The American Journal of Chinese Medicine, Vol. 42, No. 2, 303–314 © 2014 World Scientific Publishing Company Institute for Advanced Research in Asian Science and Medicine DOI: 10.1142/S0192415X14500207
Am. J. Chin. Med. 2014.42:303-314. Downloaded from www.worldscientific.com by UNIVERSITY OF ST ANDREWS on 02/01/15. For personal use only.
Clinical Effectiveness of Acupuncture for Carpal Tunnel Syndrome Chien-Yi Ho,*,‡ Hsiu-Chen Lin,† Yu-Chen Lee,*,§ Li-Wei Chou,*,¶ Ta-Wei Kuo,§ Heng-Wei Chang,§ Yueh-Sheng Chen*,|| ,a and Sui-Foon Lo*,¶,a *School
of Chinese Medicine, College of Chinese Medicine †Department
of Physical Therapy China Medical University, Taichung, Taiwan ‡
Department of Family Medicine §Department
of Acupuncture
¶
Department of Physical Medicine and Rehabilitation China Medical University Hospital, Taichung, Taiwan
||Department of Biomedical Informatics Asia University, Wufeng, Taiwan
Abstract: Acupuncture and electroacupuncture treatments of symptomatic carpal tunnel syndrome (CTS) may improve symptoms and aid nerve repair as well as improve sensory and motor functions. However, limited evidence is available regarding the effects of these treatments based on comprehensive evaluation methods. This research completed the treatment and evaluation of 26 patients with confirmed CTS. Participants were divided into two treatment groups based on a modified neurophysiological grading scale. Of the total number of participants, 15 received acupuncture and 11 received electroacupuncture on both upper limbs. Acupoints were PC-7 (Daling) and PC-6 (Neiguan) along the pericardial meridian compatible with the median nerve tract. The treatment program consisted of 24 sessions of 15 min duration over 6 weeks. After electroacupuncture treatments, symptom severity was evaluated using the short clinical questionnaire by Lo and Chiang, which indicated improvements in the respective symptom severity score. After the acupuncture treatment, grip strength in the major symptomatic side in CTS patients could be significantly increased. Electrophysiology evaluation likewise indicated a significant increase in the distal median motor amplitude of the palm-wrist segment. In addition, Tinel’s sign significantly decreased in the major symptomatic side. Our findings indicated that electroacupuncture could improve symptomatology, while acupuncture could exert positive therapeutic effects for CTS patients, as evidenced by improved symptomatology, grip strength, electrophysiological function, and physical provocation sign.
Correspondence to: Dr. Sui-Foon Lo, Department of Physical Medicine and Rehabilitation, China Medical University Hospital, No. 91 Hsueh-Shih Road, Taichung, Taiwan 40402, E-mail: [email protected] a These authors contributed equally to this work.
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C.-Y. HO et al. Keywords: Acupuncture; Carpal Tunnel Syndrome; Electroacupuncture; Median Nerve; Safety Depth Needling.
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Introduction Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper limbs, and represents a mainly median nerve degeneration process at the wrist (Von Schroeder and Botte, 1996). CTS diagnosis is often based on clinical symptoms, physical signs, electrophysiological measurements, or image study (Szabo and Steinberg, 1994). Most studies in the literature focus on surgical treatments of CTS. Recently, the application of non-surgical treatments that combine acupuncture and electrical stimulation, such as electroacupuncture, has become one of the popular complementary alternative treatments in clinical rehabilitation to facilitate nerve function recovery (Tang et al., 1999; Freedman, 2002; Gerritsen et al., 2002; Naeser et al., 2002; Brunelli and Gorson, 2004; Carlson et al., 2010). Acupuncture and electroacupuncture have likewise been reported to promote nerve repair and blood supply after a peripheral nerve injury (Hsieh et al., 2000; Ma et al., 2006; Lu et al., 2008; Dong et al., 2013). CTS is a kind of median nerve damage due to mechanical overuse or inappropriate posture, resulting in ischemia of the nerve; hence, acupuncture and electroacupuncture are believed to be complementary methods to treat CTS. However, the effectiveness of acupuncture and electroacupuncture in treating CTS patients is still unknown. Therefore, an urgent need to evaluate the therapeutic effects of acupuncture and electroacupuncture on CTS exists. In the literature, it has been reported that short-term acupuncture treatment at the classic acupuncture points of PC-7 (Daling) and PC-6 (Neiguan) can improve the subjective symptoms of CTS (Sim et al., 2011; Yang et al., 2011; Khosrawi et al., 2012; Yao et al., 2012). The Boston Carpal Tunnel Questionnaire (BCTQ), developed by Levine et al. in 1993, provides an important screening method and is widely used to assist CTS evaluation and diagnosis (Levine et al., 1993; Fok et al., 2007). BCTQ is a quantitative instrument that consists of two parts: the Functional Status Scale (FSS) and the Symptom Severity Scale (SSS), which needs considerable time to fulfill all the questions (Levine et al., 1993). In Asia, the differences in languages and cultures have led to the development of a HongKong Chinese version of the self-administered questionnaire (Fok et al., 2007). In our previous studies, we investigated work-related CTS risk factors and severity grading among computer users in the workplace, and designed the Lo and Chiang’s clinical questionnaire for CTS evaluation (Jung, 2009). Among the three questionnaires, the validity of the BCTQ questionnaires is divided into SSS 0.91 and FSS 0.93 (Levine et al., 1993), that of the Hong-Kong Chinese version is SSS: 0.83 and FSS: 0.87 (Fok et al., 2007), and that of Lo and Chiang’s is 0.92 (Jung, 2009). Lo and Chiang’s quick clinical questionnaire showed the advantages of high validity, simplicity, and convenience to apply. The aim of this study is to test the effectiveness of acupuncture and electroacupuncture treatments for patients with symptomatic CTS. The well-established Lo and Chiang’s
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clinical questionnaire, electrodiagnostic measurements, muscle strength evaluation, and provocation signs were used to evaluate CTS patients before and after treatment to gauge the treatment effectiveness. Materials and Methods
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General Design The potential participants were patients who visited our outpatient clinics with symptoms that suggested CTS, after excluding the medical and surgical conditions that predispose one to peripheral neuropathy. Informed consent, as approved by the local ethics committee, was obtained from every enrolled participant before the study. The clinical symptoms were first evaluated using Lo and Chiang’s quick clinical questionnaire. This quick questionnaire contains only six categories with three regarding different types of daytime symptoms (numbness, tingling, and pain), one for the predominant nocturnal symptoms, one for hand weakness and one for symptoms related to the difficulty experienced in manual work. To comprehend more, both the severity and lasting duration of each of these four daytime and nocturnal symptoms are rated in this questionnaire. Each of the severity/lasting duration questions are rated from 1 (no symptom/never happened) to 5 (extremely severe/lasted continuously). Therefore, this simple and well-described questionnaire contains only 10 questions with a total score of 50, which is convenient and is quick to apply for CTS symptom severity evaluation. CTS is diagnosed clinically with at least one of the symptoms of numbness, tingling, or pain in the wrist or hand. The diagnosis is confirmed with electrodiagnostic studies, which indicate at least one of the following criteria: (1) prolonged distal motor latency (DML) to the abductor pollicis brevis muscle (= 4:5 ms, stimulation over the wrist, 8 cm proximal to the active electrode); (2) prolonged orthodromic distal sensory peak latency (DSPL) from the second digit to the wrist (= 3:5 ms; stimulation over the index, 14 cm distal to the active electrode) and decreased orthodromic palm–wrist sensory nerve conduction velocity at a distance of 8 cm (P–W SNCV < 35 m/s); or (3) decreased orthodromic index–wrist sensory nerve conduction velocity (I–W SNCV) at a distance of 14 cm (I–W SNCV < 40 m/s) and P–W SNCV < 35 m/s. Patients with electrodiagnostically confirmed CTS were invited to participate in our study. Possible beneficial and side effects were fully explained before allocation to the treatments. We then divided the participants into two treatment groups matched with a modified neurophysiological grading scale for CTS severity (Bland, 2000). One group received traditional acupuncture (Acu group) and the other group received electroacupuncture with 0.8 mA, 2 Hz current (Elec-Acu group) at two selected acupoints, PC-7 (Daling) and PC-6 (Neiguan), on both upper limbs (Fig. 1A). For all participants, sterile disposable steel needles (0.35 mm outer diameter, 12 mm length) were used and the skin was wiped with alcohol before each insertion. The needles were inserted perpendicularly at PC-6 to a depth of 0.5 cm to 0.75 cm and at PC-7 to a depth of 0.25 cm to 0.5 cm, based on the thickness of the soft tissue and safety depth needling technique, and then manipulated by twirling with lifting-thrusting methods to produce a characteristic sensation known as
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Palmaris longus tendon
median nerve
flexor carpi radialis tendon Ventral side
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flexor pollicis longus tendon
Dorsal side
5cm ◎
5cm away from middle of first wrist crease
(A)
Ventral side
palmaris longus tendon median nerve flexor carpi radialis tendon
flexor pollicis longus tendon
◎
Middle of first wrist crease
Dorsal side
(B) Figure 1. Representative MRI cross-sectional images showing the median nerve located between radial flexor tendon and Palmaris longus tendon. PC6 (Neiguan) is away from the wrist at approximately 2 inches (panel A) and PC7 (Daling) is at the middle of the wrist (panel B). Red arrow: radial flexor tendon of wrist; Green arrow: Palmaris longus tendon; Yellow arrow: median nerve.
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De Qi (an awareness of numbness, soreness, swelling, heaviness, or radiating feeling from the point of needling deemed to indicate proper needle position and effective needling) (Kou et al., 2007). For applying electric stimulation in the Elec-Acu group, one stainless steel needle electrode at the middle aspect of the wrist PC-7 was connected to the negative wick (cathode) of a stimulator (HC-0601, Taiwan), and the positive electrode (anode) was positioned around the site of the forearm PC-6 along with the pericardium meridian. The treatment program consisted of 24 sessions of 15 min duration, administered over 6 weeks (four sessions per week). To establish the baseline manifestation, the following examinations were performed before the treatment program started: electrodiagnostic study; symptom severity assessment; grip strength; pinch strength; two-point discrimination evaluation; and physical examination with provocation test, namely, Tinel’s sign and Phalen test. To examine the therapeutic effectiveness, all the examinations were re-evaluated two weeks after the completion of the treatment program, except the electrodiagnostic study which was conducted four weeks after the treatment program. Subject Participant’s age, sex, body weight, height, education, and pertinent medical history were recorded before the treatment. This study first included 40 participants (21 in the Acu group and 19 in the Elec-Acu group). Nine and six participants in the Acu group and the ElecAcu group, respectively, exhibited CTS symptoms in both hands. Their side with more severe symptoms was defined as the major symptomatic side, whereas the side with less severe symptoms was defined as the minor symptomatic side. All needling procedures were performed based on Lin’s safety depth needling suggestions (Chou et al., 2011) and magnetic resonance images (Fig. 1). During the study, six participants in the Acu group and eight in the Elec-Acu group did not complete the treatment due to insufficient time available for treatment or intolerance to needling discomfort. At the end of the study, 15 participants (12 females, 3 males) in the Acu group and 11 (8 females, 3 males) in the ElecAcu group completed the treatment program. Electrodiagnostic Studies Electrodiagnostic studies were performed based on the Kimura technique (Kimura and Yamada, 1982; Kimura et al., 1986), adhering to the uniform operating protocol of the electrodiagnostic machine (NEuropack-MEM3202) in a laboratory, with a controlled ambient room temperature of 25 C. Sensory and motor nerve conduction studies of the median and ulnar nerves were conducted using surface electrodes for stimulating and recording. Latencies were measured from the stimulus onset to the initial or peak responses for motor or sensory conduction studies, respectively. The sensory nerves were orthodromically simulated with the stimulating surface electrodes over the fingers or palm and recorded over the wrist. Participants with suggested ulnar neuropathy based on the nerve conduction study were excluded.
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Statistical Analysis
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A two-way mixed model ANOVA was used to compare the parametric measurements between the treatment program (before and after) and between the groups (Acu and ElecAcu). A paired t-test was then used to examine the pre- and post-treatment effects in each group as post-hoc analysis. The Mann–Whitney U test was used to compare the nonparametric measurements between the treatment groups. The changes of non-parametric measurements before and after the treatment program were compared with Wilcoxon’s signed rank test. Statistical significance was considered when p < 0:05. Results Age, gender, body mass index, and symptom severity were similarly distributed in the two groups (Table 1). Tinel’s sign at the major symptomatic side in the Acu group revealed decreased percentage of positive findings after the treatment (7=15 ¼ 46:7% vs. 3=15 ¼ 20:0%, p ¼ 0:046) and with a lower ranking compared to the Elec-Acu group after treatment (mean rank 10.6 vs. 17.5, p ¼ 0:024). Questionnaire scores before and after the treatment programs were shown in Fig. 2 to demonstrate the symptom severity and functional status. The results showed a decreased trend in symptom severity scores in CTS patients after the acupuncture or electroacupuncture treatment, especially the differences in the Elec-Acu group that reached the statistically significant level ( p ¼ 0:02). Table 2 shows the results of the electrophysiology study before and after the treatment programs. After the acupuncture treatment, a significant increase in the median motor distal amplitude of the major symptomatic side was determined in patients ( p ¼ 0:02). Significantly shortened median sensory latency (P-W) of the major symptomatic side was likewise noted ( p ¼ 0:04). In the major symptomatic side, the median nerve F wave mean latency evaluation exhibited a significantly shortened latency ( p ¼ 0:002), and the F wave
Table 1. Demographic Data, Symptom Duration, and Electrodiagnostic Classification of CTS Severity
Age (y/o) Height (cm) Weight (kg) BMI
Group
N
Acu Elec-Acu Acu Elec-Acu Acu Elec-Acu Acu Elec-Acu
15 11 15 11 15 11 15 11
Acu Elec-Acu
15 11
Severity
Mean SD
Mild 2 2
49.5 9.7 50.1 10.1 159.9 6.0 161.6 5.7 66.9 19.1 62.6 9.3 25.9 5.6 23.9 2.7 Moderate Severe 6 1 3 0
p-value 0.884 0.474 0.499 0.295 Extreme 6 6
0.701
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Figure 2. Lo and Chiang’s questionnaire: Symptom severity and functional status questionnaire score: *p < 0:05, statistical significance between pre- and post-treatment.
Table 2. Electrophysiology Study of the Median Nerve before and after the Treatment Programs Major Symptomatic Side Group (N) Acu (15) Elec-Acu (11) Distal motor amplitude Acu (15) (mV) Elec-Acu (11) Distal motor NCV (m/s) Acu (15) Elec-Acu (11) Sensory latency (P–W) Acu (15) (ms) Elec-Acu (11) Distal sensory latency Acu (15) (ms) Elec-Acu (11) Distal sensory amplitude Acu (15) (¹V) Elec-Acu (11) Distal sensory NCV Acu (15) (m/s) Elec-Acu (11) Sensoryamplitude Acu (15) (P–W) (¹V) Elec-Acu (11) Sensory NCV (P–W) Acu (15) (m/s) Elec-Acu (11) Nerve F wave mean Acu (15) latency (ms) Elec-Acu (11) F wave persistence (%) Acu (15) Elec-Acu (11) DML (ms)
† Statistical
Pre-tx 6.35 6.68 6.49 7.83 52.99 51.61 3.70 3.78 5.70 5.16 6.81 7.26 29.27 32.16 13.39 21.30 23.76 23.28 29.11 28.12 63.00 72.73
1.53 2.31 2.70 4.23 7.61 6.26 1.15 1.12 2.36 2.22 4.69 5.51 13.01 13.44 9.80 20.53 7.50 7.11 3.38 3.54 29.26 28.32
Post-tx 6.05 6.39 7.62 8.19 52.10 52.17 3.22 3.67 5.23 5.27 6.27 8.41 29.95 29.97 7.29 18.25 27.01 23.84 28.27 27.19 76.67 72.73
2.16 2.08 2.87 † 2.95 4.81 7.48 1.02 † 1.11 2.02 2.09 3.99 4.75 9.09 9.55 16.27 18.44 7.53 7.44 3.76 † 4.22 20.24 † 20.05
Minor or No Symptom Side Pre-tx 4.86 5.52 6.87 8.20 55.42 51.31 2.89 2.72 3.79 3.62 11.06 13.35 37.65 40.05 23.59 38.95 29.05 31.62 27.03 26.95 74.67 72.73
0.66 2.09 2.48 3.93 6.84 10.70 0.67 0.81 0.56 0.74 7.20 9.78 5.20 7.47 20.51 35.97 6.20 8.19 2.78 2.82 26.15 26.11
Post-tx 4.63 5.49 7.61 8.00 54.97 51.07 2.69 2.82 3.61 3.82 9.80 13.48 39.31 37.87 29.63 34.78 30.73 30.82 26.49 26.95 60.00 71.82
0.43 2.03 3.10 2.91 3.22 11.33 0.54 0.84 0.45 0.71 5.85 9.93 4.59 7.33 28.66 32.82 5.26 9.14 2.75 3.57 25.07 21.83
significance between pre- and post-treatment at p < 0:05.
persistence (%) significantly increased ( p ¼ 0:04). No significant electrophysiological changes were observed in the minor or no symptom side of CTS patients. Table 3 shows the motor and sensory performance of the upper limbs before and after the treatment programs. Post-treatment evaluation indicated that grip power increased in the major symptomatic side in both the Acu and Elec-Acu groups, with the differences in grip power of patients in the Acu group reaching the statistically significant level
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Table 3. Motor and Sensory Performance of the Upper Limbs before and after the Treatment Programs Major Symptomatic Side
Grip (kg) Pinch (kg) Two-point discrimination (mm)
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† Statistical
Group (N)
Pre-tx
Acu (15) Elec-Acu (11) Acu (15) Elec-Acu (11) Acu (15) Elec-Acu (11)
23.3 26.87 3.35 3.53 3.87 3.55
9.85 11.53 1.80 2.10 1.88 1.63
Post-tx 27.88 27.22 3.47 3.11 3.40 3.73
12.44 † 11.29 1.79 1.78 0.99 1.01
Minor or No CTS Symptoms Pre-tx 24.20 25.79 3.07 3.39 3.47 3.27
12.17 9.21 1.97 1.61 1.13 0.90
Post-tx 27.53 26.98 3.35 2.53 3.73 3.45
11.46 11.35 1.74 1.81 † 0.59 0.93
significance between pre- and post-treatment at p < 0:05.
( p ¼ 0:01). On the other hand, pinch strength significantly decreased in the minor or no symptomatic side after the electroacupuncture treatment ( p ¼ 0:005). No changes in the two-point discrimination were found in both of the Acu and Elec-Acu groups. Discussion The results of this study showed that electroacupuncture could alleviate clinical symptoms while acupuncture could improve grip strength, decrease physical provocation signs and improve nerve conduction function in CTS patients. In the literature, several studies have indicated that acupuncture and electroacupuncture can promote nerve regeneration and improve nerve function (Inoue et al., 2003; Lu et al., 2008; Kumnerddee and Kaewtong, 2010; Chen et al., 2013), in addition to the alleviation of CTS symptoms (such as pain, numbness, paresthesia, nocturnal awakening, and weakness) and improvement daily activity function (Yang et al., 2011; Chen et al., 2012; Kumnerddee and Pattapong, 2012). In this study, we found the increased median motor distal amplitude, shortened median sensory latency from palm to wrist segment, shortened median nerve F wave mean latency, and increased F wave persistence (%) in the major symptomatic side of CTS patients after acupuncture treatment, all suggested improvement of the neurophysiological status of the affected nerve. At the same time, the grip power in the major symptomatic side also improved after acupuncture. These results agreed with the previous studies, indicating that acupuncture could promote nerve regeneration and improve functional performance. McCaig et al. claimed that electroacupuncture may promote nerve regeneration through an increase of calcium concentration, leading to the activation of nerve outgrowth and repair (McCaig et al., 2002). In this study, electroacupunture showed beneficial effects only in the clinical symptom severity, indicating less effective treatment responses compared to those previous studies. The positive effects on nerve function were mainly observed in the Acu group, but not in the Elec-Acu group. Such discrepancies may lie in the differences of stimulating current parameters used and study design. For example, electrical stimulation at approximately 500 A was suggested to achieve the greatest effect of increased ATP concentrations and protein synthesis on the cellular level (Cheng et al., 1982). Lu et al. reported that the best effect of electrical stimulation on regeneration of
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transected rat peripheral nerve was administered at 1 mA and 2 Hz (Lu et al., 2008). In comparison, we used a 0.8 mA and 2 Hz electrical current for the electroacupuncture stimulation, with reference to reports related to animal and cellular studies that may not be applicable to human beings. Therefore, future studies exploring the best stimulation parameters for electroacupuncture for human beings are needed to achieve effective CTS treatment. In this study, we found acupuncture treatment could improve both motor and sensory nerve conduction. The grip power in the major symptomatic side in CTS patients likewise significantly increased after the acupuncture treatment, indicating corresponding median nerve motor function improvement (Mathiowetz et al., 1985; Shim et al., 2013). In the literature, similar findings were obtained in that acupuncture and electroacupuncture could increase hand grip strength (Tsui and Leung, 2002; Kang et al., 2009; Yang et al., 2011; Hoang et al., 2012). Interestingly, we found that electroacupuncture would significantly decrease the pinch power in the minor or no symptomatic side in CTS patients. A previous study showed that a lidocaine-blocked flexor pollicis longus would decrease the pinch strength without affecting the median nerve (Goetz et al., 2012). The flexor pollicis longus is located under the PC-7 (Daling) acupoint used in the present study; hence, we believe that electroacupuncture could exert lidocaine-like effects on the flexor pollicis longus and then affect the pinch strength in CTS patients. However, such a lidocaine-like effect was not observed in the major symptomatic side in CTS patients, implying that a stronger electroacupuncture treatment effect might be present in the more severe symptomatic side and overwhelm the deleterious effect of electroacupuncture. This clinical study reveals the positive effects in CTS treatment via safety depth needling acupuncture. Future studies investigating different electrical stimulation modes (continuous or pulsed), meridian acupoints, electroacupuncture frequency, and intensity in CTS recovery may be needed to gain further understanding of the therapeutic effects of acupuncture and electroacupuncture for CTS. Our research provides an integrated platform to acupuncture and electroacupuncture treatments on CTS patients, with multi-approach examinations for advancing evaluation efficacy and prognosis. Limitations The insufficient number of participants to complete the study may limit some positive findings to reach a statistically significant level in this study despite a trend towards improvement being found in several evaluated parameters. Conclusions Despite the limitations in this study, we found that safety depth acupuncture and electroacupuncture could exert different positive therapeutic effects for patients with CTS. As evidenced by the improvement of symptomatology using electroacupuncture and improvements of grip strength, electrophysiological findings, and physical provocation
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sign of using acupuncture, the findings of this study provide references in clinical decision making when selecting proper treatment programs for symptomatic CTS patients.
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Acknowledgments This study is supported by the grant of the National Science Council (NSC 99-2314-B-039010-MY2), China Medical University Hospital (DMR-102-008), and the Taiwan Department of Health Clinical Trial and Research Center of Excellence (DOH102-TD-B111-004). The authors would like to thank the practitioners in the Departments of Physical Medicine and Rehabilitation, Acupuncture, China Medical University Hospital, for their expert assistance in data collection.
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Hsieh, C.L., C.C. Kuo, Y.S. Chen, T.C. Li, C.T. Hsieh, C.J. Lao, C.J. Lee and J.G. Li. Analgesic effect of electric stimulation of peripheral nerves with different electric frequencies using the formalin test. Am. J. Chin. Med. 28: 291–299, 2000. Inoue, M., T. Hojo, T. Yano and Y. Katsumi. The effects of electroacupuncture on peripheral nerve regeneration in rats. Acupunct. Med. 21: 9–17, 2003. Jung, T.T. The Analysis of Carpal Tunnel Syndrome for Clinical Characteristics of Patients and Risk Factors of Workplace Computer Users. University of China Medical, Taichung Taiwan, 2009. Kang, H.S., S.R. Sok and J.S. Kang. Effects of meridian acupressure for stroke patients in Korea. J. Clin. Nurs. 18: 2145–2152, 2009. Khosrawi, S., A. Moghtaderi and S. Haghighat. Acupuncture in treatment of carpal tunnel syndrome: a randomized controlled trial study. J. Res. Med. Sci. 17: 1–7, 2012. Kimura, J., M. Machida, T. Ishida, T. Yamada, R.L. Rodnitzky, Y. Kudo and S. Suzuki. Relation between size of compound sensory or muscle action potentials, and length of nerve segment. Neurology 36: 647–652, 1986. Kimura, J. and T. Yamada. Short-latency somatosensory evoked potentials following median nerve stimulation. Ann. N.Y. Acad. Sci. 388: 689–694, 1982. Kou, W., I. Gareus, J.D. Bell, M.U. Goebel, G. Spahn, G. Pacheco-Lopez, M. Backer, M. Schedlowski and G.J. Dobos. Quantification of Deqi sensation by visual analog scales in healthy humans after immunostimulating acupuncture treatment. Am. J. Chin. Med. 35: 753–765, 2007. Kumnerddee, W. and A. Kaewtong. Efficacy of acupuncture versus night splinting for carpal tunnel syndrome: a randomized clinical trial. J. Med. Assoc. Thai. 93: 1463–1469, 2010. Kumnerddee, W. and N. Pattapong. Efficacy of electro-acupuncture in chronic plantar fasciitis: a randomized controlled trial. Am. J. Chin. Med. 40: 1167–1176, 2012. Levine, D.W., B.P. Simmons, M.J. Koris, L.H. Daltroy, G.G. Hohl, A.H. Fossel and J.N. Katz. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J. Bone Joint Surg. Am. 75: 1585–1592, 1993. Lu, M.C., C.Y. Ho, S.F. Hsu, H.C. Lee, J.H. Lin, C.H. Yao and Y.S. Chen. Effects of electrical stimulation at different frequencies on regeneration of transected peripheral nerve. Neurorehabil. Neural. Repair 22: 367–373, 2008. Ma, T., M.J. Kao, I.H. Lin, Y.L. Chiu, C. Chien, T.J. Ho, B.C. Chu and Y.H. Chang. A study on the clinical effects of physical therapy and acupuncture to treat spontaneous frozen shoulder. Am. J. Chin. Med. 34: 759–775, 2006. Mathiowetz, V., N. Kashman, G. Volland, K. Weber, M. Dowe and S. Rogers. Grip and pinch strength: normative data for adults. Arch. Phys. Med. Rehabil. 66: 69–74, 1985. McCaig, C.D., A.M. Rajnicek, B. Song and M. Zhao. Has electrical growth cone guidance found its potential? Trends Neurosci. 25: 354–359, 2002. Naeser, M.A., K.A. Hahn, B.E. Lieberman and K.F. Branco. Carpal tunnel syndrome pain treated with low-level laser and microamperes transcutaneous electric nerve stimulation: a controlled study. Arch. Phys. Med. Rehabil. 83: 978–988, 2002. Shim, J.H., S.Y. Roh, J.S. Kim, D.C. Lee, S.H. Ki, J.W. Yang, M.K. Jeon and S.M. Lee. Normative measurements of grip and pinch strengths of 21st century Korean population. Arch. Plast. Surg. 40: 52–56, 2013. Sim, H., B.C. Shin, M.S. Lee, A. Jung, H. Lee and E. Ernst. Acupuncture for carpal tunnel syndrome: a systematic review of randomized controlled trials. J. Pain 12: 307–314, 2011. Szabo, R.M. and D.R. Steinberg. Nerve entrapment syndromes in the wrist. J. Am. Acad. Orthop. Surg. 2: 115–123, 1994. Tang, J.L., S.Y. Zhan and E. Ernst. Review of randomised controlled trials of traditional Chinese medicine. BMJ 319: 160–161, 1999.
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Tsui, P. and M.C. Leung. Comparison of the effectiveness between manual acupuncture and electroacupuncture on patients with tennis elbow. Acupunct. Electrother. Res. 27: 107–117, 2002. Von Schroeder, H.P. and M.J. Botte. Carpal tunnel syndrome. Hand Clin. 12: 643–655, 1996. Yang, C.P., N.H. Wang, T.C. Li, C.L. Hsieh, H.H. Chang, K.L. Hwang, W.S. Ko and M.H. Chang. A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up. J. Pain 12: 272–279, 2011. Yao, E., P.K. Gerritz, E. Henricson, T. Abresch, J. Kim, J. Han, K. Wang and H. Zhao. Randomized controlled trial comparing acupuncture with placebo acupuncture for the treatment of carpal tunnel syndrome. PM R 4: 367–373, 2012.
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Clinical Effectiveness of Acupuncture for Carpal Tunnel Syndrome Chien-Yi Ho,*,‡ Hsiu-Chen Lin,† Yu-Chen Lee,*,§ Li-Wei Chou,*,¶ Ta-Wei Kuo,§ Heng-Wei Chang,§ Yueh-Sheng Chen*,|| ,a and Sui-Foon Lo*,¶,a *School
of Chinese Medicine, College of Chinese Medicine †Department
of Physical Therapy China Medical University, Taichung, Taiwan ‡
Department of Family Medicine §Department
of Acupuncture
¶
Department of Physical Medicine and Rehabilitation China Medical University Hospital, Taichung, Taiwan
||Department of Biomedical Informatics Asia University, Wufeng, Taiwan
Abstract: Acupuncture and electroacupuncture treatments of symptomatic carpal tunnel syndrome (CTS) may improve symptoms and aid nerve repair as well as improve sensory and motor functions. However, limited evidence is available regarding the effects of these treatments based on comprehensive evaluation methods. This research completed the treatment and evaluation of 26 patients with confirmed CTS. Participants were divided into two treatment groups based on a modified neurophysiological grading scale. Of the total number of participants, 15 received acupuncture and 11 received electroacupuncture on both upper limbs. Acupoints were PC-7 (Daling) and PC-6 (Neiguan) along the pericardial meridian compatible with the median nerve tract. The treatment program consisted of 24 sessions of 15 min duration over 6 weeks. After electroacupuncture treatments, symptom severity was evaluated using the short clinical questionnaire by Lo and Chiang, which indicated improvements in the respective symptom severity score. After the acupuncture treatment, grip strength in the major symptomatic side in CTS patients could be significantly increased. Electrophysiology evaluation likewise indicated a significant increase in the distal median motor amplitude of the palm-wrist segment. In addition, Tinel’s sign significantly decreased in the major symptomatic side. Our findings indicated that electroacupuncture could improve symptomatology, while acupuncture could exert positive therapeutic effects for CTS patients, as evidenced by improved symptomatology, grip strength, electrophysiological function, and physical provocation sign.
Correspondence to: Dr. Sui-Foon Lo, Department of Physical Medicine and Rehabilitation, China Medical University Hospital, No. 91 Hsueh-Shih Road, Taichung, Taiwan 40402, E-mail: [email protected] a These authors contributed equally to this work.
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C.-Y. HO et al. Keywords: Acupuncture; Carpal Tunnel Syndrome; Electroacupuncture; Median Nerve; Safety Depth Needling.
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Introduction Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper limbs, and represents a mainly median nerve degeneration process at the wrist (Von Schroeder and Botte, 1996). CTS diagnosis is often based on clinical symptoms, physical signs, electrophysiological measurements, or image study (Szabo and Steinberg, 1994). Most studies in the literature focus on surgical treatments of CTS. Recently, the application of non-surgical treatments that combine acupuncture and electrical stimulation, such as electroacupuncture, has become one of the popular complementary alternative treatments in clinical rehabilitation to facilitate nerve function recovery (Tang et al., 1999; Freedman, 2002; Gerritsen et al., 2002; Naeser et al., 2002; Brunelli and Gorson, 2004; Carlson et al., 2010). Acupuncture and electroacupuncture have likewise been reported to promote nerve repair and blood supply after a peripheral nerve injury (Hsieh et al., 2000; Ma et al., 2006; Lu et al., 2008; Dong et al., 2013). CTS is a kind of median nerve damage due to mechanical overuse or inappropriate posture, resulting in ischemia of the nerve; hence, acupuncture and electroacupuncture are believed to be complementary methods to treat CTS. However, the effectiveness of acupuncture and electroacupuncture in treating CTS patients is still unknown. Therefore, an urgent need to evaluate the therapeutic effects of acupuncture and electroacupuncture on CTS exists. In the literature, it has been reported that short-term acupuncture treatment at the classic acupuncture points of PC-7 (Daling) and PC-6 (Neiguan) can improve the subjective symptoms of CTS (Sim et al., 2011; Yang et al., 2011; Khosrawi et al., 2012; Yao et al., 2012). The Boston Carpal Tunnel Questionnaire (BCTQ), developed by Levine et al. in 1993, provides an important screening method and is widely used to assist CTS evaluation and diagnosis (Levine et al., 1993; Fok et al., 2007). BCTQ is a quantitative instrument that consists of two parts: the Functional Status Scale (FSS) and the Symptom Severity Scale (SSS), which needs considerable time to fulfill all the questions (Levine et al., 1993). In Asia, the differences in languages and cultures have led to the development of a HongKong Chinese version of the self-administered questionnaire (Fok et al., 2007). In our previous studies, we investigated work-related CTS risk factors and severity grading among computer users in the workplace, and designed the Lo and Chiang’s clinical questionnaire for CTS evaluation (Jung, 2009). Among the three questionnaires, the validity of the BCTQ questionnaires is divided into SSS 0.91 and FSS 0.93 (Levine et al., 1993), that of the Hong-Kong Chinese version is SSS: 0.83 and FSS: 0.87 (Fok et al., 2007), and that of Lo and Chiang’s is 0.92 (Jung, 2009). Lo and Chiang’s quick clinical questionnaire showed the advantages of high validity, simplicity, and convenience to apply. The aim of this study is to test the effectiveness of acupuncture and electroacupuncture treatments for patients with symptomatic CTS. The well-established Lo and Chiang’s
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clinical questionnaire, electrodiagnostic measurements, muscle strength evaluation, and provocation signs were used to evaluate CTS patients before and after treatment to gauge the treatment effectiveness. Materials and Methods
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General Design The potential participants were patients who visited our outpatient clinics with symptoms that suggested CTS, after excluding the medical and surgical conditions that predispose one to peripheral neuropathy. Informed consent, as approved by the local ethics committee, was obtained from every enrolled participant before the study. The clinical symptoms were first evaluated using Lo and Chiang’s quick clinical questionnaire. This quick questionnaire contains only six categories with three regarding different types of daytime symptoms (numbness, tingling, and pain), one for the predominant nocturnal symptoms, one for hand weakness and one for symptoms related to the difficulty experienced in manual work. To comprehend more, both the severity and lasting duration of each of these four daytime and nocturnal symptoms are rated in this questionnaire. Each of the severity/lasting duration questions are rated from 1 (no symptom/never happened) to 5 (extremely severe/lasted continuously). Therefore, this simple and well-described questionnaire contains only 10 questions with a total score of 50, which is convenient and is quick to apply for CTS symptom severity evaluation. CTS is diagnosed clinically with at least one of the symptoms of numbness, tingling, or pain in the wrist or hand. The diagnosis is confirmed with electrodiagnostic studies, which indicate at least one of the following criteria: (1) prolonged distal motor latency (DML) to the abductor pollicis brevis muscle (= 4:5 ms, stimulation over the wrist, 8 cm proximal to the active electrode); (2) prolonged orthodromic distal sensory peak latency (DSPL) from the second digit to the wrist (= 3:5 ms; stimulation over the index, 14 cm distal to the active electrode) and decreased orthodromic palm–wrist sensory nerve conduction velocity at a distance of 8 cm (P–W SNCV < 35 m/s); or (3) decreased orthodromic index–wrist sensory nerve conduction velocity (I–W SNCV) at a distance of 14 cm (I–W SNCV < 40 m/s) and P–W SNCV < 35 m/s. Patients with electrodiagnostically confirmed CTS were invited to participate in our study. Possible beneficial and side effects were fully explained before allocation to the treatments. We then divided the participants into two treatment groups matched with a modified neurophysiological grading scale for CTS severity (Bland, 2000). One group received traditional acupuncture (Acu group) and the other group received electroacupuncture with 0.8 mA, 2 Hz current (Elec-Acu group) at two selected acupoints, PC-7 (Daling) and PC-6 (Neiguan), on both upper limbs (Fig. 1A). For all participants, sterile disposable steel needles (0.35 mm outer diameter, 12 mm length) were used and the skin was wiped with alcohol before each insertion. The needles were inserted perpendicularly at PC-6 to a depth of 0.5 cm to 0.75 cm and at PC-7 to a depth of 0.25 cm to 0.5 cm, based on the thickness of the soft tissue and safety depth needling technique, and then manipulated by twirling with lifting-thrusting methods to produce a characteristic sensation known as
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Palmaris longus tendon
median nerve
flexor carpi radialis tendon Ventral side
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flexor pollicis longus tendon
Dorsal side
5cm ◎
5cm away from middle of first wrist crease
(A)
Ventral side
palmaris longus tendon median nerve flexor carpi radialis tendon
flexor pollicis longus tendon
◎
Middle of first wrist crease
Dorsal side
(B) Figure 1. Representative MRI cross-sectional images showing the median nerve located between radial flexor tendon and Palmaris longus tendon. PC6 (Neiguan) is away from the wrist at approximately 2 inches (panel A) and PC7 (Daling) is at the middle of the wrist (panel B). Red arrow: radial flexor tendon of wrist; Green arrow: Palmaris longus tendon; Yellow arrow: median nerve.
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De Qi (an awareness of numbness, soreness, swelling, heaviness, or radiating feeling from the point of needling deemed to indicate proper needle position and effective needling) (Kou et al., 2007). For applying electric stimulation in the Elec-Acu group, one stainless steel needle electrode at the middle aspect of the wrist PC-7 was connected to the negative wick (cathode) of a stimulator (HC-0601, Taiwan), and the positive electrode (anode) was positioned around the site of the forearm PC-6 along with the pericardium meridian. The treatment program consisted of 24 sessions of 15 min duration, administered over 6 weeks (four sessions per week). To establish the baseline manifestation, the following examinations were performed before the treatment program started: electrodiagnostic study; symptom severity assessment; grip strength; pinch strength; two-point discrimination evaluation; and physical examination with provocation test, namely, Tinel’s sign and Phalen test. To examine the therapeutic effectiveness, all the examinations were re-evaluated two weeks after the completion of the treatment program, except the electrodiagnostic study which was conducted four weeks after the treatment program. Subject Participant’s age, sex, body weight, height, education, and pertinent medical history were recorded before the treatment. This study first included 40 participants (21 in the Acu group and 19 in the Elec-Acu group). Nine and six participants in the Acu group and the ElecAcu group, respectively, exhibited CTS symptoms in both hands. Their side with more severe symptoms was defined as the major symptomatic side, whereas the side with less severe symptoms was defined as the minor symptomatic side. All needling procedures were performed based on Lin’s safety depth needling suggestions (Chou et al., 2011) and magnetic resonance images (Fig. 1). During the study, six participants in the Acu group and eight in the Elec-Acu group did not complete the treatment due to insufficient time available for treatment or intolerance to needling discomfort. At the end of the study, 15 participants (12 females, 3 males) in the Acu group and 11 (8 females, 3 males) in the ElecAcu group completed the treatment program. Electrodiagnostic Studies Electrodiagnostic studies were performed based on the Kimura technique (Kimura and Yamada, 1982; Kimura et al., 1986), adhering to the uniform operating protocol of the electrodiagnostic machine (NEuropack-MEM3202) in a laboratory, with a controlled ambient room temperature of 25 C. Sensory and motor nerve conduction studies of the median and ulnar nerves were conducted using surface electrodes for stimulating and recording. Latencies were measured from the stimulus onset to the initial or peak responses for motor or sensory conduction studies, respectively. The sensory nerves were orthodromically simulated with the stimulating surface electrodes over the fingers or palm and recorded over the wrist. Participants with suggested ulnar neuropathy based on the nerve conduction study were excluded.
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Statistical Analysis
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A two-way mixed model ANOVA was used to compare the parametric measurements between the treatment program (before and after) and between the groups (Acu and ElecAcu). A paired t-test was then used to examine the pre- and post-treatment effects in each group as post-hoc analysis. The Mann–Whitney U test was used to compare the nonparametric measurements between the treatment groups. The changes of non-parametric measurements before and after the treatment program were compared with Wilcoxon’s signed rank test. Statistical significance was considered when p < 0:05. Results Age, gender, body mass index, and symptom severity were similarly distributed in the two groups (Table 1). Tinel’s sign at the major symptomatic side in the Acu group revealed decreased percentage of positive findings after the treatment (7=15 ¼ 46:7% vs. 3=15 ¼ 20:0%, p ¼ 0:046) and with a lower ranking compared to the Elec-Acu group after treatment (mean rank 10.6 vs. 17.5, p ¼ 0:024). Questionnaire scores before and after the treatment programs were shown in Fig. 2 to demonstrate the symptom severity and functional status. The results showed a decreased trend in symptom severity scores in CTS patients after the acupuncture or electroacupuncture treatment, especially the differences in the Elec-Acu group that reached the statistically significant level ( p ¼ 0:02). Table 2 shows the results of the electrophysiology study before and after the treatment programs. After the acupuncture treatment, a significant increase in the median motor distal amplitude of the major symptomatic side was determined in patients ( p ¼ 0:02). Significantly shortened median sensory latency (P-W) of the major symptomatic side was likewise noted ( p ¼ 0:04). In the major symptomatic side, the median nerve F wave mean latency evaluation exhibited a significantly shortened latency ( p ¼ 0:002), and the F wave
Table 1. Demographic Data, Symptom Duration, and Electrodiagnostic Classification of CTS Severity
Age (y/o) Height (cm) Weight (kg) BMI
Group
N
Acu Elec-Acu Acu Elec-Acu Acu Elec-Acu Acu Elec-Acu
15 11 15 11 15 11 15 11
Acu Elec-Acu
15 11
Severity
Mean SD
Mild 2 2
49.5 9.7 50.1 10.1 159.9 6.0 161.6 5.7 66.9 19.1 62.6 9.3 25.9 5.6 23.9 2.7 Moderate Severe 6 1 3 0
p-value 0.884 0.474 0.499 0.295 Extreme 6 6
0.701
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Figure 2. Lo and Chiang’s questionnaire: Symptom severity and functional status questionnaire score: *p < 0:05, statistical significance between pre- and post-treatment.
Table 2. Electrophysiology Study of the Median Nerve before and after the Treatment Programs Major Symptomatic Side Group (N) Acu (15) Elec-Acu (11) Distal motor amplitude Acu (15) (mV) Elec-Acu (11) Distal motor NCV (m/s) Acu (15) Elec-Acu (11) Sensory latency (P–W) Acu (15) (ms) Elec-Acu (11) Distal sensory latency Acu (15) (ms) Elec-Acu (11) Distal sensory amplitude Acu (15) (¹V) Elec-Acu (11) Distal sensory NCV Acu (15) (m/s) Elec-Acu (11) Sensoryamplitude Acu (15) (P–W) (¹V) Elec-Acu (11) Sensory NCV (P–W) Acu (15) (m/s) Elec-Acu (11) Nerve F wave mean Acu (15) latency (ms) Elec-Acu (11) F wave persistence (%) Acu (15) Elec-Acu (11) DML (ms)
† Statistical
Pre-tx 6.35 6.68 6.49 7.83 52.99 51.61 3.70 3.78 5.70 5.16 6.81 7.26 29.27 32.16 13.39 21.30 23.76 23.28 29.11 28.12 63.00 72.73
1.53 2.31 2.70 4.23 7.61 6.26 1.15 1.12 2.36 2.22 4.69 5.51 13.01 13.44 9.80 20.53 7.50 7.11 3.38 3.54 29.26 28.32
Post-tx 6.05 6.39 7.62 8.19 52.10 52.17 3.22 3.67 5.23 5.27 6.27 8.41 29.95 29.97 7.29 18.25 27.01 23.84 28.27 27.19 76.67 72.73
2.16 2.08 2.87 † 2.95 4.81 7.48 1.02 † 1.11 2.02 2.09 3.99 4.75 9.09 9.55 16.27 18.44 7.53 7.44 3.76 † 4.22 20.24 † 20.05
Minor or No Symptom Side Pre-tx 4.86 5.52 6.87 8.20 55.42 51.31 2.89 2.72 3.79 3.62 11.06 13.35 37.65 40.05 23.59 38.95 29.05 31.62 27.03 26.95 74.67 72.73
0.66 2.09 2.48 3.93 6.84 10.70 0.67 0.81 0.56 0.74 7.20 9.78 5.20 7.47 20.51 35.97 6.20 8.19 2.78 2.82 26.15 26.11
Post-tx 4.63 5.49 7.61 8.00 54.97 51.07 2.69 2.82 3.61 3.82 9.80 13.48 39.31 37.87 29.63 34.78 30.73 30.82 26.49 26.95 60.00 71.82
0.43 2.03 3.10 2.91 3.22 11.33 0.54 0.84 0.45 0.71 5.85 9.93 4.59 7.33 28.66 32.82 5.26 9.14 2.75 3.57 25.07 21.83
significance between pre- and post-treatment at p < 0:05.
persistence (%) significantly increased ( p ¼ 0:04). No significant electrophysiological changes were observed in the minor or no symptom side of CTS patients. Table 3 shows the motor and sensory performance of the upper limbs before and after the treatment programs. Post-treatment evaluation indicated that grip power increased in the major symptomatic side in both the Acu and Elec-Acu groups, with the differences in grip power of patients in the Acu group reaching the statistically significant level
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Table 3. Motor and Sensory Performance of the Upper Limbs before and after the Treatment Programs Major Symptomatic Side
Grip (kg) Pinch (kg) Two-point discrimination (mm)
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† Statistical
Group (N)
Pre-tx
Acu (15) Elec-Acu (11) Acu (15) Elec-Acu (11) Acu (15) Elec-Acu (11)
23.3 26.87 3.35 3.53 3.87 3.55
9.85 11.53 1.80 2.10 1.88 1.63
Post-tx 27.88 27.22 3.47 3.11 3.40 3.73
12.44 † 11.29 1.79 1.78 0.99 1.01
Minor or No CTS Symptoms Pre-tx 24.20 25.79 3.07 3.39 3.47 3.27
12.17 9.21 1.97 1.61 1.13 0.90
Post-tx 27.53 26.98 3.35 2.53 3.73 3.45
11.46 11.35 1.74 1.81 † 0.59 0.93
significance between pre- and post-treatment at p < 0:05.
( p ¼ 0:01). On the other hand, pinch strength significantly decreased in the minor or no symptomatic side after the electroacupuncture treatment ( p ¼ 0:005). No changes in the two-point discrimination were found in both of the Acu and Elec-Acu groups. Discussion The results of this study showed that electroacupuncture could alleviate clinical symptoms while acupuncture could improve grip strength, decrease physical provocation signs and improve nerve conduction function in CTS patients. In the literature, several studies have indicated that acupuncture and electroacupuncture can promote nerve regeneration and improve nerve function (Inoue et al., 2003; Lu et al., 2008; Kumnerddee and Kaewtong, 2010; Chen et al., 2013), in addition to the alleviation of CTS symptoms (such as pain, numbness, paresthesia, nocturnal awakening, and weakness) and improvement daily activity function (Yang et al., 2011; Chen et al., 2012; Kumnerddee and Pattapong, 2012). In this study, we found the increased median motor distal amplitude, shortened median sensory latency from palm to wrist segment, shortened median nerve F wave mean latency, and increased F wave persistence (%) in the major symptomatic side of CTS patients after acupuncture treatment, all suggested improvement of the neurophysiological status of the affected nerve. At the same time, the grip power in the major symptomatic side also improved after acupuncture. These results agreed with the previous studies, indicating that acupuncture could promote nerve regeneration and improve functional performance. McCaig et al. claimed that electroacupuncture may promote nerve regeneration through an increase of calcium concentration, leading to the activation of nerve outgrowth and repair (McCaig et al., 2002). In this study, electroacupunture showed beneficial effects only in the clinical symptom severity, indicating less effective treatment responses compared to those previous studies. The positive effects on nerve function were mainly observed in the Acu group, but not in the Elec-Acu group. Such discrepancies may lie in the differences of stimulating current parameters used and study design. For example, electrical stimulation at approximately 500 A was suggested to achieve the greatest effect of increased ATP concentrations and protein synthesis on the cellular level (Cheng et al., 1982). Lu et al. reported that the best effect of electrical stimulation on regeneration of
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transected rat peripheral nerve was administered at 1 mA and 2 Hz (Lu et al., 2008). In comparison, we used a 0.8 mA and 2 Hz electrical current for the electroacupuncture stimulation, with reference to reports related to animal and cellular studies that may not be applicable to human beings. Therefore, future studies exploring the best stimulation parameters for electroacupuncture for human beings are needed to achieve effective CTS treatment. In this study, we found acupuncture treatment could improve both motor and sensory nerve conduction. The grip power in the major symptomatic side in CTS patients likewise significantly increased after the acupuncture treatment, indicating corresponding median nerve motor function improvement (Mathiowetz et al., 1985; Shim et al., 2013). In the literature, similar findings were obtained in that acupuncture and electroacupuncture could increase hand grip strength (Tsui and Leung, 2002; Kang et al., 2009; Yang et al., 2011; Hoang et al., 2012). Interestingly, we found that electroacupuncture would significantly decrease the pinch power in the minor or no symptomatic side in CTS patients. A previous study showed that a lidocaine-blocked flexor pollicis longus would decrease the pinch strength without affecting the median nerve (Goetz et al., 2012). The flexor pollicis longus is located under the PC-7 (Daling) acupoint used in the present study; hence, we believe that electroacupuncture could exert lidocaine-like effects on the flexor pollicis longus and then affect the pinch strength in CTS patients. However, such a lidocaine-like effect was not observed in the major symptomatic side in CTS patients, implying that a stronger electroacupuncture treatment effect might be present in the more severe symptomatic side and overwhelm the deleterious effect of electroacupuncture. This clinical study reveals the positive effects in CTS treatment via safety depth needling acupuncture. Future studies investigating different electrical stimulation modes (continuous or pulsed), meridian acupoints, electroacupuncture frequency, and intensity in CTS recovery may be needed to gain further understanding of the therapeutic effects of acupuncture and electroacupuncture for CTS. Our research provides an integrated platform to acupuncture and electroacupuncture treatments on CTS patients, with multi-approach examinations for advancing evaluation efficacy and prognosis. Limitations The insufficient number of participants to complete the study may limit some positive findings to reach a statistically significant level in this study despite a trend towards improvement being found in several evaluated parameters. Conclusions Despite the limitations in this study, we found that safety depth acupuncture and electroacupuncture could exert different positive therapeutic effects for patients with CTS. As evidenced by the improvement of symptomatology using electroacupuncture and improvements of grip strength, electrophysiological findings, and physical provocation
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sign of using acupuncture, the findings of this study provide references in clinical decision making when selecting proper treatment programs for symptomatic CTS patients.
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Acknowledgments This study is supported by the grant of the National Science Council (NSC 99-2314-B-039010-MY2), China Medical University Hospital (DMR-102-008), and the Taiwan Department of Health Clinical Trial and Research Center of Excellence (DOH102-TD-B111-004). The authors would like to thank the practitioners in the Departments of Physical Medicine and Rehabilitation, Acupuncture, China Medical University Hospital, for their expert assistance in data collection.
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