Acupuncture in Sports Medicine

Introduction Acupuncture is one of the more popular types of complementary medicine that athletes use to help control pain, hasten recovery, and treat injury. Acupuncture is also used to treat conditions unrelated to sports participation, such as migraine headache and dysmenorrhea. A recent large-scale survey of Americans' use of complementary and alternative medicine therapies indicated that acupuncture is one of the most utilized forms of complementary medicine [1]. Other studies have indicated that musculoskeletal conditions are the most common reason for seeking complementary care [2]. A basic understanding of the theories behind acupuncture, its risks, and potential benefits will aid the sports medicine physician in advising athletes about this potentially useful therapy. History Acupuncture has been practiced in Asia for over 2000 years. One of the earliest surviving medical texts is the Huang Di Nei Jing (The Medical Classic of the Yellow Emperor), dated to approximately 500 bc. The principles of traditional Chinese medicine were described much as practiced today. Qi, the energy of life, is composed of yin and yang. These complementary, opposing components of energy must be in balance for optimum health. This energy flows through the body in a specific pattern along “meridians” or “channels.” When yin and yang become unbalanced, illness results. According to traditional Chinese medicine, the flow of qi can be influenced by placement of needles at specific points in the body, many of which are along the meridians. Traditional Chinese medicine uses alternative diagnostic methods, such as observing the eyes, tongue, and skin, palpating subtle variations in the radial pulses, and other means to assess the balance and flow of qi. Specific points are treated, and frequently Chinese herbs are prescribed to augment the acupuncture treatment. Acupuncture has become “Westernized” over the past century as the practice of acupuncture has spread across Europe and the United States. Modern acupuncturists use sterile, disposable acupuncture needles to treat acupuncture points selected according to symptom location and origin. Any painful, tender point can be considered for treatment (myofascial trigger points, lateral epicondy-lalgia). Some points are purported to treat symptoms related to specific organ systems, and other points are used to treat pain in other locations (points on the hands to treat headache, for instance). Many of these points have been validated by modern tools such as functional MRI and positron emission tomography studies [3–6]. Typically, six to 12 needles are placed in a treatment session for a localized problem such as tennis elbow, for example. Some patients are very sensitive to the effects of acupuncture and require only a few needles. For patients with widespread pain, such as fibromyalgia, more needles may be used. Only sterile, disposable needles should be used, and needles should never be reused. Needles may be stimulated manually, electrically, or just left in place during treatment. Most treatments last between 10 and 30 minutes, but occasionally needles are retained for 45 minutes or longer. A trial of three or four weekly treatments will usually result in symptomatic relief in individuals who respond to acupuncture. For chronic conditions, some improvement should be noted within the first six treatments. If no relief is experienced during the trial period, acupuncture will not likely benefit that patient and should be discontinued. For individuals who respond to acupuncture, the treatments continue weekly until pain is controlled, then the interval between treatments is increased. Typically, six to 12 treatments are needed to control chronic conditions, whereas acute injuries may improve within two to four treatments. Most patients do not require any ongoing treatment after the problem has improved, although a small percentage of those with chronic conditions benefit from periodic treatment. Safety In experienced, well-trained hands, acupuncture is extremely safe. Benign, self-limited problems such as bruising and pain with insertion are the only common complications. Other symptoms may occur, including lightheadedness, syncope, and fatigue. Serious complications have been reported with acupuncture, including pneumothorax, spinal cord injury, cardiac puncture, septic arthritis, seizure, and drowsiness sufficient to cause an automobile accident [7,8]. Serious complications are generally associated with poor technique and inexpert needle placement. It is estimated that serious complications occur at a rate of 0.05 per 10,000 treatments [7]. Research Acupuncture has been studied by Western medicine increasingly over the past 30 years. Many of the early clinical trials were of poor quality, with unrandomized or no control groups. An additional limitation of acupuncture research is that most of the research protocols are based on specific, predetermined acupuncture points, whereas in the clinical setting, points are determined individually, frequently based on localized tender points. It is difficult to design an appropriate placebo treatment for acupuncture. Controversy exists in the selection of appropriate control groups for acupuncture studies [9]. Studies utilizing sham acupuncture along with another control group (eg, wait list) frequently show inter-mediate effectiveness of sham acupuncture, with the sham acupuncture group falling between acupuncture and the other control groups [10,11]. The most plausible theory regarding this phenomenon may also explain the basis for acupuncture analgesia. Any needling of skin may increase endorphins and activate diffuse noxious inhibitory control systems, supraspinal structures that modulate the transmission of nociceptive signals [12]. A new placebo acupuncture needle has been developed with some early validation [13], although it has not yet been widely used in published acupuncture studies. Early studies convincingly demonstrated an increase in endorphin release into the cerebrospinal fluid [14,15], and inhibition of acupuncture analgesia with naloxone [16]. These results have been supported by animal studies as well [17,18]. Clinical trials and meta-analyses have supported the effectiveness of acupuncture for treatment of a variety of conditions treated by sports medicine specialists. These include some of the more chronic and difficult conditions seen in sports medicine, such as lateral epicondylalgia [19–21], patellofemoral pain [22], and low back pain [23,24]. Several of these trials included objective functional assessment, showing improvement in walking or stair-climbing performance in addition to improvement in pain scales. One of the more impressive recent trials studied the effectiveness of acupuncture for treatment of osteoarthritis of the knee [11]. A total of 570 patients with osteoarthritis of the knee were included in this trial, which compared acupuncture with sham acupuncture and education control groups. The acupuncture group demonstrated significant improvement in the Western Ontario and McMaster Universities Osteoarthritis Index pain and function scores at 8 and 26 weeks and in the Patient Global Assessment Score at week 26. To date, this is the largest acupuncture study performed for treatment of any musculoskeletal condition, and included both sham acupuncture and noninvasive control groups. The sham acupuncture group showed intermediate results, as noted in other studies. Also of note is that the education control group had higher pain scores at the end of the study despite taking higher doses of nonsteroidal anti-inflammatory drugs. Other studies evaluating acupuncture for treatment of osteoarthritis of the knee have demonstrated significant improvement [25]. Two previous trials involving patients on waiting lists for total knee arthroplasty have shown significant improvement in knee pain and functional improvement; 10% of subjects in one study [26] and 25% of patients in another study [27] experienced improvement to an extent that they withdrew themselves from the joint replacement waiting lists. Recent attention has been given to the effects of acupuncture on immune function. A recent study evaluating immune function and mood after exhaustive exercise found increased salivary IgA and salivary cortisol levels and lower ratings of “fatigue” and “confusion” on the Profile of Mood States in subjects versus controls [28]. Other studies have shown complex effects on immune function, felt to be modulated by the central nervous system [29,30]. Conclusions Acupuncture is a minimally invasive, relatively safe medical procedure that appears to have complex effects on the central and peripheral nervous system, immune system, and pain perception. Although acupuncture should not supplant the role of conventional therapies such as rehabilitation to treat these conditions, it is a useful adjunct to treat pain, which can inhibit muscular contraction, interfering with rehabilitation and athletic performance. It is also useful for treatment of chronic conditions that fail to respond to more conventional therapies. Although recent studies are of higher quality, problems remain in the design and interpretation of acupuncture research. Larger, better-controlled studies are needed to determine the effectiveness of acupuncture compared with more conventional treatments.

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