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.
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.
She went on to mention how she was concerned about the harmful side effects of conventional medication in the treatment of this condition. It was later discovered that this concern is common among patients, which might explain why more are looking to more ‘natural’ treatments such as acupuncture.1 In further discussion with her, I mentioned how large numbers suffering from functional bowel disorders have used some type of complementary or alternative therapy, the most popular being Traditional Chinese Medicine (TCM), which would often include acupuncture.2 On the basis that Mrs. P had responded positively to electroacupuncture (EA) for her hip pain, we discussed a trial of treatment for her IBS symptoms.
The typical symptoms relating to irritable bowel syndrome were present.3,4 This included abdominal discomfort associated with intermittent cramps/spasms which she felt in the mid/upper abdomen. There was some associated nausea and she reported feeling constipated with no bowel movements over the last two days. She also reported not having an appetite over the last few days and was restless at night because of the discomfort.
The current exacerbation had been present for three days and was not settling. She reported suffering from regular bouts of IBS symptoms, associated with changes in bowel function, for up to two weeks every couple of months. Mrs. P had an anxious disposition and reported feeling under a lot of stress recently. She felt this may have been responsible for the recurrence of her IBS type symptoms. She had consulted her GP who confirmed that this was another bout of IBS and had suggested Paracetamol as needed for symptomatic relief. She reported having tried anticholinergic/antispasmodic medication in the past but this had not been well tolerated.
Mrs. P had a right total hip replacement three years previously and was otherwise in good general health.
Although abdominal examination is usually reported to reveal no abnormality, with no somatic hypersensitivity to pain,4,5 Mrs. P was tender over the abdominal wall to moderate pressure palpation of the musculature overlying the transverse and lower part of the descending colon. Although the musculature was generally tender, no focal trigger point (TrP) activity within segmentally related muscle tissue could be located.
Mrs. P was suffering from a bout of IBS as diagnosed by her GP, and was in accordance with the Rome 11 classification criteria as having the type with constipation predominant.4 It has been recognized that psychosocial factors may also have an etiological role in the development and recurrence of IBS,5 which may be relevant with regard to Mrs. P’s history.
The tenderness over the musculature of the abdominal wall may have been a result of a viscero-somatic sensitisation effect as described by Travell & Simons.6
A graded multi component approach has been recommended depending on dominant symptoms, severity and psychosocial factors.4 In addition to simple analgesia, the use of EA would be trialed to determine whether the duration of the current episode could be reduced from the normal two weeks. As such, duration of symptoms was the main outcome measure as opposed to the symptom severity on this occasion.
It was decided to select acupuncture points based on the autonomic sympathetic and parasympathetic segmental innervation of the large intestine. The points included were ST21 and ST25 bilaterally (which also corresponded with areas of overlying muscle tenderness), as well as SP6 and LV3 bilaterally. These points were included in a clinical trial by Schneider et al7 with positive results, and also correspond with points used to treat IBS according to Traditional Chinese Medicine (TCM).8 The above points were supplemented using the Cefar ®Acus 4 Electro acupuncture device with a frequency alternating between 2Hz and 80Hz (programme 5).9
EA had already been used to treat her right hip pain, as such Mrs. P was familiar with the sensation and the use of the device. The possibility of minor adverse reactions including bruising, sedation, dizziness and drowsiness post treatment was again discussed, however none of these had occurred previously. There had also been very little post treatment soreness. To avoid the risk of infection, sterile disposable needles were used.
Considering Mrs. P was now three days into what is normally an episodic bout of IBS, usually lasting approximately two weeks, treatment frequency was set at three sessions during the first week. Duration would be 20 minutes per treatment. The treatment dose (level of sensory input to the central nervous system) would be increased by increasing the intensity level of the EA, but remaining within non aversive limits over the course of the treatment.
The intention of treatment was to determine whether a short course of alternating frequency, relatively high dose (as determined by level of stimulation) treatment could provide symptomatic relief during an acute bout of episodic IBS.
Vinco (40mm x 0.22mm) needles were used unless otherwise stated.
Treatment and results
(Monday): Mrs. P was positioned comfortably in supine with the abdominal area and lower legs exposed. The following points were needled.
ST21: Using CV12 as a reference point (mid way between the centre of the umbilicus and the lower border of the sternum), ST21 is located 3cm lateral of CV12. This point was needled bilaterally with the abdominal musculature being more tender on the left side. Needle penetration was approximately 3cm at an angle of 45 degrees allowing a real depth of approximately 1.5cm. The needle was angled towards and just penetrating the rectus abdominus fascial sheath (determined by the end feel of the needle). Care was taken not to needle too deeply. No added stimulation was given at this stage.
ST25: Located 3cm lateral to the naval as a reference point, the point was needled in exactly the same manner as ST21 above. Again this point was more tender on the left side. No added stimulation was given at this stage.
SP6: Needled bilaterally to a depth of 1cm. Care was taken to avoid the deeper posterior tibial vessels, and cutaneous branches of the great saphenous vein. No added stimulation was given at this stage.
LV3: Needled bilaterally to a depth of 1.5cm. Care was taken to avoid superficial vessels which were located in this area. No added stimulation was given at this stage.
The electrodes of the Cefar Acus4 device were then clipped to the needles just below the hilt to avoid contact with and possible contamination by the skin. Using programme 5, a setting already familiar to Mrs. P, she was handed the device and asked to increase the intensity to a strong but non-aversive level. She was asked to sustain this level of stimulation for the duration of the 20 minute treatment session by increasing the intensity level if required. During the course of treatment Mrs. P was supervised.
Sessions: 2 & 3
(Wednesday) and 3 (Friday): These sessions took place one day apart, with a total of three sessions in the first week. There had been no adverse reactions following session 1. The treatments were repeated as for session 1.
(Monday): There had been no change in symptoms following session 1, 2 and immediately following session 3. However, by session 4 the following Monday, a significant improvement was reported over the weekend with the symptoms having ‘almost settled completely’ by Sunday evening. The treatment was repeated as per sessions 1, 2 and 3.
Mrs. P was originally due to be reviewed on the Wednesday (two days later), however she re-booked for the Friday instead, bringing the interval to 4 days. Her reason for this was that she had been in no discomfort for the duration of the week. The treatment was repeated for the last time, following which she was advised to monitor her condition.
It would seem that in this instance, the use of regular, relatively high dose EA was effective in providing symptomatic relief of an acute bout of IBS. This was concluded on the basis that her symptoms had settled at least one week sooner with EA treatment than would be normal given her reported history. On the basis of this, it was suggested that should the need arise, this form of treatment may be of benefit to her in the future. A similar result was achieved by Chan et al,10 however this study did not contain a control group, therefore conclusions are limited.
The outcome measurement used in this case study was the duration of symptoms. On further review of the literature relating to IBS, other outcome measurements such as the quality of life (QoL)11 score, or the IBS symptom severity score (SSS)12 could have been included.
When considering the evidence to support the use of acupuncture for the treatment of IBS, a systematic review by Lim et al13 discussed the increasing use of acupuncture and other complementary therapies for treating IBS. However the poor quality trials showed better results and the better quality trials showed no clear evidence in support of the use of acupuncture. Overall the conclusion was there is no clear evidence to support its use. However many of the studies reviewed showed similar results (often both improving) for both the true acupuncture and ‘sham’ acupuncture groups. This would lead this practitioner to conclude that acupuncture may be effective for the treatment of IBS, and furthermore that with respect to this condition at least, ‘sham’ acupuncture may not be relevant.
The extent of the physiological effects taking place in the true and ‘sham’ acupuncture groups may be debated. In a study by Schneider et al,11 true acupuncture (TA) was performed at 15 acupuncture points chosen according to TCM and including the points used in this case study. The sham acupuncture (SA) group received treatment using a blunted, telescopic needle (Streitberger needle). This simulates an acupuncture procedure without penetrating the skin, and was performed at points 2cm adjacent to the TA points. It was found that although both groups responded to TA and SA almost equally, the needle specific physiological effects responsible for the improvement of the TA group were different from those in the sham acupuncture group. This included a decrease in salivary cortisol in both groups but greater in the TA group. There was also an increase in parasympathetic tone in the TA group only, resulting in a reduction in heart rate and positively correlated with improvements in pain. The results of this study reveal specific needle effects which cast further doubt on the concept of ‘sham’ acupuncture and its use as a credible control treatment.
In a recent pilot study by Reynolds,14 acupuncture plus usual GP care was compared with usual GP care alone i.e. a controlled trial but not using sham acupuncture for the treatment of IBS. The group receiving acupuncture and usual GP care showed a more significant reduction in the IBS SSS. What was interesting however, is that the acupuncture techniques used were adapted from a pilot study for depression and neck pain.
In conclusion, acupuncture seems to be effective for the treatment of IBS in some cases, this may not be necessarily dependant on point specificity and level of stimulation. From a physiological point of view, the effects may be different according to where the needle is placed and how it is stimulated, however the end result may be beneficial to those suffering from IBS symptoms.
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