Microsoft word - tennis elbow november 2014.docx
ACUPUNCTURE AND TENNIS ELBOW
About tennis elbow Tennis elbow (lateral epicondylitis) is characterised by pain and tenderness over the
lateral epicondyle of the humerus. In the UK, the annual incidence of lateral elbow
pain in general practice is around 4/1000 to 7/1000 people.(Hamilton 1986) It is most
common in people aged between 40 and 50 years (Allander 1974); for example, the
incidence is as much as 10% in women aged 42 to 46 years.(Chard 1989; Verhaar
Tennis elbow is considered an overload injury, and it typically occurs after minor trauma of the extensor muscles of the forearm; tennis is a direct cause in only 5% of people with the condition.(Murtagh 1988). It is primarily a type of tendonitis though the muscles and bones of the epicondyle joint may also be involved. Pain can also occur on the inner side of the elbow, which is known as golfer's elbow. Although generally self-limiting, symptoms of tennis elbow can persist for 1.5 to 2 years or even longer in a minority of people.(Hudak 1996)
The aims of conventional medical interventions are to relieve pain, control inflammation and accelerate repair in order to improve function. Treatments include corticosteroid injections, topical and oral NSAIDs, other analgesics, exercises, ultrasound, orthoses and surgery.
Allander E. Prevalence, incidence and remission rates of some common rheumatic diseases and syndromes. Scand
J Rheumatol 1974; 3: 145-53.
Chard MD, Hazleman BL. Tennis elbow - a reappraisal. Br J Rheumatol 1989; 28: 186-90.
Hamilton P. The prevalence of humeral epicondylitis: a survey in general practice. J R Coll Gen Pract 1986; 36: 464-5.
Hudak P et al. Understanding prognosis to improve rehabilitation: the example of lateral elbow pain. Arch Phys Rehabil 1996; 77: 568-93.
Murtagh J. Tennis elbow. Aust Fam Physician 1988; 17: 90-1, 94-5.
Verhaar J. Tennis elbow: anatomical, epidemiological and therapeutic aspects. Int Orthop 1994; 18: 263-7.
How acupuncture can help One systematic review concluded that acupuncture was beneficial for pain, at least in the short term, although the amount of evidence was limited (Green 2002). Two years later, a second review with more data available, found strong evidence of short-term pain relief (Trinh 2004). Most randomised controlled trials not included in these systematic reviews have compared different types of acupuncture, so can tell us little about the overall effectiveness of acupuncture for the treatment of tennis elbow.(Su 2010; Gu 2007; Xia 2004; Tsui 2002) One trial, however, compared electroacupuncture plus moxibustion with lidocaine plus prednisone treatment, and found the acupuncture treatment to be more
effective.(Jiang 2005) The fact sheet on Sports Injuries has more information on other tendinopathies.
In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical' brain, which is responsible for anxiety (Wu 1999).
Acupuncture may help relieve symptoms of tennis elbow, such as pain and inflammation by:
• stimulating nerves located in muscles and other tissues, which leads to release of
endorphins and other neurohumoral factors (e.g. neuropeptide Y, serotonin), and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Han 2004, Zhao 2008, Zhou 2008, Lee 2009, Cheng 2009);
• delivering analgesia via alpha-adrenoceptor mechanisms (Koo 2008); • increasing the release of adenosine, which has antinociceptive properties
• modulating the limbic-paralimbic-neocortical network (Hui 2009); • reducing inflammation, by promoting release of vascular and immunomodulatory
factors (Kavoussi 2007, Zijlstra 2003);
• improving muscle stiffness and joint mobility by increasing local microcirculation
(Komori 2009), which aids dispersal of swelling.
About traditional acupuncture Acupuncture is a tried and tested system of traditional medicine, which has been used in China and other eastern cultures for thousands of years to restore, promote and maintain good health. Its benefits are now widely acknowledged all over the world and in the past decade traditional acupuncture has begun to feature more prominently in mainstream healthcare in the UK. In conjunction with needling, the practitioner may use techniques such as moxibustion, cupping, massage or electro-acupuncture. They may also suggest dietary or lifestyle changes. Traditional acupuncture takes a holistic approach to health and regards illness as a sign that the body is out of balance. The exact pattern and degree of imbalance is unique to each individual. The traditional acupuncturist's skill lies in identifying the precise nature of the underlying disharmony and selecting the most effective treatment. The choice of acupuncture points will be specific to each patient's needs. Traditional acupuncture can also be used as a preventive measure to strengthen the constitution and promote general well-being. An increasing weight of evidence from Western scientific research (see overleaf) is demonstrating the effectiveness of acupuncture for treating a wide variety of conditions. From a biomedical viewpoint, acupuncture is believed to stimulate the nervous system, influencing the production of the body's communication substances - hormones and neurotransmitters. The resulting biochemical changes activate the
body's self-regulating homeostatic systems, stimulating its natural healing abilities and promoting physical and emotional well-being.
About the British Acupuncture Council With over 3000 members, the British Acupuncture Council (BAcC) is the UK's largest professional body for traditional acupuncturists. Membership of the BAcC guarantees excellence in training, safe practice and professional conduct. To find a qualified traditional acupuncturist, contact the BAcC on 020 8735 0400 or visit www.acupuncture.org.uk
ACUPUNCTURE AND TENNIS ELBOW
Systematic reviews (SRs)
Trinh KV et al. Acupuncture for the
A systematic review that evaluated the effectiveness of
alleviation of lateral epicondyle pain: acupuncture as a treatment for lateral epicondylitis. Six a systematic review. Rheumatology
randomised controlled trials (four sham-controlled) were
2004; 43: 1085-90.
included. All the studies suggested that acupuncture was effective in the short-term relief of lateral epicondyle pain. Five of
the six studies indicated that acupuncture treatment was more
effective compared to a control treatment. The reviewers concluded that there was strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain.
Green S et al. Acupuncture for lateral A systematic review that included four small randomised elbow pain. Cochrane Database of
controlled trials. One trial found that needle acupuncture resulted
Systematic Reviews 2002, Issue 1.
in relief of pain for significantly longer than placebo and was
Art. No.: CD003527. DOI:
more likely to result in a 50% or greater reduction in pain after
one treatment (RR 0.33, 95% CI 0.16 to 0.69). A second trial demonstrated needle acupuncture to be more likely to result in
overall participant reported improvement than placebo in the short term (RR = 0.09, 95% CI 0.01 to 0.64). No significant differences were found in the longer term (after 3 or 12 months). A third trial of laser acupuncture versus placebo demonstrated no differences between laser acupuncture and placebo with respect to overall benefit. A fourth trial found no difference between Vitamin B12 injection plus acupuncture, and Vitamin B12 injection alone. The reviewers concluded that there is insufficient evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral elbow pain, but that needle acupuncture is of short term benefit with respect to pain.
Randomised controlled trials (not in the SRs)
Su X et al. Effects of
A randomised controlled trial that assessed the different effects
electroacupuncture of different
of electroacupuncture of different frequencies in 85 patients with
frequencies for treatment of patients
refractory tennis elbow syndrome. The patients were allocated to
with refractory tennis elbow
continuous wave or rarefaction wave electroacupuncture at the
syndrome. Zhongguo Zhen Jiu 2010; same acupoints. A Visual Analogue Scale (VAS) was used to 30: 43-5.
evaluate the tenderness score. The effective rate was 82. 9% in continuous wave group and 84. 1% in rarefaction wave group,
with no significant difference between the two groups. The healing rate was better in rarefaction wave group (56. 8% vs. 31.7% in the continuous wave group; p<0.05). The VAS scores were significantly reduced after electroacupuncture treatment in both groups (both p<0.001). The researchers concluded that rarefaction wave electroacupuncture is better than continuous wave electroacupuncture for refractory tennis elbow syndrome.
Gu JQ, Shan YH. Therapeutic effect
A randomised controlled trial that compared the therapeutic
of triple puncture at Tianzong (SI 11) effects of triple puncture at SI11 plus routine acupuncture with as main method on obstinate tennis
routine acupuncture alone in 62 patients with obstinate tennis
elbow. Zhongguo Zhen Jiu 2007; 27: elbow. Changes in symptoms and signs were compared 109-11.
between the two treatment groups. The cure rate was better in the triple puncture group (71.9% vs. 43.3% with routine
acupuncture alone; p<0.05). The researchers concluded that triple puncture combined with routine acupoint selection therapy has a better therapeutic effect on obstinate tennis elbow than routine acupuncture alone.
Jiang ZY et al. Controlled observation A randomised controlled trial that compared electroacupuncture on electroacupuncture combined with plus moxibustion with lidocaine plus prednisone treatment in the cake-separated moxibustion for
treatment of 128 patients with tennis elbow. The cure rate and
treatment of tennis elbow. Zhongguo the effective rate were 40.6% and 93.7% in the Zhen Jiu 2005; 25: 763-4.
electroacupuncture group, and 25.0% and 78.1% in the conventional medicine group, respectively, with a significant
difference between the two groups in favour of acupuncture (p<0.05). The researchers concluded that electroacupuncture combined with moxibustion is an effective treatment for tennis elbow.
Xia DB, Huang Y. Combination of Fu A randomised controlled trial that assessed the clinical effect of needling with electric acupuncture for Fu needling combined with electroacupuncture in 100 patients tennis elbow. Di Yi Jun Yi Da Xue
with tennis elbow. Patients were allocated to receive Fu
Xue Bao 2004; 24: 1328-9.
needling, electroacupuncture or a combination of the two. All three therapies had good effects, but the combined therapy was
the most effective. The researchers concluded that Fu needling combined with electroacupuncture may produce a higher cur rate of tennis elbow than either of the therapies used alone.
Tsui P, Leung MC. Comparison of the A single-blinded randomised controlled trial that compared the effectiveness between manual
relative effectiveness of manual acupuncture and
acupuncture and electro-acupuncture electroacupuncture in 20 patients with chronic tennis elbow. on patients with tennis elbow.
After 6 treatments, significant differences were observed
Acupunct Electrother Res 2002; 27:
between groups favouring electroacupuncture in relation to pain
relief (measured on a pain visual analogue scale) and pain free hand grip strength. The researchers concluded that
electroacupuncture is superior to manual acupuncture in treating patients with tennis elbow.
Research on mechanisms
Goldman N et al. Adenosine A1
A study that found the neuromodulator adenosine, which has
receptors mediate local anti-
anti-nociceptive properties, was released during acupuncture in
nociceptive effects of acupuncture.
mice, and that its anti-nociceptive actions required adenosine A1
Nat Neurosci 2010 May 30. [Epub
receptor expression. Direct injection of an adenosine A1
receptor agonist replicated the analgesic effect of acupuncture. Inhibition of enzymes involved in adenosine degradation potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive effect. The researchers concluded that their observations indicate that adenosine mediates the effects of acupuncture and that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.
Hui K.K.-S. The salient
A study that assessed the results of fMRI on 10 healthy adults
characteristics of the central effects
during manual acupuncture at 3 acupuncture points and a sham
of acupuncture needling: limbic-
point on the dorsum of the foot. Although certain differences
were seen between real and sham points, the hemodynamic and
modulation. Human Brain Mapping
psychophysical responses were generally similar for all 4 points.
2009; 30: 1196-206.
Acupuncture produced extensive deactivation of the limbic-paralimbic-neocortical system. Clusters of deactivated regions
were seen in the medial prefrontal cortex, the temporal lobe and the posterior medial cortex. The sensorimotor cortices, thalamus and occasional paralimbic structures such as the insula and anterior middle cingulate cortex showed activation. The researchers concluded that their results provided additional evidence that acupuncture modulates the limbic-paralimbic-neocortical network. They hypothesised that acupuncture may mediate its analgesic, anti-anxiety, and other therapeutic effects via this intrinsic neural circuit that plays a central role in the affective and cognitive dimensions of pain.
Cheng CH et al. Endogenous Opiates An animal study that investigated the involvement of the nucleus in the Nucleus Tractus Solitarius
tractus soliatarius opioidergic system in electroacupuncture-
Mediate Electroacupuncture-induced induced alterations in sleep, the findings of which suggested that Sleep Activities in Rats. Evid Based
mechanisms of sleep enhancement may be mediated, in part,
Complement Alternat Med 2009 Sep by cholinergic activation, stimulation of the opioidergic neurons 3. [Epub ahead of print]
to increase the concentrations of beta-endorphin and the involvement of the µ-opioid receptors.
Lee B et al. Effects of acupuncture on In animal studies, acupuncture has been found to significantly chronic corticosterone-induced
reduce anxiety-like behaviour, and increase brain levels of
depression-like behavior and
neuropeptide Y, which appear to correlate with reported anxiety.
expression of neuropeptide Y in the rats. Neuroscience Letters 2009; 453: 151-6.
Komori M et al. Microcirculatory
Experimental study on rabbits in which acupuncture stimulation
responses to acupuncture stimulation was directly observed to increase diameter and blood flow and phototherapy. Anesth Analg
velocity of peripheral arterioles, enhancing local microcirculation.
2009; 108: 635-40.
Koo ST et al. Electroacupuncture-
An animal study that investigated the underlying mechanism of
induced analgesia in a rat model of
electroacupuncture (EA) analgesia, and the effects of various
ankle sprain pain is mediated by
antagonists on known endogenous analgesic systems in a rat
spinal alpha-adrenoceptors. Embase model of ankle sprain. EA significantly improved the weight-Pain 2008; 135: 11-9.
bearing capacity of the affected hind limb for 2 hours, suggesting an analgesic effect. The alpha-adrenoceptor antagonist
phentolamine completely blocked the EA-induced analgesia, whereas naloxone failed to block the effect. Further experiments showed that intrathecal administration of yohimbine, an alpha2-adrenergic antagonist, reduced the EA-induced analgesia in a dose-dependent manner, whereas terazosin, an alpha1-adrenergic antagonist, did not produce any effect. The researchers concluded that the results suggest EA-induced analgesia is mediated by alpha-adrenoceptor mechanisms and, at least in part, mediated by spinal alpha2-adrenoceptor mechanisms.
Zhao ZQ. Neural mechanism
Review article that discusses the various peripheral and central
underlying acupuncture analgesia.
nervous system components of acupuncture anaesthesia in
Prog Neurobiol 2008; 85: 355-75.
Zhou Q et al. The effect of electro-
A study of the regulatory effect of electro-acupuncture on the
acupuncture on the imbalance
imbalance between monoamine neurotransmitters and GABA in
the central nervous system of rats with chronic emotional stress-
neurotransmitters and GABA in the
induced anxiety. The levels of serotonin, noradrenaline and
CNS of rats with chronic emotional
dopamine fell significantly, while GABA levels were significantly
stress-induced anxiety. Int J Clin
higher in the rats given acupuncture (P<0.05, or P<0.0). The
Acupunct 2008;17: 79-84.
researchers concluded that the anti-anxiety effect of electro-acupuncture may relate to its regulation of the imbalance of neurotransmitters.
Kavoussi B, Ross BE. The
Review article that suggests the anti-inflammatory actions of
neuroimmune basis of anti-
traditional and electro-acupuncture are mediated by efferent
inflammatory acupuncture. Integr
vagus nerve activation and inflammatory macrophage
Cancer Ther 2007; 6: 251-7.
Han JS. Acupuncture and
A literature review of studies relating to the release of
endorphins. Neurosci Lett 2004; 361: endorphins by acupuncture. 258-61.
Zijlstra FJ et al. Anti-inflammatory
An article that suggests a hypothesis for anti-inflammatory action
actions of acupuncture. Mediators
of acupuncture: Insertion of acupuncture needles initially
Inflamm 2003; 12: 59-69.
stimulates production of beta-endorphins, CGRP and substance P, leading to further stimulation of cytokines and NO. While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied 'low-dose' treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.
Wu MT et al. Central nervous
An experimental study using MRI to characterise the central
pathway for acupuncture stimulation: nervous system pathway for acupuncture stimulation, which localization of processing with
found that acupuncture activates structures of descending
functional MR imaging of the brain--
antinocioceptive pathway and deactivates areas mediating pain
preliminary experience. Radiology
1999 ; 212: 133-41.
Pomeranz B. Scientific basis of
Needle activation of A delta and C afferent nerve fibres in
acupuncture. In: Stux G, Pomeranz
muscle sends signals to the spinal cord, where dynorphin and
B, eds. Acupuncture Textbook and
enkephalins are released. Afferent pathways continue to the
Atlas. Heidelberg: Springer-Verlag;
midbrain, triggering excitatory and inhibitory mediators in the
spinal cord. Ensuing release of serotonin and norepinephrine onto the spinal cord leads to pain transmission being inhibited
both pre- and postsynaptically in the spinothalamic tract. Finally, these signals reach the hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.
Terms and conditions
The use of this fact sheet is for the use of British Acupuncture Council members and is subject to the strict conditions imposed by the British Acupuncture Council details of which can be found in the members area of its' website www.acupuncture.org.uk.
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British Journal of Anaesthesia 103 (5): 711–18 (2009) Advance Access publication August 22, 2009 Apoptosis induction by different local anaesthetics in a neuroblastoma cell line R. Werdehausen1, S. Fazeli1, S. Braun1, H. Hermanns1, F. Essmann3, M. W. Hollmann4, I. Bauer2 and M. F. Stevens5* 1Department of Anaesthesiology and 2Department of Experimental Anaesthesiology, University of Du¨sseldorf,Du¨sseldorf, Germany. 3Institute of Biochemistry, University of Tu¨bingen, Tu¨bingen, Germany. 4Department of