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RESEARCH ARTICLE

Effect of acupuncture at tender-points for fibromyalgia syndrome management: a

case series

Jessica Lucia Neves Bastos1, Elisa Dria Pires1, Marcelo Loureno Silva3, Fernanda Lopes Buiatti de

Arajo1,2, Josie Resende Torres Silva3*

1Acupuncture specialization course, Instituto Paulista de Estudos Sistmicos (IPES), Praa Boaventura

Ferreira da Rosa 384, CEP 14049-900, Ribeiro Preto, SP, Brazil.

2Universidade Paulista (UNIP), Av. Carlos Consoni 10, CEP 14024-270, Ribeiro Preto, SP, Brazil.

3Department of Pharmacology, Faculty of Medicine of Ribeiro Preto-USP, Av. Bandeirantes, 3900, CEP

14049-900, Ribeiro Preto, SP, Brazil.

Running title: Acupuncture at tender-points for fibromyalgia

* Corresponding author. E-mail address: Josie R. T. da Silva, Department of Pharmacology, Faculty of

Medicine of Ribeiro Preto-USP, Av. Bandeirantes 3900, CEP 14049-900, Ribeiro Preto, SP, Brazil. Tel:

55-16-36023184; Fax: 55 16 3633 2301; E-mail: [email protected]

No financial supports.
mailto:[email protected]:[email protected]


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Abstract

Background Affecting more women than men, Fibromyalgia (FMS) is a rheumatic

syndrome characterized by chronic, diffuse and widespread musculoskeletal pain,

whose pathogenesis is still unknown. Among the recommended treatments, the

acupuncture, for its analgesic effects, stands like an effective option when the reduction

of painful sensitivity and improvement of life quality is aimed. Therefore, this research

aimed to investigate whether the acupuncture at tender points could be effective for the

management of fibromyalgia syndrome. Methods Eight female subjects with previous

diagnosis of fibromyalgia were submitted to an initial assessment involving pressure

algometer measurements for pain tolerance and questionnaires (FIQ, HAQ, BDI and

BAI), followed by the treatment. Over a two month period, once a week, acupuncture

treatment was performed at five tender points, located bilaterally at the occipital,

trapezius, rhomboid, upper chest and lateral epicondyle. At the end of the treatment, the

subjects were submitted to a reassessment for final review of the applied methods.

Results The results pointed not only to a reduction in pain threshold sensitivity, but also

an improvement in the tables of anxiety and depression, and in quality of life, which

were demonstrated through questionnaires FIQ, BDI and BAI, but not in HAQ.

Conclusions The results pointed for clear effectiveness of the tender point acupuncture

treatment in providing improvements on the individuals overall framework, not only in

their life quality, but also in reducing the painful sensitivity of FMS.

Key-words: Acupuncture, fibromyalgia, tender points, pain.


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Background

The Fibromyalgia (FMS) is a rheumatic syndrome characterized by chronic, generalized

and diffuse musculoskeletal pain disorder, whose pathogenesis is still unknown [1]. The

diagnosis, determined by the American College of Rheumatology (ACR) in 1990, is

given by the so-called tender points, a total of 18 points distributed throughout the body,

and the individual diagnosed with FMS has a great sensitivity to pressure (~ 4Kgf) in at

least 11 of these points [2]. In addition to the painful points, affected individuals also

have musculoskeletal pain lasting more than three months, morning stiffness,

headaches, intestinal disorders and psychological characteristics such as anxiety,

depression, stress, and dyspnea [3 5].

Affecting eight times more women than men (80 - 90% of cases), with a higher

incidence on individuals aged between 45 and 64 years [6 9]. In general, treatments

are based on global stretching, physical conditioning exercises with light aerobic

exercise, cognitive-behavioral work and some systemic medications like anti-

inflammatory drugs, antidepressants and opioid and non-opioid analgesics [10 12]. All

these features aim to provide the individual some pain relief and restore its functionality.

Acupuncture, for its analgesic effects, is also an effective treatment option when the

reduction of painful sensitivity, with consequent improvement of the affected individual

life quality is aimed. This ancient art uses needles and moxas to relief pain and other

symptoms related to several diseases [13].

Acupuncture treatment involves both stimulation of systemic specific points (points of

therapeutic action) and the simple deactivation of tender points (Ashipoints - referred


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pain). For Traditional Chinese Medicine (TCM) the body illness occurs as a result of a

vacuum energy (Qi) in the meridians, thus allowing the penetration of perverse energy

(external factors such as excessive cold, heat, wind, dryness and humidity) which

blocks the Qimovement, causing pain, contractures and injuries to the individual body.

The acupuncture practice restores energy flow through the meridians, rebalancing the

body and reducing pain conditions, and allowing a faster and more effective recovery of

injuries and contractures [13, 14].

Several studies have showed that certain acupuncture points stimulation is able to

determinate the brain and local release of analgesic substances such as serotonin and

norepinephrine, reducing the pain symptoms [15 19]. These effects are of great

importance for the treatment of FMS once with a reduction in pain, the individual is able

to resume their activities of daily living (ADL), improve their life quality, and feel

motivated to continue treatment.

Many studies have shown the effectiveness of acupuncture in the treatment of FMS [20

24]. In fact, this rheumatic syndrome is characterized in TCM as an emotional disorder

which affects the Liver. A TCM based treatment aims to remove the excess of damp

and disperse the cold, restoring the Qi(energy) andXue (blood) flux. Despite of all

these positive results with systemic acupuncture treatment, it would be also important to

consider the possibility of applying acupuncture atAshipoints, which in the case

overlap with the fibromyalgia tender points [24, 25]. The direct puncture of the tender

points could lead to a stimulation of the local circulation ofQiandXue, providing an

improvement in pain to the affected individual [25 27]. Therefore, the purpose of this


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study was to evaluate the effectiveness of acupuncture performed at tender points for

the management of FMS symptoms.

Methods

Subjects

Eight female subjects (aged 20-80 years) with previous diagnosis of fibromyalgia

syndrome were submitted to an initial assessment involving questionnaires and

measurement of pain tolerance through pressure algometer on five tender points,

followed by the treatment itself. All candidates were informed beforehand about the

project, and those who were willing to participate in the experiments signed an informed

consent in two ways, according to resolution 196/96 of National Health. All the treatment

procedures were submitted to the ethics committee from Instituto Paulista de Estudos

Sistmicos (IPES), being approved through the process number 2011-0001. Before

enrollment, each patient was asked to give an informed consent to participation in the

study.

Evaluation

The classification and recording of FMS tender points were performed using the

pressure algometer (Pain Diagnosis and Treatment Inc. New York, NY), recording the

value of pressure supported by the subject before and after the treatment period in

kilogram-force (kgf) in 10 of 18 tender points more sensitive. The selected points were

located bilaterally on edge of upper breast (upper chest), bellow side bone at elbow


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(lateral epicondyle), base of the skull (occipital), neck and shoulder (trapezius), and

upper inner shoulder (rhomboid) tender points (Figure 1).

Aiming to investigate any possible effects on the life quality questionnaires were

applied: assessment of life quality throughFibromyalgia Impact Questionnaire (FIQ);

evaluation of ADL by theHeath Assessment Questionnaire (HAQ); assessment of

depression by the Beck Depression Inventory (BDI); assessment of anxiety by Beck

Anxiety Inventory (BAI). A lower score indicates that the individual is healthier, while

high scores indicates the worst results.

Treatment

Acupuncture was performed bilateral at the occipital, trapezius, rhomboid, upper chest

and lateral epicondyle tender points. These five tender points were chosen considering

theirs easier accessibility for the application of the acupuncture treatment. Each session

last for 20 min and the sessions were carried out once a week over a two month period.

All the individuals were placed in a sitting position, with the upper body unclothed,

allowing the easy access to the selected points. The needles (Dong Bang, 0,25 x 30

mm), were inserted in a perpendicular position to a depth of ~ 2,0 cm. All needles were

manipulated by combined rotating and twisting with lifting thrusting manipulation each

five minutes in session. The treatments were all carried out by a trained licensed

specialist and there were no adverse events related to the applied treatment. At the end

of the follow up, subjects were submitted to a reassessment for final review of the


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applied method (Figure 1). The results were submitted to analysis of variance (ANOVA)

with a confidence level of 95%, using the Origin software v.8 (Origin Lab Corporation).

Figure 1

Results

Among the 8 subjects who completed the treatment and assessments, all reported

some improvement in their major FMS symptoms. Table 1 presents the results of the

FMS tender points pressure sensibility before and after acupuncture treatment. After 8

weeks, the mean at left and right occipital was enhanced by 84% and 98%, respectively

(from 3.26 to 6.3 and 2.94 to 5.76); left and right trapezius was enhanced by 70% and

74%, respectively (from 4.18 to 5.8 and 4.14 to 6.16); the mean at left and right

rhomboid was enhanced by 68% and 83%, respectively (from 4.66 to 6.38 and 4.2 to 7);

the mean at left and right upper chest was enhanced by 61% and 71%, respectively

(from 2.78 to 3.4 and 2.34 to 3.36); and the mean at left and right epicondyle was

enhanced by 72% and 83%, respectively (from 3.4 to 4.9 and 2.98 to 4.94).

Table 1

In addition, patients reported significant improvement in pain symptoms with mean FIQ

scores dropping from 66 to 31.8, a 52% reduction; mean HAQ scores from 24.67 to

18.67, a 24% reduction not statistically significant; mean BDI depression scores

dropping from 21.33 to 9.5, a 55% reduction; and the mean BAI anxiety scores dropping


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from 36 to 8, a 78% reduction (Figure 2). We also observed significant decreases in

other symptoms including gastrointestinal complaints and fatigue.

Figure 2

Discussion

The etiopathogeny of fibromyalgia syndrome (FMS) remains unknown, although

current hypotheses centre on anomalous peripheral nociception caused by windup,

central sensitivization, high levels of substance P and neurotrophins, and alterations to

the hypothalamus-hypophysis-adrenal axis [28, 29]. Levels of anxiety and depression

among patients with musculoskeletal pain are known to be related to FMS [30]; thus,

the prevalence of patients with FMS and severe depression varies from 20-80% [31].

The present study demonstrated a statistically significant difference before and after the

treatment of acupuncture at tender points eight weeks after the first treatment. The

results pointed not only to a reduction in pain threshold sensitivity, but also an

improvement in the state of anxiety and depression, and in quality of life, which were

demonstrated through questionnaires BDI, BAI and FIQ, but not in HAQ. These results

suggest that acupuncture treatment is capable of giving additional improvement to the

standard medication in the treatment of FMS.

The studies reporting the acupuncture effectiveness for FMS treatment show that

positive results have been achieved by removing excess moisture, dispersing cold and

restoring the flow of Qi (energy) and Xue (blood) in the affected body [32 34]. The

improvement in pain tolerance may be related to the local action of the punctured


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needles through the ashi points technique, stimulating the local circulation of Qi

(energy) and Xue (blood), and a local release of anti-pain substances, leading to an

improvement in pain and comfort feeling [25, 35]. On the other hand, this improvement

in the overall framework of the subjects may be related to the selected tender points,

which can coincide with systemic acupuncture points whose effects, presented in Table

2 [36].

Table 2

Beyond these points and their effects, there are also the emotional matrices related

to the used meridians, which were balanced, providing an improvement in the condition

of sadness, melancholy, depression, fear and lack of courage to follow through with the

treatment of FMS until the end. Such actions can also be identified as responsible for

causing an overall improvement in quality of life of treated women [14].

In general, the data showed not only a restoring in the flow of Qi and Xue,

possibly obtained through the simple application of needles at points of referred pain

(ashi), but also a removal of excess moisture and cold dispersion in treated women.

These effects were possibly achieved through balancing the meridians of the lung,

bladder, gall bladder and triple burner, which were fueled by points that coincided with

the used tender points. Thus, data analysis demonstrates that the puncture of these 5

tender points was effective not only to increase the pain tolerance of the volunteers, but

also to improve, in general, the life quality of each woman.


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Conclusion

The results of this study show that the acupuncture at tender points may be an

effective tool for the treatment of fibromyalgia syndrome symptoms, providing

improvements in the individuals overall framework, not only in reducing the painful

sensitivity, but also in their life quality. Although more research clearly needs to be

done, these results do seem promising.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

JLN and EDP performed the experimental design of the project, made the data

collection, performed the statistical analysis and drafted the manuscript. FLBA helped to

design the project and data analysis. JRTS and MLS participated of study coordination

and helped to draft the manuscript.

Acknowledgements

The authors wish to thank Prof. Patricia Driusso for having ceded his laboratory

at Federal University of So Carlos (UFSCar) to perform the data collection of this

research.


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Legends


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Figure 1: Flow chart of process and disposition of patients.

Figure 2: Averages and standard deviations of the volunteers questionnaires, before

and after the treatment.

Table 1: Average obtained through pressure algometer (kgf), before and after treatment, followed by thepercentage increase tolerance to pain after applying the acupuncture at tender points.


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Points Means Before Means After Increase %

Right Occipital 3.26 6.3 84%

Left Occipital 2.94 5.76 98%

Right Trapezius 4.18 5.8 70%

Left Trapezius 4.14 6.16 74%

Right Rhomboid 4.66 6.38 68%

Left Rhomboid 4.2 7 83%

Right Upper Chest 2.78 3.4 61%

Left Upper Chest 2.34 3.36 71%

Right Lateral Epicondyle 3.4 4.9 72%

Left Lateral Epicondyle 2.98 4.94 83%

Table 2: Punctured tender points and corresponding acupuncture points and function according TCM [36].


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Tender Points Acupuncturepoints

Function according TCM

Occipital Gallbladder 20(GB20)

Eliminates the wind, frees thesenses, becomes permeable

channel energy, improvesheadache and stiff neck.

Trapezius Triple heater 15(TH15)

Leads the wind and moisture outof the chest, improves pain in

upper limbs and neck stiffness.

Rhomboid Urinary Bladder 13 (BL13)

Enforces, distributes and reduceslung Qi, nourishes yin and filters

the lungs heat; lung back shupoint.

Upper Chest Lung 2 (LU2) Conducts heat out of the ends,make permeable the channel

power.

Lateral Epicondyle Large Intestine11 (LI11)

Filter out the heat, expels wind,treat all upper extremity problems.

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