Objective To observe the effectiveness of acupuncture applied to the cervical region of patients with upper extremity radicular symptoms due to cervical spondylotic radiculopathy (CSR).
Methods 15 subjects diagnosed with CSR and with upper extremity pain and/or paraesthesiae for 13.1±18.0 months were selected. The 15 patients had 16 affected limbs and scored a total of 17 symptom scores of pain and/or paraesthesiae. All patients were treated with acupuncture once a week for 4 weeks at up to 10 sites in the cervical paraspinal region centred on the affected area. The severity of the symptoms was recorded using a visual analogue scale (VAS) and functional evaluation was conducted using a Neck Disability Index (NDI).
Results A significant reduction over time was seen for both mean VAS (p<0.0001) and NDI (p<0.0001). Changes were still significant at 4-week follow-up. A 50% reduction in symptoms was scored for 15 of the 17 symptoms scored.
Conclusions Favourable results were seen in nearly 90% of cases. These results show that acupuncture treatment to the cervical region may be effective as a conservative therapy for treating CSR.
- Complementary Medicine
- Pain Management
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Neck/shoulder pain and upper extremity radicular symptoms develop in a variety of conditions, although the majority of cases are degenerative caused by degeneration of cartilage and ligaments of the cervical spine.1 ,2 Conservative management is generally considered appropriate for treating cervical spondylotic radiculopathy (CSR) caused by cervical spondylosis or cervical disk herniation. However, many patients with CSR have severe symptoms affecting their daily life and also their social life.3–6 It is therefore desirable to establish alternative conservative therapies that will also be effective in these cases.
In clinical practice where acupuncture and moxibustion are routinely used to ease pain, many clinicians have observed the effects of acupuncture on radicular syndrome such as pain and paraesthesiae through their experiences. However, there are few reports in the literature and the treatment is not based on established evidence.7 We previously studied the effects of acupuncture treatment on the cervical region for shoulder/neck pain due to degenerative cervical vertebra disease in a randomised controlled trial. Acupuncture was found to be effective compared with local injections used as general conservative therapy in orthopaedics.8 The study also revealed a trend for acupuncture to be effective not only for neck/shoulder pain but also for upper extremity radicular symptoms. Therefore, in this study we aimed to explore the effects of acupuncture on upper extremity radicular symptoms due to CSR.
Sixteen upper extremities of 15 patients (8 men, mean age 60±9 years) who were diagnosed with CSR in the orthopaedic outpatient clinic of Meiji University of Integrative Medicine Hospital by physical examination, x-ray and MRI imaging were selected. Patients had to have symptoms for at least 3 months. Those considered to have other disorders causing symptoms in the neck, shoulder or upper extremities were excluded. The selected patients were informed of the purpose of the research by their physicians. Participants were told they would receive conventional treatment if they refused acupuncture treatment, so there would be no disadvantage in refusing. None of those invited declined to participate.
The nerve roots responsible for symptoms were C5 for 12 extremities, C6 for 5 extremities and C8 for 2 extremities (some had more than one root involved). Of the upper extremity radicular symptoms, 9 cases (9 extremities) exhibited upper extremity pain, 5 cases (5 extremities) exhibited paraesthesiae and 1 case (in both upper extremities) exhibited both pain and paraesthesiae. Of the 6 cases with upper extremity paraesthesiae, in one case the loss of sensation was estimated at 7/10 where 10 represents normal. The other 5 cases showed no sensory loss. The mean duration of symptoms was 13.1±18.0 months, and >3 months in all cases. Two subjects had started taking non-steroidal anti-inflammatory drugs and vitamins more than 1 month before this study and continued taking them throughout the study. These two subjects were instructed not to change the drugs/vitamins they were using until after completion of the study.
Acupuncture treatment was applied once a week for 4 weeks. Needles were placed at sites of induration within sites of tension of the cervical paraspinal muscles identified by medical examination and inspection. A stainless steel needle (40 mm in length, 0.18 mm in diameter, SEIRIN Co Ltd, Japan) was inserted 10–20 mm. After stimulation by the sparrow pecking method (1 Hz, 20 s), the needle was removed immediately. We used the same technique and regime as proved successful in our earlier study.8 We did not specifically attempt to elicit de qi.
Using a 100 mm visual analogue scale (VAS), neck/shoulder pain, upper extremity pain and upper extremity paraesthesiae were evaluated before each treatment and 1 month after completion of the treatments. For upper extremity radicular symptoms, pain and paraesthesiae were recorded separately if patients had both. In addition, participants completed a Japanese translation of the Neck Disability Index (NDI),9 a functional evaluation tool, before the start of treatment, after four treatments and 1 month after completion of the treatments.
All results are expressed as mean±SD. A repeated measures analysis of variance was used for changes over time in VAS and NDI. The significance level was set at 5%. A t test was conducted to compare the VAS score before the first and the fourth treatments and, for the sustained effect, before the first treatment and 1 month after completion of the treatments, in which the significance level was set at 1% according to the Bonferroni correction (five pairwise mean comparisons).
All statistical analyses were performed using Statview V.4.5 (SAS Institute, Japan).
All the participants completed the study. A significant reduction was seen in mean upper extremity radicular pain VAS (p<0.0001, ANOVA) and paraesthesiae VAS (p<0.001, ANOVA) associated with the sequential acupuncture treatments (figure 1). Changes between baseline and 4 weeks were significant for neck/shoulder pain (p<0.0001, t test), upper extremity pain (p<0.0001, t test) and upper extremity paraesthesiae (p<0.001, t test; figure 1). The difference was still significant 4 weeks after the end of treatment (p<0.001; figure 1). A significant pattern of change over time was also seen in the NDI (p<0.0001; figure 2).
The response rate was calculated as a reduction in symptom scores of at least 50% by completion of the treatment. Of 16 extremities with 17 symptoms, 15 extremities with 15 symptoms showed a response to a course of four treatments. The two extremities that did not show a response were cases with upper extremity paraesthesiae, including the case with sensory loss.
Our earlier study showed a significant effect of acupuncture on neck/shoulder pain compared with general conservative therapy when the pain originated from degenerative cervical vertebral disease including CSR.8 Very similar results were observed in this study, supporting the results of the preceding study. A response was seen in upper extremity radicular symptoms, except for the two cases with paraesthesiae whose improvement rates were lower than 50%. This latter result is consistent with our experience in daily clinical practice that the response rate tends to be lower among the patients with paraesthesiae. Our study showed that both upper extremity pain and paraesthesiae gradually reduced during repeated treatment, and the effect of the treatment was maintained for at least a month. Acupuncture often produces an immediate relief of symptoms, and it is important to study whether or not the improvement will be maintained. Our results indicate a sustained effect of at least 4 weeks.
The reduction in pain in the neck/shoulder region with acupuncture and also in upper extremity radicular symptoms is probably explained by the effect of acupuncture in stimulating the nerves. In the cervical paraspinal region are the paraspinal muscles including the splenius, longissimus and iliocostalis muscles, and application of acupuncture to these muscles stimulates the posterior ramus of the spinal nerve which is the main nerve supply. This may induce reflex effects throughout the spinal segment, alleviating upper extremity radicular symptoms. For lower extremity symptoms originating from lumbar spine disease, in an investigation similar to the present study our research group has already reported on a clinical effect in about half of the patients given acupuncture treatment to the lumbar paraspinal region.10 In addition, in animal experiments it was found that application of acupuncture to the lumbar paraspinal region increased the sciatic nerve blood flow in approximately 60% of animals.11 It is possible that such a change would also occur in the cervical spine, which is very similar to the lumbar spine in terms of structure and innervation. This study explored clinical effectiveness, but the mechanisms must be elucidated through other experimental studies.
Our study is limited by the lack of control group and small sample size, as well as the short follow-up period. Controlled trials will be necessary to reach more robust conclusions on the effectiveness of acupuncture in this condition.
Positive results were obtained for all symptoms when acupuncture treatment was applied to the cervical paraspinal muscle group in patients with neck and shoulder pain and upper extremity radicular symptoms due to CSR. The treatment method used in this study may be useful as a conservative therapy for this condition.
Patients with upper limb symptoms are often excluded from neck pain studies.
We observed the effects of four acupuncture sessions on upper limb symptoms.
Improvements in symptoms were highly significant.
The authors thank Professor Naoto Ishizaki, Department of Clinical Acupuncture and Moxibusion, Meiji University of Integrative Medicine for his valuable suggestions.
Contributors MN: study design, conducted research, data analysis and wrote the manuscript. MI: correction of the manuscript and supervision of the study. MI: analysis and interpretation of data. HK: revision of the article critically for important intellectual content and overall control.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None.
Patient consent Written consent was obtained from all participants.
Ethics approval This study was performed with the approval of the Meiji University of Integrative Medicine research ethics committee (Approval No.24-68).
Provenance and peer review Not commissioned; externally peer reviewed.
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