Comparing analgesic effect of manual vs laser acupuncture for lateral epicondylalgia

A team of researchers from China Medical University and Da-Chien General Hospital in Taiwan (R.O.C.) recently compared the analgesic effect of laser acupuncture and manual acupuncture for the treatment of lateral epicondylalgia. Manual acupuncture is effective in short-term pain relief for the treatment of lateral epicondylalgia.

The acupuncture increases endorphin secretion to relieve pain and affects the pathway of the Aδ nerve fiber to inhibit painful sensation and relieves pain in certain body regions. The acupuncture causes a De Qi sensation and a sour and warm feeling at the acupuncture point. It is critical in pain relief because it activates the descending pain inhibitory system in the central nervous system.

Low-level laser therapy for laser acupuncture has been recently used for treatment of orthopedic diseases. Compared with manual acupuncture, laser therapy applied to the acupuncture point has more advantages because it is painless, aseptic, safe, dosage adjustable, and user friendly. The pain relief achieved using laser acupuncture is related to the metabolism of adenosine triphosphate because it encourages the myofascial trigger point to absorb energy and thereby causes local hypoxia to increase blood circulation, which subsequently decreases the pain caused by lateral epicondylalgia.

The team conducted a systematic review and meta-analysis to compare the analgesic effect of laser acupuncture and manual acupuncture for treating lateral epicondylalgia. We investigated studies in the Medline, PubMed, and CINAHL databases, published from January 1980 to December 2013.

Based on these statistics, the research team calculated the experimental event rate (EER), control event rate (CER), absolute risk reduction (ARR), and relative risk reduction (RRR) of the studies and analyzed the number needed to treat (NNT). The total effect was calculated by a total random effect model to assume the analgesic effect of laser acupuncture and manual acupuncture. The results indicated that manual acupuncture exhibited a substantial difference in treatment effect.

Lateral epicondylitis is the most common overuse syndrome in the elbow. Lateral epicondylitis or tennis elbow is an injury involving the extensor muscles of the forearm. These muscles originate on the lateral epicondylar region of the distal of the humerus.

The most common type of lateral elbow pain is lateral epiconylitis. In occupations requiring repetitive upper extremity activities and particularly those involving computer use, heavy lifting, forceful forearm pronation and supination, and repetitive vibration, lateral epicondylitis is repeatedly seen. The clinical examination of lateral epicondylitis is often clear. This is shown with local tenderness over the common forearm extensor tendon insertion at the lateral epicondyle. This can be extended to the extensor mass, with less annular ligament. Pain can be reproduced with resisted wrist and middle finger extension and with gripping activities. It is possible that symptoms are generated by passive wrist flexion with elbow extension. It is often seen that the flexibility and the strength in the wrist extensor and posterior shoulder muscles are deficient. However, in the workplace where repetitive elbow and wrist motion is involved, lateral epicondylitis occurs. On the lateral epicondyle it’s about 7 times more common than on the medial epicondyle.

In a lot of cases of this specific pathology, the insertion of the extensor carpi radialis brevis is involved. However the extensor carpi radialis longus and anterior extensor communis tendons rarely occur. The description of microscopic failure at the enthesis is a result of repetitive overuse of the extensor forearm muscles. Pathology research has added mucinioid degeneration and granulation tissue in the subtendinous space. Today, the state of lateral epicondylitis is well known to arise spontaneously or in combination with other recreational and occupational pursuits. Recently, researchers have advised using the terms “tendinosis” or “tendinopathy” to reflect the chronicity of the condition because a lack of acute inflammatory markers in patients with tennis elbow is indicated.

Clinically Relevant Anatomy

The elbow joint is made up of three bones: the humerus (upper arm bone), the radius and ulna (two bones in the forearm). At the distal end of the humerus there are two epicondyles, one lateral (on the outside) and one medial (on the inside).

Musculature involved is most commonly the extensor carpi radialis brevis (ECRB), but this injury can also involve the extensor carpi radialis longus (ECRL), extensor digitorum, and extensor carpi ulnaris.

The radial nerve is also in close proximity to this region, and divides into the superficial radial nerve and the posterior interosseous nerve.

Comparing analgesic effect of manual vs laser acupuncture for lateral epicondylalgia According to the Philadelphia Panel Classification System, they assigned as evidence-based results:

  The short-term effect of manual acupuncture on the relief of pain caused by lateral epicondylalgia is Level B

  The long-term effect of manual acupuncture of the relief of pain caused by lateral epicondylalgia is Level C+

  The analgesic effect of laser acupuncture in treating lateral epicondylalgia is Level D

  The analgesic effect of manual acupuncture on the treatment of lateral epicondylalgia is Level B.

Manual acupuncture immediately relieves the pain of lateral epicondylalgia, but its long-term analgesic effect is unremarkable. Applying it at a suitable acupuncture point and to an optimal acupuncture depth can effectively treat lateral epicondylalgia. The study indicates that manual acupuncture applied to lateral epicondylalgia produces stronger evidence of pain relief than the laser acupuncture does.

Tennis elbow or lateral epicondylalgia (LE) is a challenging musculoskeletal condition to treat. This is largely due to the lack of research-based evidence of the clinical efficacy of the myriad of treatment approaches espoused in the literature. In view of this, successful rehabilitation of LE is based on choosing treatments that address the physical impairments found during clinical examination. The primary physical impairment in LE is a deficit in grip strength predominately due to pain and its consequences on motor function. Hence the mainstay of successful management of this condition is therapeutic exercise, providing it is not pain provocative. Adjunctive procedures such as manipulative therapy and sports taping techniques have recently been shown to provide substantial initial pain relief. Early relief of pain in the rehabilitation program helps accelerate recovery and most importantly motivates the client to persist with the therapeutic exercise program. The manipulative therapy and taping treatments presented in this masterclass warrant consideration in the clinical best practice management of LE, and serve as a model for other similar musculoskeletal conditions.

The condition first known as “tennis elbow” has been recognized for over a century. Typical signs and symptoms include pain and tenderness over the lateral epicondyle, exacerbated by resisted wrist extension and passive wrist flexion, and impaired grip strength. Although many tennis players may experience this condition, most cases are associated with work-related activities or have no obvious precipitating event. As a result, the term now most widely used is lateral epicondylitis. Yet, this name implies a pathological basis that is contrary to longstanding, albeit evolving, evidence that it is not an inflammatory condition. It is therefore recommended that it is time to adopt a new and more appropriate term, such as epicondylalgia (suffix algia means pain), that does not reflect such underlying pathology. This Journal has recently embraced this terminology. J Orthop Sports Phys Ther 2005; 35(4):200–202. doi:10.2519/jospt.2005.0104

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Additional co-authors of the American Journal of Chinese Medicine paper are Wen-Dien Chang, Ph.D., Ping-Tung Lai, and Yung-An Tsou, Ph.D.

This work was funded by the China Medical University under the contract No. CMU100-N2-05.

Comparing analgesic effect of manual vs laser acupuncture for lateral epicondylalgia To read more about this study click on this link. The article is published in The American Journal of Chinese Medicine Corresponding author for this study is Wen-Dien Chang, .(JavaScript must be enabled to view this email address).

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