Acupuncture case report and evaluation of literature: Chronic thoracic pains following a T12 wedge fracture.
Word Count: 2562
Mark : FAIL 38%
Abstract: This is a single case report detailing a holistic, effective treatment of a 35-year-old female who presented to the clinic with a four-year history of thoracic pain. The report reviews relevant literature focusing particularly on the local, segmental and supraspinal benefits of acupuncture and its complementary effect when combined with traditional physiotherapy. What were the outcomes and what validated scale did you use ? There is sufficient evidence to suggest that a similar approach to thoracic pain could be applied to a larger population if a suitable clinical reasoning model is adopted with the understanding that each case is unique and treatments adapted accordingly.
Key Words: Chronic pain, Mechanical nociceptive thoracic pain, Acupuncture
A 35-year-old female presented with a four-year history of severe constant thoracic back pain (A1) with rib referral (A2) following a T12 wedge fracture after falling from her horse. Initially she was X-rayed, prescribed anti-inflammatories and treated conservatively but was offered no physiotherapy after the event. Her symptoms had never fully resolved and she was referred to the clinic after pain had become intolerable, sleep was disturbed (3-4 times per night) and everyday function was greatly limited.
Her past medical history included a hysterectomy and she was receiving hormone replacement therapy. Medication consisted of tramadol, paracetamol and thyroxine for an underactive thyroid. There were no yellow flags or litigation considerations. Her biggest aim was to be in a position where she could ride again, which she had been unable to since the fall.
Key Subjective Assessment Findings
History of presenting condition (HPC)
- Four-year history of left thoracic pain with T12 dermatomal rib pain.
Mechanism of Injury:
- Fell 5ft off horse onto coccyx, unable to stand initially due to pain. Nil neural signs. Attended A and E.
- Screened by GP and referred into primary care physiotherapy.
Behaviour of symptoms
- Aggravating factors: Prolonged sitting, tactile stimulation, lifting her children or twisting, particularly to the right aggravated thoracic back pain. Her left sided rib pain appeared to be aggravated by twisting to the left.
- Easing factors: Thoracic pain was eased with change in position and analgesia however short term and symptoms never fully resolved. The rib pain was aggravated by left thoracic rotation.
- 24 hour pattern: Thoracic pain was reported as the main cause of sleep disturbances. Symptoms were constant, worse in the morning and eased as the day went on then increased towards the end of the day.
- Prior to the onset of her symptoms the patient had not been taking any medication. She had gradually increased medication as advised by the GP. She was now taking 6 tramadol daily and 8 paracetamol.
- She worked in finance, which involved sitting for long periods and occasionally standing. She reported that symptoms had significantly affected her work and private life and that she previously liked to run and attend the gym, which she could no longer do due to pain.
- No red flags identified.
Self reported outcome measures
- Numerical rating scale (NRS) at initial assessment: Thoracic pain: 7/10 Rib pain: 9/10.
Key Objective Assessment Findings
- Allodynia of paraspinals adjacent to T10-T12. Trigger points in bilateral rhomboids and trapezuis. Dermatomes and myotomes intact with increased sensitivity of T8-T12 segments left. Normal reflexes.
Range of motion (ROM)
- Thoracic rotation (TR) Left = 10% Right = 20%
T12 joint dysfunction (hypomobile) with subsequent bilateral facet joint inflammation was clinically diagnosed. In light of allodynia in the thoracic paraspinals it was felt that perhaps there was an element of central sensitization. An emotional component was noted taking into consideration the impact of pain and reduced function in her life. A problem list was formulated to provide a framework for management as shown in table 1.
|Problem||Physiological cause of pain||Plan|
|Allodynia of paraspinals adjacent to T8-T12.||Central sensitization therefore looking to access segmental and supraspinal mechanisms of pain relief.Dysfunction of the somatosensory pathway.||Tactile stimulation as tolerated.Acupuncture points that stimulate supraspinal opiod mechanisms for pain relief and, at a later stage, local points to increase blood flow and encourage the release of local endorphins.|
|Reduced active and passive range of movement of the thoracic spine.||Symptoms were aggravated by static positions suggesting that a postural strain on tissues may be the cause. Mechanical nociceptive pain was also a likely mechanism due to the mechanical dysfunction in the thoracic spine.||Posture re-education, muscles stretches to increase tissue length. Acupuncture points to stimulate segmental benefits of acupuncture and locally to treat the tissues directly.|
|Trigger points within rhomboids, latissimus dorsi and paraspinals.||Pathophysiology of TP’s are unknown but it is thought to be a dysfunction of the motor end plate due to excessive acetylcholine liberation (Manuel and Hernandez, 2005)||Patient education, soft tissue mobilizations including stretches, a home exercise program and dry needling have all been advocated in the treatment of myofascial pain (Manuel and Hernandez, 2009).|
|Kinesiophobia||Encourage gym activities and normal general fitness. Education on fear avoidance, pain pathways and the importance of mechanical stimulation in accordance with the acupuncture to encourage supraspinal effects.|
Clinical reasoning and underlying mechanisms
Bradnam (2003) suggested a clinical reasoning paradigm, which has been used alongside up-to-date evidence on chronic pain to choose acupuncture points based on the pain mechanisms involved. Gifford and Butler (1997) described nociceptive, neurogenic and centrally evoked pain and this classification is useful when establishing whether the clinician is intending to access peripheral, segmental and supraspinal benefits of acupuncture (Bradnam, 2007).
Due to the chronic nature of this case aims were to increase blood flow locally, to promote tissue healing and reduce ischemic pain. You tell me above there is an inflammatory component so is this inflammatory or chronic? Due to the central sensitization, which has been described as an increased excitability and/or reduction in inhibitory influences of neurons within the central nervous system (Abbott, 2001), low level intensity, peripheral stimulation was chosen to reduce sympathetic outflow in the segment (Sato et al 1997). At this stage the author felt stimulation of the four gates (Bilateral LI 4 and LIV 3) would encourage supraspinal effects such as diffuse noxious inhibitory controls (DNIC), beta endorphin mediated descending pain inhibitory pathways (Sterner-Victorin et al, 2002) and increase blood flow to the hypothalamus (Lewith et al, 2005). Further evidence suggests that manual stimulation of the four gates causes de-activation of some pre-frontal cortex and anterior cingulated cortex (Yan et al. 2005) which may assist in conditioned fear extinction and thus extinction of some chronic states (Kim and Jung, 2006). Good
At a later stage a local needle was used to provide an inflammatory reaction what do you mean by this? Surely you are producing De Qi? to increase enkephalin release, which has been shown to provide 2-3 days of pain relief (Bessen, 1999). The patient was then advised to utilize these two days to continue their home exercises program, which included thoracic joint mobilisations. These provide an immediate hypoalgesic effect, which is specific to mechanical nociception (Vicenzino et al. 1995; Vicenzino et al. 1996). This hypoalgesic effect occurs concurrently with increased sympathetic nervous system activity (Vicenzino et al. 1995; Vicenzino et al. 1998) and there is a strong correlation between the two effects (Vicenzino et al. 1998).
These findings of concurrent hypoalgesia and sympathoexcitation appear to parallel effects produced by stimulation of the dorsal periaqueductal gray area of the midbrain (dPAG) in animal research (Lovick 1991). Through the stimulation of mechanoreceptors (to produce hyopalgesia) and sympathoexcitation (through choice of acupuncture points) the author intends to stimulate the dPAG which is a primary anatomical pathway mediating opioid-based analgesia (Loyd and Murphy, 2009), thus influencing supraspinal modulation of pain.
As treatment progressed a layering approach was employed as described by Bradnam (2007). The author suggested that by increasing the number of needles, leaving the needles in situ for longer or applying greater intensity of stimulation are suitable progressions of treatment. Over stimulation of local tissue was avoided initially to reduce further sensitisation of the dorsal horn.
Local points aimed to stimulate A-Delta and C fibres (Kravis, 1997) to encourage the release of substance P and neurokinin and calcitonin gene related peptides (Weidner et al, 2000). Sensory neuropeptides modulate an immune response therefore will assist in tissue healing (Brain 1997) in addition to local inflammation prompting the release of endorphins (Carlsson, 2002).
Kubo et al (2010) found raised oxygen saturations in achilles tendons for up to 30 minutes post needling whilst using local acupuncture points. This is useful to increase blood flow to ischemic regions. By increasing oxygen saturations this may ease myofascial pain by reducing ischemia and providing adequate adenosine triphosphate (ATP) for muscle function.
As the patient began to show signs of local desensitization dry needling directly into the rhomboids was used. Hong (2000) proposed that local tenderness and taut bands (trigger points) are caused by a sustained contraction of the sacromere. Limited perfusion appears to result in decreased O2 concentration within the trigger point (Brukle, 1990), which in turn affects the efficiency of the calcium pumps. This results in a sustained increased in intercellular calcium levels and it is thought that a shortage of ATP, which serves to allow release of the myosin cross bridges, causes continuous activation of actin and myosin.
A further theory discusses that an abnormality of the motor end plates causing excessive acetylcholine levels may also cause of excessive intracellular calcium levels. The purpose of the needle is therefore to increase circulation and decrease acetylcholine levels to normalise the normal physiological function of the motor end plate and sarcomere. Insertion of needle appears to cause a localized stretch and may have an effect on straightening collagen fibres (Langevin, 2001). A pistoning action was used until the muscles relaxed and then the needle was removed.
Table 1.2 summarises the treatment dates, aims, acupuncture points and the
|Day||Treatment Aim||Rationale||Points||Additional treatment|
|1||Screen patient for contraindications of acupuncture and physiotherapy modalities: Nil noted.
Stimulation of parasympathetic nervous system.
|Stimulation of dPAG to influence opiod mediated analgesia.Stimulation of parasympathetic nervous system to reduce sympathetic outflow.||Bilateral LI 4 and LIV 3.
(20 mins in situ)
|Education on fear avoidance.Thoracic spinal mobilizations including central AP/PA GIII x 30 sec x 3 T5-T12 as tolerated. Upper trunk rotations given as a home exercise program. Posture re-education and advised to begin desensitisation via tactile stimulation as tolerated.|
|8||Provide local analgesia.Increase ROM and tissue length.
Mobilise scar tissue and collagen cross bridges.
|Stimulation of segmental benefits of acupuncture used on the opposite side to stimulate the dorsal horn and provide gate modulation of pain.Opiod mediated analgesia through the 4 gates.||Bilateral BL 16, BL 17 (T8-10)
Bilateral LI 4 and LIV 3
(20 mins in situ)
|Central AP/PA GIII x 30 sec x 3 sets T5-T12 as tolerated. Upper trunk rotations x 5 with 30 second end of range stretch applied (within pain free ranges). Upper trunk thoracic muscle energy techniques (contract/relax rotations).|
|15||Provide analgesiaImprove function of motor end plate regulation.||Dorsal horn inhibition, stimulation of dPAG through simultaneous joint mobilizations and acupuncture.
Influences on descending inhibitory pain pathways through DNIC.
|Bilateral BL 16, BL 17 (T8-10)
Bilateral LI 4 and LIV 3
(25 mins in situ)
Dry needling x 3 to left rhomboid/lower trapezius.
|Central AP/PA GIII x 30 sec x 3 sets T5-T12 as tolerated. Upper trunk rotations x 5 with 30 second end of range stretch applied (within pain free ranges). Upper trunk thoracic muscle energy techniques (contract/relax rotations). Soft tissue release and massage to increase blood flow and reduce sensitivity.|
|22||Provide segmental analgesia and continue to treat trigger points locally, improving normal muscle regulation and length.||Dorsal horn inhibition, accessing the pain gate regulation of pain.
Stimulate local blood flow to reduce myofascial pain caused by ischemia.
Prolonged length of needling to stimulate supraspinal effects.
|Bilateral BL 16, BL 17 (T8-10)
Bilateral LI 4 and LIV 3
(30 mins in situ)
Dry needling x 2 to left and right rhomboid/lower trapezius.
|Dry needling followed by ultrasound to left paraspinals T10-T12 with the following settings: 3mhz, continuous, 0.25 w/cm2 for four minutes.
Upper trunk rotations in sidelying with 1kg weight (left and right).
Pt advised to continue with home exercise program and increase repetitions of trunk rotations to 10 repetitions 4 times daily as pain allows.
|30||Maintain range of movement and provide self-management techniques in preparation for discharge.||At this stage cognitive and mood was assessed and education of future pain management and coping strategies was highlighted. The importance of long-term management was stressed and advice on pain patterning was explained to avoid relapse.||Acupressure stimulation was demonstrated and practiced under the supervision of clinician.||A hands off approach was adopted discussing future management strategies, the use of graded/weaning medication in future exacerbations and the importance of maintaining strength and range of movement.|
There is an overuse of tables in this case study. There should be no more than three and they are counted in word count
Objective measurements, results and limitations
The outcome measurements used were range of movement (ROM) of the thoracic spine (%), a numerical pain scale (NPS 1-10) and functional achievements were also noted. The patient’s main aims were to get back onto a horse and manage pain effectively with a focus of reducing pain medications. Due to NHS funding a limitation of five treatment sessions (40mins per treatment) was indicated and the patient received acupuncture, manual therapy and a home exercise program as demonstrated in table 1.2.
Overall there was a significant increase in thoracic ROM, significant reduction in the numerical pain scale and functional improvement. Due to the chronic nature of this case and sensitised pain pathways the author feels a longer course of combined traditional physiotherapy and acupuncture is needed to continue improvements.
Finance and time restraints limited the optimal effect of the treatments. As with all case reports one person’s experience often will not translate to a wider population however the principles of needling dependent on pain mechanisms may be translated to other conditions/cases.
|Treatment Day||Objective score:Post treatment||Functional Improvements|
TR: Left = 20%
TR: Left = 80%
Right = 75%
|Improved sleep.Daily activities reported ‘easier’|
TR: Left and Right = 80%
|Able to dress children.|
TR: Left and Right = 90%
|Turning in car has become easier.|
TR: left and Right =90%
|Tramadol reduced to 4 per day.|
This case report attempted to analyse and present the physiotherapy management of a patient complaining of chronic thoracic pain. A movement-based treatment has been shown effective in dealing with chronic, mechanical nociceptive pain (O’Sullivan, 2005: Dankaerts et al, 2007).
Considering critique of the research the author feels that the treatment has been effective with the subject reporting significant decreased pain and demonstrating increased ROM. This may also be associated with an expectancy and belief for pain relief (Pariente et al 2005), which has also been reported in placebo trials. A longer course of treatment may have been useful to fully resolve symptoms and utilise the layering approach (Bradham, 2007).
The author feels that perhaps the first treatment of acupuncture may have been more beneficial by a segmental approach rather than targeting an opoid based analgesia in consideration of the patient’s long-term use of tramadol.
In conclusion this case report showed that a holistic, clinically reasoned treatment approach could be used with good effect. Further research is needed with a larger population to confirm validity to a wider population.
You have not discussed the sensitivity of the SNS in this patient and what precautionary measures you would take to prevent over stimulation of CSNS at local thoracic SNS chain? Here you could have discussed the use of PSNS and the 4 gates are very strong in this type of patient.
There is no research evidence to support this case study and no critique of the research which is essential to pass this component.
References (No numbers in referencing)
- Abbott, J.H. (2001) Mobilisations with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylytis. Manual Therapy.6 (3), 170-177.
- Besson. J.M. (1999) The neurobiology of pain. Lancet 353(9164). 1610-1615.
- Bekkering R, van Bussel R (1998). Segmental Acupuncture. In J. Filshie & A. White (Eds.): Medical Acupuncture: A Western Scientific Approach, Churchill Livingstone.
- Bradnam L (2001). Western Acupuncture Point Selection: A Scientific Clinical Reasoning Model. Meridian Worldwide–Newsletter of the International Acupuncture Association of Physical Therapists 10(2), October, 9-18.
- Bradnam L (2007), A proposed clinical reasoning model for western acupuncture, Journal of the Acupuncture Association of Chartered Physiotherapists, Autumn 2007, pp: 21-30.
- Brain. S. (1997) Sensory neuropeptides: Their role in inflammation and wound healing. Immunopharmocology 37(2-3), 133-152.
- Bradham. L (2003) A proposed clinical reasioning model forWestern Acupuncture. New Zealand J. physiotherapy. 20,83-94.
- Carlsson. C. 92002) Acupuncture mechanisms for clinically relevant long term effects: reconsideration and a hypothesis. Acupuncture. Med. 20(203), 82-99.
- Dankaerts, W., O’sullian, P.B., Burnett, A.F. et al. (2007) The use of mechanism-based classification systems to evaluate and direct management of a patient with non specific lower back pain.
- Gifford, L.S., Butler, D.S (1997) The integration of pain sciences into clinical practice. J. hand therapy 10(2), 87-95.
- Kim. J., Jung. M.J. (2006) Neural circuits and mechanisms involved in Pavlovian fear conditioning: a critical review. Neuroscience. Biobehav. Rev. 30, 188-202.
- Hong CZ. (2000) Myofascial trigger points: pathophysiology and correlation with acupuncture points. Acupunct Me.d18: 41–7.
- Kubo. K, Yajima, H., Takayama.M., Ikebukuro. T., Mizoguchi, H. and Takakura. N (2010) Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Eur J Appl Physiol (2010) 109:545–550
- Langevin (2001)M, Churchill DL, Fox JR, et al. Biomechanical re- sponse to acupuncture needling in humans. J Appl Physiol; 91:2471–2478.
- Lewith, G.T., white, P.J., Pariente, J. (2005) Investigating acupuncture using brain imaging techniques: The current state of play. Evidence based complementary therapies. 2(3), 315-319.
- Lovick, T. (1991) Interactions between descending pathways from the dorsal and ventrolateml periaqueductal gray matter in the rat. In:A. Depmrlis and R. Bandler (Eds.), The Midbrain Periaqueductal Gray Matter, Vol. 213, Plenum Press, New York, pp. 101-120,
- Loyd. D.R and Murphy. A.Z. (2009) The Role of the Periaqueductal Gray in the Modulation of Pain in Males and Females: Are the Anatomy and Physiology Really that Different? Neural Plasticity. 9, 12-16.
- Manuel. F. and Hernandez. F (2009) Myofascial syndromes. Reumatol Clin. 5(S2):36–39.
- O’sullivan. P. (2005) Diagnosis and classification of chronic lower back pain:maladaptive movement and motor control impairments as underlying mechanism. Man. Ther.10, 242-255.
- Pariente J, White P, Frackowiak RSJ, et al. Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture. Neruorimage 2005;25:1161-7.
- Sterling M, Jull G, Vicenzino B and Kenardy J, (2003), Sensory Hypersensitivity occurs soon after whiplash injury and is associated with poor recovery, Pain, Vol. 104, pp: 509-517.
- Sato.S., sato. Y.,Schmidt.R.(1997) The impact of somaticsensory input on autonomic functions. Springer-Verlag. Berlin.
- Sterner- Victorin,E. (2000) Acupuncture in reproductive medicine. Goteborg university, Goteborg.
- Vicenzino, B.Wright. A.(1995) Effects of novel manipulative physiotherapy techniques on tennis elbow: a single case study. Man therapy. 1, 30-35.
- Vicenzino, B.Wright. A., Collins. D.(1996) The initial effects of cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondyalgia. Pain. 68(1) 69-74.
- Vicenzino B, Collins D, Benson H, Wright A (1998) An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. Journal of Manipulative Physiological Therapeutics 21: 448–453
- Weidner, C., Kleide, M. Rukweid, R., et al. (2000) Acute effects of substance P and calcitonin gene related peptide in human skin- a mircrodialysis syudy. J. invest. Dermatology. 115, 1015-1020.
- Yan, B., Xu. J., Wang.W., Et al. (2005) Acupoint-specific fMRI patterns in human brain. Neuroscience. Lett. 383(3) 236-240.
Marking : Postgraduate Assessment and Grading Criteria for Coursework
Little or nothing of merit
|Knowledge and Application||Demonstrates an outstanding in depth understanding of specialised /applied knowledge||Demonstrates an excellent understanding of specialised /applied knowledge||Demonstrates a very good understanding of specialised /applied knowledge||Demonstrates good-satisfactory understanding of specialised /applied knowledge||Demonstrates limited understanding of specialised /applied knowledge||Demonstrates very limited understanding of specialised /applied knowledge||Demonstrates very poor /no understanding of specialised /applied knowledge|
|Clarity and progression of argument/discussion
|Outstanding, logical progression of argument/ discussion with outstanding clarity||Excellent, logical progression of argument/ discussion with excellent clarity||Very good logical progression of argument/discussion with very good clarity||Good-satisfactory progression of argument/discussion with good-satisfactory clarity||Limited progression of argument/discussion with limited clarity||Very limited progression of argument/discussion with very limited clarity||Very poor /no progression of argument/discussion with very poor/no clarity|
|Integration, synthesis and depth of referencing/ information
|Demonstrates an outstanding level of integration and synthesis of relevant and appropriate evidence,drawing upon an outstanding range of evidence/ examples
|Demonstrates an excellent level of integration and synthesis of relevant and appropriate evidence drawing upon an excellent range of evidence/examples||Demonstrates a very good level of integration and synthesis of relevant and appropriate evidence drawing upon a very good range of evidence/ examples||Demonstrates a good-satisfactory level of integration and synthesis of relevant and appropriate evidence drawing on a good-satisfactory range of evidence/examples||Demonstrates limited integration and synthesis of relevant and appropriate evidence and draws upon limited evidence/ examples||Demonstrates very limited integration and synthesis of relevant and appropriate evidence and draws upon very limited evidence/ examples||Demonstrates very poor/no integration and synthesis of relevant and appropriate evidence and draws upon very poor/no evidence/ examples|
|Critical appraisal, critical thinking/ clinical reasoning||Demonstrates outstanding evidence of critical appraisal/critical thinking/ clinical reasoning||Demonstrates excellent evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates very good evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates good-satisfactory evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates limited evidence of critical appraisal/ critical thinking||Demonstrates very limited evidence of critical appraisal/ critical thinking/clinical reasoning||Demonstrates very poor/no evidence of critical appraisal/ critical thinking/clinical reasoning|
|Structure, level of written English and Referencing||Demonstrates outstanding structure, outstanding level of written English and completely accurate referencing||Demonstrates excellent structure, excellent level of written English and almost completely accurate referencing||Demonstrates very good structure, very good level of written English and occasional referencing errors||Demonstrates good-satisfactory structure, good-satisfactory level of written English and a few referencing errors||Demonstrates limited structure, weak level of written English and several referencing errors||Demonstrates a very limited structure, very weak level of written English and many referencing errors||Demonstrates a very poor /no structure, very poor level of written English and completely inaccurate /no referencing|
|This case study does nnot fit the criteria to pass this component. Overuse of tables and limited explanation of pain mechanism, confusion as to inflammatory of CS and points chosen have a huge impact on SNS. Little use of PSNS to reduce the SNS and no critique of available research to support the point choice or the intervention.|
|1st Marker Mark 38%
Met learning outcomes r No
Word count r within the word limit