Use of Acupuncture for Treatment of Lateral Epicondylitis
Lateral epiconylitis is a commonly encountered condition resulting from minor injury to the extensor muscles of the forearm, which originate from lateral epicondyle of humerus. This condition is characterized by pain and tenderness over the lateral epicondyle of humerus. Pain is typically present upon the resisted dorsiflexion of the wrist, middle finger or both (Buchbinder, Green & Struijs, 2007).
Lateral epiconylitis is known by many analogous terms like tennis elbow (TE), rowing elbow, tendonitis of the common extensor origin, peritendonitis of the elbow etc. In the United Kingdom, the incidence of tennis elbow in general practice has been estimated to be about four to seven per 1,000 persons a year (Buchbinder et al). Though TE is a self-resolving condition its symptoms can persist for as long as 18-24 months. Pain of tennis elbow can interfere with normal day to day functioning like carrying objects, lifting and gripping things etc.
Though pain of TE can be initially cured with various conservative treatment modalities and rest, it can frequently recur after resumption of activity. Thus TE can cause significant amount of chronic pain and disability, which can lead to considerable morbidity and financial cost (Buchinder et al, 2007). Thus there is a need for an efficient treatment modality for TE.
Till date, physicians and physiotherapists are uncertain about the exact etiology and best management option for patients with TE. There are several conventional therapies which are being used for treatment of TE. These therapies are believed to relieve pain, promote tissue healing and improve joint mechanics. These conventional therapies include anti-inflammatory medicines [NSAIDS (non-steroidal anti-inflammatory drugs) and corticosteroids], physiotherapy interventions (such as stretching and strengthening exercises), cast immobilization, ultrasound therapy, using ice packs, neural stretches, deep friction massages, surgery etc (Trinh, Philips, Ho & Damsma, 2004). Various non conventional therapeutic modalities like acupuncture, pulsed electromagnetic field therapy, transcutaneous electric nerve stimulation etc have also been used for treatment of TE.
In 1992, Labelle et al attempted to perform a quantitative meta-analysis in order to evaluate the therapeutic effectiveness of above mentioned treatment modalities (both conventional and non-conventional) for patients suffering from TE. They considered the results of 18 clinical trials conducted in the period from 1966 to 1990. From their analysis they concluded that the various randomized and controlled trials, which they had analyzed, were of poor quality and did not provide sufficient scientific evidence to support or oppose the therapeutic benefit of any of these conventional or non-conventional treatment modalities. Labelle et al (1992) did find some weak evidence supporting the beneficial effect of ultrasound therapy in comparison to that of placebo therapy in treatment of patients with TE.
More recently, a systematic review of the literature, comprising of randomized controlled trials evaluating the effectiveness of various treatment options for TE was carried out by Assendelft, Green, Buchbinder, Struijs, & Smidt, (2003). They have suggested significant beneficial effect of NSAIDS (both topical and oral) in comparison to placebo in the providing short term relief from pain in patients with TE. However they found little evidence regarding the beneficial effect of NSAIDS (both topical and oral) in providing long term pain relief. While the use of topical NSAIDS was not found to be associated with significant side effects, use of oral NSAIDS, typically aspirin was associated with significant side effects like gastro-intestinal bleeding etc.
This review found limited evidence regarding the beneficial effects of steroid injections in comparison to placebo, local anaesthetic agents, elbow strapping or physiotherapy. Assendelft et al also found insufficient evidence to support long term or short term beneficial effect of treatment modalities like acupuncture, physiotherapy exercises, orthoses (elbow strapping), extra corporeal shock wave therapy and surgery.
They have recommended long term use of oral and topical NSAIDS and physical therapies (elbow strapping, physiotherapy, etc and avoidance of provoking activities as the first line of treatment, especially in the early stages of the disease. They have also suggested the use of corticosteroid injections as second line therapy for providing relief from pain. However the pain relief provided by corticosteroids is usually temporary in nature with the pain recurring again after a few months. Thus they have suggested that the patients receiving such therapy should be counselled about not subjecting the extensor muscles to increased activity during the pain-free period resulting from use of corticosteroid injections.
On the other hand, Bisset, Paungmali, Vicenzino, Beller, & Herbert, (2005) from their systematic review of literature, comprising of studies evaluating the effectiveness of various physical interventions (non – pharmaceutical or non-surgical therapeutic modalities) for treatment of TE have shown short term benefit with the use of physical interventions like ultrasound therapy, ionisation, and acupuncture.
However no evidence of long term benefit due to these therapeutic modalities was observed in this review; benefit due to these interventions was usually seen to last between two to eight weeks. Bisset et al observed insufficient evidence regarding the beneficial effect of manual therapy (involving manipulation of elbow or cervical spine), use of elbow strapping and physiotherapy exercises in the management of TE. They also observed the presence of sufficient evidence that disapproved the beneficial effect of extracorporeal shockwave therapy and laser therapy in the treatment of TE (both in short term and long term). However they have indicated the requirement of larger studies in future in order to confirm this finding.
Since no clinical study till date has been able to demonstrate definite clinical efficacy of any conventional therapeutic modality in treatment of TE, there has been increasing trend towards the use of non-pharmacological treatment modalities, especially acupuncture, since last two decades, for alleviation of chronic pain due to TE. One major advantage of using acupuncture for treating pain of TE over the conventional anti-inflammatory drugs like NSAIDS (oral or topical), corticosteroids etc is that it is free from the numerous deleterious side effects commonly associated with the use of these drugs.
Also the evidence supporting the use of these conventional pharmacological interventions is no better than that supporting acupuncture [National Institute of Health (NIH), 1998]. Despite the growing popularity of acupuncture in treatment of pain related to lateral epicondylitis, presently, there is little evidence which confirms the efficacy of acupuncture in treatment of tennis elbow. The studies conducted until now have produced conflicting results. Bisset et al (2005), in their systematic review of literature considered four studies evaluating the therapeutic effect of acupuncture in treatment of TE.
Three studies out of these four compared acupuncture with placebo whereas one study compared acupuncture with ultrasound. The overall evidence considered in this review supports short term beneficial therapeutic effect of acupuncture over placebo in patients with TE. Two studies, (Fink, Wolkenstein, Karst, & Gehrke, 2002; Molsberger & Hille, 1994) which compared acupuncture with placebo are described below in details.
Fink et al (2002) conducted a study to evaluate the clinical efficacy of acupuncture in treatment of TE. They also tried to compare the therapeutic effects produced by stimulating selected acupuncture points (as defined by traditional Chinese acupuncture) in contrast to those achieved through stimulation at non-specific points (these puncture points were at least 5 cm away from the traditional Chinese acupuncture points).
The results of this study indicated that use of acupuncture with correct location and stimulation, in accordance to the recommendations of tradition Chinese acupuncture helped in significantly alleviating the pain, reducing disability of arms, shoulders and hands (measured through DASH questionnaire) and improving the strength of the extensor muscles in the patients suffering from TE. However these therapeutic effects (pain relief and muscle strength) of acupuncture were less evident in long term. In this study, at the time of follow-up after two months, though the overall functioning of the arm was observed to be better in the treatment group as compared to the control group, the differences in pain intensity and muscle strength were no longer found to be significant.
The main aim of the study by Molsberger & Hille (1994) was to find out whether acupuncture showed an intrinsic analgesic effect even after only one treatment session in comparison to that of placebo treatment for TE pain. In one single session of acupuncture treatment, patients in the treatment group were treated at a non-segmental distal point on the fibulo-tibial joint of the homolateral leg. The painful area of the elbow itself was not needled.
The depth of insertion was 2 cm and during the procedure of needling, the patient was asked to move the painful arm. Patients were treated for a total of 5 min. Overall reduction in the pain score was 55.8% in the treatment group and 15% in the placebo group. After one treatment session, 79.2% (19 patients out of 24) patients in the treatment group reported pain relief of at least 50%, whereas in the placebo group only 25% patients (6 patients out of 24) reported pain relief.
The average duration of analgesia after one treatment was 20.2 h in the treatment group whereas that after placebo was 1.4 h. All these results show that acupuncture has a statistically significant intrinsic analgesic effect in the clinical treatment of TE pain, which exceeds that of placebo treatment. Since this study dealt with short term analgesic effects of acupuncture, further studies need to be carried out in future in order to evaluate the long-term therapeutic value of acupuncture for treatment chronic tennis elbow.
Davidson et al (2001, cited in Bisset et al, 2005) conducted a study to compare the therapeutic effect of acupuncture with that of ultrasound treatment in patients suffering from TE. Though significant improvement in two outcome measures i.e. pain reduction and disability prevention were observed in both the groups, no statistically significant differences in terms of these outcome measures were observed between the two groups.
Thus this study indicates that there is no difference in therapeutic benefit between ultrasound and acupuncture in patients with TE. However it is difficult to reach to any definite conclusion from the results of a single study. More studies are required in future in order to arrive at a definite conclusion.
In a publication by the NIH in 1998, it was determined that the results of various studies conducted till date has been promising enough to support the use of acupuncture as an adjunct treatment or an alternative to classical conventional therapeutic modalities for patients with TE. Trinh, et al (2004) conducted a systematic review of literature regarding use of acupuncture in treatment of TE, using the best evidence synthesis approach (BESA), which aimed at qualitative analysis of clinically homogeneous studies.
The results of this review strongly suggested that acupuncture was an effective therapeutic modality for attaining short-term pain relief in patients with TE. Though there was a great deal of clinical heterogeneity between various studies considered in this review, five studies out of six studies considered in this review indicated that acupuncture treatment was more effective compared to placebo treatment.
The studies conducted till date have failed to provide us with definite results. This can be attributed to a variety of factors like: flaws in study design, heterogeneous treatment protocols, small sample size, inherent difficulty in the use of appropriate controls etc (NIH publication, 1998). Selection of method for performing the procedure in control group for these studies poses to be a difficult problem.
Method of performing the procedure in control group is important because the insertion of placebo needles itself results in inherent analgesic effect due to release of local β-endorphins (opioid like substances), which can influence the outcome of the study too (NIH publication, 1998). Future research is recommended to resolve the issues discussed above. Thus there is a need for large scale, well-designed, multicentric, randomized control trials in future that will use standardized treatment protocol and appropriate methods for performing the procedure in controls.
It is evident from the above discussion that various studies which aimed at assessing the efficacy of acupuncture in treatment of TE had employed different processes for performing acupuncture, in terms of location of puncture points, depth of insertion of needles, the number of needles used, duration of treatment etc. In order to arrive at a definite conclusion regarding the efficacy of acupuncture in treatment of patients with TE and in order to maximize the chances for a successful treatment with acupuncture, there is a need for a uniform, accurate and complete description of the most effective method to be used for performing acupuncture in patients with TE.
With this in mind, Webster-Harrison, White & Rae (2002) conducted a study in order to develop a standardized treatment protocol for acupuncture therapy in patients with TE. They adopted a modified Delphi’s consensus technique to combine the opinions of fourteen British acupuncture experts into a standardized treatment protocol. This protocol contained eight items pertaining to the treatment of TE using acupuncture and has been described in table 1. The various items considered in this protocol were: selection of acupuncture points; length and diameter of needles used; depth of insertion; duration of treatment; interval between successive treatments; whether the needle should be stimulated or not; the type of response to be achieved upon stimulation and number of treatment cycles needed. Use of this protocol in randomized multicentric trials conducted in future is likely to give accurate results (Webster-Harrison et al).
From the discussion in this paper it becomes apparent that till date no study in published literature has been able to demonstrate long term beneficial effects of any pharmacological, surgical or physical therapy in comparison to that of a placebo therapy for treatment of patients with TE. Among various non-pharmacological therapeutic options, acupuncture presents an effective and safe adjunct treatment or an alternative to classical conventional therapeutic modalities, especially in cases where these conventional therapeutic modalities had previously failed (NIH, 1998).
Presently, the optimal treatment option for patients with tennis elbow in clinical care largely remains unclear. Acupuncture appears to be a lucrative treatment option for both clinicians and patients. However, the therapeutic benefits provided by use of acupuncture are not supported by sufficient evidence, at present. There is a need for well designed, high quality research studies, especially randomized control trials in future, in order to help in establishing the appropriate place for acupuncture in treatment of patients with TE in modern medical practice.
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