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sports
medicine
ACUPUNCTURE
AND SPORTS MEDICINE
A Review of Published Studies
Alec Meleger, MD
Joanne Borg-Stein, MD
ABSTRACT
Acupuncture
is frequently used as a treatment for acute and chronic sports injury.
There is a paucity of large, randomized controlled trials of efficacy.
This article reviews the available medical literature of acupuncture
treatment in lateral epicondylitis, patellar tendonitis, plantar fasciitis,
frozen shoulder, and osteoarthritis. Studies of lateral epicondylitis
suggest that acupuncture is superior to placebo. Inadequate data are
available to draw definitive conclusions about the efficacy of acupuncture
in the other diagnoses. There is a need for larger controlled trials
of acupuncture for most sports medicine musculoskeletal diagnoses.
KEY WORDS
Acupuncture,
Sports Medicine, Tendonitis, Osteoarthritis, Epicondylitis, Plantar
Faschtis, Review
INTRODUCTION
Acupuncture is one of several disciplines
extracted from a complex heritage of Chinese medicine that also include
herbal medicine, breathing exercises, manipulation, and stretching.
Not until the 1970s did a renewed interest in Chinese medicine resurface
in the United States. At present, complementary or alternative health
care is very popular and is the focus of substantial attention by the
general public as well as health care providers. In a national survey
of adults, Eisenberg et al1
found that I in 3 respondents (34%) used at least 1 unconventional therapy
in 1990, mostly for common medical conditions. The total number of visits
for "non-traditional" care was estimated to be 425 million in 1990,
which exceeded the number of visits for all primary care physicians
(388 million).1
Musculoskeletal disorders are among the most
common conditions for which patients seek help. The same is true when
patients turn to alternative medicine for the relief of pain and maintenance
of their mobility. Various surveys have shown that musculoskeletal conditions
are one of the most common reasons people present to an alternative
medicine provider.1 - 3
A
number of studies have been published dealing with the efficacy of acupuncture
in treating various musculoskeletal conditions. The purpose of this
clinical review is to assess the strength of evidence of acupuncture's
effectiveness in the treatment of diagnoses commonly encountered in
sports medicine and outpatient musculoskeletal practice.
METHODS
To identify previously published studies,
an extensive MEDLINE search was undertaken covering the period
from 1966 to September 1999. The following key words were used: acupuncture,
orthopedics, athletic injuries, musculoskeletal, soft tissue injuries,
occupational diseases, cumulative trauma disorders, tendonitis, bursitis,
sprains, strains, sports. The search was limited to articles featuring
human subjects; all languages and expenmental designs were included.
Published letters, comments, and reviews of treatment were excluded.
A total of 13 studies were identified for inclusion.
RESULTS
Lateral Epicondylitis
Lateral
epicondylitis, or tennis elbow, is an overuse syndrome involving the
region of the lateral epicondyle. Most commonly, the origin of extensor
carpi radialis brevis is involved. Patients experience pain and tenderness,
especially with resisted wrist extension, in the region of the lateral
epicondyle. Two randomized controlled trials, 2 controlled trials, and
1 case report series were identified.
Randomized Controlled Trials
Haker and Lundeberg4
examined whether patients with lateral epicondylitis receiving real
acupuncture fared better than patients receiving sham acupuncture (a
procedure designed to mimic real acupuncture using the same acupuncture
points but with more of a superficial needle insertion). Eighty-two
of the initial 86 patients completed the study. Range of symptom duration
in the intervention group was 1-60 months (median, 7 months); control
group range was 1-120 months (median, 10 months). Patients in both groups
were similar in sex and age characteristics. There were 10 treatment
sessions conducted by the same individual. Outcomes were assessed by
a physician blinded to the treatment schedule. Subjectively, an intergroup
comparison showed that 22 patients (50%) of the 44 in the intervention
group, and 8 (21%) of the 38 in the control group reported excellent
or good results (P<.01). Pain threshold on gripping was also positively
affected in the intervention group compared with the control group (P<.05).
There was also a greater number of patients in the control group experiencing
pain when lifting 3 kg (P<.05). None of these differences were found
to be significant at 3-month or I-year follow-up visits.
Molsberger and Hille5
randomized 48 patients to assess whether classic acupuncture versus
sham acupuncture (feigning needle insertion by stimulating skin area
not containing relevant acupuncture points using a pencil-like probe)
has greater effect on treatment of tennis elbow. The experimental and
control groups had comparable duration of illness, pain scores, sex,
and mean age. An examiner blinded to the study performed post-intervention
assessment. One acupuncture treatment was performed on all patients.
After treatment, 79% of classic acupuncture patients reported
pain relief of at least 50%, with 25% of patients in the placebo group
reporting the same (P<.01); average duration of pain relief was 20.2
and 1.4 hours, respectively.
Controlled Trials
Brattberg6
compared the efficacy of acupuncture (n=37) vs steroid injection (n=26)
in the treatment of lateral epicondylitis Of note, equivalence between
the groups was neither intended nor achieved. There was a longer duration
of symptoms and greater proportion of males in the acupuncture group;
group age characteristics were not reported. Six acupuncture treatments
on average were administered; there was no mention about the type of
steroid used and the number of injections given.
Follow-up was by means of a questionnaire in
which the patient indicated the degree of pain still experienced. Different
patients were followed up for various lengths of time:
1-3 months, 3-6 months, or 6-2 months. Of the acupuncture patients,
92% replied. Sixty-two percent stated that they were much better or
had no pain at all, compared with 31% of patients (P<.005) who received
steroid injection.
Chilton7
assessed the combined efficacy of acupuncture plus steroid injection
(n=16), versus steroid injection alone (n=19). The 2 groups appeared
to be comparable for average age and sex distribution; no mention was
made of the average duration of symptoms. Patients were seen at 2-3-week
intervals with a maximum of 3 sessions permitted. Tenderness over the
lateral epicondyle was used as an outcome measure. In the acupuncture-plus-steroid
injection group, 81% of patients required only 2 sessions for resolution
of symptoms; 6% did not achieve relief. The numbers for the steroid
injection-only group were 68% and 16%, respectively. Statistical significance
was not calculated; treatment assessed was not blinded.
Case Reports
He and
Wen8 described 58 patients
with tennis elbow. There were 22 men and 36 women, with ages ranging
from 27 to 73 years, and symptoms ranging from 1 week to 9 years. Reported
were (rounded) 52% considered cured, with no symptoms for more than
6 months; 40% had "excellent" outcomes, and 9% experienced no benefit.
Osteoarthritis
Osteoarthritis, a degenerative disease
of the joints with gradual loss of articular cartilage, can be a long-term
consequence of contact sports. An example is cervical osteoarthritis
in football and soccer players. Patients complain of pain and tenderness
with mobilization and weight-bearing of the joint involved. The MEDLINE
search produced 4 randomized controlled trials and I retrospective cohort
study.
Randomized Controlled Trials
Christensen and colleagues9
assessed the effects of acupuncture on pain and function in individuals
with severe knee osteoarthritis. Thirty-two patients were randomly assigned
to 2 groups: a no-treatment control group and a group that received
20 minutes of acupuncture for a total of 6 treatments.
Post-randomization group characteristics were
not reported. Sham acupuncture was not performed on the no-treatment
group. Twenty-nine patients completed baseline and 9-week evaluations.
At week 9, the treatment group reported about a 23% decrease in pain
using a visual analog scale (VAS) compared with the 12% increase in
the control group (P=.03). In the intervention group, median time to
walk 50 m and 20 steps decreased 28% and 30%, respectively, compared
with a decrease of 13% and increase of 9%, respectively, in controls
(P<.01). Subsequent similar treatment (acupuncture) of the control
group resulted in comparable changes as in the treatment group. A blinded
observer performed the objective assessment.
Gaw and colleagues10
investigated 40 patients with osteoarthriti of the knee, hip, cervical
spine, fingers, or back. Patients were randomly assigned to 2 groups
of 20:1 receiving classic Chinese acupunctur and 1, sham acupuncture.
Post-randomization groups were similar with regard to age, sex, duration
of illness, treated joint, occupation pre-treatment medications, and
mental well-being. One patient withdrew secondary to an unrelated illness.
A total of 8 acupuncture treatments were performed, followed by an assessment
by 2 blinded observers. Outcome measures were tenderness and subjective
report of pain and activity. Both groups showed a post-treatment reduction
in pain; there was no intergroup statistical difference observed.
Dickens and colleagues11
studied the effect of acupuncture vs mock transcutaneous nerve stimulation
(TNS) in patients with tra-pezio-metacarpal osteoarthritis. Thirteen
patients were initially recruited with 12 completing the trial. Recruited
patients were randomly assigned to either treatment or control and were
similar in mean age, sex, and duration of symptoms. Each participant
received sessions of either procedure. A blinded observer assessed post-intervention
functional capacity, pinch grip, joint tenderness, sleep disturbance,
medication intake, pain scores (VAS), and verbal rating of improvement.
No intergroup statistical significance was observe secondary to the
small sample size, even though the treatment group was measurably numerically
superior.
Takeda and
Wessel12 examined the efficacy
of real acupuncture sham acupuncture in subjects with radiographic evidence
of osteoarthritis of the knee. Forty subjects were randomly assigned
to the experimental and control groups in a double-blinded manner. The
groups appeared similar in mean age, sex, weight, and body mass index.
There appeared to be significantly more individuals with advanced osteoarthritis
in the real acupuncture group. Symptom duration was not reported. Outcome
measures used included the Pai Rating Index of the McGill Pain Questionnaire,
the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis
Index, and pain threshold at 4 sites in the knee. Each subject underwent
a total of 9 treatments. The study demonstrated that both interventions
& creased symptoms in persons with osteoarthritis of the knee. There
was a tendency for the true acupuncture group to show a greater response,
but this did not achieve statistical significance.
Retrospective Cohort Study
Zwolfer and associates13
conducted a retrospective study of 35 patients with osteoarthritis of
the knee who were treated with "Bachmann Point" acupuncture. There was
a 60% questionnaire responce rate; the average number of acupuncture
sessions was 26. Seventy-one percent of patients replied that the intervention
was helpful. Nineteen percent were free of pain, and 6 months later,
57% were still better than before the acupuncture therapy.
(Editor's
Note: "Bachmann Point" acupuncture is the
5 acupuncture points around the patella and knee regions which Dr G.
Bachmann, Heidelberg, Germany, wrote about in his 1992 article in the
American Joumal of Chinese Medicine, "Acupuncture in Gonarthrotic Pain
- Bachmann's Knee Program.")
Patellar Tendonitis
Patellar tendonitis (or jumper's knee)
is an inflammation of the patellar tendon secondary to repetitive trauma.
Patients complain of pain and tenderness over the patellar tendon or
the inferior pole of the patella. The MEDLINE search revealed
1 randomized controlled trial.
Wang and colleagues14
randomly assigned 156 patients into 3 groups: acupuncture and moxibustion,
microwave needling, and laser irradiation. Post-randomization group
characteristics were not reported. Group sizes consisted of 85, 38,
and 33 patients, respectively. The same acupuncture points were needled
in all cases; a similar number of
treatments were performed. Outcomes were classified as absence of symptoms,
marked efficacy, improvement, or no response. All 3 groups showed improvement;
the acupuncture-moxibustion group showed the greatest improvement. The
only intergroup statistical difference found was in the percentage of
patients responding in the acupuncture-moxibustion group versus the
microwave group.
Plantar Fasciitis
Plantar fasciitis is 1 of several causes
of heel pain secondary to chronic overuse resulting in inflammation
of the plantar fascia. The literature search revealed 1 published case
series on the efficacy of acupuncture in patients with plantar fasciitis.
Tillu et all15
investigated the effect of acupuncture in the treatment of
heel pain due to plantar fasciitis in patients without prior response
to conservative treatment. Eighteen
consecutive patients with a mean age of 49
years (range, 31-70 years), 28% male, with a mean duration of symptoms
6 of 25 months (range, 12-30 months)
received a total of 4 treatments on the
affected side. Values on a VAS were used as the outcome measure. After
4 treatments, 7 (39%) of 18 patients
reported greater than 50% pain relief; 7
others reported no relief. The authors reported a significant difference
(P<.00 1) of post-treatment compared with pre-treatment VAS scores.
Frozen Shoulder
Frozen shoulder is a condition in which
the shoulder capsule becomes contracted and thickened with a dramatic
decrease in the shoulder range of motion. Associated conditions are
cervical spondylosis, hypothyroidism, and diabetes mellitus. The MEDLINE
search produced I published case series on the effect of acupuncture
on frozen shoulder.
Ene and Odi16
published a case series on the efficacy of acupuncture in treating various
neurologic and musculoskeletal disorders. This study included 4 cases
of mild to severe frozen shoulder as based on the range of motion; the
duration of symptoms was not reported. Each patient received 6 treatments.
Post-treatment pain response to mobilization was absent in the 3 mild-to-moderate
cases; the range of motion improved from 45' to 90' and 70' to 180'
in abduction and elevation, respectively. In I case of severe frozen
shoulder, post-treatment pain response was mild with abduction improved
from 0' to 50' and elevation from 10' to 140'. Length of post-treatment
follow-up was not reported.
CONCLUSION
We have summarized the published evidence
regarding the efficacy of acupuncture in the treatment of lateral epicondylitis,
osteoarthritis, patellar tendonitis, plantar fasciitis, and frozen shoulder.
For the treatment of lateral epicondylitis,
2 randomized controlled trials show a statistically significant positive
result with acupuncture treatment when compared with placebo. One of
the non-randomized controlled trials also shows acupuncture's statistically
significant efficacy compared with steroid injection. In a non-randomized
controlled trial, Chilton' reported a higher success rate with acupuncture
and steroids versus steroid-only treatment, but the samples were too
small to reach any intergroup statistical significance. While the number
of high-quality trials is small, the evidence does suggest that acupuncture
can be effective in the treatment of tennis elbow.
We found
4 randomized controlled trials of acupuncture in osteoarthritis. Only
the study by Christensen et al9
showed statistical improvement compared with no treatment in patients
with osteoarthritis. Three other studies compared acupuncture with sham
acupuncture and reported no statistically significant benefit to acupuncture.
This suggests that acupuncture is not superior to sham needling in reducing
pain of osteoarthritis; both alleviate symptoms to approximately the
same degree.
One randomized
controlled study reported the treatment of patellar tendonitis. The
post-randomization group characteristics were not reported.
Acupuncture and moxibustion were evaluated as a combined treatment instead
of evaluating acupuncture alone. The only statistically significant
improvement was found when the intervention group was compared with
acupuncture that used exactly the same areas of stimulation with subsequent
microwave needle stimulation. There is inadequate data to formulate
a definitive conclusion for acupuncture treatment of patellar tendonitis.
Similarly, there are inadequate data to determine acupuncture's efficacy
in the treatment of plantar fasciitis and frozen shoulder. However,
case report evidence does suggest the possibility of efficacy.
Further
single-blind, randomized controlled trials are needed to assess the
efficacy of acupuncture in a variety of common sports medicine diagnoses.
Standardization of the acupuncture points used, depth of insertion,
and appropriate control treatments are needed to reach definite conclusions
regarding efficacy.
REFERENCES
1. Eisenberg DM, Kessler RC, Foster
C. Unconventional medicine in the United States: prevalence, costs,
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2. Eisenberg DM, Davis
RB, Ettner SL, et a]. Trends in alternative medicine use in the United
States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569-1575.
3. Cassidy CM. Chinese
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plurality. J Altern Complement Med. 1998; 4(l):17-27.
4, Haker E, Lundeberg
T. Acupuncture treatment in epicondylalgia: a comparative study of two
acupuncture techniques. Clin J Pain. 1990, 6:221-226.
5. Molsberger A, Hille
E. The analgesic effect of acupuncture in chronic tennis elbow pain.
Br J Rheumatol. 1994;33:1162-1165.
6. Brattberg G. Acupuncture
therapy for tennis elbow. Pain. 1983; 16:285-288.
7. Chilton SA. Tennis
elbow: a combined approach using acupuncture and local corticosteroid
injection. Acupuncture Med. 1997; 15(2):77-78.
8. He LP, Wen XA. Treatment
on tennis elbow with heat needling: a clin ical summary of 58 cases.
J Tradif Chin Med. 1988;8:129-130.
9. Christensen BV, Iuhl
IU Vilbek H. Acupuncture treatment of severe knee osteoarthrosis: a
long-term study. Acta Anaesthesiol Scand. 1992; 36:519-525.
10. Gaw AC, Chang LW,
Shaw L-C. Efficacy of acupuncture on osteoarthritic pain: a controlled,
double-blind study. N Engl J Med. 1975;293: 375-378.
11. Dickens W, et a].
A single-blind, controlled and randomized clinical trial to evaluate
the effect of acupuncture in the treatment of trapeziometacarpal osteoarthritis.
Complement Med Res. 1989;3(2):5-8.
12. Takeda W, Wessel
J. Acupuncture for the treatment of pain of osteoarthritic knees. Arthritis
Care Res. 1994;7:118-122.
13. Zwolfer W, Grubhofer
G, Cartellieri M, Spacek A. Acupuncture in gonarthrotic pain: "Bachmann's
knee program." Am J Chin Med. 1992; 20:325-329.
14. Wang LQ, Wang AM,
Zhang SD. Clinical analysis and experimental observation on acupuncture
and moxibustion treatment of patellar tendon terminal disease in athletes.
J Tradit Chin Med. 1985;5:162-166.
15. Tillu A, et a].
Effect of acupuncture treatment on heel pain due to plantar fasciitis.
Acupuncture Med. 1998; 16(2):66-68.
16. Eric EE, Odia Gl.
Effect of acupuncture on disorders of musculoskeletal system in Nigerians.
Am J Chin Med. 1983; 11: 106-111.
AUTHORS' INFORMATION
Dr Alec
Meleger is a senior Resident in the Harvard Medical School Physical
Medicine and Rehabilitation program, Cambridge, Massachusetts.
Alec Meleger, MD
Resident, Physical Medicine and Rehabilitation
Harvard Medical School
Spaulding Rehabilitation Hospital
125 Nashua Street Boston, MA 02114
Dr Joanne Borg-Stein
is an Assistant Professor at the Tufts Medical School Physical Medicine
and Rehabilitation department, Boston, Massachusetts.
Joanne Borg-Stein, MD
Medical Director, Spaulding-Wellesley Rehabilitation Center
65 Walnut Street
Wellesley, MA 02481
Phone: 781-431-9144 - Fax: 781-431-9152 E-mail: md.borj@nwh.org
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