A 25 year old 4th level student from China came to see me a few weeks ago. He was referred from one of the campus health doctors with widespread bilateral neck and back pain with muscle tension thought to be related to long hours of study, poor posture and stress.
This would be a fairly common scenario these days given the number of wound up, stressed out students I am seeing in the clinic for various issues.
So what was different about my student from China?
He had received Acupuncture previously in China and reported some short term benefit. When I suggested we try this again, but in conjunction with specific exercise and lifestyle management advice he was receptive.
Given his subjective history where stress was a large factor, he was not sleeping and generally run down as well as objective findings of widespread muscle overactivity, generalised hypersensitivity with multiple active and latent myofascial trigger points, I thought it best to take it easy in terms of dosing treatment at the first session.
I chose to use a selection of central regulatory points including LI4 and LR3 bilaterally, paraspinal needling adjacent to tender thoracic segments, and 3 trigger points within the periscapular muscles on each side. I needled to a depth of 1-2 cm in most cases, limiting additional manipulation of the needle for duration of 10 minutes, so no looking for twitches at the trigger point sites.
This was followed with a couple of exercises to improve thoracic mobility and engage his postural stabilisers. I also advised on posture, work breaks, getting out for a brisk walk each day and sleep hygiene tips.
My experience with such patients with some degree of central sensitisation would be that less is more when it comes to treatment. I have made the mistake of over-treating in the past and leaving the patient very unhappily fatigued and sore for 3-4 days post treatment.
In this case my student reported feeling a little better for a few hours before returning to his normal status quo. What became apparent over the next couple of sessions was that despite his clinical presentation he would tolerate and only respond to very high dose treatment. Further questioning about his experiences with Acupuncture in China allowed me to understand that my very dose controlled approach was not meeting his expectation based on previous experiences and I needed to ramp it up.
After a couple of sessions of fairly rapid upward dose titration we achieved lasting pain relief over 4-7 days which was steadily increasing in duration. He was responding to high intensity paraspinal electro-acupuncture coupled with the use of additional central regulatory points and vigorous twitch eliciting needling at the trigger point sites. An approach which most of my ‘western’ clients would find intolerable, even the hardiest ones.
Treatment must always be individualised
This got me thinking about the role of cultural factors, expectation, previous experiences and how these sit alongside our current understanding of pain physiology. It made me challenge preconceptions and realise that treatment needs to be individualised. Non-specific factors would seem to have a large role to play in terms of how the central nervous system interprets and processes therapeutic stimulatory input.
I recalled a discussion with a colleague where the topic was verum/real versus sham controlled studies in the west and in the east, in particular China. In the west, verum Acupuncture tends to be gentler than that given in the east which may explain why in the west sham controlled studies are less likely to show significant differences in pain outcomes. By contrast real Acupuncture in countries such as China tends to be given more regularly and at a higher dose.
This case has reminded me once again of the importance of getting the dose correct for the individual as well as well as being aware of the role of cultural factors which can have a profound impact so it would seem.
