517
Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 517–520 DOI 10.3233/BMR-140550 IOS Press
Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients Cemal Çevika, Afitap Anılb and Sevgin Özlem ˙I¸seric,∗ a
Clinical Biochemistry Department, Acupuncture Clinic, Gazi University Medical Faculty, Ankara, Turkey Anatomy Department, Gazi University Medical Faculty, Ankara, Turkey c Clinical Biochemistry Department, Hacettepe University Medical Faculty, Ankara, Turkey b
Abstract. BACKGROUND: The most common disease of the older age group in Turkey is degenerative articular disease and pain associated with the disease. Analgesics and physical therapy are preferred treatment for geriatric chronic pain but suffering from multiple medical and nutritional problems in old ages can limit treatment options with analgesics due to an increased risk of adverse effects and drug interactions. OBJECTIVES: We aim to show the effect of acupuncture on back-pain and knee-pain treatment of elderly people. METHODS: The study includes 34 patients, 24 female and 8 male. The mean age was 69.0417 ± 8.95 years for females and 73.12 ± 8.95.24 years for males. Every two days for a total of 10 sessions acupuncture treatment to Yintang, Ht 7 (Shenmen), LI 4 (Hegu), Ki 3 (Taixi) and Ki 6 were found to significantly reduce pain scores of patients. RESULTS: Mean back pain scores (8.8696 ± 1.546) and mean knee pain scores (9.1304 ± 1.4239) of patients were reduced significantly to 2.1739 ± 1.466 and 1.455 ± 0.7; p < 0.001 respectively after the acupuncture treatment. CONCLUSION: These are important results as they give rationale to use acupuncture treatment widely in chronic low back pain and knee pain in the geriatric group of patients to reduce the side effects of polypharmacy in elderly. Keywords: Acupuncture, complementary therapy, low back pain, knee pain
1. Introduction Sleep disturbance, palpitations, hypertension are common symptoms of geriatric group of patients. Kidney mass and muscle mass are reduced, cardiac output, lung capacity and also cellular immunity are reduced and glucose intolerance occurs with old age [1]. Most of the diseases seen in geriatric patients are degenerative diseases. Degenerative diseases affect bones mostly and these diseases are related to kidney chi deficiency according to acupuncture [2]. Chi can be de∗ Corresponding author: Sevgin Ö. I¸ ˙ seri, Clinical Biochemistry Department, Hacettepe University Medical Faculty, Sıhhiye, Ankara, Turkey. Tel.: +90 312 305 16 54; Fax: +90 312 310 05 80; E-mail: [email protected].
scribed as a vital life force, flows in energetic pathways or channels called meridians in the human body. Meridian system relates to the internal organs and their physiological and pathological conditions. Along these meridians, energy comes to the surface through a series of acupuncture points. A dysfunction of the Chi can be restored by stimulating these acupuncture points [3– 5]. Among the 1451 geriatric patients aged 68.3 ± 6.2 were investigated to determine the most common diseases of that age group in Turkey. It was found that 72% have degenerative articular disease, 22% osteoporosis and 16% soft tissue rheumatoid arthritis. Lumbar pain is seen mostly with degenerative articular disease while myofascial pain syndrome seen mostly with soft tissue rheumatoid arthritis. Degenerative diseases
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
518
C. Çevik et al. / Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients
have been found in the population generally with the age of over sixty [6]. Degenerative disease is the most common disease of the old age according to both acupuncture and modern medicine. Additionally low back pain and knee pain are the common symptoms of patients with degenerative disease. We may see acupuncture and modern medicine have common results at the diagnosis of the disease however treatment strategies are completely different. Low back pain and knee pain are treated by increasing Kidney, Spleen and Heart energy with acupuncture treatment. Acupuncture is among the most commonly used complementary medicine techniques, especially for the treatment of musculoskeletal pain [7]. Chronic pain leads to functional, emotional, and cognitive impairment; poor quality of life; and greater healthcare costs because of increased healthcare use in patients with unrelieved pain [8,9]. The treatment for chronic pain mainly consists of analgesics and physical therapy. Opioid analgesics are also an appropriate part of the treatment for patients with refractory symptoms, but their associated morbidity in older adults is often limiting [10–12]. The purpose of this study was to explore the effect of acupuncture treatment as an alternative nonpharmacological treatment modality for older individuals with chronic mechanical low back pain and knee pain. Geriatric patients who were included into our study were among the patients who applied to Gazi University Medical Faculty Acupuncture Out-Patient Clinic for back-pain and knee-pain symptoms.
2. Materials and methods The study group was chosen among the patients applying to acupuncture out-patient clinic of Gazi University Medical Faculty with back pain and knee pain. Acupuncture points were chosen from kidney and large intestine and heart meridian points. Thirtyfour patients were joined to our study. Twenty-four of them were female with the mean age 69.0417 ± 8.95 years and 8 of them were male with the mean age of 73.12 ± 8.95 years. Patients were diagnosed according to acupuncture rules via pulse palpation, history taking, tender point palpation and active acupuncture points detected with a pendulum. Stainless steel filiform needles (0.25 × 25 mm, Scarboroughs Ltd. Sterile acupuncture needles for single use) were used for the acupuncture treatment and average depth of the
A
B
C
D
Fig. 1. Acupuncture points selected for pain treatment A) Yintang, B) Ht 7, C) LI 4, D) Ki 6 and Ki 3.
needle insertion was 15 mm. Needles were not manipulated, and no attempt was made to elicit deqi, a composite of unique sensations experienced by patients as aching, soreness, numbness, tingling, fullness, distention, pressure or heaviness and is felt by the acupuncturists as tense, tight, and full. The needles were removed after 20 minutes. Every treatment session lasted twenty minutes. Each patient was treated every two days totaling 10 treatment sessions. In each of these sessions, before and after the acupuncture application pain scores of the patients were recorded. Numerical Rating Score (No pain: 0, severe pain: 10) were used as a pain scale [6,7]. Acupuncture points were chosen and applied bilaterally for each patient from the following acupuncture points: Yintang point, Ht 7 (Shenmen), LI 4 (Hegu), Ki 3 (Taixi), Ki 6, points punctured (Fig. 1).
3. Results Twenty-three of the patients in our study had back pain and 23 of them had knee pain. Mean back pain score of those patients recorded before the acupuncture treatment was 8.8696 ± 1.546 but after acupuncture treatment the back pain score reduced to mean pain
C. Çevik et al. / Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients
519
Fig. 2. Pain score graphic of patients before and after acupuncture treatment.
score of 2.1739 ± 1.466. This is found to be significantly different compared to the score before treatment (P < 0.001) (Fig. 2). Mean Knee pain scores were also found to be significantly reduced after acupuncture treatment (1.455 ± 0.7; p < 0.001) compared to the mean knee pain scores before acupuncture treatment (9.1304 ± 1.4239) (Fig. 2).
Results were written mean ± standard deviation. “Paired t-test” in SPSS programme were used to evaluate pain scores of patients before and after acupuncture treatment. p < 0.05 were found statistically significant.
acupuncture using a needle without stimulating the points. We observed that during acupuncture treatment, insomnia, palpitation, anxiety and fatigue symptoms were relieved and also the number of painkillers were reduced and stopped by patients. First observed effect on old aged patients during acupuncture were significant skin brightness, clearance of their face and significant healthier feeling of the patients. We have recorded significantly reduced pain scores after the acupuncture treatment (P < 0.001). Those results are important for improving the quality of life in older adults. We want to emphasize the importance of the acupuncture treatment for older people and recommend that strategies should be developed in Turkey to make the acupuncture treatment applicable in wider group of patients.
5. Discussion
6. Conclusion
4. Statistical analysis
Medications used to treat pain among older people are becoming a threat to life because of the increased risk of side effects such as gastrointestinal bleeding, increased renal, cardiovascular, central nervous system and hematological system side effects in elderly people. Narcotic analgesic and muscle relaxing agent use among older people are very common and results in an increased falls [11,13]. Literatures on the effect of acupuncture treatment for back pain of elderly patients are limited [14]. The effects of Electroacupuncture or TENS on back pain were already evaluated by researchers. Acupuncture was found to have analgesic effects via stimulating the release of βendorphins into the cerebrospinal fluid, and its analgesic effect is reversed by naloxone [15]. We applied
According to our results acupuncture is an effective and safe treatment for use in geriatric patients with low back pain and knee pain. Designing a controlled and sustained pain treatment plan with acupuncture for geriatric patients will reduce polypharmacy and prevent resultant toxicity from it and would improve the quality of life in the elderly.
References [1]
[2]
Berkow R, Fletcher AJ, editors. The Merck Manual of diagnosis and therapy. 16th ed. Rahway (NJ): Merck Research Laboratories, 1992. Dong Y, Shi JR. Biological research evaluating the Chinese medical theory of the association of the kidney with the ears. Journal of Chinese integrative medicine. 2012; 10(2): 128-34.
520 [3] [4] [5]
[6]
[7] [8]
[9]
C. Çevik et al. / Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients F. Bahr, K. Bushe-Centmayer, L. Dorfer, et al. The Big Book of Classical Acupuncture. Munich, Germany: Elsevier, 2007. T. Schnura. Diagnosis and Point Selection According to TCM. Munich, Germany: Elsevier, 2009. Jia J, Yu Y, Deng JH, Robinson N, Bovey M, Cui YH, Liu HR, Ding W, Wu HG, Wang XM. A review of Omics research in acupuncture: the relevance and future prospects for understanding the nature of meridians and acupoints. Journal of Ethnopharmacology. 2012; 140(3): 594-603. ˙ Akgün K, Eryavuz M. GeriÇakmak B, Aydın FY, Akta¸s I, ˙ atrik Hastalıklarda Kas-Iskelet Sistemi Hastalıkları. Turkish Journal of Geriatrics. 2004; 7(4): 221-4. Berman BM, Bausell RB. The use of non-pharmacological therapies by pain specialists. Pain. 2000;85: 313-5. Becker N, Bondegaard TA, Olsen AK, Sjögren P, Bech P, Eriksen J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain. 1997; 73(3): 393-400. Carey TS, Evans AT, Hadler NM, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine. 1995; 20(3): 312-7.
[10]
[11]
[12]
[13]
[14]
[15]
Shimp LA. Safety issues in the pharmacologic management of chronic pain in the elderly. Pharmacotherapy. 1998; 18(6): 1313-22. Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in communitydwelling elderly. Gerontology. 1998; 44(4): 217-21. Shorr RI, Griffin MR, Daugherty JR, Ray WA. Opioid analgesics and the risk of hip fracture in the elderly: Codeine and propoxyphene. Journal of Gerontology. 1992; 47(4): M111-5. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. Journal of the American Geriatrics Society. 1999; 47(1): 30-9. Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, Bareta J, Hochberg M. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford) 1999; 38(4): 346-54. Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry 1998; 44(2): 129-38.
Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 517–520 DOI 10.3233/BMR-140550 IOS Press
Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients Cemal Çevika, Afitap Anılb and Sevgin Özlem ˙I¸seric,∗ a
Clinical Biochemistry Department, Acupuncture Clinic, Gazi University Medical Faculty, Ankara, Turkey Anatomy Department, Gazi University Medical Faculty, Ankara, Turkey c Clinical Biochemistry Department, Hacettepe University Medical Faculty, Ankara, Turkey b
Abstract. BACKGROUND: The most common disease of the older age group in Turkey is degenerative articular disease and pain associated with the disease. Analgesics and physical therapy are preferred treatment for geriatric chronic pain but suffering from multiple medical and nutritional problems in old ages can limit treatment options with analgesics due to an increased risk of adverse effects and drug interactions. OBJECTIVES: We aim to show the effect of acupuncture on back-pain and knee-pain treatment of elderly people. METHODS: The study includes 34 patients, 24 female and 8 male. The mean age was 69.0417 ± 8.95 years for females and 73.12 ± 8.95.24 years for males. Every two days for a total of 10 sessions acupuncture treatment to Yintang, Ht 7 (Shenmen), LI 4 (Hegu), Ki 3 (Taixi) and Ki 6 were found to significantly reduce pain scores of patients. RESULTS: Mean back pain scores (8.8696 ± 1.546) and mean knee pain scores (9.1304 ± 1.4239) of patients were reduced significantly to 2.1739 ± 1.466 and 1.455 ± 0.7; p < 0.001 respectively after the acupuncture treatment. CONCLUSION: These are important results as they give rationale to use acupuncture treatment widely in chronic low back pain and knee pain in the geriatric group of patients to reduce the side effects of polypharmacy in elderly. Keywords: Acupuncture, complementary therapy, low back pain, knee pain
1. Introduction Sleep disturbance, palpitations, hypertension are common symptoms of geriatric group of patients. Kidney mass and muscle mass are reduced, cardiac output, lung capacity and also cellular immunity are reduced and glucose intolerance occurs with old age [1]. Most of the diseases seen in geriatric patients are degenerative diseases. Degenerative diseases affect bones mostly and these diseases are related to kidney chi deficiency according to acupuncture [2]. Chi can be de∗ Corresponding author: Sevgin Ö. I¸ ˙ seri, Clinical Biochemistry Department, Hacettepe University Medical Faculty, Sıhhiye, Ankara, Turkey. Tel.: +90 312 305 16 54; Fax: +90 312 310 05 80; E-mail: [email protected].
scribed as a vital life force, flows in energetic pathways or channels called meridians in the human body. Meridian system relates to the internal organs and their physiological and pathological conditions. Along these meridians, energy comes to the surface through a series of acupuncture points. A dysfunction of the Chi can be restored by stimulating these acupuncture points [3– 5]. Among the 1451 geriatric patients aged 68.3 ± 6.2 were investigated to determine the most common diseases of that age group in Turkey. It was found that 72% have degenerative articular disease, 22% osteoporosis and 16% soft tissue rheumatoid arthritis. Lumbar pain is seen mostly with degenerative articular disease while myofascial pain syndrome seen mostly with soft tissue rheumatoid arthritis. Degenerative diseases
c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00
518
C. Çevik et al. / Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients
have been found in the population generally with the age of over sixty [6]. Degenerative disease is the most common disease of the old age according to both acupuncture and modern medicine. Additionally low back pain and knee pain are the common symptoms of patients with degenerative disease. We may see acupuncture and modern medicine have common results at the diagnosis of the disease however treatment strategies are completely different. Low back pain and knee pain are treated by increasing Kidney, Spleen and Heart energy with acupuncture treatment. Acupuncture is among the most commonly used complementary medicine techniques, especially for the treatment of musculoskeletal pain [7]. Chronic pain leads to functional, emotional, and cognitive impairment; poor quality of life; and greater healthcare costs because of increased healthcare use in patients with unrelieved pain [8,9]. The treatment for chronic pain mainly consists of analgesics and physical therapy. Opioid analgesics are also an appropriate part of the treatment for patients with refractory symptoms, but their associated morbidity in older adults is often limiting [10–12]. The purpose of this study was to explore the effect of acupuncture treatment as an alternative nonpharmacological treatment modality for older individuals with chronic mechanical low back pain and knee pain. Geriatric patients who were included into our study were among the patients who applied to Gazi University Medical Faculty Acupuncture Out-Patient Clinic for back-pain and knee-pain symptoms.
2. Materials and methods The study group was chosen among the patients applying to acupuncture out-patient clinic of Gazi University Medical Faculty with back pain and knee pain. Acupuncture points were chosen from kidney and large intestine and heart meridian points. Thirtyfour patients were joined to our study. Twenty-four of them were female with the mean age 69.0417 ± 8.95 years and 8 of them were male with the mean age of 73.12 ± 8.95 years. Patients were diagnosed according to acupuncture rules via pulse palpation, history taking, tender point palpation and active acupuncture points detected with a pendulum. Stainless steel filiform needles (0.25 × 25 mm, Scarboroughs Ltd. Sterile acupuncture needles for single use) were used for the acupuncture treatment and average depth of the
A
B
C
D
Fig. 1. Acupuncture points selected for pain treatment A) Yintang, B) Ht 7, C) LI 4, D) Ki 6 and Ki 3.
needle insertion was 15 mm. Needles were not manipulated, and no attempt was made to elicit deqi, a composite of unique sensations experienced by patients as aching, soreness, numbness, tingling, fullness, distention, pressure or heaviness and is felt by the acupuncturists as tense, tight, and full. The needles were removed after 20 minutes. Every treatment session lasted twenty minutes. Each patient was treated every two days totaling 10 treatment sessions. In each of these sessions, before and after the acupuncture application pain scores of the patients were recorded. Numerical Rating Score (No pain: 0, severe pain: 10) were used as a pain scale [6,7]. Acupuncture points were chosen and applied bilaterally for each patient from the following acupuncture points: Yintang point, Ht 7 (Shenmen), LI 4 (Hegu), Ki 3 (Taixi), Ki 6, points punctured (Fig. 1).
3. Results Twenty-three of the patients in our study had back pain and 23 of them had knee pain. Mean back pain score of those patients recorded before the acupuncture treatment was 8.8696 ± 1.546 but after acupuncture treatment the back pain score reduced to mean pain
C. Çevik et al. / Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients
519
Fig. 2. Pain score graphic of patients before and after acupuncture treatment.
score of 2.1739 ± 1.466. This is found to be significantly different compared to the score before treatment (P < 0.001) (Fig. 2). Mean Knee pain scores were also found to be significantly reduced after acupuncture treatment (1.455 ± 0.7; p < 0.001) compared to the mean knee pain scores before acupuncture treatment (9.1304 ± 1.4239) (Fig. 2).
Results were written mean ± standard deviation. “Paired t-test” in SPSS programme were used to evaluate pain scores of patients before and after acupuncture treatment. p < 0.05 were found statistically significant.
acupuncture using a needle without stimulating the points. We observed that during acupuncture treatment, insomnia, palpitation, anxiety and fatigue symptoms were relieved and also the number of painkillers were reduced and stopped by patients. First observed effect on old aged patients during acupuncture were significant skin brightness, clearance of their face and significant healthier feeling of the patients. We have recorded significantly reduced pain scores after the acupuncture treatment (P < 0.001). Those results are important for improving the quality of life in older adults. We want to emphasize the importance of the acupuncture treatment for older people and recommend that strategies should be developed in Turkey to make the acupuncture treatment applicable in wider group of patients.
5. Discussion
6. Conclusion
4. Statistical analysis
Medications used to treat pain among older people are becoming a threat to life because of the increased risk of side effects such as gastrointestinal bleeding, increased renal, cardiovascular, central nervous system and hematological system side effects in elderly people. Narcotic analgesic and muscle relaxing agent use among older people are very common and results in an increased falls [11,13]. Literatures on the effect of acupuncture treatment for back pain of elderly patients are limited [14]. The effects of Electroacupuncture or TENS on back pain were already evaluated by researchers. Acupuncture was found to have analgesic effects via stimulating the release of βendorphins into the cerebrospinal fluid, and its analgesic effect is reversed by naloxone [15]. We applied
According to our results acupuncture is an effective and safe treatment for use in geriatric patients with low back pain and knee pain. Designing a controlled and sustained pain treatment plan with acupuncture for geriatric patients will reduce polypharmacy and prevent resultant toxicity from it and would improve the quality of life in the elderly.
References [1]
[2]
Berkow R, Fletcher AJ, editors. The Merck Manual of diagnosis and therapy. 16th ed. Rahway (NJ): Merck Research Laboratories, 1992. Dong Y, Shi JR. Biological research evaluating the Chinese medical theory of the association of the kidney with the ears. Journal of Chinese integrative medicine. 2012; 10(2): 128-34.
520 [3] [4] [5]
[6]
[7] [8]
[9]
C. Çevik et al. / Effective chronic low back pain and knee pain treatment with acupuncture in geriatric patients F. Bahr, K. Bushe-Centmayer, L. Dorfer, et al. The Big Book of Classical Acupuncture. Munich, Germany: Elsevier, 2007. T. Schnura. Diagnosis and Point Selection According to TCM. Munich, Germany: Elsevier, 2009. Jia J, Yu Y, Deng JH, Robinson N, Bovey M, Cui YH, Liu HR, Ding W, Wu HG, Wang XM. A review of Omics research in acupuncture: the relevance and future prospects for understanding the nature of meridians and acupoints. Journal of Ethnopharmacology. 2012; 140(3): 594-603. ˙ Akgün K, Eryavuz M. GeriÇakmak B, Aydın FY, Akta¸s I, ˙ atrik Hastalıklarda Kas-Iskelet Sistemi Hastalıkları. Turkish Journal of Geriatrics. 2004; 7(4): 221-4. Berman BM, Bausell RB. The use of non-pharmacological therapies by pain specialists. Pain. 2000;85: 313-5. Becker N, Bondegaard TA, Olsen AK, Sjögren P, Bech P, Eriksen J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain. 1997; 73(3): 393-400. Carey TS, Evans AT, Hadler NM, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine. 1995; 20(3): 312-7.
[10]
[11]
[12]
[13]
[14]
[15]
Shimp LA. Safety issues in the pharmacologic management of chronic pain in the elderly. Pharmacotherapy. 1998; 18(6): 1313-22. Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in communitydwelling elderly. Gerontology. 1998; 44(4): 217-21. Shorr RI, Griffin MR, Daugherty JR, Ray WA. Opioid analgesics and the risk of hip fracture in the elderly: Codeine and propoxyphene. Journal of Gerontology. 1992; 47(4): M111-5. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. Journal of the American Geriatrics Society. 1999; 47(1): 30-9. Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, Bareta J, Hochberg M. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford) 1999; 38(4): 346-54. Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry 1998; 44(2): 129-38.
