fibres, demonstrating that the low
reflex and pain thresholds identified were not
the result of peripheral sensitization, but rather,
60
altered spinal cord sensitivity. The presence
of spinal cord hypersensitivity in cases of
whiplash and fibromyalgia, which are two very
different pain syndromes, suggests that this
theory may also relate to other chronic MSK
pain conditions.
Acupuncture is one of the most frequently
used alternative medical interventions, and
evidence demonstrates that it reduces pain and
improves the quality of life of patients with
fibromyalgia (Targino et al. 2008). The stud-
ies that have been completed predominantly
involved Caucasian women, meaning that gen-
eralizations cannot be made. Stux & Pomeranz
(1995) found that patients with chronic neck
pain reported immediate and short-­ term pain
relief following acupuncture, and argued that the
modality prevents or modifies the perception of
pain. These authors proposed that acupuncture
alters physiological functions, including pain
control, when it is used to treat certain dysfunc-
tions of the body.
Emotions are often classified as either posi-
tive or negative. In society, it is often believed
that the expression of negative emotions is
inappropriate, which can lead to these becom-
ing repressed, resulting in muscle tightening or
disease in some part of the body. This is known
as an “energy block” in traditional Chinese
medicine, and it is believed to manifest in any
weakened area of the body. A whiplash injury
becomes an ideal focal point for this, and acu-
puncture induces an overwhelming feeling of
intensity that enables the expression of these
feelings. Emotions also increase muscle tension
in the neck, and may prolong the condition.
Patients who do not recover after a few months
become labelled as neurotic, and if symptoms
persist, the issue conflates itself with chronic
pain syndrome.
In addition, these patients usually have legal
suits pending in which there is a financial
advantage to having a severe prolonged dis-
ability (Greenwood et al. 1988). Acupuncture is
increasingly being used in the West as a tool for
pain relief, and Greenwood et al. (1988) stated
that its effectiveness is no longer questioned.
It has been successfully used to treat whiplash
injuries.
© 2017 Acupuncture Association of Chartered Physiotherapists

Case report
Background
The present subject was a 50-­year-­old female
who lived with her husband and two children.
She worked as a service redesign manager
for the National Health Service. The subject
enjoyed fitness training, and attended a spinning
class three times a week. As a charity fundraiser,
she had arranged to complete the Inca Trail to
Machu Picchu in Peru in March 2016.
The subject had been involved in a road
traffic accident in September 2015. She initially
experienced stiffness in her neck and back,
severe pain, dizziness, and pain radiating down
her right arm. The neck pain had subsequently
become more centralized and was resolving.
However, her low back pain (LBP) was still
severe, although more so on her right side than
on her left. She had already received treatment
from two physiotherapists, but reported no
major improvement in her condition. The sub-
ject was involved in an ongoing legal suit.
She had a past medical history of fibro­myalgia
and chronic fatigue syndrome. For medication,
she took gabapentin and amitriptyline.
Clinical impression
The subject experienced neck pain [Numerical
Rating Scale (NRS) = 6/10] that was aggravated
by prolonged periods of sitting at her desk dur-
ing working hours. Her peripheral symptoms
and dizziness had now stopped. The pain was
becoming more centralized, but remained in her
right trapezius muscle. This was eased by heat.
The subject also experienced LBP
(NRS = 9/10). This was also aggravated by
prolonged periods of sitting at work. She was
unable to participate in spinning classes because
of her pain, and experienced an increase in
symptoms after long walks. The LBP pain was
also eased by heat.
During a cervical spine assessment, full
range of motion (ROM) was noted, along with
reproduction of pain during left-­ side flexion,
left rotation and cervical flexion. There was no
shoulder involvement, and no red flags or signs
of vertebrobasilar insufficiency. In a lumber
spine assessment, tenderness was noted on
© 2017 Acupuncture Association of Chartered Physiotherapists
C. Hamer
palpation over L4, L5, L6 and the surrounding
right-­
side soft tissue. Reproduction of pain
occurred during trunk rotation to the right
and side flexion to the left. All other lumbar
movements were performed at full range with
no discomfort. A straight leg raise test proved
negative. There was no hip involvement, and no
red flags. Regarding yellow flags, there had been
reduced responsiveness to previous treatment,
and the ongoing lawsuit was considered. The
subject’s EuroQol – Five Dimensions – Five
Levels (EQ-­ 5D-­5L) questionnaire score was
55/100.
Treatment
There were no contraindications to acupunc-
ture treatment. The subject had previously
undergone acupuncture for right knee pain and
reported a successful outcome. Treatment com-
menced following the clinical assessment, and
after the theory of acupuncture and its possible
side effects had been discussed and a consent
form had been signed.
The acupuncture treatment sessions are sum-
marized in Table 1.
Rationale for acupuncture point selection
The initial acupuncture treatment should be
reasonably conservative, and involve between
four and eight points (White et al. 2008). This
is to ensure that the patient is comfortable and
to see how he or she responds to acupuncture
(Dupuis 2015).
Bladder (BL) 23 and BL24 were used as local
points, and inserted bilaterally to increase the
dosage. These were chosen because the subject’s
LBP following her whiplash injury was the most
intense source of her discomfort; therefore,
this was prioritized since only a small number
of needles were used initially. As a precaution,
the positioning of the internal organs (e.g. the
kidneys) was considered throughout. The aim
of using local points from the outset is to allow
the patient to have confidence in the treatment,
which may not happen when needling occurs
away from the injured area. This approach also
stimulates a local response, which has been
shown to contribute to pain relief.
61
Whiplash injury following a road traffic accident
Table 1. Summary of acupuncture treatment sessions: (LI) Large Intestine; (GB) Gall Bladder; (BL) Bladder; and (LBP) low back pain
Acupuncture Needle size Treatment
points (mm) Angle time (min) Dosage Effect of treatment

Session 1
LI4 (bilateral) 25 × 0.25 Perpendicular 10 Rotated × 2 No adverse effects
GB34 (right) 40 × 0.25 Perpendicular Responded well to treatment
BL23 (bilateral) 40 × 0.25 Perpendicular
BL24 (bilateral) 40 × 0.25 Perpendicular

Session 2
LI4 (bilateral) 25 × 0.25 Perpendicular 15 Rotated × 3 Reported an initial increase in
GB34 (right) 40 × 0.25 Perpendicular pain
BL23 (bilateral) 40 × 0.25 Perpendicular Tolerated increase in needles well
BL24 (bilateral) 40 × 0.25 Perpendicular Strong De Qi achieved at BL40
BL25 (bilateral) 40 × 0.25 Perpendicular
BL40 (right) 40 × 0.25 Perpendicular

Session 3
LI4 (bilateral) 25 × 0.25 Perpendicular 20 Rotated × 4 Reported a short period of pins
GB34 (right) 40 × 0.25 Perpendicular and needles around left LI4 after
BL23 (bilateral) 40 × 0.25 Perpendicular treatment
BL24 (bilateral) 40 × 0.25 Perpendicular Low back pain improving, so
BL25 (bilateral) 40 × 0.25 Perpendicular able to begin to include cervical
BL40 (right) 40 × 0.25 Perpendicular points
BL62 (right) 25 × 0.25 Oblique towards the lateral malleolus
BL10 (bilateral) 13 × 0.18 Oblique towards the lamina of C2
GB21 (bilateral) 25 × 0.25 Perpendicular

Session 4
LI4 (bilateral) 25 × 0.25 Perpendicular 20 Rotated × 4 Reported an improvement in
GB34 (right) 40 × 0.25 Perpendicular both neck and LBP
BL23 (bilateral) 40 × 0.25 Perpendicular
BL24 (bilateral) 40 × 0.25 Perpendicular
BL25 (bilateral) 40 × 0.25 Perpendicular
BL40 (right) 40 × 0.25 Perpendicular
BL62 (right) 25 × 0.25 Oblique towards the lateral malleolus
BL10 (bilateral) 13 × 0.18 Oblique towards the lamina of C2
GB21 (bilateral) 25 × 0.25 Perpendicular

Session 5
LI4 (bilateral) 25 × 0.25 Perpendicular 20 Rotated × 4 Neck pain has resolved
GB34 (bilateral) 40 × 0.25 Perpendicular Bilateral distal points needled to
BL23 (bilateral) 40 × 0.25 Perpendicular increase the extrasegmental effect
BL24 (bilateral) 40 × 0.25 Perpendicular for LBP
BL25 (bilateral) 40 × 0.25 Perpendicular
BL40 (bilateral) 40 × 0.25 Perpendicular
BL62 (bilateral) 25 × 0.25 Oblique towards the lateral malleolus

Session 6
LI4 (bilateral) 25 × 0.25 Perpendicular 20 Rotated × 4 Patient reported that she is now
GB34 (right) 40 × 0.25 Perpendicular pain-­free
BL23 (bilateral) 40 × 0.25 Perpendicular Outcomes measured again
BL24 (bilateral) 40 × 0.25 Perpendicular No further treatment required
BL25 (bilateral) 40 × 0.25 Perpendicular
BL40 (right) 40 × 0.25 Perpendicular
BL62 (right) 25 × 0.25 Oblique towards the lateral malleolus

Langevin et al. (2007) suggested that a and a consistent lack of stress leads to fibrosis,
chronic local increase of stress in the tissues adhesions and contractures. These processes can
can lead to micro-­ injury and inflammation, lead to changes in connective tissue. Connective

62 © 2017 Acupuncture Association of Chartered Physiotherapists


tissue fibrosis and myofascial trigger points are
detrimental because these lead to tissue restric-
tion and impairment in the long term (Tough
et al. 2009). Connective tissue is richly innervated
by nociceptive neurons, and Aδ and C-­ fibres
(Corey et al. 2011). Evidence suggests that
acupuncture stimulates these Aδ and C-­fibres,
which communicate with the dorsal horn in the
spinal cord, the brainstem, and higher centres
such as the hypothalamus and periaqueductal
grey matter. This leads to endogenous opioid
mechanisms stimulating descending noxious
inhibitory pathways, which causes an analgesic
effect (Zhao 2008).
Acupuncture consists of needle insertion
into muscle tissue, followed by twirling of the
needle to elicit a distinct sensation of heaviness
or numbness known as De Qi (Cheng 1987).
De Qi means “the arrival of energy”. It is
produced when the axon reflex in the terminal
network of Aδ fibres is stimulated, causing a
release of several substances, and resulting in
improved blood flow, the promotion of heal-
ing and pain relief (White et al. 2008). De Qi
was achieved during each treatment session in
the present study. Needle stimulation has been
shown to increase blood flow in patients with
fibromyalgia (Sandberg et al. 2005). As well as
having pain-­ alleviating properties, acupuncture
has also been shown to improve cutaneous
microcirculation and tissue healing in MSK con-
ditions (Ernst & Pittler 1998). Upon activation,
Aδ and C-­ fibres release vasoactive substances
such as calcitonin gene-­ related peptide and
substance P. These are conducted antidromically
from the relevant peripheral nerve terminals by
axon reflex mechanisms that are known to be
part of neurogenic inflammation (Holzer 1998).
Calcitonin gene-­related peptide is a very potent
vasodilator that increases blood flow.
Large Intestine (LI) 4 was chosen because it is
often used in experimental studies of the effects
of acupuncture analgesia, and is frequently used
in clinical practice as a point for pain (Wang &
La 2007). It is known as the pain point in the
body, and is indicated as a point to use for any
type of pain (Berman et al. 2004). The subject
reported a short period of pins and needles at
the LI4 point 1 h after the second treatment
© 2017 Acupuncture Association of Chartered Physiotherapists
C. Hamer
session ended, but the symptoms resolved that
night. Targino et al. (2008) reported that 5.8% of
their fibromyalgia acupuncture group developed
temporary oedema, and pins and needles at the
LI4 point on the left hand. Similarly, McCartney
et al. (2000) described a case of bilateral hand
oedema, and pins and needles after the use of
bilateral LI4 acupuncture points to treat chronic
LBP and sciatica. Large Intestine 4 is a major
point for extrasegmental acupuncture.
The rationale for adding points further away
from the pain was to elicit segmental effects. It
is believed that acupuncture modulates spinal
signal transmission and the perception of pain
in the brain. The release of enkephalins and
endorphins from acupuncture treatment exerts
an inhibitory effect on nociceptive reflexes at the
segmental level (Furlan et al. 2005). Enkephalin
is a naturally occurring peptide with analgesic
properties that is released by neurons in the
CNS (Zhao 2008). The Bladder meridian is
primarily used when treating LBP because it has
points local to the spine, but it can also be used
to achieve a segmental effect. The Bladder and
Gall Bladder meridians follow dermatome levels
corresponding to spinal levels. It is believed
that the analgesic effect from acupuncture is
enhanced by using points that share a common
spinal segment (Bradnam-­Roberts 2010). Moffet
(2006) suggested that using local acupunc-
ture points induces segmental pain ascending
inhibitory effects through the spinal gait control
mechanism stimulating Aδ and C-­ fibres. This
releases opioids from inhibitory neurones in the
dorsal horn of the spinal cord.
Distal points were added to provoke an
extrasegmental effect. Acupuncture can
induce pain relief throughout the whole body.
Descending pain inhibition occurs in the
periaqueductal grey matter, which is activated by
endorphins released from the hypothalamus. The
descending pain inhibition system is activated in
the brainstem by neuromodulators, particularly
noradrenaline and serotonin. Serotonin is an
important transmitter of pain control (White
et al. 2008). The limbic and paralimbic, hypo-
thalamus, and subcortical grey matter structures
have been identified as important factors in the
mediation of the effects of acupuncture and De
63
Whiplash injury following a road traffic accident
Qi. The De Qi sensation is believed to be related
to clinical efficacy, with strong sensations induc-
ing strong deactivation of the limbic system and
producing a clinically beneficial effect (Yang et al.
2013). Magnetic resonance imaging has demon-
strated that acupuncture suppresses neurological
output across the limbic system, suggesting that
the emotive element of pain can be reduced
(Zeng et al. 2012). Research into the permanent
changes to emotional centres is being developed.
This is in order to explore the possibility that the
chronicity of pain may be related to the subcon-
scious retention of pain in the memory, which
acupuncture may play a role in resetting.
The total treatment time was gradually
increased to 20 min by the third week to maxi-
mize its effects (White et al. 2008). By the final
treatment, the subject reported a significant
decrease in her pain levels, an improvement in
her quality of life and a return to her hobby of
spinning. Her compliance with ROM exercises
was evident, and all physiotherapy goals were
achieved.
Patient profile after treatment
After six acupuncture treatment sessions had
been completed, the subject reported that she no
longer suffered from neck pain (NRS = 0/10).
She rated her LBP as 1/10 at its worst on the
NRS. The subject had resumed spinning classes
three times a week, and had started training for
the Inca Trail to Machu Picchu.
Objective assessment
During a cervical spine assessment, full ROM
was noted with no reproduction of pain
throughout. During a lumbar spine assessment,
no tenderness was noted on palpation over the
lumbar region or surrounding right-­side soft tis-
sue. There was slight reproduction of minimal
pain during side flexion to the left. All other
lumbar movements were achieved at full range
with no discomfort.
The subject’s EQ-­5D-­5L score was 90/100.
Discussion
The selection of appropriate points is fundamen-
tal to obtaining a therapeutic effect from clinical
64
acupuncture (Lee et al. 2013). In the present
case, distal points were used to induce strong
analgesic effects by stimulating the release of
serotonin and oxytocin from the hypothalamus,
hippocampus and periaqueductal grey matter
to inhibit pain further (Moffet 2006). Oxytocin
blocks the memory of pain, and therefore, is
useful for chronic pain conditions.
The present subject experienced significant
improvements after completing a course of
acupuncture treatment with additional physio-
therapy. Six treatment sessions were planned
and completed to good effect. Limitations to
this study include the sample size and time since,
although the treatment was completed, only
short-­term effects could be analysed. Further
research is required to investigate the long-­term
effects of acupuncture. The subject in this study
had three pain syndromes: neck pain and LBP,
and the underlying comorbidity of fibromyalgia.
In this case, both spinal mechanical pains were
treated together because of time restraints, and
the subject experiencing severe pain in both
areas. Further development is required in the
present author’s practice to research the effects
of this, and to consider the effects of treating
specific pains individually, not simultaneously.
An alternative to using the traditional points
to treat cervical and lumbar pain following a
whiplash injury would be to use myofascial trig-
ger points. By stimulating certain points on the
body, acupuncture contracts intraspindle muscle
and produces myoelectricity. Secondary impulses
reach the central brain, producing the needling
sensation. Current Western thinking attributes
the effect of the needling to stimulation of the
motor endplate in the transverse motor band
near the centre of a muscle, thereby releasing
muscle spasm. Endorphin release also contrib-
utes to pain relief (Greenwood et al. 1988).
The present subject had previously received
acupuncture treatment for a different condition
with positive effects. This may have influenced
the outcome, and the placebo effect in acupunc-
ture, which involves the limbic system, cannot
be ignored. Kalauokalani et al. (2001) reported
that patients who had greater expectations of
acupuncture treatment were found to have bet-
ter outcomes.
© 2017 Acupuncture Association of Chartered Physiotherapists

Exaggerated pain after peripheral stimulation
is common in cases of whiplash and patients
with fibromyalgia (Sheather-­ Reid & Cohen
1998). The present subject suffered from both
conditions. Further research is required to
investigate the effects of acupuncture for MSK
injuries when fibromyalgia is a comorbidity.
Current evidence does agree that acupunc-
ture is beneficial for whiplash and patients
with fibromyalgia. The present case study has
demonstrated that acupuncture is effective in
reducing pain, and improving quality of life and
function.
Acknowledgements
I would like to thank the present subject for
giving her permission for the publication of
this study, allowing her condition and treatment
to be further researched and documented.
My gratitude also goes to the instructors on
the AACP Foundation Course for sharing their
clinical expertise and wisdom with my cohort.
Finally, I wish to thank AACP for providing
the informative course handbook that was con-
sulted throughout this case study.
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Charlotte Hamer graduated from the University of
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© 2017 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 67–74

CASE REPORT

Electroacupuncture in the treatment of patellar

tendinopathy in a 52-­year-­old male
B. Bradford
Private Practice, Norwich, UK

Abstract
A 52-­year-­old male software engineer with a 3-­month history of anterior knee pain was
referred for physiotherapy by his general practitioner. The pain had started insidiously, and
was now particularly troublesome when he ascended stairs and during sustained periods of
sitting. Clinically, the subject presented with highly specific pain at the inferolateral pole
of the patella. This was aggravated when he performed a squat. Structural tests were all
negative. The subject was treated with five sessions of electroacupuncture. The aim was to
reduce his pain in order to facilitate appropriate loading of the tendon, as per the current
evidence base for the treatment of tendon dysfunction. The subject reported significant
improvements in pain (on the Numeric Rating Scale) and knee function after three sessions,
and full resolution of the problem after the fifth.
Keywords: electroacupuncture, patellar tendinitis, patellar tendinopathy.

Introduction collagen myofibrils under stress. Insufficient

Patellar tendinopathy is a chronic, disabling
insult of the patellar tendon at its tendon–osse-
ous attachment to the inferior pole of the
patella (Kongsgaard et al. 2009). The prevalence
of this condition is high in both recreational
and elite athletes, particularly in sports requir-
ing repetitive knee extension torque, such as
running, athletics and volleyball (Larsson et al.
2012). Sedentary patients can also be affected
(Brukner & Khan 2012), particularly now that
more is known about systemic risk factors in
tendinopathy, such as central adiposity and gen-
der (Gaida et al. 2009).
Patellar tendinopathy is believed to occur as
a result of repetitive tendon overload (Maffulli
& Longo 2008). Tendon overload is thought
to occur a result of macroscopic damage to
Correspondence: Ben Bradford, Pure Physiotherapy
Ltd, 6 City Road, Norwich NR1 3AL, UK (e-­mail:
info@purephysiotherapy.co.uk).
repair of this damage can lead to a scenario in
which cumulative microtrauma and degenera-
tion of the tendon occurs (Croisier et al. 2001;
Langberg et al. 2005). This process is believed to
be hastened by the hypovascular environment
of the tendon, since vessels appear to grow into
the tendon only from the ventral surface (Neal
& Longbottom 2012). The term “degenerative
tendinopathy” was first suggested by Cook &
Purdam (2009) as the characteristic structural
degradation of the extracellular matrix (ECM)
of pathological tendons, in which disorientation
of collagen myofibrils, the presence of scattered
neurovascular ingrowth and tenocyte apoptosis
have all been demonstrated by histological
and sonographic studies (McCreesh et al. 2013;
Malliaras et al. 2013).
Although histopathological investigation has
aided understanding of the pathophysiology
of patellar tendinopathy, the underlying cause
of chronic patellar tendon pain often remains

© 2017 Acupuncture Association of Chartered Physiotherapists 67

Electroacupuncture for patellar tendinopathy
unclear (Woodley et al. 2007). As a result, it has
been difficult to establish which treatments are
effective for patients with patellar tendinopathy,
with many conservative management options
often demonstrating unpredictable levels of
success (Langberg et al. 2005).
In musculoskeletal practice, electroacupunc-
ture (EA) has been shown to be an effective
treatment for various acute and chronic pain
disorders, including myofascial pain syndrome(s)
and osteoarthritis (Leung et al. 2012; Tobbackx
et al. 2012). The physiological basis of acupunc-
ture analgesia has been the subject of extensive
research, and is a manifestation of the integra-
tive neurophysiological mechanisms at different
levels of the central nervous system (CNS) that
respond to the stimulation of Aβ and Aδ affer-
ent fibres at specific neuroanatomical points
located around the body (Shen 2001; Zhao
2008). The most efficacious inhibition of pain
is believed to occur when acupressure points
are selected that correspond either to the der-
matomal or myotomal pathway that supplies the
primary site of the pain. Segmental analgesia is
the result of highly complex inhibitory changes
in the postsynaptic membrane potential in trans-
mission cells located in the dorsal root ganglion
(Leung 2012). The secretion of β-­endorphins
and enkephalins has a modulatory effect on
the transmission of noxious stimuli from the
periphery to the higher centres of the CNS,
resulting in a segmental hypoalgesic response
(Hui et al. 2005).
Both clinical and laboratory studies have
also demonstrated that EA induces a local
vasodilatory effect in the myofascial structures
close to the site of penetration, secondary to
the secretion of a variety of local, endogenous
opioid peptides. Since angiogenesis appears to
be intricately linked to the ability of a tendon to
heal, it has been proposed that treatments that
augment tendon vascularity, such as acupunc-
ture and platelet-­rich plasma, may enhance the
optimal environment needed for tendon repair
(Neal & Longbottom 2012). Langevin et al.
(2007) suggested that acupuncture does indeed
enhance soft-­tissue microcirculation. They con-
cluded that stimulation of the needle resulted in
microscopic disruption of mast cell formation,
68
and the release of several “pro-­inflammatory”
peptides, namely β-­endorphins and chemokines,
all of which have a vasodilatory effect on the
local capillary network.
There has also been a noticeable increase in
research into the beneficial effects of EA on
the synthesis and organization of the ECM in
pathological tendons. De Almeida et al. (2012)
examined the levels of glycosaminoglycans
and hydroxyproline (a marker of collagen
concentration) in an investigation of the effects
of EA on the composition of the ECM of
the Achilles tendon in rats. Birefringence was
used to demonstrate a higher concentration of
type 1 collagen in the group of participants
treated with EA, and a significant increase in
the concentration of hydroxyproline in the
same group. De Almeida et al. (2012) concluded
that EA offers a potentially therapeutic benefit
in the treatment of tendinopathy by inducing
an increase in the rate of collagen synthesis
and augmenting the molecular organization
of the ECM. These authors then built upon
their earlier promising results by developing a
reasoned hypothesis for the anti-­inflammatory
and mechanotransduction molecular pathways
underpinning structural tendon changes fol-
lowing EA (de Almeida et al. 2014). They con-
cluded that, when at least one needle is in close
anatomical proximity to the tendon, stimulation
of that point will lead to upregulation of the
cell via activation of filamentous actin (F-­actin).
An integral part of the cytoskeleton, F-­actin is
responsible for allowing transmission of ten-
sion through the cytoskeleton to the cell nuclei,
whereby mechanical stimulus is analysed and
an appropriate biochemical response initiated.
Type 1 collagen synthesis is one example of this
appropriate cellular response to the mechanical
stimulus of EA, which may, therefore, influence
the hierarchical nature of the ECM.
Case report
Background
The subject of the present case report was a
52-­
year-­
old male with a 3-­month history of
anterior knee pain. He reported that he had
experienced a considerable increase in pain
© 2017 Acupuncture Association of Chartered Physiotherapists

and a decrease in knee function over the past
3 months, and that the pain was now interfering
considerably with his daily life.
Subjective assessment
The subject presented with insidious, highly
localized left anterior knee pain. In his role as
a software engineer, he regularly travels to the
USA, and was now finding that both sitting for
prolonged periods on flights and ascending stairs
significantly aggravated his symptoms. The sub-
ject reported that his pain was 5/10 on a visual
analogue scale (VAS), rising to 7/10 after pro-
longed sitting or ascending stairs. He described
a highly specific ache at the inferior pole of the
patella that worsened during the activities men-
tioned above. The subject reported no episodes
of locking, giving way or swelling, and had no
history of any previous knee pain or injury.
His past medical history was unremarkable. He
takes no regular prescription medications.
Objective assessment
On inspection of the subject’s left knee,
there was no evidence of redness, swelling or
deformity. There was an onset of pain over the
patellar tendon at 140°, i.e. end-­of-­range flexion
(VAS = 5/10). There was mild reproduction
of pain with resisted knee extension, but no
loss of power was evident. The single-­leg squat
test reproduced the subject’s anterior knee pain
B. Bradford
(VAS = 7/10). There was palpable tenderness
at the inferior pole of the patella (VAS = 7/10)
that was aggravated when tilting the patella
superiorly to expose the ventral fibres.
Treatment
Five weekly sessions of electroacupuncture
(EA) following the treatment schedule shown in
Table 1 were provided. The outcomes of each
treatment session are displayed in Table 2. All
risks and contraindications were considered,
and a thorough explanation of the likely ben-
eficial effects of EA was given to the subject
at the initial assessment. Verbal consent was
given prior to each session. The subject was
positioned in long sitting, and his left knee was
flexed to approximately 80° and supported with
one pillow. Two, 0.25 × 40-­mm Classic Plus acu-
puncture needles (HMD Europe Ltd, Chipping
Norton, Oxfordshire, UK) were inserted at
Stomach (ST) 35 (Dubi) and Extra Point Lower
Extremities (Ex-­ LE) 4 (Neixiyan) to allow
electrical flow between the sites. The current
was then supplied by a Cefar Acus 4 EA unit
(Cefar Medical AB, Lund, Sweden). Current
was generated at a mixed frequency stimulation
of 2–80 Hz, with a pulse duration of 180 μs,
and the subject was instructed to increase the
amplitude to the maximum tolerable intensity
(a strong, but not painful sensation of De Qi)
from 0 to 12 mA.

Table 1. Treatment schedule: (ST) Stomach; and (Ex-­LE) Extra Point Lower Extremities
Acupuncture Pulse duration Stimulation Treatment Needle size Depth of De Qi/sensation of
points Frequency (Hz) (μs) frequency (s) time (min) (mm) penetration (cm) electroacupuncture

Session 1
ST35 2–80 180 3 10 0.25 × 40 1.5 Mild to moderate
Ex-­LE4
Session 2
ST35 2–80 180 3 20 0.25 × 40 1.5 Moderate
Ex-­LE4
Session 3
ST35 2–80 180 3 20 0.25 × 40 1.5 Moderate to strong
Ex-­LE4
Session 4
ST35
Ex-­LE4 2–80 180 3 20 0.25 × 40 1.5 Strong
Session 5
ST35 2–80 180 3 20 0.25 × 40 1.5 Strong
Ex-­LE4

© 2017 Acupuncture Association of Chartered Physiotherapists 69

70
Table 2. Outcome of treatment sessions: (VAS) visual analogue scale
VAS score
Function-­specific subjective outcome after session Palpation of inferior pole Single-­leg squat Knee range of motion (onset of pain)

Session 1
The subject was treated for 10 min with electroacupuncture, as described in the treatment 7/10 7/10 0–114° flexion (VAS = 5/10)
schedule (Table 1). Because this was the initial assessment, time was taken to assess the knee
joint, and determine the intensity of the pain reported by the subject (as measured on a VAS)
using three specific objective outcome measures: palpation at the inferior pole of the patella;
during a single-­leg squat; and knee flexion and extension. The onset of pain was measured with
a goniometer in order to assess any improvements in pain through range. The subject reported
a mild-­to-­moderate sensation of De Qi during the 10-­min treatment session, which he described
as a “gentle pulsing sensation” between points.
Electroacupuncture for patellar tendinopathy

Session 2
The subject reported an improvement in his pain following the previous treatment session. 6/10 7/10 0–121° flexion (VAS = 4/10)
In particular, he found ascending stairs easier because of a reduction in the intensity of the
pain. He reported no adverse effects after the first session. The subject was again settled in
long sitting, and the treatment given in session 1 was repeated. The only difference was an
increase in the treatment duration to 20 min, as per the previously discussed recommendations
from the literature. The subject reported a moderate sensation of De Qi at the anterior knee,
and described this as a pulsating sensation between points across the tendon. Objectively,
there was an improvement in pain intensity (VAS) on palpation of the patellar tendon, and an
improvement in knee range from 126 to 132° (VAS = 4/10), but the single-­leg squat VAS score
remained the same.
Session 3
The subject reported an ongoing improvement in pain following the second session. He 3/10 5/10 0–125° flexion (VAS = 1/10)
described a slight increase in pain for 1 day following the session, but attributed this to the
longer treatment duration and a more-­significant sensation of De Qi during it. Despite this,
the subject reported a significant improvement in knee pain from baseline. He now rated his
pain when ascending stairs as 3/10 on the VAS, and said that he could now occasionally ascend
stairs without any pain, whereas he previously noted pain every time he ascended a staircase.
Objectively, there was a significant improvement in pain intensity (VAS), with firm, direct
palpation of the patellar tendon, and during a single-­leg squat. The same treatment approach
was utilized, but a stronger, uncomfortable sensation of De Qi was noted, which the subject
described as a firm “twisting, pulsating” feeling between points when increasing the amplitude
above 5.0 mA.
Continued/

© 2017 Acupuncture Association of Chartered Physiotherapists

 Table 2. (Continued  )
VAS score
Function-­specific subjective outcome after session Palpation of inferior pole Single-­leg squat Knee range of motion (onset of pain)

Session 4
The subject reported a substantial improvement in his left knee pain and function. He stated 1–2/10 3/10 0–130° flexion* (VAS = 0/10)
that he was very pleased with the progress made so far, and was delighted that he could now
ascend a staircase with minimal pain. He described the discomfort on ascending stairs as a
“twinge as opposed to pain”, and had also found that sitting for long periods while driving
provoked only minimal discomfort over the patellar tendon (VAS = 1–2/10). Objectively, there
was a significant improvement in palpable discomfort over the patella. The subject rated this
pain as only 1/10 on the VAS, and said that palpation was similar to the asymptomatic knee.
There was also an improvement in single-­leg squat range (VAS = 3/10), but again, he said that
this was more of a twinge in the knee, as opposed to frank pain. This was also the first session
in which the subject reported no discomfort during flexion and extension, which was now equal
in range to the asymptomatic side. The same treatment regime was applied, and the subject was

© 2017 Acupuncture Association of Chartered Physiotherapists

encouraged to increase the amplitude to the maximal tolerable intensity of 7.2 mA. De Qi was
again felt strongly at this amplitude, and he described it as a “pulsing, twisting” feeling between
points.
Session 5
At the final session, the subject stated that he now had minimal issues with his left knee, and 0/10 0–1/10 0–130° flexion* (VAS = 0/10)
felt that there was almost complete resolution of the problem. He stated that he had had only
one episode of knee pain in the previous 10 days, which he described as a momentary twinge
when quickly ascending two steps at a time. The subject stated that, compared to the severity
of the symptoms at baseline, he now “didn’t notice” any remaining knee pain. He rated his
overall improvement at > 90% and felt ready for discharge. Objectively, the physiotherapist was
unable to elicit any pain on palpation of the patellar tendon at the inferior pole of the patella,
and the subject said that the left side now felt the same as the right. A single-­leg squat did not
produce pain, and demonstrated an equal range to the asymptomatic side. Pleasingly, there was
still a full range of knee flexion and extension without any pain.
*Full range – equal to asymptomatic side.

71
B. Bradford
Electroacupuncture for patellar tendinopathy
Discussion
The rationale for the use EA in the present
case was influenced both by the growing body
of literature supporting the use of this modal-
ity in promoting beneficial structural change
in pathological tendons (Neal & Longbottom
2012; Speed 2015), and the frequency-­dependent
release of opioid neuropeptide secretion by the
CNS in response to peripheral electrical stimu-
lation (Zhang et al. 2014).
Opioid neuropeptides play an important
role in brain function in relation to pain.
Electroacupuncture can facilitate the release of
these neurotransmitters, which has resulted in a
surge in research into the specific frequencies
necessary for such a phenomenon to occur.
Therefore, the decision to select EA alternat-
ing between frequencies of 2–80 Hz for each
treatment session was guided by the plethora of
recent neurophysiological research suggesting
that low-­frequency EA (2–15 Hz) inhibits the
transmission of noxious stimuli more effectively
than high-­frequency EA, but that high-­frequency
EA (80–100 Hz) is preferable for the release
of greater amounts of opioid secretion in the
CNS (Kuo et al. 2013). Although research has
not been able to establish a “gold standard” in
terms of frequency of EA for optimal levels of
analgesia, the best available evidence suggests
that alternating between frequencies may result
in more-­efficacious inhibition of pain (Zhang
et al. 2014).
The above appears to support the earlier
work of Han (2003) and Lin et al. (2002), who
both concluded that different physiological
mechanisms are responsible for analgesia at
differing frequencies of EA. Through the use
of opioid-­specific antagonists, Han (2003) was
able to conclude that analgesia induced by
low-­frequency EA is modulated by both μ-­and
δ-­opioid receptors, and high-­frequency EA by
κ-­opioid receptors, suggesting that different
opioid neuropeptides are synthesized under
different conditions. In addition, to determine
whether the hypoalgesic response initiated by
stimulation at 2 or 100 Hz was modulated in
the spinal cord by enkephalin and dynorphin,
Han (2003) performed an experiment to cre-
ate a protein complex by binding the opioid
72
neuropeptide to its antibody in order to induce
a loss of its biological function as it approaches
the receptor site. A subsequent injection of an
enkephalin inhibitory substance resulted in a
significant reduction in the hypoalgesic response
initiated at 2 Hz, but this effect diminished as
the frequency was increased to 128 Hz, again
suggesting a supraspinal mechanism of opioid
secretion at higher frequencies.
This is supported by earlier the work of Lin
et al. (2002), who discovered a 61% decrease in
morphine requirement in a group of patients
receiving high-­ frequency EA following bowel
surgery, as compared to a 43% decrease in
the low-­ frequency EA group. These findings
again suggest effective but differing secretion
of enkephalins and dynorphins across the two
frequencies.
The selection of ST35 and Ex-­ LE4 was
guided primarily by their anatomical proximity
to the patellar tendon. This is particularly rel-
evant given that the aim of the treatment was
not only to reduce pain, but also to attempt to
facilitate structural changes in the pathological
ECM by stimulating the local tendon cellular
network. There has been a noticeable increase
in research into the effects of EA on the
structural degeneration of pathological tendons,
and recent high-­quality evidence suggests that,
through a specific action on tenocyte activity,
EA can both upregulate type 1 collagen synthe-
sis and enhance the molecular organization of
the ECM (de Almeida et al. 2012, 2015). Similar
results were reported by Inoue et al. (2015),
who recorded a statistically significant increase
in total cell count and basic fibroblast growth
factor with the use of EA in a ruptured, degen-
erative rat Achilles tendon.
The mechanotransduction molecular mecha-
nism of EA proposed by de Almeida et al.
(2014) stipulates that when the needle is either
inserted into or in close approximation to the
paratendinous sheath of the tendon, then acti-
vation of the cell nuclei occurs via stimulation
of F-­actin fibres within the tendon cytoskeleton.
The frequency and amplitude of this stimulus
then provokes a suitable biological response
from the nucleus, including the synthesis and
reorganization of type 1 collagen fibres. This
© 2017 Acupuncture Association of Chartered Physiotherapists

logic and research was applied during the inser-
tion of the needles, which were introduced
obliquely and upwardly towards the paratendi-
nous sheath at the inferior pole of the patella
to elicit the desired molecular response during
EA treatment.
The treatment time was limited to 10 min for
the first session in order to assess the subject’s
tolerance and monitor for any potential adverse
effects. The decision to increase the treatment
time was influenced by the subject’s positive
response to the initial session, and clinical evi-
dence supporting the efficacy of EA under dif-
fering durations of stimulation. Mori et al. (2014)
produced an interesting piece of research that
concluded that both skin blood flow and muscle
blood volume increased significantly in the EA
group in comparison to baseline. Furthermore,
> 10 min of EA treatment to the rectus femoris
muscle was of sufficient duration to induce a
statistically significant response in intramuscular
blood flow where this was a desired clinical
outcome. Similarly, encouraging evidence was
published by Kimura et al. (2015), who meas-
ured muscle oxygenation of the tibialis anterior
muscle using near-­ infrared spectroscopy after
15 min of EA at 1–20 Hz. These researchers
concluded that there was a statistically significant
increase in muscle oxygenation levels in the
recovery period after 15 min of EA at 20 Hz,
which again suggests that a treatment time of
≥ 15 min is sufficient to induce an increase in
myofascial blood flow. Although the conclu-
sion of both pieces of research was that EA
of > 15 min in duration is sufficient to facilitate
an increase in muscle blood flow/oxygenation,
it could well be possible that the effects of
such an intervention could be extrapolated to
tendinous tissue, particularly when an increase
in blood flow is desirable.
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© 2017 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 75–81

CASE REPORT

Use of acupuncture to treat an academy

football player with ankle impingement
G. Parry
Sports Science and Medicine Department, Birmingham City Football Club,
Birmingham, UK

Abstract
A 15-­ year-­
old male academy football player at a championship club sustained an ankle
impingement injury following a tackle. Acupuncture was selected as an adjunct to a rehabili-
tation programme and conservative measures. The Gall Bladder (GB) 34, GB40, Spleen (SP)
5, SP6, SP9, Stomach (ST) 36, ST41 and Kidney 7 acupoints were used to treat the subject.
A visual analogue scale, the Lower Extremity Functional Scale, and the weight-­bearing lunge
or knee-­ to-­
wall test were used as objective markers. The subject began a graded return
to football training within 30 days after a reduction in pain and a restoration of range of
motion (ROM) were achieved. There is potential for acupuncture to be used as a cost-­
effective adjunct in combination with a rehabilitation exercise programme for the treatment
of ankle impingement to reduce inflammation and pain, and restore active ROM. Western
medical and traditional Chinese medicine rationales are discussed.

Keywords: academy football, acupuncture, ankle impingement, Lower Extremity Functional

Scale.

Introduction the flow of Qi, WMA point selection adopts

Acupuncture has been used to treat a variety of
pathologies for over 3000 years (Lin et al. 2013).
While needling techniques remain broadly the
same, there are two main rationales for its use:
Western medical acupuncture (WMA) and tradi-
tional Chinese medicine (TCM) (Bradnam 2003,
2007). From a TCM perspective, acupuncture
points are located on a network of meridians
that are located longitudinally along the surface
of the skin, allowing the flow and conduction
of a form of energy known as Qi (Suko et al.
2011). While the aim of the TCM approach
is to restore the “yin and yang” balance, and
Correspondence: Gemma Parry MSc, Sports Science and
Medicine Department, Birmingham City Football Club,
300 Redhill, Birmingham B38 9EL, UK (e-­ mail:
dynamicanatomy@googlemail.com).
this approach to modulate the imbalances
between sympathetic and parasympathetic activ-
ity (Lin et al. 2013). By utilizing points within
the area of injury, WMA aims to alter pain
perception in the brain at levels such as the
hypothalamus and descending pain inhibitory
pathways. This induces segmental pain relief
(Lin & Chen 2008; Lin et al. 2013), and also
increases blood circulation locally and opti-
mizes the inflammatory processes (Zijlstra et al.
2003).
The present case study explores both WMA
and TCM approaches to acupuncture during the
treatment of a male academy football player at
a championship club. The subject had suffered
ankle impingement as a result of a traumatic
tackle during a game, and had an extensive his-
tory of ankle sprains. Because of the demands

© 2017 Acupuncture Association of Chartered Physiotherapists 75

Acupuncture for ankle impingement
of the game and the skill required to play it
at this level, youth players run a high risk of
trauma. Ankle injuries account for 10–18%
of incidents (Woods et al. 2003; Ekstrand et al.
2011), predominantly as a result of making or
being on the receiving end of a tackle (Giza
et al. 2003). Waldén et al. (2013) stated that ankle
impingement syndromes comprise 3% of all
ankle injuries. Anecdotally, it has been noted
that footballers continue to play with such
symptoms, and regularly do not refer for treat-
ment unless these are severe, which means that
research into injury management is scarce.
Although infrequent, ankle impingement
injuries occur as a result of forced plantar
flexion, supination and tractions to the anterior
capsule, and forced compression of the pos-
terior ankle (Tol & van Dijk 2006). Following
prolonged torsional joint stresses and repetitive
trauma where bony impingement can occur
between the talus and distal tibia, hypertrophy
of the bone and soft tissues through repeated
fibrosis, fibrocartilage proliferation and poten-
tial osteophyte development can lead to limited
dorsiflexion and altered joint mechanics over
time (Amendola et al. 2012), with accumulation
of scar tissue in the anteriolateral gutter and
around the anterior talofibular ligament (ATFL).
Traditionally, a conservative, non-­ operative
approach to management is advocated, and
surgical intervention is only recommended in
cases where such measures are unsuccessful.
For example, arthroscopic debridement is a
key approach for soft-­ tissue-­
related impinge-
ment because it involves a short period of
recovery and a rapid return to sporting activity
(Vaseenon & Amendola 2012). A search of the
Ovid and PubMed databases yielded no results
regarding the use of acupuncture to treat ankle
impingement syndromes. There is a larger body
of evidence for the use of acupuncture in
ankle sprains, which can be a predisposing and
or contributing factor for the development of
impingement (Anderson et al. 2014).
A systematic review and meta-­ analysis by
Park et al. (2013) determined that, while the
evidence was insufficient for acupuncture use at
the ankle, this was attributed to the small num-
bers of participants involved in the publications
76
available. With regard to the immediate reduc-
tion of pain on a visual analogue scale (VAS),
several high-­ quality primary studies have pro-
posed that acupuncture significantly alleviates
pain in comparison to other forms of manual
therapy. Sun & Ju (2011) also showed that the
use of acupuncture in conjunction with func-
tional exercise reduces the time taken to return
to normal function by 3–4 days, and that it may
be more clinically advantageous than functional
exercise alone. It should be noted that all
authors suggest that acupuncture is a safe form
of treatment for ankle pathology, and while
the methodology of the studies may be poor,
acupuncture can be a statistically significant
adjunct to improve global symptoms of ankle
pain in comparison to stand-­ alone treatments
(Park et al. 2013).
Thickening and fibrosing of the ATFL occur
during ankle sprain and impingement (Anderson
et al. 2014). Thus, it is not unreasonable to sup-
pose that the rationale for the use of acupunc-
ture to treat ankle sprain may also transfer to its
effective application in ankle impingement since
the same soft tissues are affected in a similar
way.
Case report
Social history and background
The present study describes the case of a
15-­year-­old male academy football player at a
championship club. Following a tackle during a
game, the subject’s left foot was maximally plan-
tar flexed and inverted following a strike from
an opponent, and he felt a searing, burning pain
in the anterior aspect of his ankle. Unable to
bear weight, he was immediately removed from
the field of play, where ice, medial and lateral
J-­shaped pads, and Tubigrip (Mölnlycke Health
Care Ltd, Oldham, UK) for compression had
been applied. The subject was placed in an
Aircast boot (DJO Global, Vista, CA, USA)
and provided with two elbow crutches for ease
of ambulation because he recorded his pain as
2/10 on a VAS.
Upon examination 48 h later, the subject
continued to report a pain score of 4/10 on the
VAS on walking, and palpation of the ATFL
© 2017 Acupuncture Association of Chartered Physiotherapists
 G. Parry
and retinaculum. There was swelling over the Outcome measures
lateral, anteromedial and posterior portions of Outcome measures are an important aspect
his left ankle, reduced active range of motion of the management of a patient’s injury, and
(AROM) in all directions, and pain on too much a vital part of patient-­centred care (Abbot &
pressure of the end of range during passive Schmitt 2014). The Lower Extremity Functional
inversion and dorsiflexion. Ankle strength was Scale (LEFS) (Binkley et al. 1999) was selected
also reduced through all ranges and graded because it has proven validity and reliability as
at 3/5 on the Oxford Grading Scale (OGS). an indicator of lower-­limb function in the nor-
Ligamentous stability tests could not be com- mal and sporting populations (Abbot & Schmitt
pleted because of the subject’s apprehension. 2014). A VAS was used to monitor the intensity
His gait was disrupted, and there was no heel-­ of the subject’s pain (Hawker et al. 2011). The
to-­toe pattern and a lack of left-­knee extension. weight-­ bearing lunge or knee-­ to-­
wall test was
He was provided with gentle AROM exercise selected to assess ankle ROM and replication
in all directions, non-­ weight-­bearing gluteal of impingement mechanisms because it has
and core exercises, and also regular ice and proven test-­ related reliability as a dorsiflexion
compression via a Game Ready system (Game measure (Cejudo et al. 2014). At the initial
Ready Global UK Ltd, Redhill, Surrey, UK). A assessment, the subject’s ankle pain was 4/10
diagnosis of ankle sprain was made, and the on the VAS and scored 17/80 on the LEFS,
subject remained in the Aircast boot. which indicates high levels of dysfunction and
Although he could mobilize unaided in disability.
the Aircast boot by day 6 after the injury, the
subject’s symptoms remained in status quo, and Treatment
minimal improvements in pain, ROM and Session 1 (9 days post-­injury). In the first treatment
muscle strength were noted. An ultrasound session, six needles (0.25 × 25 mm) were used
scan was completed by the club doctor that over five points, two distally and four locally.
showed intracapsular swelling and thickening Phoenix metal needles (Phoenix Medical Ltd,
of the surrounding soft tissues, and fluid in the Chelmsford, Essex, UK) used in this and all
anterior retinaculum. Therefore, the subject was subsequent treatments (Table 1). The acupunc-
diagnosed with ankle impingement. ture points were selected in order to reduce
Table 1. Summary of acupuncture treatment sessions: (ROM) range of motion; (GB) Gall Bladder; (SP) Spleen; (KI) Kidney; and (VAS)
visual analogue scale
Needle size Time
Objective Acupuncture points De Qi (mm) (min) Comments
Session 1
Reduce pain, increase active GB34 (bilateral) Yes 0.25 × 25 15 Tingling
ROM at ankle and reduce SP5 (unilateral) Yes 0.25 × 25 15 Heavy ache towards toes
swelling SP6 (unilateral) No 0.25 × 25 15 Pain reduced to 1/10 on VAS
SP9 (unilateral) Yes 0.25 × 25 15
KI7(unilateral) Yes 0.25 × 25 15
Session 2
Full, pain-­free ROM at the GB34 (bilateral) Yes 0.25 × 25 20 De Qi strongest at SP5 and SP6
ankle to reduce swelling GB40 (bilateral) Yes 0.25 × 25 20 Felt very heavy in the leg, dull warm ache
SP5 (unilateral) Yes 0.25 × 25 20 towards toes
SP6 (unilateral) Yes 0.25 × 25 20
Session 3
Full passive and active ROM GB34 (bilateral) Yes 0.25 × 25 20 Warm, tingling sensation at ST36 and ST41
at the ankle to increase GB40 (bilateral) Yes 0.25 × 25 20 Erythema seen at ST36 and ST41
strength and reflect the SP5 (unilateral) No 0.25 × 25 20
patient’s phase of SP6 (unilateral) Yes 0.25 × 25 20
rehabilitation ST36 (unilateral) Yes 0.25 × 25 20
ST41 (unilateral) Yes 0.25 × 25 20

© 2017 Acupuncture Association of Chartered Physiotherapists 77

Acupuncture for ankle impingement
pain and swelling, and increase ankle ROM.
Since Ceccherelli et al. (2014) demonstrated that
there is no significant difference in terms of
therapeutic effect and anti-­nociceptive efficacy
between three and 11 needles, six needles were
employed because this was what the subject
could comfortably tolerate. Bilateral needling of
Gall Bladder (GB) 34 was selected: from a TCM
perspective, this is one of the most significant
points for the alleviation of stagnation and re-­
regulation of Qi; and from a WMA standpoint,
it is crucial to the treatment of musculoskeletal
soft-­tissue pathology, and also strengthens and
relaxes the subject via analgesic modulation of
sympathetic activity (Zhang et al. 2009). The
Spleen meridian was selected because of the
overuse and overstrain nature of an impinge-
ment injury, which is likely to be attributed to
Qi deficiencies, and weakness in the sinews and
soft tissues. This leaves the subject prone to
Wind, Cold and Damp invasion, and subsequent
Zang Fu disharmony (Young 2005). Spleen (SP)
5, SP6 and SP9 were selected because of the
segmental effects of peroneal nerve afferent
impulse generation, which provides analgesic
relief along the L4–5 dermatomes. These points
are recommended for the alleviation of pain,
weakness and atrophy in the ankle and foot
(Jarmey & Bouratinos 2008). Finally, Kidney 7
was selected because of its purported efficacy in
moving oedema and interstitial fluids (Jun et al.
2000). Needles were inserted for 15 min and
manipulated every 5 min in order to promote a
local inflammatory healing response (Zhou et al.
2012).
Session 2 (15 days post-­injury). The subject was able
to mobilize without the Aircast boot 6 days after
the first treatment session. However, he was still
experiencing pain on twisting movements, and
graded this at 2/10 on the VAS. Palpation of
the retinaculum continued to elicit a pain score
of 2/10 on the VAS. Full AROM had returned,
with the exception of dorsiflexion, which was
restricted to three-­ quarters range. The results
of the knee-­to-­wall test had increased by 2 cm.
Swelling was greatly reduced all around the area,
with only a small pocket of oedema remaining
at the anterolateral gutter.
78
Because of these results, the previously
selected points were utilized again, but the
length of the needle insertion was increased
to 20 min, with manipulation every 5 min. The
purpose of the second treatment session was
to eliminate the last of the swelling and further
increase AROM. The focus was on manipulation
of the local needles to stimulate β-­endorphin
release and achieve a local, short-­term analgesic
segmentation effect. The insertion and manipu-
lation of needles during acupuncture induces
changes in the perforated tissue near the site of
penetration. It has been proposed that stimula-
tion of the Αδ and C-­fibres creates vasodilative
effects and calcitonin peptide release. This small
dose is important because of the potential anti-­
inflammatory actions (Zijlstra et al. 2003) and
subsequent improvement in tissue function.
In addition, from a WMA perspective, GB40
was added as a local point to optimize the
subject’s perception of pain around the ankle
area via the effect on the cortex (Xue et al.
2011). From a TCM standpoint, the inclusion
of GB40 contributed to the “eyes” of the
ankle “surrounding the dragon”, which clears
Dampness and promotes Qi within the Gall
Bladder channel (Jarmey & Bouratinos 2008).
Strong De Qi responses were noted.
Session 3 (17 days post-­injury). On examination
2 days later, the subject denied having any pain,
and reported a VAS score of 0/10 and full
AROM at the ankle. His muscle power had
increased to +4/5 on the OGS, and the result
of the knee-­to-­wall test had increased to 3 cm.
Because of the strong De Qi response in previ-
ous treatment sessions, the subsequent changes
in parasympathetic activity, adaptive changes
in responsiveness to neurotransmitters and
alleviation of the autonomic response (Lin et al.
2013) potentially contributed to the reduction in
pain and restoration of ROM. Because of this
improvement in function, the previous points
were selected again, and Stomach (ST) 36 and
ST41 were also added to optimize and reflect
the current phase of the subject’s rehabilitation.
Stomach 41 is located at the anterior aspect of
the ankle, at the junction of the dorsal foot and
leg, and is considered to be very important for
© 2017 Acupuncture Association of Chartered Physiotherapists

vertical alignment and strongly associated with
lower-­limb strengthening (Jarmey & Bouratinos
2008). Zhou et al. (2012) demonstrated that
unilateral use of manual acupuncture at ST36
improved muscle strength throughout the lower-­
limb dorsiflexors. After this treatment session,
the subject experienced no pain on palpation
of the ankle, and the result of the knee-­to-­wall
test had increased to 3.5 cm, which was almost
equal to the unaffected side. The LEFS score
had also increased to 73/80, clearly demonstrat-
ing the improvements in disability and function.
Discussion
Despite the severity of the symptoms caused
by ankle impingement, management of this
condition is only sparsely documented within
the research literature, and there is no “gold
standard” protocol; conservative treatment is
favoured over surgical management by clinicians
in all cases.
Over the 8-­day period in which the three acu-
puncture sessions described in the present study
were conducted, it appears that the subject’s level
of pain score reduced significantly from 4/10 to
0/10 on the VAS. Furthermore, his ankle ROM
and strength were restored, and there were
improvements in function. The subject’s reported
reduction in pain was similar to that reported
in a Chinese study by He & Xu (2006, cited by
Park et al. 2013), who found an immediate reduc-
tion in ankle pain after treatment, during further
sessions and at 2-­year follow-­up.
The outcome measures selected for the pre-
sent study may represent limitations. Although
the LEFS is a validated measure of both pain
and function, the VAS, while widely used in
clinical practice, is restricted to subjective inter-
pretation. Research by Boonstra et al. (2008) sug-
gested that those who report moderate levels of
musculoskeletal pain underestimate its impact
on function. This question of validity was also
supported by more recent work by Bailey et al.
(2014) involving children of a similar age to the
present subject. Range of motion was measured
before and after the present treatment using a
goniometer and improvements in this outcome
measure were reinforced by the functional
© 2017 Acupuncture Association of Chartered Physiotherapists
G. Parry
knee-­to-­wall test, which has previously been
used as a reliable and valid method of moni-
toring ankle dorsiflexion in sporting contexts
(Cejudo et al. 2014).
Muscle strength was recorded using the
clinician-­subjective OGS. To increase reliability,
this could have been determined in a more
standardized way. Electromyography was suc-
cessfully used by Costa & de Araujo (2008) and
Hübscher et al. (2010) to measure increases in
dorsiflexion strength following acupuncture
treatment. However, time and equipment
restraints meant that this was not suitable in the
context of the present study.
While the restoration of the subject’s function
may be attributable to normal healing pattern
times, and the rehabilitation exercise programme
undertaken at the football club, acupuncture
played an important role as an adjunct treatment.
This was especially the case during the first
week of rehabilitation, which focused only on a
PRICE [Protection, Rest, Ice, Compression and
Elevation] regime and muscle activation via non-­
weight-­bearing gentle AROM because of the
inflammation and pain restrictions. These non-­
analgesic effects may have been explained by the
work of Helene Langevin (Langevin et al. 2006;
Langevin 2013), who suggested that the utiliza-
tion of local acupuncture points (as selected
in the present study) creates “skin tenting” or
mechanical connection to the needle of the
connective tissues. This cellular mechanotrans-
duction, or the conversion of mechanical signals
to biomechanical responses by cells, along with
cross-­sectional reorganization of fibroblasts,
optimizes cytoskeleton reorganization. Such a
process could account for the improvement in
the present subject’s thickened and scarred soft
tissues, and subsequent increase in ROM.
The healing and analgesic effects of acupunc-
ture are well addressed in the literature, and its
enhancement of athletic performance is becom-
ing a more prominent subject of research.
Athletes are highly susceptible to “overuse
injuries” such as ankle impingement, even from
an early age, and fatigue and weakness of the
skeletal muscles are often identified as contribu-
tory factors. Muscle fatigue has been linked to
a drop in carnitine levels. Research by Toda
79
Acupuncture for ankle impingement
(2012) demonstrated that acupuncture increases
carnitine levels within muscle tissue, potentially
counteracting muscle fatigue, and may account
for the improved strength and performance
experiences by the present subject after the
final acupuncture session. Although beyond the
realms of this case study, further research into
the effects of acupuncture on muscular fatigue
in relation to overuse injuries may be an impor-
tant avenue of investigation.
Calder et al. (2009) proposed that athletes
with ankle impingement injuries are able to
return to training and then full sporting activi-
ties at 34 days and within 41 days, respectively.
The present subject resumed training at 30 days
and was available for selection at 35 days. This
suggests that acupuncture is a useful adjunc-
tive treatment that can return players to match
fitness in a shorter time frame than previously
documented. This is a similar result to that
reported by Sun & Ju (2011), who demon-
strated that electroacupuncture (EA) in addition
to functional exercise reduces the time taken to
return to function by 3–4 days. While EA was
not selected in the present study because of the
subject’s age and concerns regarding consent, it
could be utilized in future work as an alternative
approach to treatment.
Conclusion
Over the 8 days of treatment, it appears that
acupuncture in combination with a rehabilitation
exercise programme for the treatment of ankle
impingement had a good effect on reducing
inflammation and pain, and restoring AROM.
The evidence suggests that both WMA and
TCM approaches to segmental, peripheral and
local effects alleviate pain via analgesic effects,
and improve cytoskeleton reorganization through
optimization of fibroblast cellular response. To
develop and support these uses further, random-
ized controlled trials of the physiological and
performance rationales need to be conducted.
Acknowledgements
I would like to thank all the staff and players at
Birmingham City Football Club for their guid-
ance and input throughout this process.
80
Conflicts of interest
No conflicts of interest influenced the imple-
mentation and conduct of the study, or the
publication of this article.
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81
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 83–89

CASE REPORT

Acupuncture as an adjunct to standard

physiotherapy in the management of adhesive
capsulitis
L. Bennett
Private Practice, London, UK

Abstract
This case study documents the use of acupuncture in the treatment of a 53-­year-­old female
with adhesive capsulitis of the right shoulder. It also emphasizes the role of acupuncture
as an adjunct to physiotherapy treatment in this condition. The outcome measures used
included the Numeric Pain Rating Scale, the Constant–Murley Assessment (CMA), and
active and passive range of motion (ROM). The subject was initially treated with conserva-
tive physiotherapy modalities for four sessions before acupuncture was delivered. The Triple
Energizer 14, Large Intestine (LI) 15 and LI4, Stomach 38, Gall Bladder 34, and Small
Intestine (SI) 9 and SI12 acupuncture points were used. After six sessions of acupunc-
ture, the woman’s pain had reduced, the CMA score had increased and shoulder ROM had
improved greatly. Acupuncture is an effective treatment for adhesive capsulitis, and it may be
used as an adjunct to standard physiotherapy treatment.
Keywords: acupuncture, adhesive capsulitis, frozen shoulder.

Introduction be worse at night. Commonly referred to

Adhesive capsulitis, also known as frozen shoul-
der, is a common condition that is characterized
by gradual onset of pain within the shoulder,
and restriction of active and passive gleno-
humeral range of motion (ROM). Typically, the
condition restricts ROM by less than 25% in
at least two directions, particularly in shoulder
abduction and external rotation (Kelley et al.
2009). Current literature indicates that adhesive
capsulitis progresses through three overlapping
phases (Jewell et al. 2009):
(1) 2–9  months: Progressive stiffening and
reduced ROM in the shoulder joint with
increasing pain on movement, which may
Correspondence: Ms Louisa Bennett, Oxford Circus
Physiotherapy, 33 Great Titchfield Street, London
W1W 7PA, UK (e-­ mail: louisa.bennett@hotmail.
co.uk).
as the freezing or painful phase.
(2) 4–12  months: Gradual decrease in pain, but
stiffness remains and there is a consider-
able restriction in shoulder ROM. Usually
known as the frozen phase.
(3) 12–42  months: Improvement in shoulder
ROM. Known as the thawing or resolution
phase.
Adhesive capsulitis is more prevalent in women
and those aged 40–65 years (Walmsley et al.
2009), and occurs in approximately 2–5% of
the general population (Gaspar & Willis 2009).
Research has found that associated risk factors
for this condition include diabetes, trauma, pro-
longed immobilization, thyroid disease, stroke,
myocardial infraction and autoimmune disease
(Bal et al. 2008).
Although there are different views about
the pathophysiology of adhesive capsulitis,

© 2017 Acupuncture Association of Chartered Physiotherapists 83

Management of adhesive capsulitis
there are certain consistent findings that have
been identified and appear to be specific to its
pathology. Bunker (2009) reported that there
is a significant increase of fibroblasts, which
lay down scar tissue and myofibroblasts, in the
fibrous capsule surrounding the glenohumeral
joint, which results in reduced joint volume,
and consequently, restricts shoulder ROM. In
addition, pathological studies have identified
the presence of inflammatory cells, mast cells,
T-­cells, B-­ cells and macrophages, which sug-
gests that a process of inflammation leads to
scarring (Hand et al. 2007). Adhesive capsulitis
is a self-­limiting condition, and while it can take
up to 2–3 years for the symptoms to resolve,
some patients may never fully regain full ROM
(Blanchard et al. 2010). Consequently, it is
imperative for patients to undergo treatment
for pain, reduced ROM and loss of function in
place of the wait-­and-­see approach.
Several treatments for adhesive capsulitis have
been tried, including analgesia, manual therapy,
corticosteroid injection, exercises, acupuncture
and surgery. A review by Cleland & Durall
(2002) suggested that many patients diagnosed
with adhesive capsulitis benefit from physio-
therapy, and show a reduction in symptoms
and an increase in ROM, and/or functional
improvement. On the other hand, a Cochrane
Review by Green et al. (2003, p. 2) concluded
that there is “no evidence that physiotherapy
alone is of benefit for adhesive capsulitis”. A
recent Cochrane Review by Page et al. (2014)
concluded that no one treatment has been
proved to be unrivalled, and that higher-quality
randomized controlled trials (RCTs) are required.
Regardless of the vast amount of research, the
lack of validity, and poor standardization of ter-
minology, methodology and outcome measures
of the studies weakens the clinical application
of the results (Cleland & Durall 2002). For
that reason, there is a need for further RCTs
comparing different treatments so that defini-
tive guidelines for the treatment of adhesive
capsulitis can be formulated (Brue et al. 2007).
It has been argued that the primary treatment
for this condition should be based on physio-
therapy and anti-­ inflammatory methods (Brue
et al. 2007). Nevertheless, these outcomes are
84
not always greater than those achieved by other
treatments (Kelley et al. 2009).
Case report
Background
A 53-­ year-­
old female presented to a private
physiotherapy clinic with pain and restricted
movement in her right shoulder. Her symptoms
were intermittent and aggravated by shoulder
movement. No yellow or red flags were identi-
fied. The patient was systemically well, but her
past medical history included hypothyroidism,
which was being treated by levothyroxine.
Clinical examination
The present subject’s pain was localized to her
right shoulder, and she described it as a dull
ache that was worsened with shoulder move-
ment. She reported that her symptoms eased
with rest and ibuprofen. Her pain had begun
6 months ago with a gradual onset and no spe-
cific cause. The subject’s pain score was 8/10 on
the Numeric Pain Rating Scale (NRPS) (Downie
et al. 1978), and she stated that her stiffness was
worsening. On examination, active and passive
ROM was reduced globally in the right shoul-
der, particularly on abduction, and external and
internal rotation, as shown in Table 1.
Based on the subjective history and clinical
findings, a diagnosis of adhesive capsulitis was
made.
Treatment
Prior to acupuncture, the subject had under-
gone four treatment sessions that had included
a supervised exercise regimen. A Cochrane
Review by Green et al. (2005) reported that
such a routine is beneficial for mixed shoulder
disorders in both the short and long term. The
Table  1. Active and passive range of motion (ROM) at the
initial consultation: (N/A) not applicable
Variable Active ROM Passive ROM
Forward flexion 100 105
Abduction  90  95
Lateral rotation  10  20
Internal rotation Lumbosacral junction N/A
© 2017 Acupuncture Association of Chartered Physiotherapists

home exercise programme included a pendulum
exercise, passive supine forward elevation, pas-
sive external rotation, and active assisted ROM
in shoulder extension, abduction and internal
rotation. The exercises were selected because
a study by Kelley et al. (2009) found that these
were effective in treating adhesive capsulitis. The
subject was advised to complete the exercises
within her pain limits so as to avoid exacerbat-
ing the pain (NZGG 2004), and to ensure that
adequate analgesia was taken so that she would
be able to tolerate the movements. She was also
advised to avoid movements that aggravated the
pain, such as overhead movements and vigorous
stretching, but to continue her regular ROM.
The subject received grade III posterior
glenohumeral glides at each session to help
improve ROM and alleviate pain. Vermeulen
et al. (2006) stated that high-­grade mobilization
techniques are found to be helpful in improving
shoulder ROM in patients who have suffered
from adhesive capsulitis for at least 3 months.
After the four physiotherapy sessions, the
subject reported feeling a slight reduction in
pain (NRPS score = 7/10). On examination,
she now had slightly improved ROM.
Acupuncture treatment
Before acupuncture treatment began, con-
traindications were eliminated and precautions
were taken, the potential effects of treatment
were made clear to the subject, and she was
also briefed about the possible side effects of
acupuncture and adverse reactions to treatment.
De Qi, a sensation experienced during needle
stimulation, is commonly described as a sore,
numb, distended, heavy, electric and warm feel-
ing (Zhu et al. 2013). The Aδ and C-­fibres in the
tendinomuscular layers appear to be involved
in the pricking, dull and pressing sensations
experienced (Beissner et al. 2010). The subject
signed an acupuncture consent form once all
the relevant information had been provided,
and she believed that she was able to make an
informed decision.
The 30-­min treatment sessions occurred on a
weekly basis, and the needles were left in place
for 20 min and stimulated every 5–10 min.
© 2017 Acupuncture Association of Chartered Physiotherapists
L. Bennett
The point selection and treatment dose can be
viewed in Table 2.
The aim of the acupuncture treatment
was to induce a pain-­relieving response at the
local, segmental and central levels. Locally, the
insertion of needles into soft tissue causes a
microinjury; this results in a local inflammatory
response that enhances local microcirculation by
increasing the diameter and blood flow velocity
of peripheral arterioles (Komori et al. 2009).
Kim et al. (2008) also reported that acupuncture
reduces inflammation by promoting the release
of vascular and immunomodulatory factors.
Needle insertion and manipulation also stim-
ulates the Aδ fibres in the skin, and type 2 and
3 muscle fibres (White et al. 2008). This stimulus
travels to the dorsal horn in the spinal cord,
and activates the intermediate cells to produce
enkephalin, which blocks nociceptive input from
C-­fibres at that spinal segment (Hans 2011).
Continuing up from the spinal cord, the signal
is transmitted to the brain, activating the two
descending pathways. The first pathway releases
serotonin at the dorsal horn, which stimulates
intermediate cells to release met-­ enkephalin,
thereby adding to the inhibition of pain. The
second pathway releases noradrenalin through-
out the dorsal horn at every segmental level,
resulting in direct inhibition of post-­ synaptic
cell membrane transmission (White et al. 2008).
Rationale for point selection
Triple Energizer 14 and Large Intestine 15
were chosen for local effects because these
were located close to the subject’s problem-
atic area, and when both are combined these
points form the “Eyes of the Shoulder”. Large
Intestine 4 was prescribed bilaterally for its
strong pain-­alleviating and relaxation effects.
Traditional Chinese medicine (TCM) considers
this to be one of the master points for pain,
and it has been suggested that stimulation of
the distal point activates supraspinal mecha-
nisms, inducing descending pain inhibition from
the hypothalamus and the release of natural
opioids, such as β-­endorphins and enkephalins
(Bradnam 2003, 2007). Stomach (ST) 38 is
recommended for adhesive capsulitis by TCM,
85
Management of adhesive capsulitis
Table  2. Acupuncture treatment: (TE) Triple Energizer; (LI) Large Intestine; (ST) Stomach; (GB) Gall Bladder; (SI) Small Intestine;
(T + T) twist and twirl; (L + T) lift and thrust; (ROM) range of motion; and (NPRS) Numeric Pain Rating Scale

Acuuncture Size and angle of Needling

points needle technique Treatment response

Session 1
TE14 40 mm, oblique T + T Mild lightheadedness and relaxation felt after treatment
LI15 40 mm, oblique T + T Strong De Qi felt at all points
LI4 (bilateral) 30 mm, perpendicular T + T No adverse effects reported
Session 2
TE14 40 mm, oblique T + T Pain reduced for 3 days, then returned to how it was
LI15 40 mm, oblique T + T Strong De Qi felt at all points
LI4 (bilateral) 30 mm, perpendicular T + T No adverse effects reported
ST38 40 mm, perpendicular L + T, T + T
Session 3
TE14 40 mm, oblique T + T Pain reduced for 4 days, then returned to how it was
LI15 40 mm, oblique T + T Improved shoulder ROM
LI4 (bilateral) 30 mm, perpendicular T + T Strong De Qi felt at all points
ST38 40 mm, perpendicular L + T, T + T No adverse effects reported
GB34 40 mm, perpendicular L + T, T + T
Session 4
TE14 40 mm, oblique T + T Pain reduced since last appointment, NPRS score = 6/10
LI15 40 mm, oblique T + T Improved shoulder ROM
LI4 (bilateral) 30 mm, perpendicular T + T Strong De Qi felt at all points
ST38 40 mm, perpendicular L + T, T + T No adverse effects reported
GB34 40 mm, perpendicular L + T, T + T
SI12 30 mm, oblique T + T
Session 5
TE14 40 mm, oblique T + T Improved shoulder ROM
LI15 40 mm, oblique T + T Strong De Qi felt at all points
LI4 (bilateral) 30 mm, perpendicular T + T No adverse effects reported
ST38 40 mm, perpendicular L + T, T + T
GB34 40 mm, perpendicular L + T, T + T
SI12 30 mm, oblique T + T
SI9 40 mm, perpendicular T + T
Session 6
TE14 40 mm, oblique T + T Improved shoulder ROM
LI15 40 mm, oblique T + T Pain reduced, NPRS score = 5/10
LI4 (bilateral) 30 mm, perpendicular T + T Strong De Qi felt at all points
ST38 40 mm, perpendicular L + T, T + T No adverse effects reported
GB34 40 mm, perpendicular L + T, T + T
SI12 30 mm, oblique T + T
SI9 40 mm, perpendicular T + T

and research has found that it is more effective
in improving shoulder function and alleviating
shoulder pain when combined with physiother-
apy than physiotherapy alone (Vas et al. 2008).
Gall Bladder (GB) 34 was selected because
of its role in TCM, in which it is considered
to be influential on muscle and tendons, and a
strong relaxation point. A further justification
is that, in TCM, GB34 has a reputation for its
soothing and moistening effect, and since the
subject’s capsule was contracted, this action
was considered to be an important part of
healing the disorder. Small Intestine (SI) 9 and
SI12 were added to increase local effect, and
in addition, the Small Intestine meridian passes
through the shoulder area.
Outcome measures
The Constant–Murley Assessment (CMA) was
used to assess functional performance. The
CMA score is a reliable and valid instrument
for assessing overall shoulder function, and has

86 © 2017 Acupuncture Association of Chartered Physiotherapists


Table 3. Outcome measures
Outcome measure Initial session
Active forward flexion 100
Passive forward flexion 105
Active abduction  90
Passive abduction  95
Active lateral rotation  10
Passive lateral rotation  20
Active internal rotation Lumbosacral junction
low inter-­rater and intra-­rater error rates (Kemp
et al. 2012). It is a 100-­point scale that is com-
posed of four domains: pain, activities of daily
living, ROM and power. At the initial assess-
ment, a CMA score of 59 was recorded. After
the conservative treatment, the CMA score was
68, and at the final acupuncture session, a score
of 86 was reported.
The NPRS was used to assess the severity
of the subject’s shoulder pain before and after
each treatment session. The NPRS score was
reported as 8/10 at the initial assessment, 7/10
after standard physiotherapy treatment and 5/10
at the final acupuncture session.
Active and passive ROM of the shoulder was
measured using a standard goniometer before
and after each treatment. Global ROM had
improved throughout treatment, and the results
can be viewed in Table 3.
Discussion
The present subject responded very well to the
acupuncture treatment that she received. The
acupuncture point selection was logical and
aimed at resolving the complaints expressed
by her. Employing a conservative treatment
approach did bring about some short-­ term
relief; however, using acupuncture as an adjunct
to this treatment meant that the desired effects
lasted for longer.
Research has found acupuncture to be an
effective treatment for adhesive capsulitis when
combined with standard Western approaches. A
randomized, double-­blind, placebo-­controlled
trial by Sun et al. (2001) explored the use of
acupuncture in patients with adhesive capsulitis.
Thirty-­ five participants were randomly allo-
cated to an exercise group or an exercise plus
© 2017 Acupuncture Association of Chartered Physiotherapists
L. Bennett
After conservative treatment Final acupuncture session
110 150
115 160
110 160
115 170
 15  35
 25  45
Waist (L3) Interscapular (T7)
acupuncture group and treated for 6 weeks.
Compared with the exercise group, the exercise
plus acupuncture group experienced significantly
greater improvements with regard to pain, func-
tional mobility and power.
Ma et al. (2006) conducted a study that inves-
tigated the clinical effects of physiotherapy and
acupuncture for adhesive capsulitis. Participants
were randomly allocated to a physiotherapy
group, an acupuncture treatment group or
a physiotherapy plus acupuncture treatment
group. The study showed that all groups expe-
rienced improved quality of life, but pain was
better controlled with acupuncture although
ROM improved following physiotherapy. Ma
et al. (2006) concluded that a combination of
physiotherapy and acupuncture is the most
effective form of treatment.
A double-­blinded RCT conducted by Cheing
et al. (2008) compared the addition of electro­
acupuncture or interferential electrotherapy
to shoulder exercise. The authors found that
both intervention groups experienced a greater
improvement than those who received no inter-
vention, and the effect lasted until the 6-­month
follow-­up.
On the other hand, an n-­of-­1 study by
Longbottom & Green (2009) assessed the
effects of acupuncture at a single point, ST38,
compared to exercise alone on shoulder ROM,
pain and disability in four patients with adhesive
capsulitis. The results were inconclusive, and
offered only limited evidence of the efficacy
of ST38 for improving pain, stiffness and func-
tional impairment in patients suffering from
adhesive capsulitis.
A Cochrane Review including nine RCTs
assessed the current evidence for acupuncture
in the treatment of adhesive capsulitis and other
87
Management of adhesive capsulitis
causes of shoulder pain (Green et al. 2005). The
authors concluded that, because of the small
number of clinical and methodologically diverse
trials, there is little evidence to support or dis-
prove the use of acupuncture for shoulder pain,
although there may be a short-­term benefit with
respect to pain and function.
Limitations
It is important to be aware of the limitations
of the present case study. Acupuncture was
added as an adjunct at a later stage of the reha-
bilitation, and therefore, it is hard to determine
whether exercise, acupuncture or natural recov-
ery was responsible for the improved outcomes.
Because of the nature of the private setting,
the subject was not seen on a weekly basis
for follow-­up appointments. Weekly follow-­up
appointments would have allowed closer moni-
toring of her progress. Therefore, more-­regular
patient follow-­up appointments and the use of
acupuncture alone might have strengthened the
quality of this case study.
Future research
Further research in the form of RCTs is needed
to identify the full benefits of acupuncture in
the treatment of adhesive capsulitis, and sup-
port the wider use of the modality in this group
of patients. Current research into the efficacy
of acupuncture as a treatment for adhesive
capsulitis is limited because it is impossible
to blind the acupuncturist, and therefore, this
creates bias and reduces the reliability of the
study. It was further limited as a result of the
difficulties in the use of appropriate controls,
such as placebo and sham acupuncture groups.
In addition, as mentioned above, there is also a
requirement for further research into develop-
ing treatment guidelines for adhesive capsulitis.
Conclusion
In the presence of adhesive capsulitis, acupunc-
ture could be a suitable adjunct to physiother-
apy treatment including exercise. Acupuncture
should be considered for patients who have
been diagnosed with adhesive capsulitis.
88
References
Bal A., Eksioglu E., Gulec B., et al. (2008) Effectiveness
of corticosteroid injection in adhesive capsulitis. Clinical
Rehabilitation 22 (6), 503–512.
Beissner F., Brandau A., Henke C., et al. (2010) Quick dis-
crimination of Adelta and C fiber mediated pain based
on three verbal descriptors. PLoS ONE 5 (9): e12944.
DOI: 10.1371/journal.pone.0012944.
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tiveness of corticosteroid injections compared with
physiotherapeutic interventions for adhesive capsulitis:
a systematic review. Physiotherapy 96 (2), 95–107.
Bradnam L. (2003) A proposed clinical reasoning model
for western acupuncture. New Zealand Journal of
Physiotherapy 31 (1), 40–45.
Bradnam L. (2007) A proposed clinical reasoning model
for Western acupuncture. Journal of the Acupuncture
Association of Chartered Physiotherapists 2007 (January),
21–30.
Brue S., Valentin A., Forssblad M., et al. (2007) Idiopathic
adhesive capsulitis of the shoulder: a review. Knee Surgery,
Sports Traumatology, Arthroscopy 15, (8), 1048–1054.
Bunker T. (2009) Time for a new name for frozen shoulder – 
contracture of the shoulder. Shoulder and Elbow 1 (1),
4–9.
Cheing G. L. Y., So E. M. L. & Chao C. Y. L. (2008)
Effectiveness of electroacupuncture and interferential
electrotherapy in the management of frozen shoulder.
Journal of Rehabilitation Medicine 40 (3), 166–170.
Cleland J. & Durall C. J. (2002) Physical therapy for
adhesive capsulitis: systematic review. Physiotherapy 88
(8), 450–457.
Downie W. W., Leatham P. A., Rhind V. M., et al. (1978)
Studies with pain rating scales. Annals of the Rheumatic
Diseases 37 (4), 378–381.
Gaspar P. D. & Willis F. B. (2009) Adhesive capsu-
litis and dynamic splinting: a controlled, cohort
study. BMC Musculoskeletal Disorders 10: 111. DOI:
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Green S., Buchbinder R. & Hetrick S. E. (2003)
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for shoulder pain. Cochrane Database of Systematic Reviews,
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of Bone and Joint Surgery 89 (7), 928–932.
Hans J. S. (2011) Acupuncture analgesia: areas of con-
sensus and controversy. Pain 152 (3, Suppl.), S41–S48.
Jewell D. V., Riddle D. L. & Thacker L. R. (2009)
Interventions associated with an increased or decreased
likelihood of pain reduction and improved function in
patients with adhesive capsulitis: a retrospective cohort
study. Physical Therapy 89 (5), 419–429.
© 2017 Acupuncture Association of Chartered Physiotherapists

Kelley M. J., McClure P. W. & Leggin B. G. (2009) Frozen
shoulder: evidence and a proposed model guiding
rehabilitation. Journal of Orthopaedic and Sports Physical
Therapy 39 (2), 135–148.
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An evaluation of the responsiveness and discriminant
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ity. The Scientific World Journal 2012: 410125. DOI:
10.1100/2012/410125.
Kim H.-­ W., Uh D.-­ K., Yoon S.-­ Y., et al. (2008) Low-­
frequency electroacupuncture suppresses carrageenan-­
induced paw inflammation in mice via sympathetic
post-­ganglionic neurons, while high-­frequency EA sup-
pression is mediated by the sympathoadrenal medullary
axis. Brain Research Bulletin 75 (5), 698–705.
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635–640.
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point acupuncture to Stomach 38 (Tiaokou) on pain
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clinical effects of physical therapy and acupuncture to
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New Zealand Guidelines Group (NZGG) (2004) The
Diagnosis and Management of Soft Tissue Shoulder Injuries
and Related Disorders. [WWW document.] URL http://
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partes%20blandas%20hombro%20NZG%202004.pdf
Page M. J., Green S., Kramer S., et al. (2014) Manual
therapy and exercise for adhesive capsulitis (frozen
shoulder). Cochrane Database of Systematic Reviews, Issue
© 2017 Acupuncture Association of Chartered Physiotherapists
L. Bennett
8. Art. No.: CD011275. DOI: 10.1002/14651858.
CD011275.
Sun K. O., Chan K. C., Lo S. L. & Fong D. Y. T. (2001)
Acupuncture for frozen shoulder. Hong Kong Medical
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Vas J., Ortega C., Olmo V., et al. (2008) Single-­ point
acupuncture and physiotherapy for the treatment of
painful shoulder: a multicentre randomized controlled
trial. Rheumatology 47 (6), 887–893.
Vermeulen H. M., Rozing P. M., Obermann W. R., le
Cessie S. & Vliet Vieland T. P. M. (2006) Comparison
of high-­grade and low-­grade mobilization techniques
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der: randomized controlled trial. Physical Therapy 86 (3),
355–368.
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Adhesive capsulitis: establishing consensus on clini-
cal identifiers for stage 1 using the Delphi technique.
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Introduction to Western Medical Acupuncture. Churchill
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De-­qi: from characterization to underlying mechanism.
Evidence-­Based Complementary and Alternative Medicine
2013: 518784. DOI: 10.1155/2013/518784.
Louisa Bennett works at Oxford Circus Physiotherapy
in London. She trained at the University of the West
of England in Bristol, and qualified as a physio­
therapist in 2014. Since graduating, Louisa has worked
in various private practices, and treated an array of
clientele with musculoskeletal conditions. She regularly
uses acupuncture as part of her clinical practice, and
has developed a further interest in shoulder injuries.
89
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 91–93

CASE REPORT

Myofascial pain masquerading as neuropathic

pain
C. Waldock
Private Practice, Rainham, and Medway School of Pharmacy, The Universities of
Greenwich and Kent at Medway, Chatham, Kent, UK

Abstract
This study describes the successful treatment of a case of suspected neuropathic pain. Dry
needling resolved the patient’s symptoms and led to a reduction in his medication load. This
case highlights the value of a comprehensive musculoskeletal assessment, and the need to
be aware of myofascial referral patterns and how these can mimic neuropathic symptoms.
Keywords: dry needling, myofascial pain, neuropathic pain.

Introduction 8 August 2016. The patient reported a history

The purpose of the present case report is to
demonstrate how easily myofascial pain can mas-
querade as neuropathic pain, which can lead to
the prescription of neuroleptic medication and
associated forms of analgesia. As an independ-
ent prescriber, the present author is cognizant
of the drugs that are available for the treatment
of musculoskeletal (MSK) pain. He can recom-
mend and/or prescribe medication or dosage
change, as appropriate, in the best interests of
his patients. The author has also specialized in
MSK physiotherapy for over 20 years, and uses
dry needling to treat myofascial pain. He has
found these two skills to be complementary.
Case report
Background
The present subject was a 54-­ year-­
old man
who first presented at the author’s clinic on
Correspondence: Colin Waldock, Associate Lecturer,
Medway School of Pharmacy, The Universities of
Greenwich and Kent at Medway, Anson Building,
Central Avenue, Chatham Maritime, Chatham, Kent
ME4 4TB, UK (e-­mail: C.waldock-­551@kent.ac.uk).
of left-­sided facial pain that had begun on 15
July 2016. This was associated with altered sen-
sation in his left arm and hand. The pain had
had a sudden onset in the absence of trauma.
Because of concerns that his symptoms might
have a possible cardiac origin, the subject was
seen in the accident and emergency department
of a hospital close to his place of employment
in London, UK (Cooper et al. 2010). The find-
ings of the examination suggested that he was
not suffering from a cardiac event. He was
subsequently seen by his general practitioner
and referred for physiotherapy assessment.
There was no serious medical history of note.
However, the fact that he had suffered from
left-­sided neck and shoulder pain approximately
2 years previously, and had not received physio-
therapy treatment, was of possible significance.
The subject reported that he had been pre-
scribed two, 300-­mg tabs of gabapentin three
times a day to relieve his neuropathic symptoms
(i.e. the altered sensation), and also 8/500 mg
of co-­ codamol and Nurofen Plus [Reckitt
Benckiser Healthcare (UK) Ltd, Slough, UK] as
additional pain relief medication. Nurofen Plus
is an over-­the-­counter medication that combines

© 2017 Acupuncture Association of Chartered Physiotherapists 91

Myofascial pain masquerading as neuropathic pain
200 mg of ibuprofen and 12.8 mg of codeine
(eMC 2015). He reported that he had no aller-
gies and was not taking any other medication,
but was suffering from slight constipation.
Constipation is a common side effect of non-­
opioid analgesics and gabapentin, and therefore,
this issue may well have been related to his
current medication (eMC 2017).
Gabapentin is recommended as a first-­ line
pharmacological option in the presence of
signs of neuropathic pain (NICE 2013), which
can be treated with medications used to allevi-
ate mild-­ to-­
moderate pain such as codeine
phosphate, paracetamol and non-­steroidal anti-­
inflammatory drugs (NICE 2015). Gabapentin’s
mode of action is via the inhibition of calcium
currents, and subsequently, excitatory activity at
the dorsal horn (Kremer et al. 2016).
The physical examination revealed that the
subject’s neck and shoulders had a normal range
of motion (ROM). No abnormalities were
detected during the neurological examination,
which included testing his reflexes, myotomes,
and sensitivity to light touch and vibration.
Upper-­ limb tension manoeuvres did not pro-
voke any discomfort or symptoms.
The results of an examination of acces-
sory movements in the subject’s neck were
unremarkable.
Palpation of the muscles of his neck and
shoulder girdle revealed the presence of active
myofascial trigger points (MTPs) in his left
infraspinatus muscle, and paravertebrally, in
the splenius cervicis and capitis muscles of the
left side of his neck (Simons et al. 1999, p. 553,
Fig. 22.1; Triggerpoints.net 2014a). These find-
ings were associated with weakness on resisted
external rotation of his left shoulder, suggesting
inhibition of the infraspinatus muscle because
of the presence of active MTPs (Graven-­
Nielsen et al. 2002).
The infraspinatus is one of the rotator cuff
muscles, and has been implicated in mimick-
ing radicular referral to the arm and even the
production of paraesthetic symptoms. The
splenius cervicis and capitis muscles can pro-
duce referral patterns to the side of the face
and head (Simons et al. 1999, p. 433, Fig. 15.1B;
Triggerpoints.net 2014b).
92
Treatment
Following the examination, the subject agreed
to undergo a course of dry needling focused
on his left infraspinatus and splenius muscles.
These were needled in such a way as to achieve
De Qi and muscle twitch, which was noted in
both. After treatment, he was advised to con-
tinue with his medication for the moment, but
if symptoms improved, then he would be able
to be weaned off his analgesia. He was told that
gabapentin should be reduced gradually over a
period of 1–2 weeks, as advised in the summary
of the product’s characteristics (eMC 2017), in
order to minimize the side effects of sudden
withdrawal. The present author followed up
the dry needling with advice on stretches for
splenius and infraspinatus muscles. This took
the form of a home exercise programme com-
prised of simple mobility exercises for the neck
and shoulder girdle, and isometric rotator cuff
strengthening.
On review 7 days later, the subject reported
that the paraesthesia in his arm had eased for
approximately 1 h. In view of the change in his
symptoms, he was keen that the dry needling
should be repeated. This was done following
further examination and identification of the
MTPs in his left infraspinatus and splenius
muscles. He was advised to continue his home
exercise regime.
The subject reported that he was very
happy with his progress when he returned to
the clinic 9 days later, and that his symptoms
were at least 80% resolved. He commented
that, although the present author had been
reluctant to discuss the potential of “curing”
problems, he felt that his symptoms were so
much better that he was now expecting full
resolution.
Assessment of his neck and shoulder girdle
revealed full active ROM, and no tenderness
on palpation of either the infraspinatus or
splenius muscles. The subject reported that he
had ceased taking co-­ codamol and Nurofen
Plus, and that he had made significant progress
in weaning himself off gabapentin: he was only
taking one, 300-­mg tablet a day and intended to
stop that in the next few days. The decision was
made to discharge him from physiotherapy, and
© 2017 Acupuncture Association of Chartered Physiotherapists

he was instructed to continue with his normal
activities.
Discussion
The present case report highlights the ease with
which MSK pain can be erroneously categorized
as neuropathic pain because of the presence of
paraesthesia. With careful MSK examination, it
is possible to enhance the accuracy of the diag-
nosis, which is a key component of successful
treatment. Accurate clinical MSK diagnosis can
often be hindered by the lack of specificity in
orthopaedic tests (Hughes et al. 2008). There
also remains the issue of inter-­rater agreement;
Downey et al. (2003) showed that there were
considerable differences in the segmental levels
of lumbar vertebrae that were identified by
physiotherapists on palpation. More recently, a
study by Mora-­ Relucio et al. (2016) suggested
that there was a greater correlation in palpation
accuracy between experienced clinicians than
inexperienced ones.
There will always be limitations to the extent
to which one can draw conclusions from a case
study; however, it is clear that the present report
highlights that it is important to carefully assess
and determine the mechanism behind the pain
symptom. Is the pain of a neuropathic nature
or is it nociceptive? In this case, awareness of
the potential referral patterns and behaviours
of MTPs led to the successful resolution of
the subject’s symptoms, and a return to normal
function.
References
Cooper A., Calvert N., Skinner J., et al. (2010) Chest
Pain of Recent Onset: Assessment and Diagnosis of Recent
Onset Chest Pain or Discomfort of Suspected Cardiac Origin.
National Clinical Guideline Centre for Acute and
Chronic Conditions, London.
Downey B., Taylor N. & Niere K. (2003) Can manipula-
tive physiotherapists agree on which lumbar level to
treat based on palpation. Physiotherapy 89 (2), 74–81.
Electronic Medicines Compendium (eMC) (2015) Nurofen
Plus. [WWW document.] URL https://www.medicines.
org.uk/emc/medicine/23377
© 2017 Acupuncture Association of Chartered Physiotherapists
C. Waldock
Electronic Medicines Compendium (eMC) (2017)
Gabapentin Sandoz 300  mg Capsules. [WWW docu-
ment.] URL http://www.medicines.org.uk/emc/
medicine/25459
Graven-­Nielsen T., Lund H., Arendt-­ Nielsen L.,
Danneskiold-­Samsøe B. & Bliddal H. (2002) Inhibition
of maximal voluntary contraction force by experimen-
tal muscle pain: a centrally mediated mechanism. Muscle
and Nerve 26 (5), 708–712.
Hughes P. C., Taylor N. F. & Green R. A. (2008) Most
clinical tests cannot accurately diagnose rotator cuff
pathology: a systematic review. Australian Journal of
Physiotherapy 54 (3), 159–170.
Kremer M., Salvat E., Muller A., Yalcin I. & Barrot M.
(2016) Antidepressants and gabapentinoids in neuro­
pathic pain: mechanistic insights. Neuroscience  338
(2016), 183–206.
Mora-­Relucio R., Núñez-­ Nagy S., Gallego-­ Izquierdo
T., et al. (2016) Experienced versus inexperienced
interexaminer reliability on location and classification
of myofascial trigger point palpation to diagnose
lateral epicondylalgia: an observational cross-­sectional
study.  Evidence-­ Based Complementary and Alternative
Medicine 2016: 8. DOI: 10.1155/2016/6059719.
National Institute for Health and Care Excellence
(NICE) (2013) Neuropathic Pain in Adults: Pharmacological
Management in Non-­Specialist Settings. [WWW document.]
URL https://www.nice.org.uk/guidance/cg173/evidence
National Institute for Health and Care Excellence
(NICE) (2015) Analgesia – Mild-­ to-­
Moderate Pain.
[WWW document.] URL http://cks.nice.org.uk/
analgesia-­mild-­to-­moderate-­pain
Simons D. G., Travell J. G. & Simons L. S. (1999) Travell
& Simons’ Myofascial Pain and Dysfunction: The Trigger
Point Manual, Vol. 1: Upper Half of the Body, 2nd edn.
Williams & Wilkins, Baltimore, MD.
Triggerpoints.net (2014a) Infraspinatus Trigger Point Diagram.
[WWW document.] URL http://www.triggerpoints.
net/muscle/infraspinatus
Triggerpoints.net (2014b) Splenius Cervicis Trigger Point
Diagram. [WWW document.] URL http://www.
triggerpoints.net/muscle/splenius-­cervicis
Colin Waldock is a physiotherapy independent pre-
scriber who works as an extended-­scope practitioner for
Physiotherapy2fit in Rainham. He is also a support
tutor on the postgraduate programme for non-­ medical
prescribing at Medway School of Pharmacy. Colin has
24 years of experience of using acupuncture in a clinical
setting, and is currently preparing a PhD on the impact
of prescribing on professional practice.
93
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 95–98
GOOD PRACTICE STATEMENT
Acupuncture for pregnancy-­related low back
pain and pelvic girdle pain
Introduction
This statement is based on a synthesis of the
best available current evidence. It will be subject
to periodic review as the evidence base evolves.
It should be noted that the statement offers
guidance, and should not be regarded as pre-
scriptive; such general advice will always require
to be modified in line with the needs of any
individual patient and the clinician’s experience.
All acupuncture should be performed accord-
ing to the guidelines of the British Acupuncture
Council, the British Medical Acupuncture Society
and the Acupuncture Association of Chartered
Physiotherapists (AACP) (www.acupuncture
safety.org.uk).
Background
The incidence of pregnancy-­ related low back
pain (LBP) and pelvic girdle pain (PPGP) is
reported to be approximately 20% (Wu et al.
2004; Kovacs et al. 2012; Malmqvist et al. 2012;
Pennick & Liddle 2013). It is attributed to multi­-
factorial changes in posture, hormones, joint
laxity, muscle imbalance, asymmetrical mechani-
cal dysfunction of the pelvis and the growing
baby in utero.
In the general population, acupuncture has
been shown to reduce pain levels and improve
physical function in adults with LBP (Witt et al.
2006; Haake et al. 2007; Cherkin et al. 2009;
Mayer et al. 2010). However, this cannot be
extrapolated to pregnancy-­related pain without
consideration of the safety of this modality in
this population.
Safety of acupuncture in pregnancy
The AACP guidelines for safe practice (AACP
2012) state that there is a danger of miscarriage
when treating patients in the first trimester
of pregnancy. This has not been reported in
© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy
supplementary literature, and may be considered
to be based on historical practice (Betts & Budd
2011) rather than evidence (Carr 2015). The
AACP (2012) defines the forbidden points as
Large Intestine (LI) 4, Spleen (SP) 6, and Bladder
(BL) 60 and 67 because of the risk of uterine
contractions (Betts & Budd 2011; Cummings
2011) since these points are used in traditional
Chinese medicine to facilitate induction and
turning breech babies. Furthermore, BL31,
BL32, BL33 and BL34 (the sacral fora­mina) and
abdominal points are to be specifically avoided
because these may compromise circulation to
the developing foetus (Betts & Budd 2011), or
potentially approximate the uterus if the needle
enters the foramen.
Cummings (2011) theorized that acupuncture
is safe to use in pregnancy, and that forbidden
points can be employed. Elden et al. (2005, 2008)
stated that forbidden points (i.e. LI4, BL32,
BL33 and BL60) have not been found to cause
serious adverse events, and no significant harm-
ful effects were reported in several randomized
controlled trials (RCTs) (Wedenberg et al. 2000;
Guerreiro da Silva et al. 2004; Kvorning et al.
2004). Carr (2015) stated that objective exami-
nation of the scientific literature does not reveal
any suggestion of harm following needling at
“forbidden” points during pregnancy, despite
historical or theoretical concerns. However, it
must be noted that the majority of this evidence
is collated from research on generally healthy
pregnancies. The efficacy and safety of acu-
puncture in pregnancies complicated by specific
obstetric conditions have yet to be determined.
Langshaw (2011) identified some studies
that have reported powerful recordable uterine
contractions after strong acupuncture at LI4
and SP6 that never caused early delivery, but
could cause patient distress. Bishop et al. (2016)
95
Acupuncture for pregnancy-related pain
reported some minor non-­ obstetric adverse
effects during acupuncture treatment in preg-
nancy, including: light-­ headedness; fainting;
mild bruising at the needle site; worsening of
symptoms; vomiting; and pain at the needle site.
All of the above might be found in acupuncture
of the general population. Similarly, two recent
systematic reviews highlighted a low incidence
of adverse events that were non-­ obstetric in
nature (Park et al. 2014; Clarkson et al. 2015).
In a systematic review, Clarkson et al. (2015)
found that there was a 14–17% chance of being
affected by an adverse event in the pregnancy
acupuncture groups, as compared to one of
15–19% in the non-­ acupuncture intervention
groups. Romer et al. (2013) demonstrated that
there was no difference in the occurrence of
adverse events between an acupuncture and a
control group.
Carr (2015, p. 418) advised clinicians “to treat
only where necessary”, and carry out a thorough
examination and risk assessment with individual
patients. It must be remembered that the opti-
mal dose for any intervention is the minimum
required to be effective. There is a suggestion
that, the greater the amount of needle stimu-
lation applied, the greater the incidence of
adverse events, although these remain mild to
moderate (Wedenberg et al. 2000; Ternov et al.
2001; Kvorning et al. 2004; Elden et al. 2008).
Auricular acupuncture resulted in the least num-
ber of adverse events (Wang et al. 2009).
Efficacy of acupuncture in pregnancy-­
related low back pain and pelvic girdle pain
In a Cochrane Review, Pennick & Liddle (2013)
identified interventions for preventing and
treating pregnancy-­ related LBP and PPGP.
These authors found moderate-­quality evidence
for the efficacy of acupuncture in the treat-
ment of PPGP, which significantly reduced
evening pain and improved function, especially
after 26 weeks, in comparison to usual care or
exercise. In a review of eight systematic reviews
and nine RCTs, Selva Olid et al. (2013) reiterated
that there is moderate evidence for acupuncture
in pregnancy-­related LBP and PPGP, and a low
incidence of adverse events. Research often
focuses on pain indicators, but other benefits
96
that have been noted are increased psychologi-
cal well-­being (Guerreiro da Silva et al. 2004),
and improved mobility and sleep (Ekdahl &
Petersson 2010; Gutke et al. 2015).
Three RCTs differentiated pregnancy-­related
LBP and PPGP as part of the inclusion criteria
(Elden et al. 2005, 2008; Lund et al. 2006), and
all identified significant benefits as a result of
using acupuncture. Six other studies researched
women with both pregnancy-­ related LBP
and PPGP, but did not stratify the women by
diagnosis before randomization or during the
analysis (Wedenberg et al. 2000; Ternov et al.
2001; Guerreiro da Silva et al. 2004; Kvorning
et al. 2004; Wang et al. 2009; Ekdahl & Petersson
2010). This prevents a definitive statement being
made regarding the response of individual
conditions to acupuncture. However, each
study showed positive benefits of acupuncture
treatment in the sample combining pregnancy-­
related LBP and PPGP.
A recent systematic review by Gutke et al.
(2015) found strong evidence for the use of
acupuncture in pregnancy-­ related LBP. Foster
et al. (2015) ran a pilot trial comparing acu-
puncture, non-­ penetrating acupuncture and
standard care in pregnancy-­ related LBP. They
found reductions in pain and disability in the
two acupuncture arms of the trial that were sig-
nificantly greater than those in the standard care
group. Non-­penetrating acupuncture or “sham”
acupuncture may show benefits because of the
effects of acupressure, contact with a therapist
or a potential placebo effect. Elden et al. (2008)
reported that sham acupuncture also provided
positive benefits and that needling may not
be necessary, but regular contact with a health
professional may be just as beneficial.
The evidence supporting the use of acupunc-
ture in the management of LBP and PPGP
in pregnancy does seem to be encouraging,
and there is an emphasis on individual patient
examination and risk assessment in each case.
Good practice points
The AACP (2012) defines the traditional forbid-
den points as LI4, SP6, BL60 and BL67, which
should be used with caution given that these are
historically contraindicated in pregnancy. The
© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy

employment of traditionally forbidden points
without any significant adverse outcomes was
noted in all RCTs reviewed that had assessed
for this outcome in pregnancy-related LBP and
PPGP (Wedenberg et al. 2000; Kvorning et al.
2004; Elden et al. 2005, 2008; Lund et al. 2006).
Bladder 31, BL32, BL33 and BL34 (the sacral
foramina), abdominal points, the wall of the
uterus, and strongly stimulating De Qi should
be avoided.
A reduction in visual analogue scale pain
scores has been seen in two, 30-­min sessions
(Ternov et al. 2001). Good outcomes with regard
to pain and functional ability have been found
with an average of eight to 12 sessions on at
least a weekly basis, and using at least 10 needles
for 25–30 min (Wedenberg et al. 2000; Guerreiro
da Silva et al. 2004; Kvorning et al. 2004; Elden
et al. 2005, 2008; Lund et al. 2006; Ekdahl &
Petersson 2010). Increasing the amount of
stimulation and the depth of needling did not
appear to have a significant positive impact on
the efficacy of the acupuncture; however, this
did increase the number of mild to moderate
adverse events.
Conclusions
Bishop et al. (2016) reported a lower use of
acupuncture by physiotherapists for the treat-
ment of pregnant patients than for those
with general musculoskeletal pain conditions.
They suggested that this may indicate a lack
of confidence, concerns about safety and a
lack of specific guidelines for physiotherapists
about the use of acupuncture in pregnancy. The
evidence for the safety of acupuncture in preg-
nancy, including the use of traditional forbidden
points, has increased (Romer et al. 2013; Park
et al. 2014; Carr 2015; Clarkson et al. 2015), and
should support it as an option in the treatment
of PPGP (Pennick & Liddle 2013; Wild 2014)
and pregnancy-­related LBP (Gutke et al. 2015).
Current evidence lacks the validity and reliability
that is required to establish specific guidelines
on precise treatment parameters, mainly because
of a lack of comparability between the inter-
ventions used in RCTs. Overall, acupuncture
for pregnancy-­related LBP and PPGP is recom-
mended since it can be a safe and efficacious
© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy
Acupuncture for pregnancy-related pain
treatment modality for reducing pain scores
(Vleeming et al. 2008), improving sleep and
mobility (Ekdahl & Petersson 2010), and increas-
ing functional capacity (Guerreiro da Silva et al.
2004). It can also be combined effectively with
other physiotherapy interventions.
The following recommendations are made:
• Following a thorough examination and risk
assessment, acupuncture is a safe treatment
modality for LBP and PPGP in uncompli-
cated pregnancies.
• Avoid abdominal points, or any approxima-
tion of the uterine wall and sacral foramina
(BL31, BL32, BL33 and BL34).
• Avoid very strong stimulation of acupuncture
points in pregnancy.
• Caution may be exercised in using traditional
“forbidden points”, i.e. LI4, SP6, BL60 and
BL67.
• Treatment parameters, such as frequency,
duration, and the number of points used,
may depend on individual patient assessment
and local practice restrictions.
• Monitor for any adverse events, and record any
such issues in your treatment documentation.
Pelvic, Obstetric and Gynaecological
Physiotherapy
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(2010) Management of chronic low back pain in active
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Ternov N. K., Grennert L., Åberg A., Algotsson L. &
Åkeson J. (2001) Acupuncture for lower back and
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167 consecutive cases. Pain Medicine 2 (3), 204–207.
Vleeming A., Albert H. B., Östgaard H. C., Sturesson B.
& Stuge B. (2008) European guidelines for the diagno-
sis and treatment of pelvic girdle pain. European Spine
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American Journal of Obstetrics and Gynecology 201 (3),
271.e1–271.e9.
Wedenberg K. A. J., Moen B. & Norling Å. (2000) A
prospective randomized study comparing acupuncture
with physiotherapy for low-­ back and pelvic pain in
pregnancy. Acta Obstetricia et Gynecologica Scandinavica 79
(5), 331–335.
Wild E. (2014) Use of acupuncture as an adjunct tool
in the management of pelvic girdle pain in preg-
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Witt C. M., Jena S., Selim D., et al. (2006) Pragmatic
randomized trial evaluating the clinical and economic
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Wu W. H., Meijer O. G., Uegaki K., et al. (2004) Pregnancy-­
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(7), 575–589.
© 2017 Pelvic, Obstetric and Gynaecological Physiotherapy
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 99–101
Book reviews
Daoist Reflections from Scholar Sage
By Damo Mitchell and his students
Singing Dragon, London, 2016, 312 pages,
paperback, £18.99
ISBN 978-­1-­84819-­321-­5
As a complete novice in the field of Daoism, I
tackled this book review with some trepidation,
but also with interest. Having practised acu-
puncture for many years, I have a great deal of
respect for traditional Chinese medicine (TCM).
However, I have never ventured into the realms
of meditation, spiritualism or the martial arts,
and so I was keen to find out how relevant
Daoist Reflections from Scholar Sage would be to
physiotherapy and acupuncture practice.
This book is a compilation of the most
popular articles that have appeared on the
© 2017 Acupuncture Association of Chartered Physiotherapists
Scholar Sage Online Magazine website (www.
scholarsage.com), and is designed to provide a
wide range of information on Daoism and the
internal arts. Generally, each chapter is inde-
pendent of the others, and so this is a collec-
tion that can be delved into at any point, which
makes for easier reading.
Chapter 1 discusses the Ding (Cauldron) and
Lu (Furnace), and how these work together
to influence the body’s three powers of Jing
(Body), Qi (Breath) and Shen (Mind). Clear
information is backed up by easily understood
diagrams, allowing readers to comprehend a
mystifying subject.
The very short second chapter describes the
processes by which Fire and Water meet in the
body, which involve the mixing and reversing
of the Dragon and Tiger on three different
levels. The ultimate result is pure yin and yang,
with the removal of Fire and Water and the
production of Heaven and Earth, which brings
harmony to the body.
Chapter 3 has the somewhat off-­putting title
of “Worms”. The theory is that three worms
(Sanchong), representing “desires and wanting”,
“attachments and regrets”, and “unconscious
habits”, reside within the head, chest and
sacrum, respectively. The worms can move in
and out of the body of their own accord. The
reader is taught how Daoism pulls together
these physical, energetic, spiritual and psycho-
logical models.
The following three chapters go on to discuss
meditation, and how to overcome the challenges
of the acquired mind. Alchemy is the system of
meditation referred to in this book. The tricks
played by the acquired mind are discussed, as
are emotions, which “are simply a form of
energy shifting in response to the movements
of your mind [and are] why therapies such as
acupuncture can directly affect your emotional
state” (p. 50).
Chapters 7 and 8 discuss the importance of
the balance between inhalation and exhalation
99
Book reviews
that allows Qi to move through the body. The
cyclical relationship of Jing and Qi discussed in
the Daoist poem “The Classic of Breath and
Qi Consolidation” is simply explained, and the
entire work is broken down into sections, which
allows the reader to grasp its meaning more
easily.
Various religions and the way in which
Daoism has grown more complex are discussed
in chapter 10. Traditional Chinese medicine is
not only supposed to help with ailments, but also
to realign a person with his or her spiritual path.
In an age in which personal cultivation is all but
ignored, and material gains are key measures of
success in life, it is no wonder that much of the
beauty of the art of TCM has been lost.
In chapter 14, the martial art of Taijiquan is
discussed. It is of interest that this ancient form
of combat revolves around the connective tis-
sue and fascia that are of such scientific interest
today. The connective tissue lines are known to
carry energy, and are referred to as the riverbed
of the meridians.
Chapter 21 is a very interesting account of the
importance of the pineal gland in history and
religion worldwide. It also provides fascinating
information about the adverse effect of fluoride
on the pineal gland and how to keep it healthy.
This book even tackles healthy eating in
chapter 23, which is entitled “Food Energetics”.
Here, various categories of food are discussed
in relation to the effect of these on our body’s
energies. As with acupuncture, some foods
will stimulate while others will calm. There is
also advice on the effects of different ways of
cooking food, as well as the influence that its
temperature has. All this is definitely food for
thought!
Finally, there is a helpful glossary of Pinyin
Chinese terms at the back of the book that
provides the reader with clear and concise
translations.
Interspersed with entertaining anecdotes and
illustrated with straightforward, comprehensive
diagrams, this book contains thought-­provoking
statements, and gives wise words of advice
about the way in which practitioners in the West
use Eastern practices, adapting them, often
unwisely or incorrectly, to suit their methods.
100
This book is well written and stimulating. It
takes a complex subject and explains it in an
understandable and readable way. It is easy to
follow, but doesn’t gloss over the depth of the
subject being discussed.
I would recommend Daoist Reflections from
Scholar Sage to anyone who, like myself, is
interested in a straightforward and enlightening
introduction to Daoism and the internal arts. It
would also serve as an easily accessible refer-
ence book for those who already are immersed
in the ways of Daoism.
Wendy Rarity
Book Review Editor
The Yellow Monkey Emperor’s Classic
of Chinese Medicine
By Damo Mitchell and Spencer Hill
Singing Dragon, London, 2016, 272 pages,
paperback, £17.99
ISBN 978-­1-­84819-­286-­7
In The Yellow Monkey Emperor’s Classic of Chinese
Medicine, much of which is in comic-­strip form,
a horse complains about his chest being as tight
as a bear’s embrace, a goat bleats about suffer-
ing from skin that is as dry as parchment and a
rat describes his urine as being darker than soy
sauce. These lively characters and their friends
then seek diagnostic help from wise animal
sages, and the Yellow Monkey Emperor himself.
The preface explains that TCM is largely
concerned with identifying the underlying
causes of disharmony in the body. The book is
divided into sections based on the seasons that
are relevant to the ailments that these cover.
This interesting and entertaining book
explains meridian point locations according to
TCM and associated terms, including Zang Fu
syndromes. It illustrates 78 of these syndromes,
and states that anything that might be out of
balance can be assessed once these are learned.
The 78 key Zang Fu syndromes of disharmony
are presented in ways that are easy to absorb. It
is advisable to use the connections between the
imagery, humour and symptoms in the comic
strips to commit each syndrome to memory.
The representation of the organs is important
for understanding their classification because it
© 2017 Acupuncture Association of Chartered Physiotherapists

enables the reader to understand how the body
was viewed in TCM. It explains the correspond-
ences between the ailments of the internal
organs and physical symptoms or personality
clues in the form of a parable.
The challenge of TCM is the huge amount of
memorization required to retain all the meridians
and treatment points. The cartoons included in
the book are employed to aid comprehension
and recall of the subject matter. The illustrations
do this by condensing a complex concept into
© 2017 Acupuncture Association of Chartered Physiotherapists
Book reviews
a single drawing, thereby enabling the reader to
remember what is being taught. A single image
or a collection of drawings can make a list of
terms easier to memorize. Each acupuncture
point has an image associated within its name
(e.g. Bladder 1: Jing Ming, “Bright Eyes”), and
this appeal to the visual aspect of the brain
enables the information to be more easily com-
mitted to memory. The authors’ emphasis is
not only on physical symptoms, but also those
associated with behaviour and mood. However,
many of the symptoms included in the book
must be memorized without the aid of an
accompanying illustration.
While acupuncture needles are referred to in
the discussion of treatments, no detail is given
about appropriate points. The book is diagnos-
tic in nature and not a treatment manual. It
would have been more complete if the authors
had suggested treatment points for the condi-
tions covered, but as it is, it needs to be used
in conjunction with other acupuncture books or
literature.
The Yellow Monkey Emperor’s Classic of Chinese
Medicine is fast reading, entertaining and holds
the attention, and many concepts explained in a
simple visual form. It could be used as a start-
ing point for learning about acupuncture, and
gives the reader a good idea of what TCM is
about in a very simple and amusing style.
Thelma Cooper
Specialist Pelvic Health Physiotherapist
Department of Physiotherapy
Boglestone Clinic
Port Glasgow
Renfrewshire
UK
101
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Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 103–108
News, views and interviews
From disempowerment to
control: patients’ perceptions of
acupuncture and moxibustion for
lymphoedema
A recently published open-­access paper by de
Valois et al. (2016), reports that acupuncture
and moxibustion (acu/moxa) can facilitate the
transition from disempowerment to improved
well-­
being and self-­ care for cancer survivors
with lymphoedema.
“‘The monkey on your shoulder’: a qualita-
tive study of lymphoedema patients’ attitudes to
and experiences of acupuncture and moxibus-
tion” was a runner-­up in the Scientific Article
Prize Competition awarded at the International
Society for Complementary Medicine Research
(ISCMR) conference in Berlin, Germany, in May
2017. This contest celebrates the best research
in the complementary and alternative medicine
(CAM), and integrative medicine (IM) field,
and establishes such work as a legitimate area
of investigation. The ISCMR is a world-­ wide
scientific organization of researchers, practi-
tioners and policy-­makers that fosters CAM/IM
research, and provides a platform for knowledge
and information exchange to enhance interna-
tional communication and collaboration.
De Valois et al. (2016) describe the results
of focus group research nested in a three-­step,
mixed-­ methods observational study. This was
carried out at the Mount Vernon Cancer Centre
in Northwood, Middlesex, UK, and funded
by the National Institute for Health Research
(Grant Reference Number PB-­PG-­0407-­10086)
(de Valois et al. 2012). This qualitative work
explored the way in which patients with lym-
phoedema secondary to cancer treatment per-
ceived and experienced acu/moxa. It involved
23 survivors of breast (n = 17), or head and
neck (n = 6) cancer who had received up to 13
acu/moxa treatments. The present author, who
was the principle investigator and also an acu-
puncturist in the clinical study, worked with a
© 2017 Acupuncture Association of Chartered Physiotherapists
team including a qualitative researcher from the
Peninsula Medical School at the University of
Exeter, Exeter, UK.
Characterized by chronic swelling that is cur-
rently incurable, lymphoedema is a consequence
of cancer treatment that has a significant
impact on health-­related quality of life (QoL).
Multidisciplinary approaches are needed to
address the complex physical, psychological
and psychosocial problems associated with a
chronic condition in patients with multiple co-­
morbidities (Lymphoedema Framework 2006).
In addition to specialist care, management of
lymphoedema requires a significant commit-
ment to daily self-­care on the part of the patient
(Keeley 2000).
Acupuncture is valued for its contribution
symptom control and improved coping by
people with chronic diseases, including cancer
(Paterson & Britten 2003; Seers et al. 2009).
Moxibustion, i.e. the use of heat to stimulate
acupuncture points, is less well-­ known and
researched in the West; however, the first
paper to report using traditional Chinese
medicine (TCM) in the management of lym-
phoedema utilized moxibustion (Kanakura et al.
2002).
De Valois et al.’s (2016) overall study inves-
tigated the feasibility of using acu/moxa to
promote well-­ being and improve QoL for
patients with breast, and head and neck cancer
who had cancer-­ treatment-­related secondary
lymphoedema. In their qualitative study, the
participants described feeling disempowered by
cancer treatment and the subsequent diagnosis
of lymphoedema, which was the “last straw”
for some. Disabling, disfiguring and distressing,
participants described a range of physical and
psychosocial consequences of the condition
that seriously affected their QoL. For many, the
opportunity to have acu/moxa treatment came
when they felt it was worth trying anything that
might help, although a fear of needles was a
concern.
103
News, views and interviews
The participants expressed their gratitude for
the cancer treatment that they received from the
National Health Service. However, they felt that
conventional medical treatment focused solely
on the disease, while they perceived the acu-
puncturists to have a “whole person” approach.
In particular, they appreciated the individual-
ized treatments as well as the time spent with
a practitioner who cared about, listened to and
responded to their needs. Not all participants
received treatment involving moxibustion, and
there were mixed responses. Some enjoyed it
immensely and found it very relaxing, while oth-
ers were ambivalent and preferred acupuncture.
In the focus groups, of which there were
six in total, the participants described physical
changes including an increase in energy and a
reduction in troublesome symptoms (e.g. sleep
problems and musculoskeletal pain), as well as
changes in lymphoedema-­ related symptoms
including a reduction in pain, an increase in
mobility and a perceived reduction in swelling.
Many reported feeling more relaxed, less anx-
ious and more motivated.
The emergent themes indicated a transition
from feelings of disempowerment, disablement
and disfigurement to ones of empowerment,
control and acceptance. Many participants felt
that their lives had changed because of the acu/
moxa treatment, perceiving it to have had a sub-
stantial and positive impact on their well-­being,
and giving them a sense of being once more
in control of their lives. One survivor of breast
cancer described this as follows:
“The biggest thing that it’s done for me is to put me
back in balance  . . . it [lymphoedema] doesn’t let
you forget the cancer I think, because it’s a physical
reminder of the fact that at one point in your life you
were so very vulnerable. So it’s a bit like a monkey
sitting on your shoulder, most of the time he’s on
your shoulder but every now and then he comes and
slaps you in the face. I just feel I can slap him back
now, you know.” (de Valois et al. 2016, p. 9)
Acupuncture and moxibustion could also act
as a catalyst that generated the motivation to
take a more active part in self-­care, a necessary
step to manage a chronic condition such as
lymphoedema.
104
Building on these findings, de Valois et al.
(2016) propose a model of acu/moxa as a
process for long-­term healthcare. They suggest
that this form of treatment has the potential
to reduce troublesome symptoms and increase
energy, which increases motivation and improves
self-­care in turn, leading to possible improve-
ments in long-­term health and well-­being.
More research is needed to explore the poten-
tial of the proposed model. In the meantime,
acupuncturists and their patients might broaden
their expectations of this treatment modality,
and consider its wider effects on well-­ being
and motivation, rather than the more frequently
expected outcome of reducing lymphoedema
swelling.
This is the first qualitative study to explore
lymphoedema patients’ perceptions of acu/
moxa treatment. Furthermore, de Valois et al.
(2016) address overall well-­ being, rather than
focusing on a single physiological symptom
(usually the reduction in swelling reported in
previous studies of lymphoedema). Their study
also included survivors of head and neck cancer
with lymphoedema, who represent an under-­
researched group of patients.
De Valois et al. (2016) indicate that acu/moxa
has the potential to benefit some people with
cancer-­ related upper body lymphoedema who
present with several symptoms related to, and
in addition to, lymphoedema. Their participants
valued acu/moxa treatment: many reported that
it facilitated a transformation from the feeling
of disempowerment engendered by their cancer
diagnosis and the consequences of its treatment
to a sense of empowerment and having more
control over their lives.
Beverley de Valois PhD LicAc FBAcC
Supportive Oncology Research Team
Lynda Jackson Macmillan Centre
Mount Vernon Cancer Centre
Northwood
Middlesex
UK
E-­mail: beverley.devalois@nhs.net
References
De Valois B. A., Young T. E. & Melsome E. (2012)
Assessing the feasibility of using acupuncture and
© 2017 Acupuncture Association of Chartered Physiotherapists

moxibustion to improve quality of life for cancer sur-
vivors with upper body lymphoedema. European Journal
of Oncology Nursing 16 (3), 301–309.
De Valois B., Asprey A. & Young T. (2016) “The
monkey on your shoulder”: A qualitative study of
lymphoedema patients’ attitudes to and experiences
of acupuncture and moxibustion. Evidence-­Based
Complementary and Alternative Medicine 2016: 4298420.
DOI: 10.1155/2016/4298420.
Kanakura Y., Niwa K., Kometani K., et al. (2002)
Effectiveness of acupuncture and moxibustion treat-
ment for lymphedema following intrapelvic lymph
node dissection: a preliminary report. The American
Journal of Chinese Medicine 30 (1), 37–43.
Keeley V. (2000) Clinical features of lymphoedema.
In: Lymphoedema (eds R. Twycross, K. Jenns & J.
Todd), pp. 44–67. Radcliffe Medical Press, Abingdon,
Oxfordshire.
Lymphoedema Framework (2006) Best Practice for the
Management of Lymphoedema. International Consensus.
MEP, London.
Paterson C. & Britten N. (2003) Acupuncture for people
with chronic illness: combining qualitative and quanti-
tative outcome assessment. The Journal of Alternative and
Complementary Medicine 9 (5), 671–681.
Seers H. E., Gale N., Paterson C., et al. (2009)
Individualised and complex experiences of integrative
cancer support care: combining qualitative and quanti-
tative data. Supportive Care in Cancer 17 (9), 1159–1167.
Misguided guidelines
A recent invited commentary by Dr Hugh
Macpherson raises some important issues about
the National Institute for Health and Care
Excellence (NICE) guidelines, which now do
not recommend acupuncture for osteoarthritis
(NICE 2014) or low back pain (LBP) (NICE
2016). In “NICE for some interventions, but
not so NICE for others: questionable guidance
on acupuncture for osteoarthritis and low-­back
pain” (Macpherson 2017), he raises three key
points.
First, the prior scoping process for Low
Back Pain and Sciatica in Over 16s: Assessment and
Management (NICE 2016) limited the review to
some interventions, but not others. Apart from
acupuncture, recommendations about the latter
interventions were made according to the previ-
ous version of the guidelines (NICE 2009).
Secondly, a new methodological approach
was used for Osteoarthritis: Care and Management
(NICE 2014). A new concept, minimum
© 2017 Acupuncture Association of Chartered Physiotherapists
News, views and interviews
clinically important difference (MCID), was
introduced that required interventions within
the scope of the update (e.g. acupuncture) to
show an MCID in effect size of at least 0.5.
Thirdly, NICE specified that this MCID
of ≥ 0.5 should be applied to a comparison
between the intervention (i.e. acupuncture) and
the placebo. It is significant that the only inter-
vention that achieves an MCID of more than
0.5 when compared with the placebo is opioid
treatment.
However, NICE did not apply its criteria
to all the interventions included, and very few
of those that were recommended met their
requirements.
What should be of clinical relevance are the
results of a comparison between an intervention
and usual care. Vickers et al. (2012) presented
high-­quality evidence from a meta-­analysis that
showed that acupuncture is effective for LBP in
comparison to usual care.
Macpherson (2017) concludes that NICE can
be considered to be inconsistent, and that the
recommendations could not only be detrimental
to the provision of acupuncture, but may also
inadvertently drive up use of opioids.
Rosemary Lillie
News Editor
References
MacPherson H. (2017) NICE for some interventions,
but not so NICE for others: questionable guidance on
acupuncture for osteoarthritis and low-­back pain. The
Journal of Alternative and Complementary Medicine 23 (4),
1–2.
National Institute for Health and Clinical Excellence
(NICE) (2009) Low Back Pain: Early Management of
Persistent Non-­specific Low Back Pain. NICE Clinical
Guideline 88. National Institute for Health and Clinical
Excellence, London.
National Institute for Health and Care Excellence (NICE)
(2014) Osteoarthritis: Care and Management. NICE Clinical
Guideline 177. National Institute for Health and
Clinical Excellence, London.
National Institute for Health and Care Excellence (NICE)
(2016) Low Back Pain and Sciatica in Over 16s: Assessment
and Management. NICE Clinical Guideline 59. National
Institute for Health and Clinical Excellence, London.
Vickers A. J., Cronin A. M., Maschino A. C., et al. (2012)
Acupuncture for chronic pain: individual patient data
meta-­analysis. Archives of Internal Medicine 172 (19),
1444–1453.
105
News, views and interviews
Acupuncture recommended for
low back pain
Contrary to the recent NICE (2016) recom-
mendations (see above), acupuncture has been
endorsed in the treatment of low back pain by
the American College of Physicians (ACP), one
of the largest medical organizations in the USA
(Quaseem et al. 2017).
The membership of ACP is made up of
“internists – specialists who apply scientific
knowledge and clinical expertise to the diagno-
sis, treatment, and compassionate care of adults
across the spectrum from health to complex ill-
ness” (ACP 2017). With over 150 000 members,
it is “the largest medical specialty organization
and second-­ largest physician group in the
United States” (ACP 2017).
In April 2017, the ACP updated their recom-
mendations for the treatment of LBP (Quaseem
et al. 2017):
“Recommendation 1. Given that most patients
with acute or subacute low back pain improve over time
regardless of treatment, clinicians and patients should
select nonpharmacologic treatment with superficial
heat (moderate-­quality evidence), massage, acupunc-
ture, or spinal manipulation (low-­quality evidence).
If pharmacologic treatment is desired, clinicians and
patients should select nonsteroidal anti-­inflammatory
drugs or skeletal muscle relaxants (moderate-­quality
evidence). (Grade: strong recommendation)
“Recommendation 2. For patients with chronic
low back pain, clinicians and patients should
initially select nonpharmacologic treatment with
exercise, multidisciplinary rehabilitation, acupuncture,
mindfulness-­based stress reduction (moderate-­ quality
evidence), tai chi, yoga, motor control exercise, pro-
gressive relaxation, electromyography biofeedback,
low-­level laser therapy, operant therapy, cognitive
behavioural therapy, or spinal manipulation (low-­
quality evidence). (Grade: strong recommendation)”
(Quaseem et al. 2017, p. 514)
It is very encouraging to see this strong rec-
ommendation from the ACP for the use of
acupuncture, and one can only hope that,
considering this, the NICE guidelines may be
successfully challenged.
Rosemary Lillie
News Editor
106
References
American College of Physicians (ACP) (2017) ACP Facts.
[WWW document.] URL https://www.acponline.org/
acp-­newsroom/acp-­facts
National Institute for Health and Care Excellence (NICE)
(2016) Low Back Pain and Sciatica in Over 16s: Assessment
and Management. NICE Clinical Guideline 59. National
Institute for Health and Clinical Excellence, London.
Quaseem A., Wilt T. J., McLean R. M., et al. (2017)
Noninvasive treatments for acute, subacute, and
chronic low back pain: a clinical practice guideline
from the American College of Physicians. Annals of
Internal Medicine 166 (7), 514–530.
Acupuncture and infantile colic
In a recent multicentre, three-­ armed, single-­
blind, randomized controlled trial (RCT),
Landgren & Hallström (2017) reported the
effects of minimal acupuncture on infantile
colic. Their aim was to evaluate two types of
acupuncture, i.e. minimal acupuncture at Large
Intestine (LI) 4 (Hegu) and semi-­standardized
individual acupuncture inspired by TCM, against
no acupuncture. One hundred and forty-­seven
infants were included in the trial, and acupunc-
ture was administered by trained medical staff.
The goal of the study was to investigate whether
it was both practical and effective to administer
acupuncture in children’s health centres in the
Swedish public health system. Previous studies
by Reinthal et al. (2008, 2011) and Skjeie et al.
(2013) had only examined treatments that had
been administered in private clinics, which could
have resulted in inbuilt bias.
The TCM-­ inspired points used were any
combination of Extra Upper Extremity 10 (Si
Feng), Stomach 36 (Zu San Li) and LI4. All
these points are considered important in treating
gastrointestinal symptoms and infantile colic.
The Standards for Reporting Interventions in
Clinical Trials of Acupuncture were followed.
No placebo was used. The infants received
treatment twice a week for 2 weeks.
In comparison with usual care, the results
showed a statistically significant reduction in
the magnitude of crying in both acupuncture
groups.
Landgren & Hallström (2017) suggest that a
diet free of cow’s milk protein, and an evalua-
tion of the infant crying should be undertaken
© 2017 Acupuncture Association of Chartered Physiotherapists

to avoid unnecessary treatment. If an infant
continues to cry for more than 3 h a day,
acupuncture can be considered. Both methods
of acupuncture are effective and have no side
effects.
Despite the low number of participants
involved, this is a useful study that suggests that
acupuncture can be effective in treating colic.
It also demonstrates the treating infants with
acupuncture is safe. The choice of points used
was not statistically significant, but it is difficult
to compare the two groups because the semi-­
standardized group did not receive treatment
at the same points as those receiving minimal
acupuncture at LI4. However, the three points
selected are all effective, and could be used in
clinical practice.
Further research is necessary, of course.
Rosemary Lillie
News Editor
References
Landgren K. & Hallström I. (2017) Effect of minimal
acupuncture for infantile colic: a multicentre, three-­
armed, single-­blind, randomised controlled trial (ACU-­
COL). Acupuncture in Medicine 35 (3), 171–179.
Reinthal M., Andersson S., Gustafsson M., et al. (2008)
Effects of minimal acupuncture in children with infan-
tile colic – a prospective, quasi-­randomised single blind
controlled trial. Acupuncture in Medicine 26 (3), 171–182.
Reinthal M., Lund I., Ullman D. & Lundeberg T. (2011)
Gastrointestinal symptoms of infantile colic and their
change after light needling of acupuncture: a case
series study of 913 infants. Chinese Medicine 6: 28. DOI:
10.1186/1749-­8546-­6-­28.
Skjeie H., Skonnord T., Fetveit A. & Brekke M. (2013)
Acupuncture for infantile colic: a blinding-­ validated,
randomized controlled multicentre trial in general
practice.  Scandinavian Journal of Primary Health Care  31
(4), 190–196.
Acupuncture for chronic
prostatitis/chronic pelvic pain
syndrome
A recent review by Qin et al. (2016) concludes
that real acupuncture leads to significant reduc-
tions in the pain, urinary symptoms and QoL
domains of the National Institutes of Health
Chronic Prostatitis Symptom Index (NIH-­
CPSI). Compared with conventional Western
© 2017 Acupuncture Association of Chartered Physiotherapists
News, views and interviews
medicine, acupuncture may be effective in
decreasing the total NIH-­CPSI score, especially
in terms of pain relief.
With regard to urinary symptoms and QoL,
there was no significant difference between acu-
puncture and conventional Western medicine.
Out of 1054 RCTs searched, only seven
studies met the authors’ criteria for their meta-­
analysis. This demonstrates the paucity of
good-­quality research that is available. Since the
aetiology and pathology of chronic prostatitis/
chronic pelvic pain syndrome (CP/CPPS) is
poorly understood, the goal of treatment is to
control the symptoms that patients experience.
Even in the seven studies that were analysed by
Qin et al. (2016), there was little heterogeneity in
the methods used, the questionnaires, the drug
comparisons and whether sham acupuncture
was employed. A previous review (Posadzki et al.
2012) included nine Asian RCTs, and concluded
that acupuncture was an encouraging therapy
for CP/CPPS; however, these trials were pub-
lished in Chinese and were not available for
data abstraction for Qin et al.’s (2016) study.
This is a useful review of the use of acu-
puncture in the treatment of CP/CPPS, and the
comprehensive reference list provides further
reading and research opportunities for anyone
with an interest in this field. This open-­access
paper is available online (Qin et al. 2016), which
is very helpful.
As always, the caveat remains: further research
is needed.
Rosemary Lillie
News Editor
References
Posadzki P., Zhang J., Lee M. S. & Ernst
E. (2012) Acupuncture for chronic nonbacterial
prostatitis/chronic pelvic pain syndrome: a systematic
review. Journal of Andrology 33 (1), 15–21.
Qin Z., Wu J., Zhou J. & Liu Z. (2016) Systematic review
of acupuncture for chronic prostatitis/chronic pelvic
pain syndrome. Medicine 95 (11): e3095. DOI: 10.1097/
MD.0000000000003095.
Erratum
Two amendments need to be made to Janis
Short’s Lung meridian masterclass, which was
107
News, views and interviews
published in the Winter 2016–2017 edition of
the journal (Short 2017):
(1) In “Lung 3: Tian Fu, ‘Palace of Heaven’”
section (p. 58, col. 2), the first paragraph
should read as follows: “Lung 3 is located
6 cun above LU5 (Chi Ze), on the radial
border of the biceps muscle. According to
Quirico (2008, p. 3), ‘In the seated posi-
tion, have the patient rotate his or her head
and take the arm toward the face. The
acupuncture point is located where the
tip of the nose touches the arm, above
the biceps muscle.’ Lung 3 can be needled
108
perpendicularly to a depth of 0.5–1.0 cun.”
(2) In the section on “Lung 9; Tai Yuan, ‘Great
Abyss’” (p. 59, col. 1), the first sentence
should refer to “LU9”, not “LU7”.
Val Hopwood
Clinical Editor
References
Quirico P. E. (2008) Teaching Atlas of Acupuncture, Vol. 2:
Clinical Indications. Thieme, Stuttgart.
Short J. (2017) The Lung meridian: the hand Tai Yin
channel. Acupuncture in Physiotherapy 28 (2), 55–61.
© 2017 Acupuncture Association of Chartered Physiotherapists
Acupuncture in Physiotherapy, Volume 29, Number 1, Summer 2017, 109–111
Guidelines for authors
Introduction
Always refer to a recent edition of Acupuncture
in Physiotherapy. Please follow the style and layout
of an article or item that is similar to your own
contribution. If something is submitted for
publication, then it is implied that it has not been
simultaneously submitted to another journal or
any other type of publication. Reprints may be
considered, but these must be clearly identified
as such and permission must be obtained from
the original publisher.
Templates for clinical papers and case reports
are available on the AACP website (www.aacp.
org.uk), or by e-mail on request. These templates
should not be deviated from if used. Manuscripts
may be returned to authors if they have not
adhered to the guidelines. If necessary, the clini-
­cal editor should be consulted in the initial stages
for clarification.
Authors may submit clinical papers, literature
reviews, clinical commentaries, case reports,
book reviews, course reports, news items, letters
or photographs for consideration for inclu-
sion in the journal. Academic and clinical
­ of five keywords that best represent the contents.
papers are subject to review by the editorial
committee and may require revision before
being accepted.
A Portable Document Format (PDF) file of
the final version of any academic article is
available free of charge if notice is given to the
clinical editor when the article is submitted.
All published material becomes the copyright
of the Association.
All submissions should be sent directly to the
clinical editor:
Dr Val Hopwood FCSP
18 Woodlands Close
Dibden Purlieu
Southampton SO45 4JG
UK
E-mail: val.hopwood@btinternet.com
© 2017 Acupuncture Association of Chartered Physiotherapists
Preparation of manuscripts
Authors should submit material by e-mail or on
CD-ROM. All articles must be typed with wide
(3-cm) margins and the pages should be num-
bered consecutively. Articles should be a maxi-
mum of 7500 words (excluding the abstract,
references and tables).
Papers should be arranged as follows:
Title
The title of the article should be in sentence case,
bold and ranged left, as in the main title above:
note that there is no full stop and no underlining.
The author’s name(s) and institutional affilia­
tion(s) should run consecutively below the title.
Again, there are no full stops.
Abstract
A summary of not more than 250 words outlin-
ing the purpose, scope and conclusions of the
paper should be submitted. This should be
followed by a minimum of three and a maximum
Text
The layout of the journal is that the main heading
of each section is in sentence case and bold.
Notice that, again, there are no full stops and no
underlining.
The first paragraph is left-justified; subsequent
paragraphs in the same section are indented, as is
this part of the guidelines. When including dia-
­grams and photographs, these should be num-
bered in the order in which they appear in the
text, and should be submitted in separate files
(do not embed images in the text). Any figure
captions should be left-justified and run after the
author’s biography at the end of the text. Any
tables should come after the figure legends, if
there are any. Please indicate placement in the
text (e.g. “Fig. 1’’ and “Table 1’’). All figures and
tables must be referred to in the text.
109
Guidelines for authors
When using numbers in the text, these should
be written out in words up to and including nine
unless these are measurements, numbers in
tables or units of time. Always use the Inter­
national System of Units (SI).
Clinical papers: referencing
All clinical papers must be fully referenced and
the citations verified by the author. No excep-
tions will be made. The reference list must be
arranged alphabetically by the name of the first
author or editor, following the Harvard style. In
the text, give the author(s) and date of publica-
tion in brackets [e.g. “(Smith 1998)’’], or if the
main author’s name is part of a sentence, then
only the year is in brackets [e.g. “as described by
Smith (1998)’’]. For more than one author,
reference can be made in the text to “Smith et al.
(1998)’’ (note the italics). However, when writ-
­ing the reference list, the convention is as fol­
lows: for up to five authors, write all the authors’
names; for six or more authors, write the first
three authors’ names, followed by “et al.”
For journals, give the author’s surname and
initials, the year of publication, the title of the
paper, the full name of the journal, the volume
number, the issue number in brackets, and the
first and last page numbers of the article (note
the correct use of italic, bold, commas and full
stops):
Ceccherelli F., Rigoni M. T., Gagliardi G. & Ruzzante L.
(2002) Comparison of superficial and deep acupuncture
in the treatment of lumbar myofascial pain: a double-
blind randomized controlled study. Clinical Journal of Pain
18 (3), 149–153.
For books, give the author’s/editor’s surname
and initials, the year of publication, the book
title in italics, and the publisher and city of
publication:
Williams P. L. & Warwick R. (eds) (1986) Gray’s Anatomy,
36th edn. Churchill Livingstone, Edinburgh.
For a chapter or section in a book by a named
author (who may be one of several contributors),
both chapter and book title should be given,
along with the editor’s name(s), and the first and
last page numbers of the chapter:
110
Bekkering R. & van Bussel R. (1998) Segmental acupunc­
ture. In: Medical Acupuncture: A Western Scientific Approach
(eds J. Filshie & A. White), pp. 105–135. Churchill
Livingstone, Edinburgh.
For references to documents on the World
Wide Web (WWW), give the author’s surname
followed by all initials, the year of publication in
brackets, the document title in italics, an indica­
tion that it is a WWW document in square
brackets and the complete Uniform Resource
Locator (URL):
List D. (2004) Maximum Variation Sampling for Surveys and
Consensus Groups. [WWW document.] URL http://
www.audiencedialogue.net/maxvar.html
Please adhere strictly to this style of referencing
in any contribution to the journal.
Acknowledgements
Please state any funding sources, or companies
providing technical or equipment support.
Photographs
Photographs may be submitted in colour or
black-and-white, but will be printed in mono­
chrome. Images must be in sharp focus. Photo­
graphs should be numbered and their placing
indicated in the text. Digital photographs should
be of high resolution (i.e. a minimum of 300 dots
per inch).
Line illustrations
These should follow the style used in the journal,
i.e. any labelling text should be in sentence case
(10-point, Arial font), graphs should be two-
dimensional and all images must be mono-
chrome. As with photographs, line illustrations
should be numbered and their placement indi­
cated in the text. All images should be of high
resolution (i.e. a minimum of 1200 dots per
inch).
Case reports
The journal welcomes case reports of up to
3000 words. These should be structured as
follows: title, abstract and keywords, a brief
© 2017 Acupuncture Association of Chartered Physiotherapists

introduction, a concise description of the patient
and condition, and an explanation of the assess-
ment, treatment and progress, followed finally by
a discussion and evaluation of the implications
for practice. The study must be referenced
throughout. Further guidance is available upon
request.
Book reviews
At the beginning of the review, give all details of
the book including the title in bold, the author/
editor’s full name(s), publisher, city and year of
publication, price, whether hardback or paper-
back, number of pages, and ISBN number. The
reviewer’s name should appear at the end of the
review in bold, right-justified, followed by their
title and place of work in italics. Reviews of
DVDs and DVD-ROMs should follow the same
format. Book reviews and reports are normally
© 2017 Acupuncture Association of Chartered Physiotherapists
Guidelines for authors
no more than 500 words in length; query for
longer.
Please contact the book review editor before
writing a review.
General points to note
Please enclose your home, work and e-mail
addresses, and telephone number.
It is the author’s responsibility to obtain and
acknowledge permission to reproduce any
material that has appeared in another journal or
textbook.
A brief biographical note about the author(s)
should be included at the end of a clinical paper
in italics.
All notes and news should have clinical rel-
evance to AACP. Please refer at all times to the
style and layout of previous issues of the journal
for whatever you are writing. Using these guide-
lines will save the editorial team time.
111
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two day course is aimed at a wide range of health practitioners, including
KhZD/EWZdEZ acupuncturists, physiotherapists, medical and sports massage therapists and
tĞůĐŽŵĞ ƚŽ ƚŚĞ ĐƵƉƵŶĐƚƵƌĞ ƐƐŽĐŝĂƟŽŶ medical doctors - indeed anyone who has to deal with patients suffering from
disease of the locomotor system.
ŽĨŚĂƌƚĞƌĞĚWŚLJƐŝŽƚŚĞƌĂƉŝƐƚƐ;WͿ Dr. Karl Zippelius, head of the TCM department of the
National Austrian Institute for Sports Medicine, is one of
dŚĞWŝƐĂůǁĂLJƐůŽŽŬŝŶŐƚŽŵĂŬĞLJŽƵƌĞdžƉĞƌŝĞŶĐĞĂƐĂŵĞŵďĞƌ the foremost authorities in TCM orthopaedics, traumatology
ĂƐ ŝŶĨŽƌŵĂƟǀĞ ĂŶĚ ƵƐĞƌͲĨƌŝĞŶĚůLJ ĂƐ ƉŽƐƐŝďůĞ͘ Ɛ ƉĂƌƚ ŽĨ ƚŚŝƐ ĚƌŝǀĞ ůĂƐƚ and sports medicine.

ƐƵŵŵĞƌ ƐĂǁ ƚŚĞ ůĂƵŶĐŚ ŽĨ ŽƵƌ ŶĞǁ ĂŶĚ ŝŵƉƌŽǀĞĚ ǁĞďƐŝƚĞ ǁŝƚŚ ŵŽƌĞ Early bird price (until September 1st 2017) £180

ĐŽŶƚĞŶƚ͕ ŝŶƚĞƌĂĐƟǀĞ ĨĞĂƚƵƌĞƐ ĂŶĚ Ă ƐŵŽŽƚŚĞƌ ŝŶƚĞƌĨĂĐĞ͕ Ăůů ĐŽŶƚƌŝďƵƟŶŐ

ƚŽ ĂŶ ĞŶŚĂŶĐĞĚ ƵƐĞƌ ĞdžƉĞƌŝĞŶĐĞ͘
W DĞŵďĞƌƐ ƌĞĐŝĞǀĞ ϯϱй
ƵĞƚŽƚŚŝƐŶĞǁǁĞďƐŝƚĞLJŽƵǁĞƌĞĂƐƐŝŐŶĞĚŶĞǁůŽŐŝŶĚĞƚĂŝůƐ͕ƐĞŶƚƚŽ Žī ŶĞĞĚůĞ ƉƵƌĐŚĂƐĞƐ
LJŽƵƌ ƌĞŐŝƐƚĞƌĞĚ ĞŵĂŝů ĂĐĐŽƵŶƚ ŽŶ &ƌŝĚĂLJ ϴƚŚ :ƵůLJ ϮϬϭϲ͘ /Ĩ LJŽƵ ĂƌĞ ƵŶƐƵƌĞ
ŽĨ LJŽƵƌ ŶĞǁ ůŽŐŝŶ ĚĞƚĂŝůƐ ĂŶĚ ĐĂŶŶŽƚ ĮŶĚ ƚŚŝƐ ĞŵĂŝů͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ W ŵĞŵďĞƌƐŚŝƉ ƚĞĂŵ ǀŝĂ ƚŚĞ
ĐŽŶƚĂĐƚ ĚĞƚĂŝůƐ ďĞůŽǁ ĂŶĚ ƚŚĞLJ ǁŝůů ĂƐƐŝƐƚ ŝŶ ŐĞƫŶŐ LJŽƵ ůŽŐŐĞĚ ŝŶ͘

KŶĐĞ ůŽŐŐĞĚ ŝŶ Ă ŶĞǁ ŵĞŶƵ ǁŝůů ĂƉƉĞĂƌ ƵŶĚĞƌŶĞĂƚŚ ƚŚĞ ŵĂŝŶ ŵĞŶƵ͘ hƐĞ ƚŚŝƐ ŵĞŶƵ ƚŽ ŶĂǀŝŐĂƚĞ ĂƌŽƵŶĚ
ƚŚĞ ŵĞŵďĞƌƐ͛ ĐŽŶƚĞŶƚ͘ zŽƵ ĐĂŶ ŶŽǁ ĐŚĞĐŬ ĂŶĚ ƵƉĚĂƚĞ LJŽƵƌ ƉĞƌƐŽŶĂů ĚĞƚĂŝůƐ͕ ƉƌŽĨĞƐƐŝŽŶĂů ŝŶĨŽƌŵĂƟŽŶ͕
ĂĐƟǀŝƟĞƐͬŝŶƚĞƌĞƐƚƐ ĂŶĚ ƌĞĐŽƌĚ LJŽƵƌ W͘ zŽƵ ĂƌĞ ĂůƐŽ ĂďůĞ ƚŽ ƐĞĞ LJŽƵƌ ƐƵďƐĐƌŝƉƟŽŶ ŝŶĨŽƌŵĂƟŽŶ ĂŶĚ
ŚŝƐƚŽƌLJ ŽĨ ƉĂLJŵĞŶƚƐ ŵĂĚĞ ƚŽ ƚŚĞ W͕ ǁŝƚŚ ĚŽǁŶůŽĂĚĂďůĞ ƌĞĐĞŝƉƚƐ ĨŽƌ LJŽƵƌ ƌĞĐŽƌĚƐ͘ ͚DLJ ǀĞŶƚƐ͛ ĂůůŽǁƐ
LJŽƵ ƚŽ ŬĞĞƉ ƚƌĂĐŬ ŽĨ W ĐŽƵƌƐĞƐ ĂŶĚ ĐŽŶĨĞƌĞŶĐĞƐ LJŽƵ ĂƌĞ ďŽŽŬĞĚ ŽŶ ƚŽ ĂƐ ǁĞůů ĂƐ ĂĐĐĞƐƐ ƚŽ Ăůů ƌĞůĞǀĂŶƚ
ĚŽĐƵŵĞŶƚƐ ĨŽƌ ŬĞĚ ĐŽƵƌƐĞƐ͘ dŚĞ ͚ŽĐƵŵĞŶƚƐ͛ ƐĞĐƟŽŶ ĐŽŶƚĂŝŶƐ Ă ǁĞĂůƚŚ ŽĨ ƌĞƐĞĂƌĐŚ͕ ĐĂƐĞ ƐƚƵĚŝĞƐ͕
ŐƵŝĚĂŶĐĞ ĚŽĐƵŵĞŶƚƐ͕ ŵĂƌŬĞƟŶŐ ƌĞƐŽƵƌĐĞƐ ĂŶĚ ŵŽƌĞ͘

dŚĞŶĞǁWKŶůŝŶĞ^ŚŽƉŝƐĂůƐŽŶŽǁĂĐĐĞƐƐŝďůĞŽŶůLJďLJůŽŐŐŝŶŐŝŶƚŽƚŚĞŵĞŵďĞƌ͛ƐƐŝĚĞŽĨƚŚĞW
ǁĞďƐŝƚĞ͘

ĚĚŝƟŽŶĂůůLJ͕ LJŽƵ ĂƌĞ ŶŽǁ ĂďůĞ ƚŽ ĚŽǁŶůŽĂĚ LJŽƵƌ ŵĞŵďĞƌƐŚŝƉ ĐĞƌƟĮĐĂƚĞ ĨƌŽŵ ƚŚĞ ǁĞďƐŝƚĞ͘ /Ĩ LJŽƵ
ƌĞƋƵŝƌĞ Ă ĨŽƌŵĂů ĐĞƌƟĮĐĂƚĞ ŽŶ W ŚĞĂĚĞĚ ƉĂƉĞƌ͕ Žƌ ŚĂǀĞ ĂŶLJ ŵĞŵďĞƌƐŚŝƉ ƋƵĞƌŝĞƐ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƚŚĞ
ŵĞŵďĞƌƐŚŝƉƚĞĂŵŽŶϬϭϳϯϯϯϵϬϬϬϳηϭ Žƌ ǀŝĂ ƐĞĐΛĂĂĐƉ͘ƵŬ͘ĐŽŵ͘
 Acupuncture in PhysiotherapyTM
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KE>/E
^ŚŽƉ
džĐůƵƐŝǀĞƚŽWŵĞŵďĞƌƐ
Acupuncture in Physiotherapy TM

Journal of the Acupuncture Association

of Chartered Physiotherapists
KE>z&KZWDDZ^ >Kt^dWZ/^'hZEd d,^dYh>/dzWZKhd^
Summer 2017
WKE>/E^,KWEKtKWE Volume 29, Number 1
dŚĞ ŶĞǁ W ŽŶůŝŶĞ ƐŚŽƉ ŽīĞƌƐ ĞǀĞƌLJƚŚŝŶŐ LJŽƵ ŶĞĞĚ ĨŽƌ LJŽƵƌ ĂĐƵƉƵŶĐƚƵƌĞͲƉŚLJƐŝŽƚŚĞƌĂƉLJ ƉƌĂĐƟĐĞ Ăƚ
ĞdžĐůƵƐŝǀĞƉƌŝĐĞƐ͊
ůů ƉƌŝĐĞƐ ĂƌĞ ƚŚĞ ůŽǁĞƐƚ ƉŽƐƐŝďůĞ ǁĞ ĐĂŶ ĂĐŚŝĞǀĞ͖ ǁŝƚŚ ŶŽ ŬŝĐŬͲďĂĐŬƐ ĨŽƌ ƚŚĞ W Žƌ ĂŶLJ ŽƚŚĞƌ ƉĂƌƚLJ͕
ƐŽ ĂƐ ĂŶ W ŵĞŵďĞƌ LJŽƵ ďĞŶĞĮƚ ƚŚĞ ŵŽƐƚ͘
WƌŽĚƵĐƚƐ ŝŶĐůƵĚĞ͗

ĐƵƉƵŶĐƚƵƌĞŶĞĞĚůĞƐ
ƵƉƉŝŶŐƉƌŽĚƵĐƚƐ
<ŝŶĞƐŝŽůŽŐLJƚĂƉĞ
WŽƌƚĂďůĞĐŽƵĐŚĞƐ
ůŝŶŝĐĂůƐƵƉƉůŝĞƐĂŶĚŵŽƌĞ͘͘͘

WƌŝĐĞDĂƚĐŚWƌŽŵŝƐĞ͊
tĞ ĂƌĞ ĐŽŵŵŝƩĞĚ ƚŽ ƉƌŽǀŝĚŝŶŐ LJŽƵ ǁŝƚŚ ƚŚĞ ďĞƐƚ ƉƌŽĚƵĐƚƐ Ăƚ ƚŚĞ ŵŽƐƚ ĐŽŵƉĞƟƟǀĞ ƉƌŝĐĞƐ͘ /Ĩ LJŽƵ ǁŝƐŚ
ƚŽ ƉƵƌĐŚĂƐĞ ĂŶLJ ƉƌŽĚƵĐƚ ŽŶ ŽƵƌ ŽŶůŝŶĞ ƐŚŽƉ ĂŶĚ ĂƌĞ ĂǁĂƌĞ ŽĨ ƚŚĞ ƉƌŽĚƵĐƚ ďĞŝŶŐ ƐŽůĚ Ăƚ Ă ůŽǁĞƌ ƉƌŝĐĞ Volume 29, Number 1, Summer 2017
ǁŝƚŚŝŶ ƚŚĞ h< ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ƵƐ ĂŶĚ ǁĞ ǁŝůů ŵĂƚĐŚ ƚŚĞ ƉƌŝĐĞ Žƌ͕ ŝĨ ƉŽƐƐŝďůĞ͕ ďĞĂƚ ŝƚ͘

y>h^/s>z&KZ WZ/Dd, WZKhd^KhZ/E'

WDDZ^ WZKD/^͊ ^Zs/

EŽƚ ĨŽƵŶĚ ǁŚĂƚ LJŽƵ͛ƌĞ ůŽŽŬŝŶŐ

ISSN 2058-3281
KīĞƌƐ Θ ŝƐĐŽƵŶƚƐ ĨŽƌ͍ ZĞƋƵĞƐƚ ƵƐ ƚŽ ƐƚŽĐŬ ŝƚ͊