This case report is aimed to assist you with the clinical decision making and management of the condition known as irritable bowel syndrome. Particular emphasis is placed on the integrated use of Medical Acupuncture.

This case was selected from patients seen in an urban private physiotherapy practice.

Introduction

As a course of acupuncture for pain and dysfunction following a right hip replacement was coming to an end, Mrs. P (80 years old) mentioned she was suffering from an exacerbation of symptoms associated with irritable bowel syndrome (IBS). This exacerbation had begun a few days previously with IBS having been diagnosed by her general practitioner (GP) some years previously.

When discussing acupuncture for chronic knee pain we are referring, for the most part, to OA of the knee. Clinically there may be other forms of chronic knee pain such as that due to meniscal injury, patellofemoral maltracking/ chondromalacia patella which may also respond well to acupuncture when used as an adjunct.

What's the evidence?

A systematic review by White et al, 2007 concluded the following:

• Acupuncture at traditional points in the vicinity of the knee (verum acupuncture) is superior to minimal, off point needling which avoided needling points which share the same segmental innervation as the knee (sham acupuncture)
• Acupunctures benefits for pain and function last for more than 6 months
• In view of acupuncture’s advantages, such as safety, and no need for a daily dose, it should be considered as a genuine alternative to NSAID’s

A more recent systematic review by Manheimer et al, 2010, also confirms efficacy of verum acupuntcure over sham and that providing Acupuncture is more effective with clincially relevant effects over leaving the patient on a waiting list i.e doing nothing.

A quick review of the NICE clinical guidelines for chronic headache tells us that when taking a history, be on the lookout for red flags.

If a headache sufferer presents with red flags they may have what is known as a secondary headache which may be a result of pathology, in which case further investigation is required.

If no red flags are present it is likely the headache is primary in nature. This would suggest a functional or physiological cause not related to specific pathology. Migraine and Tension Type Headache are typically primary headaches. When dealing with a primary headache, start treatment using an evidence based approach which may include Medical Acupuncture, unless your patient develops atypical features in which case refer on immediately.

This is part 3, the final post, in the series of: 

• Part 1 - How I Integrate Dry Needling of Myofascial Trigger Points In A Course of Physiotherapy
• Part 2 - Dry Needling & Manual Therapy

Session 1.

Identify the TrP/s, after explaining the needling process and referring to your information and consent form, answering any questions and then proceed to needling the points with consent.

Dose:

Start with the needle inserted into/ over the trigger point, not too deep with no added stimulation for 5 mins and remove. You could leave the needle in for less time eg 30 secs to im min a la Baldry. Reassess.

Session 2.

If there has been symptomatic improvement and better objective findings e.g a decrease in muscle tenderness, improvements in muscle length, power - maintain dose level for session 1. If an increase in dose is necessary, you can increase dose by leaving needle in situ for up to 10 mins with light stimulation (rotation) after 5 mins and remove. Reassess.

This is part 2 of last week's post - How I integrate Dry Needling of Myofascial Trigger Points in a course of Physiotherapy

Be aware of ‘dose’ i.e. level of sensory input applied to the central nervous system. Dry needlers are notorious for providing too high a dose during treatment due to use of very vigorous techniques. I feel there is not enough emphasis on dose control during training.

Control dose by the no. of needles used, depth, duration and level of stimulation applied i.e. gentle rotation< lift thrust

Remember dose is cumulative, be careful with needling and then doing manual therapy and exercise as all provide sensory input. If including needling in treatment, any soft tissue therapy should be very gentle and short of pain, see above, so as not to ‘over-treat’ the patient.

The dose should be carefully titrated upwards until a therapeutic response is achieved and then maintained at that level. May need to increase dose slightly if patient response starts to plateau.