carvalho 2010_manuscript_acupuncture improves flexibility

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For Peer Review Medical Acupuncture: http://mc.manuscriptcentral.com/acupuncture Acupuncture Improves Flexibility: Acute Effect of Acupuncture Before a Static Stretch of Hip Adductors Journal: Medical Acupuncture Manuscript ID: ACU-2010-0773.R1 Manuscript Type: Original Article Date Submitted by the Author: 15-Oct-2010 Complete List of Authors: Carvalho, Alessandro; Universidade Federal do Rio de Janeiro Cabral, Leonardo Rubini, Ercole Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801 Medical Acupuncture

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Carvalho 2010_Manuscript_Acupuncture Improves Flexibility

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  • For Peer Review

    Medical Acupuncture: http://mc.manuscriptcentral.com/acupuncture

    Acupuncture Improves Flexibility: Acute Effect of

    Acupuncture Before a Static Stretch of Hip Adductors

    Journal: Medical Acupuncture

    Manuscript ID: ACU-2010-0773.R1

    Manuscript Type: Original Article

    Date Submitted by the Author:

    15-Oct-2010

    Complete List of Authors: Carvalho, Alessandro; Universidade Federal do Rio de Janeiro Cabral, Leonardo Rubini, Ercole

    Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

    Medical Acupuncture

  • For Peer Review

    1

    Abstract

    Background: Acupuncture has been used for many years to treat illnesses, and

    seems to have benefits when combined with other interventions such as exercise,

    though still little investigated. Objective: Investigated the acute effect of acupuncture on traditional acupoints, local no-acupoints (adductor magnus muscle) and sham acupuncture before static stretching exercise on the maximum range of

    motion of hip abduction. Design, Setting, and Subjects: This study was a randomized controlled trial carried out on 44 healthy and untrained undergraduate

    students at a university located in Rio de Janeiro, Brazil. Intervention: Subjects were randomly assigned to four groups and receive 1 session with a acupuncture

    treatment followed by 4 sets of static stretching of the hip abductors. Group 1 (G1) were treated with acupuncture in five points (acupoints) followed by stretching of the hip abductors (N=10). Group 2 (G2) had the acupuncture treatment in the adductor magnus muscle (no-acupoints) and stretching of the hip abductors (N=12). Group 3 (G3) the control group, used a placebo acupuncture and stretching of hip abductors (N=10). Group 4 (G4) just the acupoints, with no stretching (N=12). Main Outcome Measure: Maximum range of motion of hip abduction was evaluated before and after intervention with a flexometer. Results:

    There was a significant increase in the amplitude of hip abduction when measures

    before and after the intervention were compared in G1 (p = 0.007; CI95% = -7.46 to -1.54) and G2 (p = 0.009; CI95% = -13.14 to -2.36). There was no significant difference in the comparison between groups (p = 0.399). Conclusions: The results have demonstrated that the accomplishment of an acupuncture application

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    in acupoints and no acupoints before exercises of static stretching can generate an

    acute significant increase on hip range of motion.

    Keywords: Acupuncture, Range of Motion, Muscular Relaxation.

    Introduction

    Acupuncture is a therapy that has been used by the ancient Chinese

    Traditional Medicine (CTM) for approximately 2500 years, and has been practiced in the West for a few decades, where it has become well-known for its analgesic

    and anesthetic effects and in the treatment of a certain number of orthopedic,

    rheumatic, respiratory and neurological diseases.1 According to CTM, there is a

    network of meridians (jingluo) connecting functional organs in the human body. Acupuncture at specific acupoints along the meridians exerts therapeutic effects on

    nearby and/or distant regions. The physiological effects is yet to be well explained 2

    and some studies have observed the interaction between the effects of

    acupuncture and physical exercise, showing that acupuncture appears to improve

    exercise performance though the mechanisms of how it does so are not well

    understood.2,3,4,5,6

    Stretching is an activity included in most training programs7 and practiced by

    professional atheletes and practitioners of recreational exercises for flexibility

    training. 8 Some of the physiological effects of stretching in the musculoskeletal

    complex are similar to those of acupuncture, mainly in relation to the decrease in

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    3

    pain perception and analgesia. The main physiological effects of muscular

    stretching are the viscoelastic accommodation in the tendon-muscle unity,9,10,11

    increase of tolerance to stretching,12,13 decrease of -motoneuron excitability and

    that of 1a fibers,14,15,16 and these effects generate mechanical and

    neurophysiological responses of which the most commonly observed results are

    muscular relaxation and gain in range of motion, induced by an increase in

    nociceptors threshold and by a decrease in passive tension in the muscle. 17

    The analgesia caused by acupuncture seems to occur through the change

    in the perception of pain, which is generated by the nociceptive inhibitory action in

    the spinal cord, as well as by the activation of several cortex areas, such as

    somatosensory area, hypothalamus and limbic system.18,19,20 Some studies have

    observed the effects of acupuncture in the central nervous system (CNS) in areas such as the hypothalamus, nucleus accumbens, and descending nociceptive

    structures. 18,21,22 A theory presented by Langevin (2001) about one of the traditional acupuncture techniques, the De-Qi, i.e. sensation of shock after

    inserting the acupuncture needle, showed this to be essential to the effectiveness

    of acupuncture therapy, for it generates a biomechanical response which involves

    the connective tissue.22,23 The sensation of the De-Qi seems to activate nervous

    fibers, generating inhibition of pain in the spinal cord and in the brain.24,25

    Both methods, acupuncture and stretching exercises, present similar

    physiological effects in relationship of analgesia caused by nociceptive inhibitory

    action. Our hypothesis is that acupuncture given prior to passive stretching of hip

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    4

    adductors will enhance abduction range of motion more than stretching exercises

    alone.

    This study aims to compare the acute effects of acupuncture on adjacent traditional acupoints (LR 1, LR 3, LR 8, REN 2, GB 34), local no-acupoints (adductor magnus muscle) and sham acupuncture before static stretching exercise on the maximum range of motion of hip abduction.

    Materials and Methods

    Participants

    A convenience sample of 44 healthy male subjects aged of 18-45 years were from the University Estcio de S were invited to participate in this study. The

    exclusion criteria included presence of orthopedic injuries in the lower limbs, needle phobia, skin lesions, use of anti-inflammatory drugs, nutritional

    supplements or anabolic androgenic steroids. All subjects signed an informed consent containing all information about the procedures, as well as possible risks

    and discomfort involved in studies of this nature. The Committee of Ethics in

    Research at University Estcio de S approved the study methods and

    procedures.

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    Study protocols

    Subjects visited the laboratory twice and drawn randomly into four groups. The choice for each group was made through the drawing of lots (numbers) from a previously sealed envelope.

    In their first visit, subjects were familiarized with the experimental treatment according to the group to which they were assigned and a morphologic evaluation

    was conducted (Table 1). Measures taken were: stature (cm), body mass (kg), and skinfold thickness. From the measures of skinfold thickness, body density was

    predicted through the chemical model of two compartments, using the equation

    proposed by Jackson and Pollock.26 After body density prediction, fat (%) was determined by Siris equation. 27

    In the second visit the procedures were: (I) pre-test, which corresponds to the measure of maximal hip abduction range of motion; (II) experimental treatment (acupuncture); (III) post-test, the new measure of maximal hip abduction range of motion being taken immediately after the treatment.

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    All subjects in the four groups were eyes covered during the any acupuncture treatment, in order to minimize the possibility of any kind of motivation

    which might affect the results.

    Experimental procedures

    In G1, as a pre-test, the measure of MRM was taken, and immediately

    after that, the subjects receive treatment with acupuncture in five traditional acupoints: Dadun (LR 1), located on the ungual lateral angle of the hallux; Taichong (LR 3), in instep, on the space between the first and second metatarsals, 1,5cun28 from the web between the toes; Ququan (LR 8), just superior to the medial end of the popliteal crease, in the depression anterior to the tendons of

    semitendinosus and semimembranosus muscles; Qugu (REN 2), in pubic region, on the superior edge of the pubic symphysis , on the mid-line of the body. These

    four points give origin to an extra meridian called "Jue Yin Liver Tendinomuscular

    Channel (Chanel of the Liver Tendon-muscle Energy). Besides these points, the Yanglingquan (GB 34) was also selected. This acupoint located in the depression anterior and inferior to the fibular head, and is traditionally recommended for

    treatment of decreased joint mobility. Immediately after the acupuncture treatment, subjects were given four sets of static stretching of the hip adductors, each lasting 30 seconds and having an interval of 1 minute between them. The post-test with a

    new measure of MRM was performed immediately after stretching.

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    In G2 the pre-test was done, followed by the acupuncture on no-acupoints,

    then the static stretching of the hip abductor muscles, then the post-test. Five

    needles were inserted along the muscular belly of the adductor magnus muscle

    (bilaterally); the distance between the points was of 6 cm, starting from the point of origin of the muscle up to the point of insertion, taking into consideration the

    anatomical and morphological characteristics of the individual.

    In G3, which was the control group, subjects had the pre-test and then received a superficial stimulus on the same no-acupoints used in G2, where the

    needle was inserted in the skin and immediately taken off (Sham acupuncture), similar to the studies of Vincent et al30 and Goddard et al. 31 Right after that

    subjects were submitted to the stretching protocol and the post-test.

    In G4, subjects had the pre-test and then were submitted to a treatment in which the same acupoints used in G1, followed by a new measure of MRM (post-test), without the stretching exercises protocol.

    Acupuncture

    The acupuncture treatment was conducted on a mattress, at the same hour

    of day, room temperature of 21 degrees Celsius. Individual disposable needles of

    0.25x30 mm (HUA-TUO - Korea) were used. The trained acupuncturist conducted all procedures. All acupoints selected were fixed according to muscle and bone

    anatomic references, and the measures recommended by CTM theory. 28 Before

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    insertion of needles, the skin was cleaned with 70% alcohol. The needles were

    inserted perpendicularly, bilaterally, with stimulus of unilateral clockwise rotation for

    attainment of the De-Qi18 and depth varying from 8 to 50 mm according to the

    anatomic location of the points.

    Stretching

    Static stretching of hip abductor muscles was done in the same position of

    the test for maximum range of motion (MRM). Four sets of stretching were done with the duration of 30 seconds3 each and an interval of one minute between them.

    None of the subjects performed any kind of exercise involving the adductor muscles of the hip joint, from 24 hours preceding the beginning of the study to the end of it.

    Flexibility outcome measure

    Two flexometers (FL) (Fleximeter, Instituto Code de Pesquisas - Code Institute of Research - Brazil) were used for the measure of joint range of motion. Three trained evaluators applied the tests. The first evaluator performed the

    maximum passive stretching on the subjects. The second and third evaluators

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    were responsible for reading the amplitude of movement, in degrees, in the

    fleximeters.

    The FLs were fixed right below the head of fibula, having their faces placed

    right below the tibial tuberosity. The subjects stayed lying with his back on the ground, with the hip flexed at approximately 90 degrees, knees totally extended,

    the gluteus and lower limbs leaning against the wall. Both FLs started from zero

    degrees, which is the angle associated with the position in which the feet touch

    each other. The feet of subjects stayed united and in slight abduction, leading the hip to a slight external rotation during the test (Figure 1). After putting the subject in the right position, the first evaluator calibrated the FLs to zero degrees and then

    performed the stretching of the hip adductor muscles, pressing the subjects thighs down with the hands touching them right above the knees, preventing the knees

    from flexing (Figure 2). MRM was measured when the subject reported discomfort (pain). This position was sustained for about three seconds, so that the evaluators could read the measure. The second and third evaluators took place on each side

    of the subject, reading the measures for each leg when the point of MRM of the hip adduction was reached.

    The final measures read on both FLs was added up, and the result was

    considered the maximum range of motion. A pilot study performed with 45

    volunteers showed that these measurement procedures have 95% limits of

    agreement of -10.1 to 17.3 degrees and high intraday reliability (ICC=0.91; CI95%=0.80 to 0.95).

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    Statistical Analysis

    A paired t test was used to determine the effect of the treatment on the

    amplitude of hip abduction, from pre to post-intervention situation. A one-way

    analysis of variance (ANOVA) of the percent rates of change from the moment of pre-intervention to the moment of post -intervention was used to determine the

    effects of the different types of treatment on hip range of motion. Tukeys post hoc

    test was used when F was significant. All analyses were done by the statistic pack

    SPSS v.13.0 (SPSS Inc., Chicago, IL, USA). The level of significance used was P

    0.05.

    Results

    In the intra-group analysis groups G1 (P = 0.007; CI95% = -7.46 to -1.54) and G2 (P = 0.009; CI95% = -13.14 to -2.36) showed significant differences from pre to post-intervention. There was no significant difference from pre to post-

    intervention in groups G3 (P = 0.115; CI95% = -12.39 to 1.59) and G4 (P = 0.079; CI95% = -9.08 to 0.58) (Figure 3). The ANOVA showed no significant difference in the delta (%) between the groups (P = 0.399).

    Discussion

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    The results have shown that, in an acute form, there was significant

    difference in degrees of flexibility in hip abduction in subjects treated with static stretching preceded by acupuncture either in acupoints (G1) and no-acupoints (G2).

    Our hypothesis was that the acupuncture treatment before performing

    stretching exercises would be improve flexibility of hip abduction more than

    stretching exercises alone. Such fact could be observed in groups G1 and G2, but

    not in the comparison between groups.

    Up to this moment, no study specifically investigating the effect of

    acupuncture on flexibility has been published, which makes the comparison of

    these results more difficult. Experimental study results have shown combining

    acupuncture treatment with exercise therapy is beneficial. In the few studies that

    measured the effect of acupuncture on the flexibility, Huguenin (2005) found no significant differences in range of motion for internal rotation or flexion of the hip

    after treatment with acupuncture intervention. Among the limitations of this study is

    the evaluation of the flexibility that was made through pictures and treatment with

    acupuncture (needles were inserted only superficially into the skin)32.Another study by Edwards and Knowles (2003) showed a significant improvement in myofascial pain in the group treated with an intervention that combined acupuncture and

    active stretching exercises as compared with a group treated only with active

    stretching exercises, and a control group33.

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    There is a consensus about the alteration in the perception of pain and in

    the analgesia caused by the stimulus of acupuncture needles, either in acupoints

    or in no-acupoints. 2,17,32,33 Chu34 reports that insertion and intramuscular

    manipulation of acupuncture needles may generate depolarization of single muscle

    fibers and electromyographic alterations classified as micro-twitches which, in turn,

    are capable of causing a micro stretching effect in the shortened fibers adjacent to the stimulated muscle and reduce the effect of mechanical traction of those

    fibers in nociceptive structures, including nerves and intramuscular blood vessels.

    As a result, muscular relaxation may occur in the stimulated area through the

    increase of blood circulation, which may induce the relief of local muscular pain,

    which in turn may have an effect on the gate of pain in the spinal cord.

    Two studies confirm this hypothesis, as they observed, through

    photoplethysmography, evidence of local increase of blood circulation after

    acupuncture treatment in the tibialis anterior muscle in healthy subjects, and in the trapezoid muscle in subjects with fibromyalgia. 35,36 Other studies, however, demonstrate that there is a possible controversy about the hemodynamic alteration

    caused by acupuncture. 37,38 Knardahl (1998) observed an increase of 15% to 20% in muscle electrical activity and increased tolerance of pain immediately after 30

    minutes of treatment with electroacupuncture, and this effect remained high,

    between 10 and 30% after the intervention37. Kimura (2006) conducted a stimulus with acupuncture for two minutes in 12 volunteers and found similar results

    regarding the increase of muscular activity and decreased skin perfusion during

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    acupuncture stimulation38. Both studies found a negative correlation between the

    hemodynamic and autonomic responses that occurred during acupuncture.

    One comprehensive literature review39 describes that the alterations of the

    nociceptive system occur from noxious stimulus, chemical, mechanical or thermal

    in their nature, in the skin or in the muscular and visceral tissues, and that those

    are perceived primarily by the afferent free nerve endings ( fibers C and A). Fibers

    C and some fibers A innervate areas near the vascular wall in the muscular tissue

    in the zones of muscle-tendon insertions and in the tendons themselves. These

    fibers are susceptible to noxious mechanical stimulus such as stretching, torsion

    and compression. 39 Pea et al.40 also corroborated this hypothesis in their study.

    High thresholds of tensive or compressive stimulus generate a mechanism of

    transduction, and this implicates in the activation of cation channels in the free

    nervous endings and also neurochemical alterations in their neural membrane

    (increase in the influx of Na+, K+ and Ca+, for example). The activation of cation channels occurs from the distortion of the collagen bridge between the free nerve

    endings and in adjacent tissues. The depolarization of the nociceptors membrane occurs from their neurochemical alterations, and as a consequence there is an

    increase in their thresholds. 39,40 Making the translation between knowledge, we

    can consider that the stimulation with acupuncture needles (harmful) and stretching exercises (mechanical) fits in here and they both have a lot in common physiological pathway.

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    In the acupuncture case, one study about the remodeling of fibroblast in the

    subcutaneous tissue and the possible mechanisms of mechanotransduction

    brought about by acupuncture through the connective tissue, report that alterations

    in the extracellular matrix caused by the manipulation of acupuncture needles may

    generate modulation in the entrance of sensory stimuli in afferent nociceptors41.

    Another hypothesis of our study is about the relation between tissue

    alterations and the neurophysiological responses caused by acupuncture and

    stretching exercises. There is a possible increase of the articular amplitude

    promoted by the stimulus of acupuncture, through the mechanism of

    mechanotransduction, i.e. mechanical alterations in the connective tissue

    generated by the insertion and rotation of the needles and, in the case of

    stretching, the mechanotransduction promoted by the pulling of the muscular

    tissue; common to both interventions is the alteration of nociceptive thresholds and

    the increase of tolerance to pain. Although it has not been investigated in a direct

    way, the improve of flexibility after acupuncture and stretching exercise in the

    comparison in to groups that received the treatment with different techniques,

    which had only stretching exercise or only acupuncture demonstrate the viability of

    this hypothesis, but other studies must be carried out to investigate objectively this.

    Conclusion

    To the best of our knowledge this is the first study to show that the use of

    acupuncture before performing a static stretching exercise for the hip adductors,

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    can generate a significant acute increase in flexibility. In the comparison between

    the groups that received acupuncture and static stretching with the control group

    (stretching exercises only), the first intervention proved to be significant in the comparison of pre and post-intervention results.

    The use of acupuncture associated to stretching exercises is a clinical

    practice employed by acupuncture specialists, and it may become useful in the

    treatment of injuries and/or training of athletes or practitioners of recreational exercises who need an acute increase of flexibility to perform a specific activity.

    Some of the physiological effects of acupuncture and of skeletal muscle stretching

    are similar, such as muscular relaxation and the increase of pain tolerance, which

    can justify the association of these methods for greater flexibility.

    Acknowledgements

    The authors would like to thank the Fundao de Amparo Pesquisa do

    Estado do Rio de Janeiro (FAPERJ) for their financial support.

    Author Disclosure State

    No competing financial interests exist.

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    Rosen BR, Makris N, Kennedy DN. Characterization of the "deqi" response in

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    299x388mm (72 x 72 DPI)

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    Figure 1 - Initial position of measure of flexibility and stretching exercise 135x101mm (300 x 300 DPI)

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    Figure 2 - Final position of measure of flexibility and stretching exercise 135x101mm (300 x 300 DPI)

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    299x388mm (72 x 72 DPI)

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