Therapeutic Observation on Tuina plus Electroacupuncture for Lateral Humeral Epicondylitis

Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 200233, China

CLINICAL STUDY

Therapeutic Observation on Tuina plus Electroacupuncture for Lateral Humeral Epicondylitis

Li Shi-sheng, Wu Yao-chi, Zhang Jun-feng, Zhou Jing-hui

Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 200233, China

Author:Li Shi-sheng, master of medicine, resident physician

Objective: To observe the clinical efficacy of tuina combined with electroacupuncture (EA) in treating lateral humeral epicondylitis.

Methods: Totally 118 patients were randomly allocated into a treatment group and a control group, 59 cases in each. The patients in the treatment group were treated with tuina combined with EA treatment, while those in the control group were treated by EA alone. Clinical efficacies of the two groups were compared after the treatment.

Results: The total effective rate was 93.2% in the treatment group, versus 84.7% in the control group, and the difference was statistically significant (P＜0.05).

Conclusion: Tuina combined with EA treatment for lateral humeral epicondylitis has a significant effect.

Massage; Tuina; Electroacupuncture; Acupuncture Therapy; Tennis Elbow; Osteoarthritis

Lateral humeral epicondylitis, also termed ‘tennis elbow’, refers to aseptic inflammation caused by acute or chronic injury of the total tendon that join the forearm muscles on the outside of the elbow (lateral epicondyle), mainly characterized by pain and tenderness on the lateral side of the elbow, difficulty in rotating the forearm and resistance in wrist extension. Currently, there are many therapeutic methods for this problem and the therapeutic effects are different[1-5]. From April of 2012 to October of 2013, the author treated 59 cases with lateral humeral epicondylitis with tuina plus electroacupuncture (EA), in comparison with 59 cases treated simply by EA. Now, the report is given as follows.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnostic criteria were stipulated upon thePractical Handbook of Orthopaedics[6]and theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[7]. Pain in the lateral side of the elbow joint, radiating to the medial aspect or forearm, but without red or swelling inflammatory manifestation in the local skin; tenderness at the external condyle of humerus of the elbow joint; pain aggravated by grabbing object and rotating the forearm inward; positive in Mills sign; exclusion of bone lesions by X-ray examination of the elbow joint.

1.2 Inclusion criteria

Those in conformity with the above diagnostic criteria; aged between 25 and 65; having not taken medications or received other therapeutic methods in the recent one week; in conformity with indications by the treatment of manual techniques, and with the duration less than one year; voluntary for two courses of the treatment and signed the informed consent.

1.3 Exclusion criteria

Those not in conformity with the above diagnostic criteria; sick with mental disorders; women in pregnancy or lactation; with history of surgery for the external condyle of humerus; complicated with caridio-cerebro-vascular diseases or primary hepatic or renal diseases; and those diagnosed as dislocation of the elbow joint by X-ray or traumatic arthritis; and those sick with rheumatism or tuberculosis or tumor.1.4 Statistic methods

The data were processed by SPSS 19.0 verstion software. The accounting materials were expressed by mean ± standard deviationThe comparisons of visual analogue scale (VAS) scores before and after treatment between the two groups were processed by pairedt-test. The comparison of the therapeutic effects between the two groups was processed by rank sum test, andP＜0.05 expresses the statistically significant difference.

1.5 General data

Totally 118 cases with lateral humeral epicondylitis were recruited and randomly divided into a treatment group and a control group by their visiting order, 59 cases in each group. The differences of general data in gender, age, and duration of the two groups were not statistically significant (allP＞0.05), and it suggested that the two groups were comparable (Table 1).

Table 1. Comparison of general data between the two groups

2 Therapeutic Methods

2.1 Treatment group

2.1.1 Tuina treatment

Take the left sick elbow for example. After the patient took a sitting position, the practitioner stood at the left, lateral and anterior side of the patient. Dragged and held the posterior part of the patient’s left elbow, to abduct and flex the patient’s left elbow forward, with the thumb at the patient’s left external condyle of humerus and the other four fingers at the medial side of the sick elbow.

First, the practitioner held the patient’s left wrist with the left hand, and An-pressed and Rou-kneaded the attached site of the total tendons of the muscles on the radial side of the forearm (around painful spot), to produce a sore, distending and numb sensation. The practitioner rotated the patient’s forearm with the left hand leftward and rightward, to passively extend and flex the elbow joint of the patient, for about 10 min (Figure 1).

Figure 1. An-pressing, Rou-kneading and rotating

Then, the practitioner Tanbo-plucked the tenderness and the extensor muscle of the wrist on the radial side with the thumb of the right hand, for about 5 min (Figure 2).

Figure 2. Tanbo-plucking

Then, the practitioner An-pressed tenderness with the thumb of the right hand, and held the patient’s left wrist with the left hand to flex and extend the elbow joint and rotate the forearm, for about 5 min (Figure 3).

Figure 3. Passive flexion, extension and rotation

Finally, the practitioner An-pressed and Roukneaded the sick area with the thumb of the right hand, and then Ca-scrubbed the extensor muscle of the wrist on the radial side and the external condyle of humerus, for about 10 min (Figure 4).

Figure 4. Ca-scrubbing

Tuina treatment was given once every day, with ten sessions as one course and five days between the courses, for totally two courses.

2.1.2 EA treatment

Acupoints: Ashi point, Shousanli (LI 10), Shouwuli (LI 13), Quchi (LI 11), and Zhouliao (LI 12).

Operation: After the patient took a sitting position, the sick arm was abducted and flexed forward and put on the treatment table, with the elbow joint slightly flexed and a cushion placed under the elbow. Then, disposable filiform needles of 0.30 mm in diameter and 40 mm in length were selected for treatment. After the arrival of the needling sensation, Ashi point and one of the other four acupoints were selected to connect with BT701-1B EA apparatus, by continuous wave of 2 Hz, with the stimulating intensity within the patient’s tolerance, for 20 min each time.

The treatment was given once every day, with ten sessions as one course and five days between the courses, for totally two courses.

2.2 Control group

Those in the control group were treated by EA alone. The acupoints selection, operation and courses were the same as those in the treatment group.

3 Observation of Therapeutic Effects

3.1 Observation indexes

Assessment of pain degrees of the elbow joint: Visual analogous scale (VAS) was adopted to assess pain degrees of the elbow joint. A 10 cm scale was used, with one end of the scale marked with 0, representing no pain, and the other end marked with 10 representing the most severe pain of the patient’s subjective sensation. Guided by one doctor, the patient was told to mark the corresponding position representing his pain degrees on the scale before the treatment and after two courses of the treatment. The practitioners recorded his scores upon the positions marked by the patient.

3.2 Criteria of therapeutic effects

The criteria of the therapeutic effects were stipulated upon theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[7], in combination of VAS score-reducing rate.

VAS score-reducing rate ＝ (VAS score before treatment – VAS score after treatment) ÷ VAS scores before treatment × 100%.

Clinical cure: Pain and tenderness at the lateral side of the elbow disappeared or basically disappeared, and pain in the anti-resistance backward extension of the wrist joint and forward-rotating action of the forearm disappeared, and there was no pain in holding object and free motion of the elbow. VAS score-reducing rate was ≥95%.

Remarkable effect: Painful sensation at the elbow disappeared and tenderness was obviously relieved. Painful reaction was not obvious in the antiresistance backward extension of the wrist joint and forward-rotating action of the forearm. VAS score-reducing rate was ≥75%, but ＜95%.

Effect: Pain and tenderness at the elbow were slightly relieved. Painful reaction still existed in the anti-resistance backward extension of the wrist joint and forward-rotating action of the forearm. VAS score-reducing rate was ≥30%, but ＜75%.

Failure: No improvement in the symptoms, and VAS score-reducing rate was ＜30%.

3.3 Therapeutic results

3.3.1 Comparison of VAS score

Before treatment, the difference of VAS scores between the two groups was not statistically significant (P＞0.05). VAS scores in the two groups were obviously decreased after treatment (P＜0.05). Moreover, the improvement was more significant in the treatment group than that in the control group (P＜0.05), (Table 2).

The difference in therapeutic effects was statistically significant between the two groups by rank sum test (P＜0.05), indicating that the therapeutic effect was better in the treatment group than that in the control group (Table 3).

Table 2. Comparison of VAS scores before and after treatment between the two groups (point)

Table 2. Comparison of VAS scores before and after treatment between the two groups (point)

Note: Compared with the same group before treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

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Table 3. Comparison of therapeutic effects between the two groups (case)

4 Discussion

Lateral humeral epicondylitis refers to chronic strain of the total tendons of the extensor muscles of the external condyle of humerus, induced by the repeated overuse. Because of the excessive stretching of the local blood vessels and ligaments inside the muscular fibers, fiber avulsion or slight bleeding appear at the attached site of the extensor muscles of the wrist, gradually forming the local adhesion with the self-healing of the human body. When the extensor muscles are forcefully contracted, adhesion will be torn apart, leading to the reactive proliferation of the granulation tissues and presenting the typical pain at the lateral side of the elbow[8].

This disease belongs to the scope of tendon injury and Bi-Impediment syndrome in traditional Chinese medicine. Its causative factor is mainly related to injury of the tendon collaterals due to long-term overexertion. While tendon collaterals are injured and qi and blood are deficient and weak, pathogenic wind, cold and dampness will take the chance to invade the human body, leading to obstruction of the meridians and collaterals, and causing the problem because of pain due to obstruction.

The treatment by the appropriate tuina techniques is able to lubricate the joints, dredge the meridians and collaterals, promote the local blood circulation, promote the dispersion of the aseptic inflammation, so as to relax the adhesion[9-10]. The application of the strong and continuous plucking technique on obvious tenderness on the lateral side of the elbow can relieve the spasm of the extensor muscle of the forearm, separate the adhesion of the soft tissues on the lateral side of the elbow, and reduce the compression on the neurovascular bundle, so as to restore the normal physiological functions of the elbow[11]. To press and knead the extensor muscle on the lateral side of the elbow can relax the adhesion of the local tissues of the elbow joint, and increase the action of the elbow joint by the passive flexion and extension of the elbow joint, so as to enable the local tissues, blood vessels and nerves of the chronically injured elbow joint to have a low-degree benign stimulation, and enhance the excitement of the local tissues and improve local blood circulation and micro-environment, so as to restore the normal metabolism of the pathologic tissues gradually, and hence to control the inflammation and relieve pain.

EA treatment can smoothen the local blood vessels, nourish the tendons and bones, and promote the extension and flexion of the joint, and also can promote the release of the analgesic substance, such as endogenous morphine peptides, so as to enhance the pain threshold and realize the analgesic aim[12]. When EA functions on the nerves and muscles, it can enable the muscle to have rhythmic contraction, and the passive muscular motion can improve blood circulation and tissue nutrition, and enhance metabolism and produce the regulatory effect on the blood circulation and vasomotoricity, so as to promote the elimination of inflammatory exudates from sick area[13]. At the same time, when impulse current of the EA functions on the human body, the directional movement of ions in the tissues will take place, to eliminate the polarized state of the cellular membrane and have a remarkable change in the concentration and distribution of ions, so as to influence the functions of the human tissues[14].

The outcomes of this study indicate that tuina in combination of EA for lateral humeral epicondylitis isbetter in the therapeutic effects and is less in sufferings for the patients. It has a better therapeutic effect than simple EA treatment. Therefore, it can be promoted for extensive application as the clinical therapeutic program for lateral humeral epicondylitis.

Conflict of Interest

The authors declared that there was no conflict of interest.

Acknowledgments

This work was supported by Lu’s Acupuncture Inheritance Study of Shanghai Schools of Traditional Chinese Medicine (No. ZYSNXD-CC-HPGC-JD-004).

Statement of Informed Consent

All of the patients in the study signed the informed consent.

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Translator:Huang Guo-qi

Wu Yao-chi, chief physician, professor, doctoral student tutor.

E-mail: wuyaochi11238@hotmail.com

R244.1

: A

Date:June 20, 2014