Effect of Combined Traditional Acupuncture and Applied Kinesiology on Lumbar Diseases
Article information
Abstract
Background
Several Korean medical doctors have been practicing applied kinesiology (AK), invented in 1964 by Dr. George J Goodheart, USA. Although the efficacy of traditional acupuncture (TA) and pharmacopucture treatment for lumbar conditions/diseases has been examined, the possible benefits of combining TA and AK have not been reported. Therefore, the aim of this study was to report the effects of combining TA and AK treatment for lumbar disorders using the Japanese Orthopedic Association lumbar score (JOALS) assessment.
Methods
There were 21 outpatients treated at Samse Korean Traditional Hospital between March 2018 and September 2018, who presented with L4/L5 or L5/S1 root radiculopathy associated with lumbar spinal stenosis (LSS) and lumbar herniation of intervertebral disk (LHID). They were treated 10×(2 sessions per week, for 5 weeks) with TA and AK approaches that included a category block, manipulation or strain/counterstrain treatments. The primary outcome was mainly assessed using the JOALS score which was used before (0 ×), during (5 ×), and after treatment (10 ×).
Results
There were 19 patients diagnosed with LSS and 2 were diagnosed with LHID. Using the JOALS assessment, TA and AK combined approaches improved the lumbar conditions of all 21 patients after 5 × treatmentsand continued to improve after 10 × treatments (p < 0.001).
Conclusion
Combined TA and AK treatment was effective in treating spinal conditions/diseases. Prospective, relevant, well-controlled protocols for TA and AK therapies for various conditions are needed.
Introduction
Spinal conditions/diseases such as lumbar spinal stenosis (LSS) and lumbar herniation of intervertebral disk (LHID) have been treated in Korea using traditional acupuncture (TA) [1–4], but the available evidence for the efficacy of acupuncture remains contradictory and controversial from a biomedical viewpoint [5]. Spinal stenosis is the narrowing of the vertebral canal which places pressure on the spinal nerve and is typically a degenerative condition. Stenosis in the center of the spine can cause bilateral leg pain, while lateral stenosis may cause a more localized nerve root compression [6,7]. LHID is the rupture or herniation of a lumbar intervertebral disc that causes back pain. It can be aggravated by movement which causes pain to radiate down the back of the leg, muscle weakness, decreased sensation, and hyporeflexia of leg and foot [6,7]. Therapies combining TA, and applied kinesiology (AK) have not been reported, even though Korean traditional medical doctors are implementing AK treatments.
Pain scores are determined using the Japanese Orthopedic Association lumbar score (JOALS) [8], and many other assessment methods [9–11], to quantify the pain associated with spinal conditions/diseases [9–16]. This study aimed to report the effects of combined TA and AK therapies on lumbar conditions/diseases using the JOALS assessment of pain.
Materials and Methods
Design
This study was a retrospective chart review of patients who were treated at the Department of Acupuncture and Moxibustion, Samse Korean Traditional Medical Hospital, Busan, Korea between March 1st, 2018 and September 30th, 2018.
Patients
There were 232 patients who presented with lumbar conditions/diseases and were treated at out-patient clinics. There were 140 cases of lumbar strain and sprain, 14 cases of LHID and 78 cases of LSS. There were 21 patients who were selected for this study according to the inclusion/exclusion criteria. Patients’ history, age, sex, previous diagnosis, period of illness, lumbar back pain intensity using the JOALS assessment, and the visual analogue scale (VAS) score were recorded.
Inclusion criteria
Patients were included in this study if they were diagnosed with ≤ 3 conditions concurrently (e.g. LSS and LHID). Patients with a VAS score of > 3, a JOALS > 5 were included. Patients who remained in the study until completion i.e. received combined TA and AK treatment 10 ×, were included in the analysis.
Exclusion criteria
Patients with severe hip, and knee joint disorders, and spondylolisthesis causing pain above a moderate degree (VAS score < 3, JOALS < 5) were excluded. Patients who had received treatments for LSS and LHID such as acupuncture or medication in the last 7 days were excluded. Patients who were treated < 10 × with combined TA and AK therapies were excluded.
Ethics statement
This study was a retrospective review which was approved for exemption for deliberation by Korea National Institute for Bioethics Policy (no.: P01-202001-21-0111).
Acupuncture interventions
Traditional acupuncture
The patients underwent 10 sessions of acupuncture (usually 2 sessions per week, for 5 weeks)and the point locations are according to WHO acupoint locations[17]. The acupuncture needles were 40 × 0.25 mm. Five acupoints (such as GB30, BL40, BL25, BL23, GB34, that are recommended in the “Korean Medicine Clinical Practice Guideline for Lumbar Herniated Intervertebral Disc in Adults” [18]) were chosen. Patients were needled to a depth of approximately 1 cm (without any stimulation). BL23, BL25, GB30, BL40 and GB34 on the culprit side were needled first, followed by BL23 and BL25 on the contralateral side. The retention time was 20 minutes. The acupuncture treatments were performed by a traditional medicine doctor who has been practicing for 50 years.
AK intervention
Pelvic categories
The pelvic category system was developed by DeJarnette [19]and is practiced when using the Sacro Occipital technique. The original system of evaluation and viable correction is the basis for additional diagnosis and therapeutic developments in applied kinesiology. If the examination for pelvic faults is negative but symptoms indicate a probable fault, cervical motion may allow discovery of the fault. Anterior or lateral cervical flexion can increase dural tension to reveal the fault.
Category I
A Category I pelvic fault will not have a positive challenge when only 1 sacroiliac is challenged. Challenge is a technique of measuring the response of an indicator muscle to external stimulus [19,20]. Challenging a correction is the technique utilized after a successful correction to check if the correction was complete. This is a differentiating factor between a Category I and Category II fault. Where only 1 sacroiliac is challenged, the sacrum is stabilized with 1 hand and the posterior superior iliac spine or ischium of 1 side is challenged. A strong indicator muscle is tested for weakness.
Category II
A Category II pelvic fault is an osseous subluxation between the sacrum and the innominate. It is identified by positive therapy localization over the sacroiliac articulation. Therapy localization is usually performed with the patient supine, which yields a higher percentage of positive results than when performed in a prone position. The posterior ilium is nearly always associated with dysfunction of the sartorius and/or gracilis muscles on the side of involvement where anterior support is given to the pelvis. Sometimes the muscles will not test weak initially, but a subclinical weakness may be discovered by therapy localizeing the reflex points or other factors involved with the muscles. Muscles may also test weak in a weight bearing position. The relationship of the muscle with the sacroiliac subluxation can be demonstrated by correcting the subluxation.
Strain/counter strain on psoas
The AK treatment was devised by Jones and revised by Goodheart. This will create areas of pain similar in nature to those described by Travell and Simons in books and articles on myofascial pain. Goodheart [19] has devised a system for evaluating the muscles to determine if Jones’ procedure of static positioning is indicated. Among muscles [20] which are used, psoas is used commonly for lumbar pain.
How to treat pelvic fault according to the categoryusing strain/ counter strain
Category I
Category Iis diagnosed by conducting muscle tests using therapy localization (Fig. 1). After challenge, DeJarnette blocks are placed under the prone patient’s anterior superior iliac crest and acetabulum in a manner that relieves pelvic torsion (Fig. 2). Next, a pumping-type movement is performed on the side opposite to the positive side (Fig. 3). Lastly, the muscle is retested to ascertain the results of the treatment Category Ican be demonstrated by correcting the subluxation
The first step in therapy localization for category I pelvic fault (with the permission of Deseong Medical Publication).
The second step placing DeJarnette blocks (with the permission of Deseong Medical Publication).
Pumping manipulation opposite the positive side (with the permission of Deseong Medical Publication).
Category II is diagnosed by conducting muscle tests using therapy localization. After challenge, DeJarnette blocks are placed under the posterior superior iliac spine on the posterior ilium side and under the ischium on the posterior ischium side, so that they correct osseous subluxation between the sacrum and the innominate. Next, with the patient remaining on the blocks, their ankle and knee are grasped to move the leg on the posterior ischium side into flexion at the hip and knee. The thigh is adducted, bringing the knee across the body sufficiently enough to roll the patient gently onto the posterior ilium block. The knee and hip are then brought towards neutral, and the maneuver is repeated approximately 6 times in a rolling fashion. Lastly, the muscle is retested through therapy localization to ascertain the results of the treatment (Fig. 4).
Leg movement with supine block adjusting technique for categoryII (with the permission of Deseong Medical Publication).
Strain/counter strain [19]
The patient maximally contracts their psoas to test for weakness. Next, the patient maximally flexes their hip to shorten the psoas (Fig. 5). This allows the practitioner to use their fingers to find the most painful point along the psoas muscle spindle. Lastly, the patient takes a deep breath and holds it while the practitioner spreads their fingers over the previously tender point. The patient is held in this fine-tuned position with the practitioner spreading the point,whilst breathing normally for 30 seconds (Fig. 6). Upon completion, the patient is slowly and passively returned to a neutral position. The tender point in the psoas should have disappeared, and any associated pain such as lower back pain should be greatly reduced or have disappeared. The psoas is retested after the patient has maximally contracted it for 3 seconds. There should now be no weakness if the treatment was successful.
Maximal psoas contraction (with the permission of Deseong Medical Publication).
Maximal hip flexion and strain/counter strain technique (with the permission of Deseong Medical Publication).
Measurement tool
Primary tool
JOALS [8,21]
The JOALS consists of 4 categories such as subjective symptoms, clinical signs, restrictions of activities of daily living (ADL), and urinary bladder function. In this study, there were no patients who had bladder dysfunction due to cauda equina disorder. The degree of lower back pain, leg pain and tingling, and gait varies from 3 (any signs) to 0 (severe signs), and ADL varies from turning over while lying, standing, washing, leaning forwards, sitting, lifting, waking, and clinical signs such as SLR test, sensory disturbance, and motor disturbance. It was checked before treatment, and after 5 and 10 treatments (Table 1).
Japanese Orthopedic Association Lumbar Score (JOALS).
Secondary tool
VAS [14]
The VAS score gives the degree of pain on a scale from 0 (no pain) to 10 (most severe pain) and it was checked before treatment and after 5 and 10 treatments.
Statistical analysis
Statistical analyses were conducted using SPSS, version 21 (SPSS Inc., Chicago, IL, USA). Characteristics of the study patients were analyzed by means, and standard deviation, but the combined treatments were performed by paired t test. The level of statistical significance was set at p < 0.05 ADL, activities of daily living; MMT, manual muscle test.
Results
Baseline data
Baseline data such as age, gender, onset, diagnosis, period of illness and severity of condition were collected on the first day of the treatment. The average age was 69.8 ± 11.51 years. Eleven patients in the study were female. Nineteen patients were diagnosed with LSS, and 2 were diagnosed with LHID. 47.6% (n = 10) of patients had a VAS score between 6 to 7. The average period of disease was 6.80 ± 3.80 years. From the AK points, Category Iposterior ilium (PI) with SCS occupied 57.1% while CategoryII PI with SCS occupied 42.9% (Table 2).
Characteristics of the Study Patients.
Variation in pain alleviation depending on lapse of treatment
The JOALS improved significantly after 5 combined treatments (t = −8.83, p < 0.001). The analysis of the JOALS such as subjective symptoms (t = −2.33, p = 0.030), and restriction of ADL (t = −9.68, p < 0.001) was also significantly improved, but clinical signs (t = −1.83, p = 0.083) did not improve significantly. The VAS score significantly improved after 5 combined treatments indicating a reduction in pain in these patients (t = 8.11, p < 0.001). The JOALS were significantly improved after 10 combined treatments (t = −10.02, p < 0.001) and the analysis of the JOALS such as clinical signs (t =−8.56, p < 0.001) ADL (t = −8.08, p < 0.001) was also significantly improved, but subjective symptoms (t = −1.50, p = 0.149) did not show significant improvements. The VAS score significantly improved after 10 combined treatments (t = 8.97, p < 0.001;Table 3).
Comparison of JOALS Score Before and After 5 and 10 Treatments in Patients with Back Pain.
Discussion
LSS is the narrowing of spaces in the spine which results in pressure on the spinal cord and/or the nerve roots. It is one of the major causes of pain and numbness in the back and legs. The lack of available space for the neural and vascular elements leads to variable clinical syndromes such as intermittent claudication, and back, gluteal, and lower extremity pain [6,7,22]. LHID or disc lesions are the most common cause of sciatica and lower back pain. Only in this century, was it finally understood that most, if not all cases of sciatica were caused by the herniation or rupture of intervertebral discs [7,23], and that degenerative changes around lumbar structures are the causes of LSS and LHID.
The efficacy of acupuncture treatment is controversial though acupuncture, among complementary alternative medicinetreatments, is widely practiced [24] and Stux and Hammerschlag [25] concluded that acupuncture is an important supplement in the management of chronic lower back pain and Qin et al [26] concluded that acupuncture can relieve the symptoms of the sciatica with an increase in pain threshold. However, moderate and high-quality evidence for nonoperative treatment for spinal canal stenosis is lacking. Szpalski and Gunzburg [5] reported that although stimulation analgesia techniques such as transcutaneous electrical nerve stimulation or acupuncture are used frequently in pain clinics, they are of little benefit in LSS, except when specific radicular pain is accompanied by general back ache. Kim et al [27]reported no conclusive evidence for the effectiveness and safety of acupuncture treatment of LSS.
In contrast, Oka et al [28] asserted that acupuncture was significantly more effective than physical exercise according to the physical function score of the Zurich Claudication Questionnaire (ZCQ) and medication according to the satisfaction score. Hadianfard et al [29] reported acupuncture had a significant positive short-term effect on pain and quality of life in LSS patients. Most treatises which cover the efficacy of acupuncture on pain adopt the subjective VAS score rating that is variable for patients.
The JOALS assessment for lumbar disorders was first developed by the Japanese Orthopedic Association (JOA) 1986, and recently Ohtori et al [30] suggested that theJOALS was reliable and valid after comparing it to a Japanese version of the Roland-Morris Disability Questionnaire. In addition, Jung et al [31] suggested that the Korean version of the JOALS was a reliable and valid instrument for assessing lower back pain. The JOALS assessment was selected for this current study.
AK is a system for evaluating body function by using muscle tests, and many doctors and dentists have been using AK since 2000 in Korea. Techniques used widely in AK evaluation and treatment involve adjustment of the spinal column and manipulation of extraspinal articulations, nerve receptor treatment, balancing of the acupuncture meridians, treatment of the cranial-sacral primary respiratory system, and nutritional therapy. When AK is used in conjunction with the standard methods of diagnosis developed in medicine, osteopathy, and chiropractice, one has a greater ability to understand a patient’s health problems [19]. There are many AK methods that can treat LSS and LHID [32].
This study examined combined treatments of TA and AK though there are some complex treatments such as acupuncture with sweet bee venom, chuna and herbal medicine which are used to treat LSS and LHID [33–35]. The results of this current study was associated with the reduction of pain in patients with LSS and LHID which was assessed using the JOALS though the average duration of disease was 6 years. Subjective symptoms were significantly improved after 5 treatments with no significant difference between 5 and 10 treatments. Clinical signs were significantly improved after 10 treatments but not after 5 treatments. ADL showed significant improvement after both 5 and 10 treatments. The VAS score was significantly improved after both 5 and 10 treatments.
There were some limitations in this study. Firstly, as the study did not have control group or enough patients to propose that combining TA and AK treatments would significantly reduce the pain associated with LSS and LHID, although the results from 21 patients showed improvement in the level of pain they experienced. Secondly, some patients’ level of pain may have improved due to passage of time, placebo effect, or other factors as previously reported by Hadianfard et al [29]. Kim et al [35] asserted that although they did not find statistically significant evidences, their study suggested that Korean Medicine combination therapy may be beneficial in reducing pain and improving function in LSS patients, and may have comparatively fewer relapses for over 1 year. Thirdly, Hadianfard et al [29] suggested that 10 sessions of acupuncture have a 6-week short-term effect but because this current study was a retrospective study, it was difficult to determine. The short-term and long-term effects of Korean Medicine combination therapy should be studied in future. Future trials using well-planned methodology, appropriate comparison, and clinically relevant outcomes may be pursued using the JOALS assessment.
Conclusion
The combined traditional acupuncture and applied kinesiology treatment were effective at treating lumbar disorders such as LSS and LHID when using the JOALS assessment.
Notes
Conflicts of Interest
The authors have no conflicts of interest to declare.