NEUROPATHIC PAIN AND SPASTICITY RESPONSE TO TRADITIONAL ACUPUNCTURE AFTER SPINAL CORD INJURY

Gabriella Fizzottia, Giovani Fassinab, Livio Tronconib

a Spinal Unit, ICS Maugeri SPA SB, Institute of Pavia, IRCCS, Pavia, Italyb IRCCS Mondino Foundation Pavia, University of Pavia, Pavia, Italy

ABSTRACT

IntroductionOne of the most relevant disabilities is caused by spinal cord injury (SCI). Typical causes of spinal cord damage are trauma, disease, or congenital disorders. Tetraplegia is a paralysis results in the partial or total loss of use of all limbs and torso; paraplegia is similar but does not affect the arms. Pain and spasticity are common sequelae of SCI (1). Both pain and spasticity can have a late onset and develop slowly over time after SCI, and once developed, they often become chronic.In this paper we have provided to assess the effectiveness of acupuncture for treating SCI sequelae and summarize the potential mechanisms of acupuncture therapy.MethodWe considered 30 patients with diagnosis of tetra or paraplegia after SCI complicated by neuropathic pain and spasticity. Neurologist trained in medical acupuncture conducted the therapeutic treatments. A specific set of acupuncture points was used in all sessions. Participants were treated for 8 sessions of acupuncture over 4 weeks period. Pain and spasticity were evaluated with Numeric Raiting Scale (VAS) (2) and the Modified Ashworth Scale (3) at the beginning of the first, the fourth an the eighth treatment session. Results28 patients (93%) showed improvement in pain intensity and spasticity after two weeks of acupuncture treatment. The therapeutic effect continued until the eighth week of treatment. However, 15 patients (53,5%) reported an increase in spasticity and pain 2 months after acupuncture sessions.ConclusionsAcupuncture sessions using defined acupoint set reduced pain intentensity and spasticity in patients with SCI.

Keywords: acupuncture, pain spasticity, spinal cord injury

INTRODUCTION

According to the World Health Organization the term ‘spinal cord injury’ refers to damage to the spinal cord resulting from trauma (e.g. a car crash) or from disease or degeneration (e.g. cancer). (4) Traumatic spinal cord injuries most commonly occur as a result of motor vehicle and motor-bike accidents, followed by falls. Sport, in particular, water-based activities and work-related injuries are also common, with a further small but increasing contribution from a gun, knife or war-related injury. (5,6) (Fig-1)Tetraplegia, also known as quadriplegia, is a paralysis caused by illness or injury that results in the partial or total loss of use of all limbs and torso; paraplegia is similar but does not affect the arms. The loss is usually sensory and motor, which means that both sensation and control are lost (7). The rehabilitation process following a spinal cord injury normally begins in the acute care setting. The clinical outcomes of SCI depend on the severity and location of the lesion and may include partial or complete loss of sensory and/or motor function below the level of injury. A primary goal of rehabilitation is to restore, to the greatest possible extent, the physical functioning of an individual after illness or injury.Knowledge of possible complications during the acute phase is important because they may be life-threatening and/or may lead to prolonged rehabilitation.The range of conditions following SCI can be categorized into neurological consequences and resulted from the injury itself, following interruption and decentralization of central nervous system and may be regarded as sequel to the injury. (8) Example are neurogenic pain or spasticity; the latter being part of the upper neurone syndrome. Neuropathic pain is present in 50–60% and spasticity in about 70% of individuals living with a SCI.. (9-10) Central neuropathic pain shares many features with spasticity and has even been termed ‘sensory spasticity’.(11) Both pain and spasticity can have a late onset and develop slowly over time after SCI, and once developed, they often become chronic. Neuropathic pain is defined as ‘pain caused by a lesion or disease of the somatosensory nervous system.(12)Neuropathic pain following SCI includes at- and below-level SCI neuropathic pain, where at-level pain may consist of both peripheral and central neuropathic pain, while below-level pain is a central neuropathic pain condition. (13) Studies have found that patients with spinal cord injury who suffer from pain have less life satisfaction than do patients in whom pain is well controlled; this may also affect the patients' general outlook on life (14, 15).Spasticity has been defined as ‘a disordered sensorimotor control resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles’, and this broad definition of spasticity is adopted in the spinal cord injury musculoskeletal data set. (16)Neurological consequences may interfere with the start of active rehabilitation, can slow down the achievement of outcomes during rehabilitation and sometimes lead to re-hospitalizationLife expectancies for patients with spinal cord injury continues to increase but are still below the general population. Patients aged 20 years at the time they sustain these injuries have a life expectancy of approximately 35.7 years (patients with high tetraplegia [C1-C4]), 40 years (patients with low tetraplegia [C5-C8]), or 45.2 years (patients with paraplegia) (17). Individuals aged 60 years at the time of injury have a life expectancy of approximately 7.7 years (patients with high tetraplegia), 9.9 years (patients with low tetraplegia), and 12.8 years (patients with paraplegia).Originally the leading cause of death in patients with spinal cord injury who survived their initial injury was renal failure, but, currently, the leading causes of death are pneumonia, pulmonary embolism, or septicemia. Heart disease, (18-19) subsequent trauma, suicide, and alcohol-related

deaths are also major causes of death in these patients (20-21). In persons with spinal cord injury, the suicide rate is higher among individuals who are younger than 25 years.

There are many treatments for functional recovery from injury and the related complications that result from SCI; these include surgery (22), prescription drugs (23), behavioral therapy (24), physical therapy (25)], and supportive treatment (26). There are also a variety of treatments used for the secondary complications of SCI, such as intermittent catheterization for bladder dysfunction, analgesics for pain, and others (27). Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy.These treatments tend to be administered over long periods of time, and because of the potential complications of treatment, there has been an increased interest in alternative medical treatments, including acupuncture and other related therapies (moxibustion and acupressure) (28).Acupuncture is an important part of Traditional Chinese Medicine, which has been used for more than 4000 years to prevent and treat a variety of diseases. . Even though the technique was first developed in China, it is now practiced by thousands of clinicians worldwide and has become one of the most frequently used complementary medicine therapies among SCI patients. Many researchers have found acupuncture to be effective in a large number of patients for not only nociceptive condition but also for neuropathic pain (29,30,31,32,33). The effect of acupuncture on spasticity has been proven by several studies, Zhang et al. concluded that the nanometer acupoint mounting method through defined acupoints can significantly alleviate myospasms complicated by spinal injury, compared with the non-acupuncture group (34). Another Chinese study also proved that acupuncture combined with Western medicine could improve SCI-induced spasticity after spinal cord injury, compared with treatment with Western medicine alone (35). It is important to advance knowledge on people with SCI and strengthen the evidence base for prevention, support and care of people with SCI. In this paper we have provided to assess the effectiveness of acupuncture for treating post-SCI complications and summarize the potential mechanisms of acupuncture therapy for SCI.

Common Causes of Spinal Cord Injury (2016)

Vehicular / Automobile Accidents 38%  Falls 30.5% Violence (Primarily From Gunshot Wounds) 13.5%  Sports Injury 9% 

Medical / Surgical Complications 5%  Miscellaneous / Other Causes 4% 

Fig.1 Causes of traumatic spinal cord injury. Source: The National Spinal Cord Injury Statistical Center

MATERIAL AND METHOD

Acupuncture has been administered to 30 SCI patients, aged between 16 and 80, treated at the Spinal Unit of Maugeri IRCCS Foundation. Patients were recruited consecutively from January 2019 to December 2019. Spinal cord injuries were classified as complete and incomplete by the American Spinal Injury Association (ASIA) classification (36). The ASIA scale grades patients based on their functional impairment from A to E, where A represents the greatest impairment and E represents the normal condition. Neurologist trained in medical acupuncture conducted the therapeutic treatments. During the procedure, a hair-thin needle is inserted into the skin at distinct acupoints (Table1). Participants were treated for 8 sessions of acupuncture over a 4 week period. After insertion, needles were left in place for 30 minutes and were not manually or electrically stimulated. Needles were inserted to a depth of 15 to 30 mm. A specific set of acupuncture points was used with all participants: 5TB Waiguan, 41 GB Linqi. 20 GB Fengchi, 34 GB Yinglingquan, 4 GI Hegu, 3 LV Taichong, 36 ST Zusanli. We have focussed on inserting needles into fixed anatomical locations (table 1). At the beginning of the first, fourth an eighth treatment session, each participant was asked to describe the quality and location of pain and spasticity: an operator evaluated VAS(2) and Modified Ashworth (3) scale respectively.

Acupuncture Point LocationGB 41 Zulinqi Posterior to the 4th metatarsophalangeal joint, in the depression lateral to the tendon of m. extensor digiti minimi of the foot. TH 5 Waiguan On the dorsal aspect of the forearm, on the line connecting SJ 4 and the tip of the elbow, 2 cun above the transverse crease of the wrist between the ulna and radius. GB 20 FengChi At the top of the sternocleidomastoid muscle which runs from the back of the head down to the front of the shoulders at the clavicle.GB 34 YangLingQuan In the depression anterior and inferior to the small head of the fibula.GI 4 Hegu On the dorsum of the hand, between the first and second metacarpal bones, at the midpoint of the second metacarpal bone and close to its radial border.LV 3 Taichong On the dorsum of the foot in a depression distal to the junctions of the 1st and 2nd metatarsal bones.ST 36 Zusanli On the finger breadth lateral to the lower border of the tuberositas tibiae 3 cun below the knee joint

Table 1 Acupoints

RESULTS

At the time of the acupuncture treatment, all patients were hospitalised. Thirty patients presented a traumatic spinal cord injury. Median age was 58 years in men and 69 years in women. Patients in acute phase of disease were 12. Patients distribution among ASIA categories was well balanced (14 patients were ASIA A or B). Acupuncture may be effective in treating a subgroup of patients who have pain and spasticity after traumaic SCI. Sixty-five percent of the present study sample reported

moderate to significant pain relief immediately after the course of 16 treatments and 25% of the sample continued to report pain relief at 2-month follow-up.Our data provide preliminary evidence indicating that the subgroup reporting spasticity relief after acupuncture. Forty-six percent of the present study sample reported moderate to significant spasticity relief immediately after the course of 16 treatments and 5% of the sample continued to report spasticity relief at 2-month follow-up. Patients with incomplete injuries appear to do better than those with complete ones.VAS scale evidenced a reduced pain intensity in 64,4% patients with acute SCI and 30% with chronic SCI. Fifty - seven percent of acute SCI patients reported spasticity relief and 30% of chronic SCI reported the same result. Spasticity responds better in acute incomplete SCI compared to chronic; the percentage change is equal to 31,5%..In term of safety no serious adverse events related acupuncture were reported in anyone of the 30 patients.

Acute Chronic 0

10

20

30

40

50

60

70

Percentage improvement in incomplete SCI

Pain Spasticity

Fig1 Pain and Spasticity improvement after acupuncture treatment in incomplete acute and chronic spinal cord injury

DiscussionOur data provide preliminary evidence indicating that the subgroup reporting neuropatic pain and spasticity relief after acupuncture. Patients with incomplete injuries appear to do better than those with complete ones . This result might explain because the pathway to the central nervous system is still intact. Acute SCI evidenced better results than chronic SCI patients. Despite the fact that response to acupuncture was not effective in the long term it is still encouraging that 65% of partecipants reported moderate to significant pain and 46 % to spasticity relief immediately after treatment.Several theories about the mechanism of acupuncture may explain why neuropatic pain relief after acupuncture. One suggests that the insertion of acupuncture needles stimulates the release of endorphins. (37) Given that central pain is more refractory to conventional treatment (38), this finding suggests that acupuncture may provide a viable treatment alternative for some individuals with this kind of pain.

The mechanism of the effect of acupuncture on spasticity is still unclear. It is widely accepted that acupuncture can reduce pain. Acupuncture therapy could break the pain-spasm-pain cycle and relax muscles by controlling pain (39). The threshold of pain receptor is increased after location stimulation (40-41). However, the mechanism cannot explain all causes because spasticity is not always painful and the link between spasticity and pain is not clearly established. SCI can trigger neuroplasticity that potentially promotes recovery from the injury but it also may have deleterious consequences. Neuropathic pain and spasticity are multifactorial and complex consequences of maladaptive neuronal plasticity after SCI. (1). Following an initial impact after spinal cord injury (SCI), there is a cascade of downstream events termed 'secondary injury', which culminate in progressive degenerative events in the spinal cord. These secondary injury mechanisms include, but are not limited to, ischemia, inflammation, free radical-induced cell death, glutamate excitotoxicity, cytoskeletal degradation and induction of extrinsic and intrinsic apoptotic pathways (42) Different aspect of pain and spasticity, and injury characteristics may reflect different underlying mechanisms. (1) Decrease oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increase regenerative stem cell production are the possible mechanism of acupuncture therapy for SCI. McCouch proposed another aetiological mechanism: the distruption in the balance between excitatory and inhibitory inputs to motoneurons observed during spasticity. Enhanced excitability of motoneurons and interneurons and axonal sprouting are the most likely mechanisms involved in spasticity (43). Management of spasticity can include physical exercise, medication, and electrostimulation (44). Evidence from experiments in humans and animal models of spasticity demonstrated that alterations in the excitability of numerous excitatory and inhibitory spinal pathways occur after SCI. The pathogenesis of spasticity resulting from SCI is multifactorial and extend beyond the stretch reflex. It also depends on the type, site, and duration of injury. The alteration in excitability of various inhibitory pathways has historically been studied the most, with less focus until recently on the alterations in excitability of motoneurons and interneurons themselves. This latter alteration appear to play critical role in the manifestation of spasticity after SCI.(45) . The enhancement in excitability of motoneurons is most likely involved in pathophysiology of spasticity following SCI. Acupuncture therapy may regulate the activity of spinal motor neurons by decreasing the hyperexcitability of gamma and alfa motor neuron and/or increasing the inhibition of interneurons. Fink et al. (46) and Lee et al. (47) found that after the fist acupuncture treatment, H/M ratios decreased immediately as compared with controls. The improvement in H/M ratio may be associated with decreased excitability of alfa motor neurons. Yu et al. (48) found that acupuncture on the antagonist muscle of the spastic muscle could prolong the mean H-reflex recovery time, which may be caused by the increased inhibition of interneurons. The use of complementary and alternative medicine (CAM) to relieve pain for the patients with SCI has been assessed in several studies. As in our survey, CAM was used as a supplementary rather than an exclusive treatment. In Pannek’s study 73% of the SCI patients reported the use of CAM for chronic pain(49). Acupuncture was the most frequent technique (28% of the participants), with a pain relief that lasted for weeks in 19% of the users (50). A meta-analysis showed positive results for the use of acupuncture for pain in SCI (51). The percentage of SCI patients seeking help for their chronic medical conditions by CAM is high. Therefore, a comprehensive care of SCI patients should not be limited to the various forms of conventional treatments, but should include CAM procedures as well.

CONCLUSION Acupuncture seems to be a potential therapeutic intervention for SCI pain and spasticity. Neurological complication of SCI may interfere with the start of active rehabilitation, can slow down the achievement of outcomes during rehabilitation and sometimes lead to re-hospitalization. The possibility to use acupuncture sessions complementary to the individual rehabilitation program

(PRI) in SCI can be useful to perform activities of daily living without shooting and burning pain, spasms and increased muscle tone. There are several limitations to the described study. These findings must be replicated in a longer term study that has a larger sample, including a nonacupuncture control group. Further researches are needed in this direction to develop valid and reliable instruments to assess the health status in people with SCI.

Funding

This research received no specific grant from any finding agency in the public, commercial or not for profit sectors.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research authorship and/or publication of this article.

Patient consent

Obtained.

The study was approved by the Ethics Committee of our Centre and all patients provided written informed consent before study treatment.

Provenance and peer reviewNot commissioned; externally peer reviewed.

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DISCUSSIONE The percentage of SCI patients seeking help for their chronic medical conditions by complementary and alternative medicine CAM

is high in Switzerland. Therefore, a comprehensive care of SCI patients should not be limited to the various forms of conventional treatments, but should include CAM procedures as well.

There may be moderate-quality evidence that combined

BIBLIO Use of complementary and alternative medicine (CAM) in persons with spinal cord injury in Switzerland: a survey study

PIU EFFICACE NEGLI ACUTI RISPETTO AI CRONICI

CRONICO LE MODIFICAZIONI SONO INVETERATE

Dopo quanto tempo viene meno la neuroplasticit

STOP

52 spasticity after spinal cord injury: current techiniques and future directions. Neurirehabil Neural Repair 2010; 24(1): 23-33. CERCARE

53 53 Bethoux F. Spasticity Management after stroke. Phys Med Rehabil Clin N Am2015: 26(4):625-39. CERCARE

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16 54 S.M. Lim, J. Yoo, E. Lee, et al.Acupuncture for spasticity after stroke: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med, 2015 (2015), Article 870398

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MECHANISM OF ACUPUNCTURE ON SPASTICITY articolo Y Zhu Does acupuncture help patients with spasticity

VEDI ARTICOLO ACUpuncture in clinical neurology (47)

Acupuncture seems to be a potential therapeutic intervention for spasticity. There may be moderate-quality evidence that electroacupuncture???? combine with conventional routine care (parmacological/rehabilitation) could reduce spasticity in stroke patients. However the effectiveness of this therapy remains unclear in order CNS diseases with spasticity. (1,28,31) ARTICOLO Does acupuncture help patients with spasticity ? A narrative review

CERCARE (31) Shin BC Acupuncture in spinal cord injury survivors in Chinese literature a sistematic review Complement Med 20091:17 316-27.

NEGLI ACUTI la risposta è piu rapida perche non si sono ancora verificati gli effetti negativi della neuroplasticità sono in DIVENIRECERCARE NB VOCE 33 biblio Acupuncture effective in treating chronic pain after spinal cord injury

PRIMA DI CHIUDERE LA DISCUSSIONE

CITARE ARTICOLO PER COMPROVARE L’USO DELLA MEDICINA ALTERNATIVA Use of complementary and alternative medicine in persons with spinal cord injury in Switzerland: a survey study

Paraplegici SE GLI ACUìTI COMPLETI RISPONDONO COME GLI INCOMPLETI) (confermato dalla letteratura Articolo a pagamento) rispetto ai cronici ove si escluda il soggetto giovane che risponde velocemente (fattore età). Risponde anche la spasticità ma piu lentamente ?????

CALCOLI PARAPLEGICI

VAS PARA INCOMPLETI

ACUTI INCOMPLETI inizio / fine trattamento migliora la VAS del 75%CRONICI INCOMPLETI inizio / fine trattamento migliora la VAS del 28,5%

VAS PARA COMPLETI

ACUTI COMPLETI inizio / fine trattamento MANCA DATO

CRONICI COMPLETI inizio / fine trattamento migliora la VAS del 30,7%

NC : Il dolore risponde Completi CRONICI DEL 30,7

ASHWORTH SPASTICITA’ PARA INCOMPLETI

ACUTI INCOMPLETI inizio / fine trattamento migliora la SPASTICITA’ del 60%CRONICI INCOMPLETI inizio / fine trattamento migliora la SPASTICITA’ del 28,5%

NC : LA SPASTICITA risponde meglio negli Incompleti acuti rispetto ai cronici DELTA = 31,5

ASHWORTH SPASTICITA’ PARA COMPLETI

ACUTI COMPLETI inizio / fine trattamento MANCA DATO

CRONICI COMPLETI inizio / fine trattamento migliora la SPASTICITA’ del 36%

NC : LA SPSTICITA’ risponde Completi CRONICI DEL 36%

COMMENTO

SPASTICITA’ INCOMPLETI ACUTI E CRONICI Dal confronto tra para acuti e cronici INCOMPLETI ho una differenza del 20/ Negli acuti la spasticità diminuisce del 60% e nei cronici del 28,5% Gli acuti incompleti rispondono maggiormente DEI CRONICI.

SPASTICITA’ COMPLETI ACUTI E CRONICI ho solo il cronico dove diminuisce del 36% MANCA l’acutoCONFRONTO COMPLETI – INCOMPLETI NEI CRONICI (Incompleto= 28,5 % Completo cronico = 36% ) L’incompleto cronico diminuisce piu del completo anche se per poco. DOLORE VAS diminuisce a fine sedute nel confronto tra para Incompleti acuti (75%)e cronici 28,5%) La VAS diminuisce maggiormente rispetto all’ashworth nei para Incompleti acuti e cronici differenza è VAS 46,5% e Ashworth 20% nel confronto inizio e fine sedute

Confronto COMPLETI CRONICI inizio sino a fine sedute diminuisce del 30,7% Confronto CRONICI VAS ed Ashworth 30,7 e 36% Paradossalmente nei cronici COMPLETI diminuisce maggiormente la SPASTICITA

Il DOLORE come dimostrato in letteratura è uno dei parametri che risponde sicuramente all’agopuntura.

TetraplegiciCRONICI LA SPASTICITà ARTI SUPERIORI SCENDE DI PIU NEGLI INCOMPLETI RISPETTO AI COMPLETI MENO RAPIDAMENTE RISPETTO AGLI ACUTI

Acuti meglio dei cronici Incompleti meglio dei completi.Dolore piu rapidoSapsticità più lenta Trand uguale sia nei complete che incomplete negli acuti e nei cronici.

Grado di spasticità piu’ elevato e quadro inveterato nei cronici.La cronicità influenza meno le vVie del Dolore ??????

CALCOLI TETRAPLEGICI

VAS Tetra INCOMPLETI

ACUTI INCOMPLETI inizio / fine trattamento migliora la VAS del 53,8%CRONICI INCOMPLETI inizio / fine trattamento migliora la VAS del 31,5%

NC : Il dolore risponde meglio negli Incompleti acuti rispetto ai cronici

VAS TETRA COMPLETI

ACUTI COMPLETI inizio / fine trattamento migliora la VAS del 40%

CRONICI COMPLETI inizio / fine trattamento migliora la VAS del 38,57%

NC : Il dolore risponde meglio negli Completi acuti rispetto ai cronici ma meno rispetto agli Incompleti

ASHWORTH Tetra INCOMPLETI

ACUTI INCOMPLETI inizio / fine trattamento migliora la SPASTICITA del 53,8%CRONICI INCOMPLETI inizio / fine trattamento migliora la SPASTICITA del 31,5%NC : LA SPASTICITA’ risponde meglio negli Incompleti acuti rispetto ai cronici

PRIMA DI CHIUDERE LA DISCUSSIONE

In our study, CAM was most frequently used for pain and UTI. The use of CAM to relieve pain for the patients with SCI has been assessed in several studies. As in our survey, CAM was used as a supplementary rather than an exclusive treatment. 73% of the SCI patients reported the use of CAM for chronic pain. Acupuncture was the most frequent technique (28% of the participants), with a pain relief that lasted for weeks in 19% of the users.13 A meta-analysis showed positive results for the use of acupuncture for pain in SCI.14

Despite the rather limited evidence for acupuncture and the virtually nonexistent evidence for homeopathy in SCI patients, both the treatments are very popular among Swiss SCI patients and provide a very high rate of patient satisfaction. Several aspects are important: none of the patients replaced conventional treatment by CAM, so the risk that CAM users may miss standard therapeutic options seems to be negligible. None of the medical problems could be sufficiently treated by the conventional medicine, as only the combination of CAM with the standard procedures led to the mentioned high satisfaction rates. The percentage of SCI patients seeking help for their chronic medical conditions by CAM is high. Therefore, a comprehensive care of SCI patients should not be limited to the various forms of conventional treatments, but should include CAM procedures as well.

Third, sham controls in acupuncture research for SCI may represent an ethical issue [65].Therefore, an adjunctive treatment of acupuncture to conventional treatments for SCI can be evaluated by RCTs comparing acupuncture plus conventional treatment to sham acupuncture plus conventional treatment or through comparative effectiveness research (CER) [66].METTERE NELLE CONCLUSIONI O A FINE DISCUSSIONE

[65] S. D. Pearson, “Placebo-controlled trials, ethics, and the goals of comparative effectiveness research: comment on ‘lack of head-to-head trials and fair control arms’,” Archives of InternalMedicine, vol. 172, no. 3, pp. 244–245, 2012.[66] C. M. Witt, E. Manheimer, R. Hammerschlag et al., “How well do randomized trials inform decision making: systematic review using comparative effectiveness research measures on acupuncture for back pain,” PLoS One, vol. 7, no. 2, article e32399, 2012.

51] D. Moher, S. Hopewell, K. F. Schulz et al., “CONSORT 2010Explanation and Elaboration: updated guidelines for reporting parallel group randomised trials,” Journal of Clinical Epidemiology, vol. 63, no. 8, pp. e1–e37, 2010. CERCARE PER REGOLE TRIAL

CONCLUSIONS (or DISCUSSION)

Central neuropathic pain shares many features with spasticity and has even been termed ‘sensory spasticity’.19 Both pain and spasticity can have a late onset and develop slowly over time after SCI, and once developed, they often become chronic. In addition, both conditions

19 Sjolund BH. Pain and rehabilitation after spinal cord injury: the case of sensory spasticity? Brain Res Brain Res Rev 2002; 40: 250 –256. CERCARE

LIMITI DELLO STUDIO IMPORTANTANTE

Popolazione piccola, no control group però risultato positivo senza effetti collaterali

Methods—Twenty-eight subjects over the age of 18 and diagnosed with chronic myofascial pain of the jaw muscles were randomized to receive real (n = 16) or sham (n = 12) acupuncture. Prior to treatment, each

Even if, given the absence of a control arm, this study did not evaluate the true impact of the game-based rehabilitation, it showed the feasibility of integrating conventional exercises with iPad educational games to recover trunk control. From patients’ self-perception, this helped them either to achieve rehabilitation outcomes or to improve the relationship with themselves by raising abilities awareness.This method has an parzialmente affordable cost since all the apps used were free of charge. Ma iPad era a costo pieno.Training was not operator-dependent: during the course of the games the supervision of the physiotherapist was not strictly necessary and so the patient could manage himself. This advantage can be exploited in hospital but especially at home.The same applications used for the rehabilitation of the patients with SCI may be extended to other outcomes. The same games suggested to patients in upright position can became exercises to improve balance and proprioception in case of orthopedic problems and/or other kind of neurologic diseases. Moreover, adapting skeletal tracking technology used in gaming software could automate exercise tracking, documentation and feedback for patient motivation and clinical treatment planning and interventions.Conversely, these applications are exclusively available for Apple tablets. Their porting on other operating systems could give opportunity to a bigger number of patients to continue the training at home.

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9 Burke D, Fullen BM, Stokes D, Lennon O. Neuropathic pain prevalence following spinal cord injury: A systematic review and meta-analysis. Eur J Pain 2017; 21: 29 –44.

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11 Jensen TS, Baron R, Haanpaa M, Kalso E, Loeser JD, Rice AS et al. A new definition of neuropathic pain. Pain 2011; 152: 2204–2205.

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64 C. Norrbrink, T. Lundeberg. Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study, Acupunct Med, 29 (2) (2011), pp. 108-115

65 Y.S. Gwak, H.Y. Kim, B.H. Lee, C.H. YangCombined approaches for the relief of spinal cord injury-induced neuropathic pain. Complement Ther Med, 25 (2016), pp. 27-33

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Medical complications after SCI are both common and severe. A significant number of patients develop a chronic pain syndrome several months to years after SCI

Neuropathic pain is present in 50–60% and spasticity in about 70% of individuals living with a SCI. (8–9-10)

Acupuncture session using using a defined acupoint set at Hegu large intestine 4 significantly reduced most myofascial pain endpoints when compared to sham acupuncture

Neuropathic pain is a multidimensional constellation of phenomenologically different symptoms and is defined as ‘pain caused by a lesion or disease of the somatosensory nervous system’.12,

12 Jensen TS, Baron R, Haanpaa M, Kalso E, Loeser JD, Rice AS et al. A new de finition of neuropathic pain. Pain 2011; 152: 2204–2205

Many researchers have found this treatment to be effective in a large number of patients for not only nociceptive conditions [16] but also for neuropathic pain [17], [18], [19], [20]. The effect of acupuncture on spasticity has been proven by several studies, especially in stroke patients where this technique has been shown to improve their rehabilitation [54], [55], [56]. Lim et al. [54] explicitly pointed out that acupuncture and EA could effectively decrease spasticity after a stroke. Zhang et al. concluded that the nanometer acupoint mounting method through the bilateral Shenshu (BL23), Shangliao (BL31), Ciliao (BL32), Yang-lingquan (GB34), and Xuanzhong (GB39) acupoints can significantly alleviate myospasms complicated by spinal injury, compared with the nonacupuncture group [57]. Another Chinese study also proved that acupuncture combined with Western medicine could improve SCI-induced spasticity after spinal cord injury, compared with treatment with Western medicine alone [58].

The mechanism of the effect of acupuncture on spasticity is still unclear. It is widely accepted that acupuncture can reduce pain. Acupuncture therapy could break the pain-spasm-pain cycle and relax muscles by controlling pain [21].In this paper we have provided to assess the effectiveness of acupuncture for treating post-SCI complications and summarize the potential mechanisms of acupuncture therapy for SCI.

I. SPASTICITY

Spasticity is a common complication after SCI, presenting in 70% of post-SCI survivors [51]. It not only restricts patients' rehabilitation and recovery but also leads to an increased social burden. The pathogenesis of spasticity following SCI remains uncertain. Enhanced excitability of motoneurons and interneurons and axonal sprouting are the most likely mechanisms involved in spasticity [52]. Management of spasticity includes physical exercise, medication, and electrostimulation [53].

The effect of acupuncture on spasticity has been proven by several studies, especially in stroke patients where this technique has been shown to improve their rehabilitation [54], [55], [56]. Lim et al. [54] explicitly pointed out that

acupuncture and EA could effectively decrease spasticity after a stroke. Zhang et al. concluded that the nanometer acupoint mounting method through the bilateral Shenshu (BL23), Shangliao (BL31), Ciliao (BL32), Yang-lingquan (GB34), and Xuanzhong (GB39) acupoints can significantly alleviate myospasms complicated by spinal injury, compared with the nonacupuncture group [57]. Another Chinese study also proved that acupuncture combined with Western medicine could improve SCI-induced spasticity after spinal cord injury, compared with treatment with Western medicine alone [58].

New evidence also suggests that the effect of acupuncture on SCI-induced pain depends on the location and type of pain, as well as the type of injury [25]. Since the central nervous system pathway is still intact and the insertion of acupuncture needles stimulates the release of endorphins, acupuncture recipients with incomplete injuries (60%) appear to do better than those with complete injuries (33%), and those with musculoskeletal pain (80%) responded better to therapy compared with patients with central pain (42%). Additionally, participants with moderate pain were more likely to experience long-term pain relief than those with severe pain [26]. Rapson et al. [27] showed that individuals whose pain was described as bilateral or symmetrical were more likely to improve after acupuncture treatment

Articolo Does acupuncture help patients with spasticity? A narrative review

Spasticity is a neurological consequence of spinal cord injury (SCI). It can be result from the injury itself, following interruption and decentralization of the nervous system and may be regarded as sequelae to the injury. Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy. Neurological consequences may interfere with the start of active rehabilitation, can slow down the achievement of outcomes during rehabilitation and sometimes lead to re-hospitalization.(P = .04), and neck pain (P = .04), and a significant increase in pain tolerance of the masseter muscle (P = .001). Real acupuncture was given by penetrating the needle through a sticky foam pad at the acupoint.

Pain above the level of injury may respond better because the pathway to thecentral nervous system is still intact. This hypothesis might also explain why participants with incomplete injuries appear

to do better than those with complete ones. A second possibility is that people with complete injuries are more likely to havecentral pain than musculoskeletal pain. Although not statistically significant, responders were also more likely to have incomplete rather than complete SCIs and musculoskeletal rather than central pain. Despite the fact that response to acupuncture was not as good among participants with central pain, it is still encouraging that 42% of them reported moderateto significant pain relief immediately after treatment. Given that central pain is more refractory to conventional treatment,44 this finding suggests that acupuncture may provide a viable treatment alternative for some individuals with this kind ofpain. Another preliminary finding is that the participants with moderate levels of pain intensity were more likely to experiencelong-term (3mo) pain relief than those who started out with more severe pain intensity. Expectancy is an unlikely explanation for the treatment Articolo Is Acupuncture effective in treating chronic pin after spinal cord injury

Patient characteristics

Patients needed to have the following inclusion criteria: post traumatic spinal cord injury esordio entro 1 anno, having had no severe limitations in passive range of motion at lower extremities and (v) having had no mental retardation.

Inclusion criteria for the study were; (i) Spastic diplegic type of CP; (ii) having had no orthopedic surgery, Botulinium toxin injection; (iii) having had no oral or intratheceal myorelaxant drugs; (iv) having had no severe limitations in passive range of motion at lower extremities and (v) having had no mental retardation. Each child was assessed by three physiotherapists in two different sessions a week apart. The intrarater reliability was determined by a paired comparison of the measurements for each therapist between the two assessments. The interrater reliability was determined by a paired comparison of the measurements of the three therapists on the same day.

Exclusion criteria were:Per la scala AshworthInclusion criteria for the study were; (i) Spastic diplegic type of CP; (ii) having had no orthopedic surgery, Botulinium toxin injection; (iii) having had no oral or intratheceal myorelaxant drugs; (iv) having had no severe limitations in passive range of motion at lower extremities and (v) having had no mental retardation. Each child was assessed by three physiotherapists in two different sessions a week apart. The intrarater reliability was determined by a paired comparison of the measurements

for each therapist between the two assessments. The interrater reliability was determined by a paired comparison of the measurements of the three therapists on the same day.

The Modified Ashworth Scale is the most widely clinical scale used to measure the increase of muscle tone [1].

Meseguer-Henarejos AB, Sánchez-Meca J, López-Pina JA, Carles-Hernández R. Inter- and intra-rater reliability of the Modified Ashworth Scale: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2018 Aug;54(4):576-590. [PubMed ]

In 1964, Bryan Ashworth published the Ashworth Scale as a method of grading spasticity while working with multiple sclerosis patients. The original Ashworth scale was a 5 point numerical scale that graded spasticity from 0-4, with 0 being no resistance and 4 being a limb rigid in flexion or extension [2].  In 1987, while performing a study to exam interrater reliability of manual tests of elbow flexor muscle spasticity, Bohannon and Smith modified the Ashworth scale by adding 1+ to the scale in order to increase sensitivity [3].  Since its modification, the modified Ashworth scale (MAS), has been applied in clinical practice and research as a measure of spasticity. The modified Ashworth scale purpose is to grade muscle spasticity.  The scale is as follows:

0: No increase in muscle tone [4] 1: Slight increase in muscle tone, with a catch and release or minimal resistance at the end of

the range of motion when an affected part(s) is moved in flexion or extension [4] 1+: Slight increase in muscle tone, manifested as a catch, followed by minimal resistance

through the remainder (less than half) of the range of motion [4]  2: A marked increase in muscle tone throughout most of the range of motion, but affected

part(s) are still easily moved [4] 3: Considerable increase in muscle tone, passive movement difficult [4] 4: Affected part(s) rigid in flexion or extension [4]

Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy. Neurological consequences may interfere with the start of active rehabilitation, can slow down the achievement of outcomes during rehabilitation and sometimes lead to re-hospitalization.

VASs of pain are popular. The most common form in an unmarked 10-cm line, with the end points labeled “no-pain” and “worst pain possible” Respondents are asked to mark the line at the point best describing their pain.

especially in stroke patients where this technique has been shown to improve their rehabilitation [54], [55], [56]. Lim et al. [54] explicitly pointed out that acupuncture and EA could effectively decrease spasticity after a stroke. Zhang et al. concluded that the nanometer acupoint mounting method through the bilateral Shenshu (BL23), Shangliao (BL31), Ciliao (BL32), Yang-lingquan (GB34), and Xuanzhong (GB39) acupoints can significantly alleviate

myospasms complicated by spinal injury, compared with the nonacupuncture group [57]. Another Chinese study also proved that acupuncture combined with Western medicine could improve SCI-induced spasticity after spinal cord injury, compared with treatment with Western medicine alone [58].

Efficacia del trattamento era uguale agli arti superiori ed arti inferiori. Senza apparenti differenze cliniche tra tetra e para Le risposte al trattamento erano evidenti dopo la 2° settimana di sedute di agopuntura

Effectiveness of treatment was equal to the upper and lower limbs without apparent clinical differences between tetra and paraplegic patients. The results to treatment were evident after the 2nd week of acupuncture sessions facilitating rehabilitation program. All patients reported no side effects and demonstrated complete acceptance of acupuncture therapy. No wash out was reported.The results confirmed the effectiveness of acupuncture included ?????in the individual rehabilitation program (PRI) for: reduce pain intensity and spasticity. Completi an incompleti Acuti e cronici Rehabilitation outcome

. 11 Burke D, Fullen BM, Stokes D, Lennon O. Neuropathic pain prevalence following spinal cord injury: A systematic review and meta-analysis. Eur J Pain 2017; 21: 29 –44..

Clinically, it may be difficult to distinguish neuropathic pain from other types ofpain such as musculoskeletal pain, which is common after SCI, due to,for example, spasms, contractures and overuse.

13 Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DL, Bouhassira D et al.

Neuropathic pain: an updated grading system for research and clinical practice.Pain 2016; 157: 1599–1606. VERIFICA LEGGENDO se è in relazione con la frase

Spasticity has been defined as ‘a disordered sensorimotor control resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles’,15 and this broad definition of spasticity is adopted in thespinal cord injury musculoskeletal data set.16Mettetere le 2 definizioni di Lance e Dquet15 Pandyan AD, Gregoric M, Barnes MP, Wood D, Van WF, Burridge J et al. Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil 2005; 27: 2–6.

16 Biering-Sorensen F, Burns AS, Curt A, Harvey LA, Jane MM, Nance PW et al. International spinal cord injury musculoskeletal basic data set. Spinal Cord 2012; 50: 797–802.

Clinically, it is often difficult to separate spasticity from symptoms and signs caused by structural changes in the muscles.18

1. 18 Nielsen JB, Crone C, Hultborn H . The spinal pathophysiology of spasticity—from a basic science point of view. Acta Physiol 2007; 189: 171–180.

Central neuropathic pain shares many features with spasticity and has even been termed ‘sensory spasticity’.19 Both pain and spasticity can have a late onset and develop slowly over time after SCI, and once developed, they often become chronic. In addition, both conditions

19 Sjolund BH. Pain and rehabilitation after spinal cord injury: the case of sensory spasticity? Brain Res Brain Res Rev 2002; 40: 250 –256. CERCARE

***THE DARK SIDE OF NEUROPLASTICITY vedi articolo per giustificare il legame tra spasticità e dolore

However, the same neuroplasticity that allows locomotor function to recover also produces negative consequences such as pain and dysfunction of organs controlled by the autonomic nervous system. In this review we focus specifically on structural neuroplasticity (the growth of new synaptic connections) after SCI and on the consequent development of pain and autonomic dysreflexia, a condition of episodic hypertension. Neuroplasticity after SCI is stimulated by the deafferentation of

spinal neurons below the lesion and by the expression of growth-promoting neurotrophins such as nerve growth factor (NGF).

SCI partially denervates spinal neurons by disrupting ascending and descending pathways to and from the brain as well as inputs from the dorsal root ganglia. This denervation provides a stimulus for intact axons of interneurons, white matter tracts and sensory neurons to replace lost inputs to the spinal neurons that have empty synapses. Moreover, the loss of connections of intact ascending sensory systems may prompt collateral sprouting in search of new targets caudal to the injury. Collateral or regenerative sprouting of intraspinal axons after SCI may allow them to make new connections or to strengthen existing synapses to partially denervated or other spinal neurons.

Two conditions, neuropathic pain and autonomic dysreflexia, are common adverse outcomes of SCI that appear to involve neuroplasticity as part of their etiology. Neuropathic pain after SCI has many underlying factors such as increases in neuronal excitability due to products of microglial activation, changes in sodium channel expression, and changes in glutamate receptor expression (Deumens et al., 2008) but this discourse will address primarily two factors that involve neural growth, namely collateral sprouting of calcitonin gene-related peptide (CGRP)-containing primary afferent fibers in the spinal cord dorsal horn (Christensen and Hulsebosch, 1997b) and aberrant growth of descending serotonergic axons in the dorsal horn rostral to the cord lesion site (Oatway et al., 2005). This growth can occur both rostral and caudal to the injury, in parallel with the neuropathic pain that can be evoked above, at and below the injury site. Autonomic dysreflexia is an abnormality of blood pressure control characterized by extreme hypertension accompanied by a pounding headache and slow heart rate [for review see (Weaver et al., 2006), (Mathias, 2006)]. This hypertension occurs in response to sensory input entering the spinal cord below the level of the lesion. This input leads to exaggerated spinal reflex sympathetic (autonomic) responses that can be associated with an increased CGRP-containing primary afferent arbor in the dorsal horn (Krenz and Weaver, 1998; Krenz et al., 1999) or, in the presence of a normal arbor, with loss of descending inhibitory influences on spinal sympathetic reflexes (Gris et al., 2005). In this condition, the key changes occur below the site of injury.

Structural neuroplasticity in pain and autonomic dysreflexia after SCI Collateral sprouting of CGRP-immunoreactive small diameter primary afferent fibers into the laminae III–V of the dorsal horn after SCI has been linked with the development of chronic neuropathic pain and autonomic dysreflexia (Christensen and Hulsebosch, 1997a, 1997b; Jacob et al., 2001; Krenz and Weaver, 1998; Krenz et al., 1999; Weaver et al., in press; Wong et al., 2000) (Fig. 1A). Sprouting of larger diameter fibers has also been noted after SCI (Krenz and Weaver, 1998) and may contribute to dysreflexia as this condition can also be induced by non-noxious stimuli such as light touch (Marsh and Weaver, 2004). Primary afferent sprouting may be important near the site of injury, for example in the case of at-level neuropathic pain, or elsewhere in the cord, for example in the region of input from pelvic afferent projections that initiate autonomic dysreflexia after a high thoracic lesion.

CGRP is expressed in less than half of nociceptive dorsal root sensory neurons and this peptide is also expressed in small myelinated and unmyelinated primary afferent neurons that are not associated with nociception, demonstrating that changes in CGRP-immunoreactive populations cannot be associated solely with sensations of pain (Lawson et al., 2002)

Acupuncture and spinal cord injury vedi articoli

ARTICOLO SPINAL CORD INJURY: HOW COULD ACUPUNCTURE HELP?

The effect of acupuncture on post-SCI orthostatic hypotension and sexual dysfunction remains unclear. Decreased oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, and increased regenerative stem cell production are the possible mechanisms of acupuncture therapy for SCI. Although many limitations have been reported in previous studies, given the evidence for the efficacy of acupuncture, we recommend that physicians should support the use of acupuncture therapy for S CI complications.

Acupuncture is an important part of Traditional Chinese Medicine, which has been used for more than 4000 years to prevent and treat a variety of diseases. During the procedure, a hair-thin needle is inserted into the skin at distinct acupoints and is manipulated manually, electrically, thermally, or pharmacologically. Even though the technique was first developed in China, it is now practiced by thousands of clinicians worldwide and has become one of the most frequently used complementary medicine therapies among SCI patients. Compared with other treatment methods, acupuncture is well known for its advantages, which include uncomplicated procedures, lack of toxicity, and lower cost. A growing body of scientific evidence has been published to illustrate the effect of acupuncture on neurological function, urinary retention, pain, pressure ulcers, and OH. Although several systematic reviews and clinical studies have indicated that there is no strong evidence to support the therapeutic efficacy of acupuncture in SCI [6], [7], [8], an increasing number of high-quality randomized controlled trials (RCTs) are currently being conducted, which may shed light on the benefits of acupuncture therapy.

Many researchers have found this treatment to be effective in a large number of patients for not only nociceptive conditions [7] but also for neuropathic pain [20], [21], [22], [23]. A large number of researchers believe that acupuncture is an essential component of pain treatment for SCI and that combining acupuncture with drugs [24] and massage [20] enhances therapeutic efficacy. New evidence also suggests that the effect of acupuncture on SCI-induced pain depends on the location and type of pain, as well as the type of injury [25]. Since the central nervous system pathway is still intact and the insertion of acupuncture needles stimulates the release of endorphins, acupuncture recipients with incomplete injuries (60%) appear to do better than those with complete injuries (33%), and those with musculoskeletal pain (80%) responded better to therapy compared with patients with central pain (42%). Additionally, participants with moderate pain were more likely to experience long-term pain relief than those with severe pain [26]. Rapson et al. [27] showed that individuals whose pain was described as bilateral or symmetrical were more likely to improve after acupuncture treatment

Articolo Does acupuncture help patients with spasticity? A narrative review

Spasticity may have positive effects; for example, it may allow for weak limb weight bearing for transfers [11]. However, it restricts motor functions and adversely affects quality of life (QoL) for many patients [12]. Hyperexcitability of muscle stretch reflexes, the characteristic feature of spasticity, results in an imbalance of forces between agonist and antagonist muscles, which leads to abnormal postural and motor control [13]. Spasticity can cause restricted joint

range of movement, loss of dexterity, and abnormal limb posture, which adversely affects mobility, transfers, and activities of daily living (ADL) [14], [15] as well as carer burden and QoL, including pain, pressure ulcers and difficulty in bowel and bladder care [16], [17].

Conventional therapies for spasticity include physical therapy, surgery, and pharmacotherapy [14], [18], [19]. Most clinical guidelines prioritize non-pharmacological interventions, such as stretching and splinting [20], [21], [22]. For moderate or severe spasticity, oral medications (such as baclofen) or invasive therapies (such as botulinum injection and chemical neurolysis) should be considered

II. 4. Mechanism of acupuncture on spasticityIII. 4.1. Breaking pain-spasm-pain cycle

The mechanism of the effect of acupuncture on spasticity is still unclear. It is widely accepted that acupuncture can reduce pain. Acupuncture therapy could break the pain-spasm-pain cycle and relax muscles by controlling pain [45]. The threshold of pain receptor is increased after acupuncture because the CNS releases opioid peptides after location stimulation [46], [47]. However, the mechanism cannot explain all cases because spasticity is not always painful and the link between spasticity and pain is not clearly established.

IV. 4.2. Regulating activity of spinal motor neurons

After a UMN lesion (brain or spinal cord), spinal motor neurons have increased excitability because of loss of inhibitory supraspinal control. The increased gamma-motor neuron activity, decreased inhibition by specific interneurons, and altered common interneuron activity increase alpha-motor neuron activity [13]. Acupuncture therapy may regulate the activity of spinal motor neurons by decreasing the hyperexcitability of γ and α motor neurons and/or increasing the inhibition of interneurons. Fink et al. [48] and Lee et al. [49] found that after the first acupuncture treatment, H/M ratios decreased immediately as compared with controls. The improvement in H/M ratio may be associated with decreased excitability of α motor neurons. Yu et al. [50] found that acupuncture on the antagonistic muscle of the spastic muscle could prolong the mean H-reflex recovery time, which may be caused by the increased inhibition of interneurons.

V. . Discussion

Acupuncture seems to be a potential therapeutic intervention for spasticity. There may be moderate-quality evidence that electroacupuncture combined with conventional routine care (pharmacological/rehabilitation) could reduce spasticity in stroke patients. However, the effectiveness of this therapy remains unclear in other CNS diseases with spasticity [1], [28], [29], [30], [31]. Despite the available range of acupuncture (including electroacupuncture) for spasticity, high-quality evidence for many diseases is lacking. Methodological limitations and low reporting quality of the existing studies limit the level of evidence for the following reasons.

Articolo Neuropathic pain and spasticity: intricate consequences of spinal cord injury NB Finnerup

Following SCI, neuroplasticity, which involves both neuronal, structural and functional responses, is essential for recovery of the neurological function, but the dark side of this neuroplasticity can be the development of neuropathic pain and spasticity.1

Neuropathic pain is a multidimensional constellation of phenomenologically different symptoms and is defined as ‘pain caused by a lesion or disease of the somatosensory nervous system’.12,1

Clinically, it may be difficult to distinguish neuropathic pain from other types of pain such as musculoskeletal pain, which is common after SCI, due to, for example, spasms, contractures and overuse.

Spasticity is also a multidimensional constellation of phenomenologically diverse symptoms and has been defined as ‘a disordered sensorimotor control resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles’,15 and this broad definition of spasticity is adopted in the spinal cord injury musculoskeletal data set.16 This definition includes velocity-dependent increase in tonic stretch reflexes (muscle tone) and phasic stretch reflexes (exaggerated tendon jerks) that formed the original definition of spasticity,17 as well as flexor- and extensor spasms, flexor reflexes, and altered motor control. Clinically, it is often difficult to separate spasticity from symptoms and signs caused by structural changes in the muscles.18

NEUROPATHIC PAIN AND SPASTICITY: TWO SIDES OF THE SAME COIN? Central neuropathic pain shares many features with spasticity and has even been

termed ‘sensory spasticity’.19 Both pain and spasticity can have a late onset and develop slowly over time after SCI, and once developed, they often become chronic. In addition, both conditions

Furthermore, the failure to differentiate between different phenotypes of pain and spasticity may prevent us from identifying similarities.

MULTIDIMENSIONAL ASSESSMENT OF PAIN

Below-level pain often develops months later than at-level pain, and sensory hypersensitivity is a predictor of below-level but not at-level pain.8,31

Sodium channel blockers are, for example, suggested to be more effective in patients with preserved pain and thermal sensation than in patients who have mainly sensory loss.38,39

One of the main reasons is the difficulty in assessing the correlate of spontaneous pain, which is the most frequent and troublesome pain symptom in humans.41,42

It has been shown that motor and projection neurons in the pain pathways are affected differently by SCI and that withdrawal reflexes do not always reflect pain-like hypersensitivity.41,46,48–50

but it is important to keep in mind that the neural circuits subserving vocalization reflexes and conscious appreciation of nociceptive intensity also can react differently to SCI.46–48,50

Figure 1 A simpli fied schematic representation of how lesions and hyperexcitability in different pathways may be involved in generating various symptoms and signs of neuropathic pain and spasticity. The grey lines indicate the spinal cord, the dark grey area the injury site, and the dashed lines interrupted axons. For details, please see the text. Adapted from Vierck et al.52

Vierck and colleagues more than 15 years ago. On the basis of extensive animal studies,68,69 they suggested that exaggerated flexion and withdrawal reflexes as well as below-level pain result from a combination of long tract damage and abnormal activity in the spinal grey matter as well as a facilitatory role of propriospinal systems, albeit with different circuits involved (Figure 1).52

CONCLUSIONS Neuropathic pain and spasticity are multifactorial and complex consequences of maladaptive neuronal plasticity after SCI.

Different constellations of pain and spasticity, and injury characteristics (for example, at- and below-level pain, ongoing and evoked pain, shooting and burning pain, spasms and increased muscle tone, complete and incomplete lesions) may reflect different underlying mechanisms.

The Modified Ashworth Scale is the most widely clinical scale used to measure the increase of muscle tone [1].

Meseguer-Henarejos AB, Sánchez-Meca J, López-Pina JA, Carles-Hernández R. Inter- and intra-rater reliability of the Modified Ashworth Scale: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2018 Aug;54(4):576-590. [PubMed ]

In 1964, Bryan Ashworth published the Ashworth Scale as a method of grading spasticity while working with multiple sclerosis patients. The original Ashworth scale was a 5 point numerical scale that graded spasticity from 0-4, with 0 being no resistance and 4 being a limb rigid in flexion or extension [2].  In 1987, while performing a study to exam interrater reliability of manual tests of elbow flexor muscle spasticity, Bohannon and Smith modified the Ashworth scale by adding 1+ to the scale in order to increase sensitivity [3].  Since its modification, the modified Ashworth scale (MAS), has been applied in clinical practice and research as a measure of spasticity. The modified Ashworth scale purpose is to grade muscle spasticity.  The scale is as follows:

0: No increase in muscle tone [4] 1: Slight increase in muscle tone, with a catch and release or minimal resistance at the end of

the range of motion when an affected part(s) is moved in flexion or extension [4] 1+: Slight increase in muscle tone, manifested as a catch, followed by minimal resistance

through the remainder (less than half) of the range of motion [4]  2: A marked increase in muscle tone throughout most of the range of motion, but affected

part(s) are still easily moved [4] 3: Considerable increase in muscle tone, passive movement difficult [4] 4: Affected part(s) rigid in flexion or extension [4]

Physiatrist (?) trained in medical acupuncture conducted all treatments. A specific set of acupuncture points was used with all partecipants

Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy. Neurological consequences may interfere with the start of active rehabilitation, can slow down the achievement of outcomes during rehabilitation and sometimes lead to re-hospitalization.

DISCUSSION

To our knowledge we present the first systemstic assessment of the use of acupuncture in patients with sequelae of SCI.

We located only 1 study 33 that examined the use of acupuncture for pain after SCI. Twelve

patients with paraplegia or tetraplegia who experienced paresthesias or hyperesthesias in

addition to upper extremity weakness and depressed reflexes were treated by using

electroacupuncture. Treatment was provided 3 times daily and was terminated based on

the degree of improvement observed. The investigator reports that all patients' functioning

improved and paresthesias decreased. However, the study did not report results on any

quantifiable outcomes, nor did it include comparisons with a control group. The present

study was designed to examine the efficacy of acupuncture treatment for chronic pain in

persons with SCI. In addition, we explored whether physical functioning, social functioning,

and depression would improve as indirect effects of pain relief. We also sought to identify

variables that predicted responsiveness to acupuncture treatment. The extent of SCI

(complete vs incomplete), neurologic level of injury, type of pain (musculoskeletal vs

other), and location of pain (above vs below the level of injury) were examined as potential

moderators of treatment outcome.

o 33 Wen HL. Acute central cervical cord syndrome treated by acupuncture and

electrical stimulation (AES).Comp Med East West. 1978; 6: 131-135

Articolo Is acupuncture effective in trating chronic pain after spinal cord injury.

A review by Doorsher and McIntosh concluded that acupuncture has been shown to improve neurological function in individuals with chronic SCI and help with management with chronic pain associated with these injuries.11

This review further described the underlying mechanisms of acupuncture for SCI complications and concluded that the effects of acupuncture appear to result from reduction of oxidative stress, inhibition of inflammation and neuronal apoptosis, regulation of the expression and activity of endogenous biological mediators, promotion of regenerative stem cells, and improvement of neuroplasticity.The identification of these mechanisms provides evidence for the efficacy and safety of acupuncture therapy for complications after SCI.Although the results of these studies substantiate the benefits of acupuncture therapy for SCI complications, it is

How acupuncture can help spinal cord injury

Da qui discussione sulla spasticità

The mechanism of the effect of acupuncture on spasticity is still unclear. It is widely accepted that acupuncture can reduce pain. Acupuncture therapy could break the pain-spasm-pain cycle and relax muscles by controlling pain [21].

11. Dorsher PT1, McIntosh PM Acupuncture's Effects in Treating the Sequelae of Acute and Chronic Spinal Cord Injuries: A Review of Allopathic and Traditional Chinese Medicine Literature. Evid Based Complement Alternat Med. 2011;2011:428108.. Epub 2010 Oct 25.

DISCUSSIONAcupuncture may be effective in treating a subgroup of individuals who have chronic pain after SCI. Forty-six percentof the present study sample reported moderate to significant pain relief immediately after the course of 15 treatments and35% of the sample continued to report pain relief at 3-month follow-up. Our data provide preliminary evidence indicatingthat the subgroup reporting pain relief after acupuncture had chronic pain located above the level of their SCI. Severaltheories about the mechanism of acupuncture may explain why this occurs. One suggests that the insertion of acupunctureneedles stimulates the release of endorphins.43 Pain above the level of injury may respond better because the pathway to thecentral nervous system is still intact. This hypothesis might also explain why participants with incomplete injuries appear

to do better than those with complete ones. A second possibility is that people with complete injuries are more likely to havecentral pain than musculoskeletal pain. Although not statistically significant, responders were also more likely to haveincomplete rather than complete SCIs and musculoskeletal rather than central pain. Despite the fact that response toacupuncture was not as good among participants with central pain, it is still encouraging that 42% of them reported moderateto significant pain relief immediately after treatment. Given that central pain is more refractory to conventional treatment,44

this finding suggests that acupuncture may provide a viable treatment alternative for some individuals with this kind ofpain. Another preliminary finding is that the participants with moderate levels of pain intensity were more likely to experiencelong-term (3mo) pain relief than those who started out with more severe pain intensity. Expectancy is an unlikely explanation for the treatment Articolo Is Acupuncture effective in treating chronic pin after spinal cord injury

Abstract (text)

Abstract

1 selected item: 19244

The effect of acupuncture on spasticity has been proven by several studies, especially in stroke patients where this technique has been shown to improve their rehabilitation [54], [55], [56]. Lim et al. [54] explicitly pointed out that acupuncture and EA could effectively decrease spasticity after a stroke. Zhang et al. concluded that the nanometer acupoint mounting method through the bilateral Shenshu (BL23), Shangliao (BL31), Ciliao (BL32), Yang-lingquan (GB34), and Xuanzhong (GB39) acupoints can significantly alleviate myospasms complicated by spinal injury, compared with the nonacupuncture group [57]. Another Chinese study also proved that acupuncture combined with Western medicine could improve SCI-induced spasticity after spinal cord injury, compared with treatment with Western medicine alone [58].

my

abstract abstract abstract 20 20

20 abstract

1 1 false

1

Pain and spasticity are common sequelae of spinal cord injury (SCI). Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy. Selected patients with post–SCI pain can respond to surgical myelotomy (DREZ lesions) or intrathecal agents (e.g., morphine clonidine), but the majority continue to suffer.Spasticity of spinal or supraspinal origin can condition rehabilitation outcomes. Until a few decades ago the therapeutic possibilities of hypertonia were restricted to destructive surgical procedures,Spinal cord injury (SCI) is often followed by complications, whichKnowledge of possible complications during the acute phase is important because they may be life threatening and/ or may lead to prolonged rehabilitation

Abstract Aims—To evaluate the effectiveness of acupuncture in treating symptoms associated with myofascial pain of the jaw muscles. Methods—Twenty-eight subjects over the age of 18 and diagnosed with chronic myofascial pain of the jaw muscles were randomized to receive real (n = 16) or sham (n = 12) acupuncture. Prior to treatment, each subject clenched his or her teeth for 2 minutes. Acupuncture or sham acupuncture was then administered at the Hegu large intestine 4 (LI4) acupoint for 15 minutes. Real acupuncture was given by penetrating the needle through a sticky foam pad at the acupoint. Sham acupuncture was conducted by pricking the skin, without penetration, with a shortened, blunted acupuncture needle through a foam pad placed away from the acupoint. General head and neck pain ratings were obtained before and after treatment on a numerical rating scale. A mechanical pain stimulus on the masseter muscle was given before and after treatment and rated on a visual analog scale to measure pain tolerance level. Paired t tests were performed to detect significant changes in pain levels. Results—Subjects receiving real acupuncture experienced a significant reduction in jaw pain (P = .04), jaw/face tightness (P = .04), and neck pain (P = .04), and a significant increase in pain tolerance of the masseter muscle (P = .001). Subjects were not able to determine whether they received real or sham acupuncture (P = .69). No significant pain reductions were observed in the sham acupuncture group. Conclusion—A single acupuncture session using one acupoint at Hegu large intestine 4 significantly reduced most myofascial pain endpoints when compared to sham acupuncture.Keywords acupuncture; analgesia; Hegu large intestine 4; myofascial pain; placebo; shamCorrespondence to: Dr Yoshi F. Shen, Department of Oral and Maxillofacial Surgery, Center for Orofacial Pain, University of California, San Francisco, 707 Pamassus Ave, Rm D1050, San Francisco, CA 94143-0768, Fax: 415-742-0082, yoshi.shen.ucsf@gmail.com.NIH Public Access Author Manuscript J Orofac Pain. Author manuscript; available in PMC 2010 June 30.Published in final edited form as: J Orofac Pain. 2009 ; 23(4): 353–359.NIH-PA Author ManuscriptNIH-PA Au

VI. 3.1.7. Spasticity

Spasticity is a common complication after SCI, presenting in 70% of post-SCI survivors [51]. It not only restricts patients' rehabilitation and recovery but also

leads to an increased social burden. The pathogenesis of spasticity following SCI remains uncertain. Enhanced excitability of motoneurons and interneurons and axonal sprouting are the most likely mechanisms involved in spasticity [52]. Management of spasticity includes physical exercise, medication, and electrostimulation [53].

The effect of acupuncture on spasticity has been proven by several studies, especially in stroke patients where this technique has been shown to improve their rehabilitation [54], [55], [56]. Lim et al. [54] explicitly pointed out that acupuncture and EA could effectively decrease spasticity after a stroke. Zhang et al. concluded that the nanometer acupoint mounting method through the bilateral Shenshu (BL23), Shangliao (BL31), Ciliao (BL32), Yang-lingquan (GB34), and Xuanzhong (GB39) acupoints can significantly alleviate myospasms complicated by spinal injury, compared with the nonacupuncture group [57]. Another Chinese study also proved that acupuncture combined with Western medicine could improve SCI-induced spasticity after spinal cord injury, compared with treatment with Western medicine alone [58].

TreatmentIn all participants, GV14was needled. In addition, Hua Tuo Jia Ji points correspondingto the level of the lesion were used. If the lesion was above T1,then BL10 was added. If the lesion was below L5, then BL40was added. If this initial combination did not seem to be veryeffective, then the acupuncturist could choose to use the BL10and BL40 combination.Other acupuncture points were chosen based on each participant’sreported location(s) of pain. If the pain was in an upperextremity, the 4 Ba Xie points located on the affected handwere used. If the pain was in a lower extremity, the 4 Ba Fengpoints in the affected foot, which correspond to the Ba Xiepoints, were used. When the pain was in the back, ulnar surfaceof the arm, and medial and posterior aspect of the legs, pointsK13, BL60, SI3, and HT3 were used. If the pain was on thelateral and medial aspects of the legs and the dorsum or volarsurface of the arms, points LR3, MH6, TH5, and GB34 wereused. When the pain was on the radial side of the arm, lateralshoulder, and lateral and medial side of the leg, points LU7,SP6, LI4, and ST36 were used. The acupuncturist was giventhe option to add up to 6 supplementary points as necessary.These included local points in the area of the pain, A-shi points(painful, nonacupuncture points), and ear points. Thus, the

protocol was somewhat standardized, in that a limited numberof specific points were to be used, but there was also someflexibility to allow the acupuncturists to address individualdifferences among patients. This flexibility was deemed necessaryto reflect the clinical practice of acupuncture.

Spasticity is a common complication after SCI, presenting in 70% of post-SCI survivors [51]. It not only restricts patients' rehabilitation and recovery but also leads to an increased social burden. The pathogenesis of spasticity following SCI remains uncertain. Enhanced excitability of motoneurons and interneurons and axonal sprouting are the most likely mechanisms involved in spasticity [52]. Management of spasticity includes physical exercise, medication, and electrostimulation [53].

CONCLUSION

ARTICOLO Use of complementary and alternative medicine in persons with spinal cord injury in Switzerland: a survey study

In our study, CAM was most frequently used for pain and UTI. The use of CAM to relieve pain for the patients with SCI has been assessed in several studies. As in our survey, CAM was used as a supplementary rather than an exclusive treatment. 73% of the SCI patients reported the use of CAM for chronic pain. Acupuncture was the most frequent technique (28% of the participants), with a pain relief that lasted for weeks in 19% of the users.13 A meta-analysis showed positive results for the use of acupuncture for pain in SCI.14

Despite the rather limited evidence for acupuncture and the virtually nonexistent evidence for homeopathy in SCI patients, both the treatments are very popular among Swiss SCI patients and provide a very high rate of patient satisfaction. Several aspects are important: none of the patients replaced conventional treatment by CAM, so the risk that CAM users may miss standard therapeutic options seems to be negligible. None of the medical problems could be sufficiently

treated by the conventional medicine, as only the combination of CAM with the standard procedures led to the mentioned high satisfaction rates. The percentage of SCI patients seeking help for their chronic medical conditions by CAM is high. Therefore, a comprehensive care of SCI patients should not be limited to the various forms of conventional treatments, but should include CAM procedures as well.

AGOPUNTI

VII. TH 5 Clinical Usages Beginning exterior conditions, tonify for wind-cold, cold-damp & sedate

for wind-heat, fever. Headache from exterior wind as well as migraines and headaches in any

area especially with stiffness or pain in the posterior and lateral aspects of the neck.

Upper limb disorders including the elbow, forearm, wrist and hand. Shaoyang stage diseases - alternating fever and chills, etc. Luo connecting point of the TH connects to the PC, TH 5 & PC 6 as master

points of the Yang Wei and Yin Wei respectively can effect the balance of yin and yang in the body. If right pulse is stronger than the left (more Qi than Blood) disperse TH 5 & tonify PC 6 and vice versa

When GB 41 is blocked, Qi can back up along the length of the meridian, producing symptoms in the sides of the legs, hips, the sides of the ribcage, shoulders, neck, head and eyes. One of the more common conditions associated with this block is occipital and frontal headache, sometimes with pain behind the eyes and/or visual distortions.

This point can also be useful when frustrations or the burdens of responsibility cause a build up of pressure in the neck and shoulders. If you press into the top of someone’s shoulders (GB 21) and there is a lot of tension, you may find that holding GB 41 will help that tension to soften and descend down the body.

GB 41 (Shu-Stream Point, the Eight Confluent Point)Chinese Name: ZulinqiEnglish NameLocation: Posterior to the 4th metatarsophalangeal joint, in the depression lateral to the tendon of m. extensor digiti minimi of the foot. 

Indications: Headache, vertigo, pain of the outer canthus, scrofula, pain in the hypochondriac region, distending pain of the breast, irregular menstruation, pain and swelling of the dorsum of foot, spastic pain of the foot and toe.Acupuncture Method: Puncture perpendicularly 0.3-0.5 inch. Moxibustion is applicable.Regional anatomy Vasculature: The dorsal arterial and venous network of foot, the fourth dorsal metatarsal artery and vein.Innervation: The branch of the intermediate dorsal cutaneous nerve of the foot.

It is a shu stream point

Five Shu PointsAlberta College of Acupuncture & Traditional Chinese Medicine Acupuncture Points 05 May 2016 Hits: 37340

The five Shu-Points, namely the Jing (Well) , Ying (Spring) , Shu (Stream) , Jing (River) and He (Sea), are an important grouping of acupuncture points of the twelve principal channels. The Five Shu Points are situated in the peripheral part of each meridian, below elbows and knees.

Traditionally, these points are the places where the Qi of channels is transferred and each of them corresponds to one of the five elements. In addition one Shu point on each channel corresponds to the same element as the channel as a whole.This point is reffered as the Horary point.

According to the relation of the Five Elements , each meridian has a "mother" point with reinforcing effect (tonification point)and a "son" point with a reducing effect (sedative point).

The Five Transporting (Shu)

The Five Transporting (Shu) points start at the tip of the four limbs and continue all the way to the elbows or knees.

Jing (Well) Points

Meridians start at Jing-Well points , They are located on the fingers and toes of the four extremities. The indications for the use of these points are fullness in the chest and mental disorders related to the Yin organs.

Ying (Spring) Points

These points are located distal to the metacarpophalangeal joints or metatarsophalangeal joints and are used for febrile diseases. In the Yin meridians, the Ying (Spring) point belongs to the Fire Element. This means that it may be very useful in the treatment of releasing heat from its related meridian or organ system.

Shu (Stream) Points

These points are located proximal to the metacarpophalangeal joints or metatarsophalangeal joints and are used for disorders related to heaviness in the body or painful joint conditions. The Shu (Stream) point in Yin organs is also what we refer to as the Yuan (Source) point. This means that the stimulation of this point is able to build strength and energy in its related meridian or organ system.

Jing (River) Points

These points are located around the joints of the wrists or ankles and are used for cough and asthma due to pathogenic cold and heat. This is also a place where Qi flows through.

He (Sea) Points

The He-Sea point metaphorically describes the merge of rivers joining and emptying into the sea. They are located around the joints of the elbows or knees. These points are indicated for perverse Qi flow such as diarrhea.

Five Shu Points Chart

{supertable table}

{rowheight 1 35px}{rowheight 8 35px}

Yin Meridians

Jing-well

(Wood)

Ying-spring(Fire)

Shu-stream(Earth)

Jing-river

(Metal)

He-Sea(Water)

LU LU 11 LU 10 LU 9 (T) LU 8 (H) LU 5 (S)PC PC 9 (T) PC 8 (H) PC 7 (S) PC 5 PC 3HT HT 9 (T) HT 8 (H) HT 7 (S) HT 4 HT 3SP SP 1 SP 2 (T) SP 3 (H) SP 5 (S) SP 9LV LV 1 (H) LV 2 (S) LV 3 LV 4 LV 8 (T)

KD KD 1 (S) KD 2 KD 3 KD 7 (T) KD 10 (H)

Yang Meridians

Jing-well

Ying-spring

Shu-stream

Jing-river

He-Sea(Earth)

(Metal) (Water) (Wood) (Fire)LI LI 1 (H) LI 2 (S) LI 3 LI 5 LI 11 (T)

TW TW 1 TW 2 TW 3 (T) TW 6 (H)

TW 10 (S)

SI SI 1 SI 2 SI 3 (T) SI 5 (H) SI 8 (S)

ST ST 45 (S) ST 44 ST 43 ST

41 (T)ST

36 (H)

GB GB 44 GB 43 (T) GB 41 (H)

GB 38 (S) GB 34

UB UB 67 (T)

UB 66 (H)

UB 65 (S) UB 60 UB 40

{/supertable table}

-(H) = Horary Point -(T) = Tonification Point-(S) = Sedative Point

VIII.GB 20 Clinical Usages Dispel Exterior or Interior Wind - (exterior) - fever/chills, stiff neck;

(internal) - paralysis, twitching, tremors, numbness, dizziness, vertigo. All issues of the head, brain (seizures, memory, mental/neurological

disorders), face, throat and sense organs (eyes, ears, nose, tongue). Headache, especially occipital. Eye issues. Issues of the neck, shoulders a/or upper back - pain, weakness, stiffness. Hypertension, especially with LV Yang Rising. Tong Ren/Tam Healing System: Used most often in conjunction with the

huatuo points of C1 and C2 to open the spinal cord, generally used to relieve neck tension.  

Acupressure Point GB20: Gallbladder 20 or Feng Chi (Wind Pool)

Feng Chi (GB20) is recommended for headache, migraine, eye blurriness or fatigue, low energy, and cold/flu symptoms.

Feng Chi (GB20) is recommended for headache, migraine, eye blurriness or fatigue, low energy, and cold/flu symptoms.

Feng Chi (GB20) is located by feeling for the mastoid (ear) bone and following the groove back to where the neck muscles attach to the skull. To use acupressure on this point, locate the point and use a deep, firm pressure towards skull to massage and stimulate the area for 4-5 seconds. Clasp your hands together then gently open your palms with your fingers interlocked to form a cup shape, using your thumbs to massage.

When applying acupressure, try to relax and breath deeply as you massage the area. The massage and the acupressure can be done by yourself, or by someone else who is there to assist you.

In the scientific literature, a review article stated that Feng Chi (GB20), in combination with other acupoints, was used to help manage migraines and yielded positive results [1]. Feng Chi (GB20) was also used in studies for dry eyes where it showed acupuncture improved signs and symptoms in dry-eye patients after 4-weeks of treatment [2].

References cercare

1. Zheng H, Chen M, Wu X, Li Y, Liang FR. Manage migraine with acupuncture: a review of acupuncture protocols in randomized controlled trials. Am J Chin Med. 2010;38(4):639-50.

2. Shin MS, Kim JI, Lee MS, et al. Acupuncture for treating dry eye: a randomized placebo-controlled trial. Acta Ophthalmol. 2010 Dec;88(8):e328-33. doi: 10.1111/j.1755-3768.2010.02027.x. Epub 2010 Nov 10.

3. Takayama S, Seki T, Nakazawa T, et al. N. Short-term effects of acupuncture on open-angle glaucoma in retrobulbar circulation: additional therapy to standard medication. Evid Based Complement Alternat Med. 2011;2011:157090. Epub 2011 Mar 7. PubMed PMID: 21437193

GB 34 Clinical Usages Hui Meeting of the Sinews - useful for treating soft tissue anywhere in the

body, contracture, cramping, pain, spasm, weakness, numbness, paralysis.

Sciatica and issues with the low back, hip, a/or lower limbs, knees. All disorders of the lateral regions of the body. Lower He Sea of the GB - effects GB organ, usually with GB Damp-Heat

conditions, cholecystitis, hepatitis, jaundice, nausea, vomiting, bitter taste in mouth, gallstones.

Shao Yang level diseases presenting with alternating chills/fevers, costal pain, bitter taste in mouth.

LV attacking SP - counterflow Qi, nausea, vomiting, indigestion. Tong Ren/Tam Healing System : Sciatic nerve issues, leg muscle issues

(cramps, fatigue), gallstones.  PUNTO MARE DEI 5 PUNTI SHU

GB-34 (any muscle / tendon issue, knee pain, Damp Heat)Posted on February 6, 2013 by Sharon Rose

GB-34 is Yang Ling Quan (Yang Mound Spring). The name refers to its location on the Yang aspect of the leg. GB-34 is the Ruler of the Sinews (musculoskeletal system), so it will treat muscles, ligaments, and tendons anywhere in the body. It’s particularly effective for knee problems, due to its location. GB-34 can also be used to treat issues like jaundice, nausea, and vomiting. It’s also good for treating Damp Heat, but that’s a fairly complicated Chinese medicine concept related to infection. Ask me if you’re curious. GB-34 is about an inch anterior and inferior to the head of the fibula. First, find the head of the fibula. This is a knob of bone on the side of your leg,  just below the knee, towards the back. Now slide your finger forward and down into a small dip. It will be tight or tender if treatment is appropriate: Press firmly for 20-30 seconds, with healing intention.

Large Intestine LI 4PUNTO DEL DOLORE PER ECCELLENZA

Chinese Name: Hegu (English translation: Joining Valley)

Location:  On the dorsum of the hand, between the 1st and 2nd metacarpal bones, in the middle of the 2nd metacarpal bone on the radial side.

Classification: Yuan-Source point of the Large Intestine MeridianCommand Point of the head and face

Indications:

Diseases of the head and face: i.e. external pathogenic headache and bodyache, dizziness, congestion, swelling and pain of the eye, nasosinusitis, epistaxis (nosebleed), toothache in the lower jaw, trismus (lockjaw), deafness, mumps, swelling of the face, facial paralysis, facial tic, swelling of the pharnyx and aphonia (inability to speak).

Aversion to cold, fever, febrile disease, anhidrosis (no sweating), hidrosis. Dysmenorrhea, amenorrhea, dystocia (difficult or abnormal labor/childbirth). Gastric pain, abdominal pain, constipation, diarrhea, dysentery. Hemiplegia, finger spasm, pain in the arm, infantile convulsion, manic psychosis and irritability. Malignant sore, urticaria, scabies. Every type pf pain and psychogenic tense. Use in conjunction with LIV 3 (the Four Gates) to strongly move the qi and blood in the body in

order to remove stagnation and alleviate pain.

Functions: Expels Wind and releases the exterior, tonifies qi and strengthens immunity, stops pain, regulates the face and head area, induces labor.

Notes: LI 4 is a very common and useful point. It is useful for any condition related to the face and head. It's also particularly useful for Wind-Heat conditions (flu). Finally, LI 4 is known as the pain point in the body. Anywhere there is pain, use LI 4.

Clinically, Yuan-Source points are of great significance in treating diseases of the internal organs. Yuan-Source points are the sites where the Yuan (Primary) qi of the Zang-Fu organs passes and stays. Puncturing the Yuan-Source points stimulates the vital energy of the regular meridians, regulates the functional activities of the internal organs, reinforces antipathogenic factors and eliminates pathogenic factors. This method of treating diseases deals principally with the root causes. The Yuan (source) point from the affected meridian is often combined with the Luo (Connecting) point of the internally-externally related meridians in use.

Needling: Perpendicular insertion .5 - 1.0 cun. Do not needle during pregnancy.

METHOD To date, a specific, validated tool for assessing quality of life in patients with SCI is not available to our knowledge. A recent meta-analysis [6] identified the SF-36 questionnaire as the most commonly used QoL instrument in the SCI literature. It has been widely promoted by the International Quality Of Life Assessment project [7] and translations have been developed and validated for more than 60 countries. Anyway, only few studies have evaluated the quality of life of SCI patients through this questionnaire in Italy and these studies involved a limited number of patients [8, 9].

The SF-36 is a 36-item self-administered survey that measures 8 health domains: physical functioning (PF), social functioning (SF), role limitations due to physical health (RP), role limitations due to mental health (MH), general health (GH), emotional well-being (RE), vitality (VT), and bodily pain (BP) [10]. The health domains described in the SF-36 range in score from 0 to 100, with higher scores representing higher levels of functioning or better health. From these scores, two further synthetic indexes may be calculated: physical (PSI) and mental (MSI).

The SF-36 questionnaire was not originally conceived to provide a utility coefficient (U), i.e. a single value that can be directly used to calculate QALYs. However, as for other similar scales, a number of mapping functions have been developed to convert its scores into a utility value. For this study we applied the algorithm developed by Brazier and colleagues [11].

The SF-36 questionnaire has been administered to 130 SCI patients treated at the Spinal Unit of Maugeri IRCCS Foundation. Patients were recruited consecutively from January 2013 to January 2014. Spinal cord injuries were classified as complete and incomplete by the American Spinal Injury Association (ASIA) classification [12]. The ASIA scale grades patients based on their functional impairment from A to E, where A represents the greatest impairment and E represents the normal condition.

A Microsoft Access database has been developed to input all the questionnaire responses and a user-friendly interface has been designed to implement the conversion algorithm that calculates for each questionnaire the scores of the 8 SF-36 scales plus two synthetic indexes, physical and mental. For the utility coefficients calculation an Excel file delivered by Brazier and colleagues was utilized.

Respondents’ quality of life was evaluated comparing the distributions of all the scales in different groups of patients (Mann-Whitney test) related to gender (M; F), disease phase (acute; chronic), ASIA grade (A-B; C-D), paralysis type (tetraplegia/paraplegia), patient status (inpatient/outpatient) and cause of the lesion (traumatic/not traumatic). Statistical analyses were performed focusing on the associations among functional status and health dimensions. Moreover, univariate and multivariate analyses were performed on U, PSI and MSI.

IX. RESULTS

At the time of the questionnaire administration, 82 out of 130 patients were hospitalised while the remaining 48 were outpatients. Sixty-six patients presented a traumatic spinal cord injury and sixty-four non-traumatic injuries/illnesses. Median age was 54 years in men and 60 years in women. Patients in acute phase of disease were 36. Patients distribution among ASIA categories was well balanced (75 patients were ASIA A or B).

Values for the ten SF-36 health domains ranged from 0 to 100 except for MH that ranged from 4 to 100. Utility coefficients ranged from 0.319 to 0.965 (mean=0.62, SD=0.14) (Figure 1). The subscale scores that revealed a stronger impact of SCI were those related to the physical domains, especially for the physical functioning and physical role functioning subscales and these results are consistent with those reported in [8]. Statistically significant differences were shown for PF scores in the two disease phases (p=0.01) and the two patient status (inpatient or outpatient) (p=0.005), for GH in the two disease phases (p=0.04), for VT in males versus females (p=0.048), and for PSI in the patient’s status (p=0.032). PF (p=0.033), RP (p=0.008), BP (p=0.032) and VT (p=0.01) scales reported statistically significant differences between two groups with different functional impairment (ASIA A-B versus ASIA C-D). BP (p=0.003), GH (p=0.004), VT (p=0.02), MH (p=0.026), and PSI (p=0.022), presented statistically significant differences for traumatic with respect to not traumatic patients. No differences were highlighted between tetraplegic and

paraplegic patients as reported in [13]. Figure 2 shows the mean values for each health dimension for the considered subgroups.

No correlation was found between the values of the health dimensions and the elapsed time from the spinal cord lesion for the entire group of patients. Only ASIA C-D subgroup showed a significant inverse correlation between GH score and the elapsed time from the spinal cord lesion (p=0.034). This finding is likely related to the poor prognosis of motor and functional recovery since the group is composed by older people in comparison to ASIA A-B group (p<0.0001).

With respect to general Italian population [14] (Figure 3), SCI patients show, as expected, very low values concerning PF, RP and BP scales.

In univariate analyses U resulted highly correlated to the patient’s age (p=0.037) and to the cause of the lesion (p=0.008) while in multivariate regression, after adjustment for the type of paralysis, U resulted only significantly predicted by the cause of the lesion, reporting lower values for not traumatic patients in comparison to traumatic patients. This is due to the presence of younger individuals in the latter group (p<0.0001 for age distribution difference). PSI resulted statistically significantly correlated to the cause of the lesion (p=0.026) and the patient’s status (p=0.04) and both resulted significant predictors, after adjustment for elapsed time from the lesion, in the multivariate regression. No significant correlations were found for MSI involving parameters regarding the functional status of the patient, neither in univariate nor in multivariate analyses.

X. CONCLUSION

Achieving an adequate quality of life is considered the final goal of the rehabilitation process following a SCI and the need for outcome measures assessing health and quality of life following rehabilitation is therefore becoming increasingly important. Since improved quality of life is indicative of the success of treatment programs, it should be routinely measured among SCI patients. The present study develops reflections on the perceived quality of life of 130 SCI Italian patients and, even if the sample size is quite small, the reported results are consistent with the ones already published.

Although in rehabilitation medicine the SF-36 questionnaire has been widely used for patients with SCI, these current measures could be insufficient to represent their serious disability because many items were developed for use in the general population. An example can be related to PF subscale which includes 3 questions referring to walking and 2 others that are related to climbing stairs. The questions posed in these terms may lead to an underestimation of the subscale scores regarding the physical functionalities. To overcome this issue, a modified version of the SF-36 questionnaire can be implemented as proposed in [15] where concepts like “climbing stairs” and “walking” are replaced with the word “going”. Further researches are needed in this direction to develop valid and reliable instruments to assess the health status in people with SCI.

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