No Pain equals More Gain!

In my private practice clients generally expect to be treated gently and specifically. Clients come to our clinic to be made comfortable not made to feel more pain. 

Current evidence supports treatment below the pain threshold (Nijs et al, 2009).

But why should treatment be below pain threshold?

A quick explanation…

Pain causes more pain; the nervous system will reconfigure in response to a persistent pain input and create more pain! (Nijs et al, 2009).

This process has been referred to as ‘wind up’  and occurs as the response of some spinal cord transmission cells becomes more vigorous (Woolf, 1996).

Further nociceptive input (on top of that arising due to injury) converging at dorsal horn may also cause increased activation of second glutamate receptors, the NMDA receptors. These previously ‘dormant’ receptors may become activated semi-permanently and contribute to the central sensitization process. Activation of NMDA receptors results in a much greater pain response to stimulation then the basic ‘AMPA’ receptor which is the first one which responds to the release of glutamate from the primary afferent nociceptive nerve (White et al, 2008).

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Acupuncture More Effective Than Local Injections for Low Back Pain

Inoue et al (2009) have shown in a randomised controlled clinical trial that repeated Acupuncture stimulation is more effective when compared to repeated local anaesthetic injection targeting ‘the most painful points’ once weekly over 4 weeks.

Two to five points were chosen, the depth was similar at 10-20 mm however the gauge of the injection needle was larger as would be expected at 0.5 mm vs 0.18mm for the Acupuncture needles.

The outcome measure was the VAS applied immediately before and after the first treatment, before each subsequent treatment and and 2 and 4 weeks following treatment with each measure showing improvements for both types of treatment but a significant difference in favour of the Acupuncture group.

The authors suggest this may be due to different mechanisms of pain suppression, however given the common use of the needle in both cases there could well be some overlap. This could be further evidence to support the notion that its not what you inject but the physiological effects of the needle itself. The advantage of ‘dry’ needling perhaps being a better ability to control dose thereby reducing the risk of over-stimulating more sensitive patients?

Acupuncture changes our Sympathetic Drive

An interesting study by Paulson & Shay (2013) confirms that Acupuncture activates the sympathetic nervous system during and after treatment. 

Their single blinded randomised descriptive study showed that those who received acupuncture to the forearm muscles (on one side) after a bout of fatiguing wrist extension exercises measured a bilateral decrease in skin resistance and distal skin temperature. There was a significant difference in outcome measures when compared to sham acupuncture or no treatment. The fact that the changes were measured bilaterally suggests central control changes, probably at the level of the hypothalamus.

The acupuncture group also measured an increase in perfusion (blood flow) but on the side of treatment only, which the authors suggest is likely to be due to a local circulatory versus central/systemic control change.

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Medical Acupuncture for Pelvic Pain?

Many would support the idea that the pelvis is crucially important as a platform to support the spine and lower limbs. It has also been suggested that in the same way a pelvic dysfunction can affect the function of the extremities, so too can extremity function or dysfunction, such as an ankle sprain, affect the normal function of the pelvis.

The pelvic girdle as a whole, including the sacro-iliac joints (SIJ) can also be a source of pain. Mark Laslett describes a series of pain provocation tests which have been validated as a means of diagnosing
pain arising from the SIJ (Laslett et al, 2003).

However true SIJ (that is joint interface) related pain is rare. If present we don't want to take the approach of compress further with support belts and 'core' exercises according to physiotherapist,
author and educator Diane Lee who is an expert when it comes to matters of the pelvis.

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Dose and Relationships, What Matters?

In the latest issue of British Medical Acupuncture Society's newsletter 'The Point' Adrian White provides a very interesting review of a presentation given at the Society's Autumn Scientific meeting.
 
The presentation was given by Petra Bauemler who works in Dominic Irnich's pain unit in Munich, Germany and discussed the findings of a mixed methods study she had recently completed look at the different approaches taken when treating neck pain.
 
In the presentation she describes how 14 patients with neck pain were treated in Argentina, China and Germany and the findings where as follows:
 
  • In Argentina patients received up to 10 needles in individualised points over 10 visits, one or twice per week. 
  • In China patients received up to 52 needles, mostly in fixed standard points and have to go for daily treatment for up to 30 visits.
  • In Germany patients receive treatment which falls somewhere in between.
 
What was interesting is that the outcome on neck pain and range of movement was the same in all three treatment settings!
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