A Case Report - by Simon Coghlan MSc BSc(Hons) Physio DipMedAc MISCP BMAS
This case was selected from patients seen in an urban private physiotherapy practice.
Note on use of the visual analogue score (VAS)
A 10cm line was used, blank apart from ‘0 No pain’ at one end and ‘10 Worst imaginable pain’ at the other. Patients made a mark on the line corresponding to their level of pain on average over the preceding week. The line was measured using a ruler to give a score out of 10. A new, blank score sheet was used each time.
An acupuncture based approach has been used to treat patients suffering from whiplash following motor vehicle accidents (MVA), and is considered to be effective in relieving the associated signs and symptoms.1
AJ, a 16 year old scholar, presented with a two week history of bilateral neck and upper thoracic pain and stiffness. This was aggravated by prolonged immobility, especially if in a poor posture e.g while at school or travelling in a car. Her sleep was disturbed by pain associated with changes of position. There were occasional headaches felt as ‘dull pressure’, mainly through a bilateral occipital and temporal distribution. She found it difficult to concentrate due to the headaches with an average VAS of 6 given. There were no symptoms suggesting vertebro-basilar artery insufficiency, radiculopathy, or upper cervical instability.
AJ was involved in an MVA two weeks previously. She was a passenger in a stationary car impacted from the rear. Her neck began to feel stiff almost immediately and was taken to a local hospital that day. X-Rays excluded any bone injury. She used a cervical collar provided for approx 8 hours before discarding it as being more of a nuisance than a help. A course of Aulin (nimesulid) was prescribed for five days. She was also advised to seek physiotherapy treatment which brought her to the clinic.
AJ is a sporty person who plays hockey, tennis as well as cricket. She had no medical history and had not suffered any previous musculo-skeletal injuries of any significance.
There was a general increase in tone within the cervical and periscapular muscles including the upper trapezius, levator scapulae, semispinalis capitis (upper), infraspinatus and pectoralis minor all bilaterally. Exquisitely tender latent trigger points (TrP’s) were found in the infraspinatus muscles (closely corresponding with SI11) bilaterally. The reproduction of her familiar bilateral headache could be reproduced by palpation of active TrP’s within the upper trapezius (corresponding with GB21), and semispinalis capitis (in the region of GB20 and BL10). She was tender on postero-anterior pressure over the spinous processes of C6-T3. There was an associated postural deformity with an exaggerated upper thoracic kyphosis with elevated and protracted scapulae. Her cervical movements were painful and stiff towards end range rotation and side flexion on both sides. Shoulder movements were limited into elevation by scapular dyskinesis associated with altered periscapular muscle activity.
AJ’s familiar pain was brought about by palpation of irritable active TrP’s, with latent TrP’s within the myofascial tissues also present. As such it was considered the pain and restriction in joint range was most likely due to trauma induced myofascial dysfunction.1
Due to the presence of active TrP’s, a treatment plan consisting of a combination of acupuncture, gentle stretching and postural retraining exercises was discussed. Principles of point selection would focus on needling the TrP sites2 located on assessment which in this case closely corresponded with local acupuncture points. These would include GB21, GB20 and SI11. GV14 would also be used as a local tender point. The inclusion of a distant point LI4, a point used ubiquitously to moderate pain and considered to be a point of special action according to Chinese principles,3 would be used if tolerated. A course of six sessions was suggested initially but explained that from experience with this sort of condition, progress can vary significantly on an individual basis. These sessions would take place on a weekly basis. Treatment would be progressed by increasing the number of needles, increasing retention time, or increasing the level of stimulation by adding manual manipulation of the needles if necessary. This approach would be reconsidered if there was no improvement after four sessions, with at least three having been given at an ‘optimum dose’ i.e. the maximum level of sensory input to the nervous system without causing aversive pain or a significant reaction to treatment. It was explained that some minor adverse reactions such as dizziness, sedation, bruising or treatment soreness may occur. The risk of pneumothorax was mentioned, but assured the incidence of this was low and could be theoretically avoided using safe needling techniques.(4)
As well as acupuncture, postural stabilisation exercises would be included in her treatment.
Outcome measures would be a change in the VAS, and physical assessment of range of movement. Full consent was obtained from AJ and her mother who sat in with us at each session.
To limit infection risk, standard hygiene practice was followed as well as single use, sterile and disposable Vinco (30mm x 0.20mm) needles unless otherwise stated. On removal these were disposed of in a sharps box for incineration.
Treatment and Results
TrP’s at GB21 were needled bilaterally, these were needled to a depth of 1 cm. AJ was apprehensive at first but soon relaxed as I was able to insert the needle with little discomfort. Care was taken to angle the needle correctly so as to avoid potentially penetrating the apical pleura of the lungs which are also exposed between the first and second rib. Manual stimulation was minimal, but sufficient to elicit de qi. A wheel and flare response was noted. The needles were left in situ for three minutes and then removed. AJ reported no increase in pain symptoms or other adverse reactions immediately following treatment. A gentle stretch to the upper trapezius muscles was given as well as exercises to recruit the lower trapezius4 and deep neck flexors6 which function as postural stabilisers.
On follow up, AJ reported being aware of the area needled for a few hours after session 1. She mentioned being able to turn her head more freely, and her headache intensity had reduced. Her pain on the VAS had reduced to 5. On assessment reduced pain at the end range of cervical movement was reported. Due to the positive response, the treatment above was repeated followed by a review of the exercises.
A similar response was reported following session 2. The VAS had reduced to 4 with a further reduction in pain reported on end range cervical movements. Treatment was progressed by including further acupuncture points, needled bilaterally and increasing retention time. Other local points used in addition to GB21 (now retained for 10 minutes) included the following:
GB20: Needled bilaterally to 1,5cm with correct angulation towards the opposite eye. Care was taken not to needle too deeply due to proximity of vertebral artery (40-60mm in average adult, likely to be less for adolescents). No added stimulation was given. De qi was felt locally along with some headache referral. Needling duration was ten minutes.
SI 11: Needled bilaterally to depth of 1.5cm, with no added stimulation. Care was taken to avoid needling through the infraspinous foramen. Local de qi was felt along with some mild non familiar sensation to the anterior aspect of the shoulders. The needles were retained for ten minutes.
GV14: Needled to depth of 1cm. Minimal sensation was reported. As such the needle was manually rotation to elicit de qi. Needle duration was ten minutes. Care was taken to avoid deep penetration as spinal cord and dura are accessible at this point.
LI4: Needled to a depth of 1cm, a good local de qi response was obtained with no added stimulation required. Care was taken to avoid the palmar branch of radial artery by angling the needle perpendicularly.
On removal of the needles, AJ reported no increase in pain symptoms or other adverse reaction. Her postural stabilisation exercises were then checked and progressed
Sessions 4 – 8:
This treatment approach was continued for the following five sessions continued at weekly intervals. On reassessment at the beginning of each session her pain on the VAS and at end range cervical range of movement had shown improvement. In order to maintain a comfortable de qi sensation it was necessary during the course of treatment to manually manipulate the needles (using a gentle rotation technique) to increase the level of stimulation. Only mild stimulation was required which suggested AJ was sensitive to needle stimulation. On occasion a small local twitch response was noted, usually at GB 21 on both sides, this however was not deliberate. AJ never reported to be in any real discomfort and was pleased by the beneficial effects of the needles. Her exercises were progressed at each session.
After eight sessions full pain free cervical mobility had been restored. AJ’s headaches had subsided with a VAS of 0. Her TrP activity had also resolved, with no local or referred pain on palpation. She was able to return to sport and had no problems at school. She was discharged and asked to call if any further problems arose.
White & Ernst7 have carried out a systematic review of randomised controlled trials of acupuncture for neck pain. Twenty four studies were included having met predefined inclusion and exclusion criteria. There were five sham controlled studies, one was positive and four were negative, however the trials seemed highly heterogeneous, with the origin of pain either being muscular, skeletal, neuropathic or a combination of these. On the basis of these findings it was concluded there was insufficient evidence at this stage to support the use of acupuncture in neck pain over sham acupuncture, or other types of controls. From clinical experience the response to acupuncture is likely to be very different depending on the nature of the condition, with pain arising from TrP’s likely to respond more favourably to needling8 as in the case of AJ. As such, on the basis of heterogeneity, I would find the results of this systematic review of little clinical relevance.
When searching for evidence to support the use of acupuncture in whiplash, I was initially pleased to find a trial by Irnich et al 10 which included the terms ‘whiplash’ and ‘TrP’s’ when diagnosing and sub-classifying those with neck pain taking part in the trial. The subjects were divided into two groups, one considered to have pain arising from whiplash, and the other with pain arising from TrP’s. There was no mention of how many subjects suffering from whiplash may also have had TrP’s or vice versa. Furthermore the treatment techniques in the treatment groups were very varied and included needling at TrP sites, points chosen according to traditional Chinese medical principles and auricular acupuncture. This therefore became another example of a study which I found confusing on the basis of insufficient information regarding diagnosis and further highlights the need for properly homogenised clinical trials. The different styles of acupuncture used would make the results difficult to interpret, especially if trying to argue for a specific effect which may be dependant on needle placement at TrP sites.
A systematic review by Cummings & White8 assessed the effects of needling (wet and dry) specifically for myofascial pain arising from TrP’s. This would be a good example of a homogenised review. In this case improvements were considered to be independent of what substance was injected, with dry needling being as effective as wet needling. Those suffering from whiplash often seem to develop TrP’s which may result in some or all of the pain complaints.1 This review, although not considering a whiplash diagnosis specifically, would support the use of dry needling in this condition considering how often TrP’s seem to develop.
However as Baldry points out, even though whiplash dysfunction may be primarily myofascial it is also important to consider facet joint damage, possibly resulting in upper cervical instability, as well as intervertebral disc damage as contributing factors in whiplash patients.9
In terms of how to approach needling a TrP, for example in the upper free border of trapezius (usually coinciding with GB21), a number of needling techniques have been proposed by various authors. Hong,10 and Chu11 both advocate the use of a more aggressive technique involving a rapid lift and thrust or vigorous fanning aimed at eliciting ‘twitch responses’ from the muscle. In my own practice I have used this technique to good effect but have found it necessary only with those not responding to gentler forms of needling. I have made the mistake of needling some patients, particularly those who are sensitive, too aggressively with the result being much treatment soreness and little overall improvement. In AJ’s case, given her age and general sensitivity it would have been inappropriate to deliberately elicit twitches using the rapid lift and thrust technique.
I was pleased AJ responded well to treatment, with no adverse reactions. One could also argue that given the amount of time involved there may have been a degree of natural remission, especially given her age.
1. Baldry PE. Whiplash injuries. Acupunct Med 1996 XIV(1):22-28.
2. Simons DG, Travell JG, Simons PT. Travell & Simons’ myofascial pain & dysfunction. The trigger point manual. Volume 1. Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999.
3. Deadman P, Al-Khafaji M, Baker K. A manual of acupuncture, Hove, East Sussex: Journal of Chinese Medicine Publications; 1998.
4. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32000 consultations with doctors and physiotherapists. BMJ 2001;323:485-486.
5. Brukner P, Khan K. Clinical sports medicine. 3rd ed. Australia: McGraw Hill; 2006.
6. Jull GA. Deep neck flexor muscle dysfunction in whiplash. J Musculoskelet Pain 2000;8:143-154
7. White AR, Ernst E. A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatol 1999;38:143-147.
8. Cummings TM, White AR. Needling therapies in the treatment of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82(7):986-992.
9. Baldry PE. Acupuncture, trigger points and musculoskeletal pain. 3rd ed. Edinburgh: Elsevier Churchill Livingston; 2005.
10. Irnich D, Behrens N, Molzen H. Randomized trial of acupuncture compared with conventional massage and ‘sham’ laser acupuncture for the treatment of chronic neck pain. BMJ 2001;322:1574-1577.
11. Hong C-Z, Simons DG. Lidocaine injection versus dry needling to myofascial trigger points. Am J Phys Med Rehabil 1994;73:256-263.
12. Chu J. Does EMG (dry needling) reduce myofascial pain symptoms due to cervical nerve root irritation? Electromyogr Clin Neurophysiol 1997;37:259-272.