51 year old male “Jack” presented with osteoarthritis in the fingers of both hands, worse in the left hand and most pronounced in the 5th phalange (pinkie finger). He complained of pain for the past year growing increasingly worse as the months progressed. Jack works as a bus driver and is an avid golf enthusiast, fitting in a game even on his split shift breaks between work.
Initially Jack was unable to bend his left pinkie finger which hindered his golf swing as he was unable to maintain a consistent grip on the handle of the club. Jack says his hands hurt all of the time and this also affects his work as his hands are on the wheel for up to 4 hours at a time.
His GP prescribed a topical arthritis cream which had no effect and he didn’t want to have to live on Panadol Osteo for the rest of his life.
- Bouchard’s nodes present on both 5th phalanges (proximal interphalangeal joint), Heberden’s nodes present on 2nd – 5th phalanges (distal interphalangeal joints)
- Pain and stiffness on finger flexion of 2nd to 5th phalanges
- Range of motion (ROM) – 5th phalange on left hand unable to complete flexion at both proximal and distal interphalangeal joints
- Distal interphalangeal joint on left 5th finger appeared almost to be fused and had extremely limited to no ROM
- Pain is constant throughout the day, Jack describes the severity as reaching up to 10/10 sometimes when it is bad and is aggravated when he knocks his hands or fingers on something
- Better for heat and rest
- ADLs – Jack commented on the fact that when playing golf he had to hold his left 5th finger out like “holding a teacup” as it would not bend.
3 x 0.14 x 8mm Sooji hand needles applied with a needles injector at the proximal interphalangeal joints of the 5th phalanges and the distal interphalangeal joints of the 2nd through to 5th phalanges
0.25 x 30mm needles used at CO4, Baxie – spaces between metacarpophalangeal joints with electrical stimulation of the 1st and 3rd positions. Stimulation D~D alternating between below and above 100Htz
0.25 x 30mm – CO11, CO4, ST36, SP6, LIV3
Moxibustion for a few minutes on each hand at the most affected areas and electro points
Jack was advised to come for weekly treatments.
0.14 x 8mm Sooji hand needles next to 0.20 x 30mm for comparison
(Second value refers to length of the needle not including the handle)
2nd Treatment 6 days later
- Following the first treatment, Jack said that his pain had decreased to 2-3/10
- He said he gained relief the day following the treatment which lasted until the second visit
- Pain in all fingers reduced greatly except for the 5th finger on the left hand and it still would not bend
3rd Treatment 8 days later
- Following the second treatment, Jack was able to bend all fingers with ease and commented that he didn’t even feel the pain in his right index finger anymore
- The 5th finger on his left hand had also regained some movement with flexion at the proximal interphalangeal joint
- Jack mentioned that he no longer had to hold his finger out like holding a teacup and was able to wrap his finger more around the golf club handle
4th Treatment 6 days later
- Following the 3rd treatment now only has pain remaining in his 5th finger on his left hand and only when he bends it, the pain presents at the metacarpophalangeal joint
- All other fingers are pain free and freely moveable
- Jack was advised to now come for fortnightly treatments
5th Treatment 19 days later
- Jack says his hands are still mostly pain free
- The 5th left finger was inflamed and swollen as Jack had knocked it earlier that day, other than that he said his hands are feeling great
6th Treatment 7 days later
- Now only the 5th left finger hurts whenever Jack accidentally knocks it, otherwise he has no pain at all in his other fingers
- ROM has increased greatly in the proximal interphalangeal joint of the left 5th finger
- No change in ROM in distal interphalangeal joint
7th Treatment 7 days later
- Still only 5th finger on left hand hurts when he bumps it, otherwise there is no pain
- The duration and intensity of the pain that follows when he knocks it is also greatly reduced
Treatments have ceased for the time being due to work commitments.
I approached this treatment purely from a physiological perspective. While using traditional acupuncture points, I did not adhere to Traditional Chinese Medicine (TCM) theory. As osteoarthritis is due to the breakdown of articular cartilage in the joint with resulting inflammation (1), the treatment protocol was to improve circulation to the joints, lubricate and warm the joints, and reduce inflammation in the area. Proposed physiological pain relief mechanisms of acupuncture are the gate control mechanism as well as through the release of the body’s own chemical mediators (2).
The gate control theory of pain states that pain transmitted from a peripheral nerve that passes through the spinal cord is subject to modulation by intrinsic neurones, as well as controls emanating from the brain (3). Stimulation of certain nerve fibres would open the gate while others would close it, ultimately affecting a person’s capacity to feel and perceive pain (4).
As for chemical mediators, the body’s own array of endogenous opioids including, but not limited to, endorphins, enkephalins and dynorphins, have been found to be more potent than even some of the most powerful pharmaceutical medicines (5, 6). The release of these endogenous opioids has been found to be potentiated by the use of electroacupuncture – below 100Htz has been found to stimulate the release of β-endorphins and enkephalins while over 100Htz stimulates the release of dynorphins (7) and 2Htz releases serotonin which is believed to play a role in acupuncture analgesia (8).
Oxytocin is another endogenous chemical mediator that may influence endocrine function, exert both anxiolytic and sedative effects, alleviate pain and decrease sympathetic nerve activity via stimulation of vagal parasympathetic nerve activity (9). Acupuncture is known to release oxytocin and, along with the previously mentioned chemical mediators, is an important component in the control of sensory, motor and cognitive elements of pain (10).
Considering this, I am a firm believer that the stimulation of the nerve pathways plays a crucial role in the mechanism of acupuncture, and that the nerves themselves underpin the very concept of the acupuncture channels. I believe that by stimulating peripheral nerves, both motor and sensory (through known acupuncture points) and following the lines of connective tissue known as fascia to alleviate pain and tension (read more here), one could build an effective treatment based on this concept alone that would be comparable to that of one based on TCM theory.
Moxibustion has been found to release heat shock proteins (HSP, also known as stress proteins) in the body that are produced in response to any form of stress such as heat, exposure to heavy metals, UV-B, ethanol or oxygen deprivation (11). Experiments show that HSP’s can protect the cells of an organism against stress-induced damage by stabilising and repairing misfolded proteins – a precursor to irreversible damage (12).
Points used on the hands were for local stimulation and pain relief.
Moxa used to enhance blood flow and synovial fluid to to lubricate the joints, as well as it’s cellular protective mechanisms.
Electro acupuncture was used to potentiate the release of neurotransmitters, i.e β-endorphin, enkephalin, serotonin, dynorphin, oxytocin.
Distal points were selected based on the stimulation of major nerve pathways:
- CO11 – distal stimulation of the brachial plexus via radial nerve (C5 – T1)
- CO4 – peripheral stimulation of brachial plexus via radial nerve (C5 – T1)
- ST36 – distal stimulation of sciatic nerve & sacral plexus via deep branch of the peroneal nerve
- SP6 distal stimulation of the tibial nerve
- LIV3 – peripheral stimulation of the deep peroneal nerve
- British Acupunctre Council 2018, ‘Osteoarthritis’, viewed 19 December 2018, source
- Selfe, T & Taylor A 2010, ‘Acupuncture and Osteoarthritis of the Knee – A Review of Randomized, Controlled Trials’, Fam Community Health, Vol. 31, Issue 3, pp. 247–254, viewed 19 December 2018, source
- Dickenson, A 2001, ‘Editorial I: Gate Control Theory of pain stands the test of time’, British Journal of Anaesthesia, Vol. 88, Issue 6, pp. 755–757, viewed 19 December 2018, source
- Baldry, P 2005, Acupuncture, Trigger Points and Musculoskeletal Pain, Elsevier Churchill Livingstone, USA, p. 56
- Loh, H, Tseng, L, Wei, E & Li 1976, ‘beta-endorphin is a potent analgesic agent’, Proceedings of the National Academy of Sciences of the United States of America, Vol. 73, No. 8, pp. 2895–2898, viewed 19 December 2018, source
- Stanford University Medical Centre 1979, ‘Stanford University Medical Centre News Bureau’, Stanford Medicine Website’, viewed 19 December 2018, source
- Lin, J & Chen, W 2008, ‘Acupuncture Analgesia: A Review of Its Mechanisms of Actions’, The American Journal of Chinese Medicine, Vol. 36, No. 4, 635–645, viewed 19 December 2018, source, p. 637
- Ibid, p. 639
- Lundeberg, T 2002, ‘Acupuncture and Related Techniques (ICMART) held in Edinburgh from 4th to 6th May 2002’, Acupuncture in Medicine, Vol. 20, Issue 2 – 3, viewed 19 December 2018, source, p. 109
- Ibid, p. 110
- Cakmak, Y 2009, ‘A review of the potential effect of electroacupuncture and moxibustion on cell repair and survival: the role of heat shock proteins’, Acupuncture in Medicine,