Medical Acupuncture for Fibromyalgia
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.
Fibromyalgia (FM) is a common rheumatological problem with a prevalence of 2% in western countries and more prevalent in middle aged females. The condition is characterised by widespread disabling pain as well as psychological problems which are commonly associated with chronic pain disorders.1 Furthermore, this condition is diagnosed by exclusion as conditions such as chronic fatigue syndrome, somatisation disorder and polymyalgia rheumatica can all present in a similar way to FM. To make diagnosis more challenging FM often co-exists with rheumatoid arthritis.2 As such, the diagnosis of FM is one which would be made in collaboration with the patient’s general practitioner (GP) who could arrange further investigations if necessary.
This case study considers a patient with a chronic history of FM who was referred to me by her GP for a trial of adjunctive acupuncture treatment.
Mrs. C was a 42 year old full time palliative care nurse who was completing her PhD. She presented with widespread pain, tenderness and a general sense stiffness affecting mainly her upper thoracic and cervical area more prominent on the right side. She also complained of pain and stiffness in the lower back and hip area bilaterally however this was not as severe. She reported an average of 4 on the VAS.
In conjunction with her upper thoracic and cervical pain and stiffness there would be times, usually towards the end of the day and/or week when prolonged ‘tension’ headache symptoms would occur. These would be bilateral but worse on the right and felt in the occipital/temporal area with a sense of ‘pressure’ and ‘heaviness’.
She also found it difficult to concentrate for long periods with impaired memory at times, particularly when tired or when suffering from a headache. Her energy levels were difficult to sustain regardless of how many hours sleep she may have had.
Mrs. C’s symptoms would fluctuate according to activity and stress levels. She found prolonged periods at her desk would provoke her symptoms. Generally she would feel worse in the morning particularly if she had suffered disturbed sleep.
Her general health was otherwise good. A tendency towards a low mood and a general sense of listlessness was noted on assessment and subsequently during treatment.
Previous radiological investigation showed some mild degenerative changes in the lower cervical and lower lumbar spine which was not considered by her GP, nor I to be significant.
Mrs. C had been involved in a motor vehicle accident twenty years previously. This had left her severely debilitated with pain and stiffness. She had not received any treatment other than simple analgesia which she took over a period of two years. Slowly her pain began to improve such that it became more episodic. The sense of stiffness did not improve however.
Approximately three years ago Mrs. C relapsed and her pain became more constant. At around this time she noticed more widespread tenderness and a greater general sense of fatigue. She could not recall any reason for this however it did coincide with a move from the United States to Ireland. She also mentioned her workload was greater at the time.
Over the last three years Mrs. C had tried self management using paracetamol and tramadol both of which offered little relief. She had also tried a course of physiotherapy which had involved mainly exercises to improve postural control, also with little improvement. She recently sought the advice of a GP known to specialise in chronic pain management who diagnosed her with FM. She began Mrs. C on a course of amitryptiline intended to improve sleep quality and had gradually increased her dose to 50mg daily. This had helped her sleep to some extent, as well as with some pain relief. After two months on amitryptiline, her GP suggested she trial a course of acupuncture.
Mrs. C is slight woman who is kyphotic in her upper thoracic spine with a poking chin. Her scalene and upper trapezius muscles were very prominent bilaterally. The pectoralis minor muscles were shortened and drawing her scapulae into protraction. She appeared drawn with heavy tired eyes and a furrowed forehead.
Her general cervical, thoracic and lumbar mobility was limited by mainly myofascial restriction with no outward joint signs other than typical mid thoracic stiffness on accessory intervertebral motion testing.
Most information as to the likely source of her pain was to be found on palpation assessment. Mrs. C was first assessed for tenderness at the nine bilateral specific tender point (TP) sites as required for a diagnosis of FM by the American College of Rheumatology (ACR).3 Tenderness to moderate palpation (approximately 4Kg) was reported at the following sites:
- The base of the occiput bilaterally, at the suboccipital muscle insertions.
- The midpoints of the upper free borders of trapezius bilaterally, within taut bands and reproducing vague familiar referred pain to the upper neck.
- Lateral epicondyle site: approximately two centimeters distal to the epicondyle's over the extensor digitorum muscle bilaterally.
- The anterior portion of the belly of the gluteus medius muscles bilaterally, found within taut bands with vague referral towards the lateral thigh.
- The belly of the supraspinatus muscle on the right side, above the scapula spine near the medial border.
- Further TP’s were found in the following muscles. (These sites did not correspond with characteristic TP sites as described by the ACR).
- The iliocostalis lumborum muscles bilaterally, level with the L1 vertebra, found within taut bands with vague familiar referred pain distally.
- The right levator scapula muscle, in close proximity to the insertion to the superomedial angle of the scapula, found within taut bands with familiar pain referral along the medial border of the scapula
Mrs. C had been suffering from widespread pain for a period longer than three months. The pain distribution was axial (spinal), affecting the upper and lower body, as well as left and right sides. She reported tenderness at nine TP sites according the ACR diagnostic criteria, with a further three TP sites located at non specified sites. She therefore, with the exception of the required number of TP’s, fulfilled the ACR’s diagnostic criteria for FM. However as Baldry explains, some modification as to the number of TP’s located is permissible in every day clinical practice when diagnosing according to ACR criteria.4 Mrs. C also suffered from fatigue and sleep disturbances which show high prevalence in those suffering from FM.5 Furthermore a high prevalence of FM has been observed in patients who have been subjected to cervical spine whiplash injury.6 As such when Mrs. C’s history was considered in context and in the absence of other pathology as excluded by her GP, FM was the most appropriate diagnosis.
Those suffering from FM require an approach which is individually tailored and may benefit from different types of treatment.5,7 When considering the proposed pathophysiology of FM, Vierck would suggest an approach aimed at silencing chronic focal pain that drives central sensitisation and enhanced sympathetic activiation.8 Pharmacological interventions are often used however acupuncture is also a method which may, from a neurophysiological point of view, be effective in suppressing nocioceptor activity.9
Electroacupuncture (EA) is often used in the treatment of FM to good effect.10,11 However it is a stronger form of treatment when compared to manual acupuncture (MA) and may aggravate if the patient has widespread allodynia or hyperalgesia.4 Mrs. C did not have widespread allodynia instead she was tender at more specific sites/ focal points. For this reason the use of EA would be considered depending on her response to MA.
Treatment would begin with MA, first using traditional points and then progressing treatment to include needling of the TP’s described above. An advantage of MA is the ability to titrate the dose of treatment effectively due to the fine control of stimulation. The dose can be determined by the number of needles used, the depth of penetration, the level and frequency of added stimulation as well as the duration of treatment. When considering the depth of needling in particular, initially superficial with a progression to deeper needling will carried out if required. The responsiveness to either will be determined by the state of the descending pain modulatory system.12 The aim would be to achieve an optimum dose defined as the maximum level of sensory input without causing aversive pain or significant reaction.
The frequency of treatments would be weekly, with an initial trial number of four sessions to determine responsiveness. If improvements in pain (as measured using the VAS) were being made it was decided that treatment would continue on a weekly basis until a plateau was reached in agreement with the patient. From clinical experience it was expected that approximately ten sessions would be required. Other factors such as quality of sleep and reported general levels of fatigue would also be considered as outcome measures. If improvements had been made the possibility of applying a maintenance approach would be discussed.
Mrs. C had not received acupuncture treatment previously. As such an explanation was given regarding the expected sensations during treatment as well as the possibility of mild adverse reactions such as dizziness, syncope, sedation, bruising, treatment soreness/exacerbation of symptoms following treatment. It was explained that every effort would be made to titrate the treatment such that these were unlikely to occur but that individual responses may vary.
Single use, sterile and disposable Vinco (25mm x 0.22mm) needles were used unless otherwise stated.
The risk of serious injury or infection from acupuncture is relatively low.13 White et al14 reported the risk of serious adverse events including pneumothorax, injury to the central nervous system or a hepatitis B infection as being 0.05 per 10,000 treatments. Theoretically these can be avoided by following safe needling practice.
When needling the sub-occipital muscle insertions the needle would be angled upwards towards the base of the skull. Care would be taken to avoid deep perpendicular penetration considering the vertebrobasilar artery is located 40-60mm from the skin surface in the average adult. Similar care would be taken when needling over the rib cage at the upper trapezius and levator scapulae insertion TP’s to avoid potential pneumothorax. In both cases the needles would be inserted at a tangent to the ribs to an appropriate depth. When needling the supraspinatus TP care would be taken to ensure the needle is inserted over the supraspinous fossa for added safety. With regard to iliocostalis lumborum the TP’s in these muscles would be needled while angling towards the lumbar transverse processes to avoid penetration of the kidney.
In all cases the depth of insertion would be moderated not only for anatomical safety considerations but also in order to titrate the dose of treatment effectively. Along with other methods of controlling dosage the aim would be to limit potential minor adverse reactions as mentioned previously.
With regard to the use of EA it was determined that Mrs. C had no intra-cardiac defibrillator, nor cardiac pace maker. She was also not an uncontrolled epileptic and had no aversion to electricity.
Treatment and results
In order to introduce the acupuncture treatment as well as to determine Mrs. C’s potential reactivity the traditional points LI4 and LR3 were used. At both points the needles were inserted to a subcutaneous depth of 0.5 cm bilaterally. This was sufficient to elicit a de qi sensation locally. No added manual stimulation was applied. The needles were left in situ for ten minutes and then removed. While Mrs. C remained supine we discussed how the treatment may be progressed by needling TP sites at the next session.
Apart from a mild to moderate sedation effect which lasted approximately 12 hours there were no other adverse reactions following the first session. No change in the VAS was reported. At session 2 the traditional points were discontinued in favour of needling the TP sites which had been located in the upper third of the body. These included TP’s in the following muscles:
- The base of the occiput bilaterally, at the suboccipital muscle insertions.
- The midpoints of the upper free borders of trapezius bilaterally.
- Lateral epicondyle site: approximately two centimeters distal to the epicondyle’s over the extensor digitorum muscle bilaterally.
- The right levator scapula, in close proximity to the insertion at the superomedial angle of the scapula.
- The belly of the supraspinatus on the right side, above the scapula spine near the medial border.
In all cases the needles were inserted to a depth of 1-1.5cm sufficient to reach the muscle layer but with care not to overstimulate. Again local de qi type sensation was felt along with vague referred pain patterns including a familiar headache in the right occipital/temporal area. No added manual stimulation was applied. The needles were left in situ for ten minutes and then removed.
A similar sedation effect was experienced following session 2 with no other adverse reactions. There had been no change in pain levels on the VAS, sleep quality or levels of fatigue. As the previous two sessions had been well tolerated the remaining TP's found in the lower two thirds of the body were included from session 3 onwards. These included TP’s in the following muscles:
- The anterior portion of the belly of the gluteus medius bilaterally.
- The iliocostalis lumborum bilaterally, level with the L1 vertebra.
A total number of twelve needles were used, all inserted to a depth of 1-1.5 cm. A strong but comfortable de qi sensation was evoked, as such no added manual stimulation was required. The needles were left in situ for ten minutes and then removed. Vague referred non familiar pain was felt while needling these additional points.
As treatment was well tolerated, the dose was increased during these sessions by increasing the duration of needling to fifteen minutes. Low frequency manual rotation manipulation was also applied every 5 minutes for approximately five seconds. This was necessary to maintain an awareness of the needles with some vague pain referral felt along with the de qi. By session 5 Mrs. C reported improvement in sleep quality and slight reduction in fatigue. Pain levels on the VAS remained unchanged.
By this session the VAS had reduced to 3 with continued improvement in sleep quality and reduction in fatigue levels. On appearance Mrs. C was looking more vitalized. The reported pain and tenderness had become more concentrated at the right cervical/medial upper scapula area. Pain which was familiar to Mrs. C could be evoked by palpation of the lower insertion of the right levator scapula and the upper free border of trapezius. Due to the more concentrated nature of the pain and in attempt to increase the healing rate it was decided to incorporate the use of EA at this session.
Using the Cefar®Acus 4 EA device the electrodes were clipped to the needles inserted at TP’s in the levator scapula and the upper trapezius. Attachment was just below the handle of the needle to avoid skin contamination. Programme 1(80Hz)15 was selected as I have found in clinical practice that higher frequencies are more comfortable and may be less likely to overstimulate. A mild intensity level was applied for 10 minutes.
The remaining TP’s were needled as previously but without the added manual stimulation. It was felt that a sufficient level of stimulation would be applied by the EA without the need for additional manual stimulation.
Three days following this session Mrs. C reported a severe sense of fatigue and generalised body pain which she felt might have been viral in nature. This lasted for a week during which time she had to take a day off work. I suggested waiting for her symptoms to settle before resuming acupuncture treatment. I was concerned that despite her good tolerance to acupuncture so far the EA may have aggravated her condition.
Following this episode the use of EA was discontinued out of caution.
Over the next 3 sessions using all points previously described, further improvements in pain and stiffness (including the right cervical/medial upper scapula area) were made. At session 13 a VAS of 1 was reported along with pain free periods at times. Sleep quality had improved significantly along with a continued decrease in fatigue levels. Very infrequent headache symptoms were reported.
No further improvements had taken place following the last two sessions and it was agreed that a plateau had been reached in treatment.
A maintenance approach has since been taken with a session every four to six weeks sufficient to maintain her improvements.
When diagnosing FM much emphasis is placed on locating TP’s. However as Gerwin points out a large proportion may also have trigger points (TrP) present.16 When assessing Mrs. C the TP’s in the upper trapezius, levator scapulae, iliocostalis lumborum and gluteus medius muscles where all found within taut bands. When palpated (or needled) they also produced a vague characteristic referred pain pattern. Furthermore, those within the upper trapezius and levator scapula muscles produced referred pain which was familiar to Mrs. C. It could therefore be argued that as well as being TP’s they also fulfilled the minimum required criteria for classification as either latent or active TrP’s.17,18 As such it would seem that certain individuals may be prone to developing concomitant TP/TrP activity. Future research may need to pay particular attention to accurately describing the nature of the points used in making a diagnosis.
Once the appropriate points have been located and accurately defined, the clinician must then decide on the best mode of stimulation if using an acupuncture approach. When considering the results of a recent systematic review19 EA has been shown to be of benefit to those suffering from FM. Symptomatic relief has been obtained even at intensities sufficient to elicit muscle contraction.11 In this case study it is possible that the introduction of EA had a negative effect and may have been responsible for the aggravation of pain and fatigue symptoms. EA is a stronger form of stimulation. It is also more difficult to titrate the EA dose given when compared to MA. It is therefore my opinion that EA should be used with care especially in FM patients who are likely to be sensitive as the risk of over treating and eliciting an adverse reaction is possible.
When considering how best to continue treatment some authors have suggested a maintenance approach.4 Clinically I have found this approach to be very useful in maintaining symptomatic relief. In Mrs. C’s case four to six weekly maintenance sessions have proven to be effective, however this may not be the case for all patients. Due to the highly individual nature of FM the intervals are likely to be determined through a process of trial and error.
In this case a good response to treatment was achieved by supplementing a commonly used medication for FM with acupuncture. It was only once the acupuncture treatment began that more significant improvements pain and fatigue symptoms began to take place. Having recently spoken to Mrs. C’s GP regarding her progress she intends to discontinue the amitryptiline for a period to prevent a tolerance effect. It will be interesting to monitor her symptoms during this period to determine whether acupuncture alone can be as effective.
This case study would be an example of how duration and severity of FM symptoms do not necessarily correlate with the outcome of treatment.7 One might have expected the chronicity in this case to have made Mrs. C more treatment resistant. This however did not turn out to be the case.
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