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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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treatment. Acupuncture is a minimally invasive procedure that is safe when
performed by properly trained individuals. Adverse events occur
approximately 7% of the time, and the most common adverse events include
pain, hematoma, and bleeding.16 More serious events can include
pneumothorax, infection, vasovagal reaction, hypertensive crisis, and
peripheral nerve injury; however, these events are exceedingly rare and
typically preventable.17 Although many of the acupuncture points target
peripheral nerves, the likelihood of injury to these nerves is limited because
the needles have a pencil-like tip that splits tissues instead of a beveled
cutting edge found in hypodermic needles (Figure 2).
There have been numerous studies on acupuncture for chronic low back
pain. A recent systematic review and meta-analysis of 25 randomized
controlled trials showed acupuncture had a clinically meaningful reduction in
self-reported pain levels when compared with sham acupuncture treatment
and improved function, both immediately postintervention and potentially up
to 3 months postintervention, when compared with no treatment.18 Function
also clinically improved when acupuncture was provided in addition to usual
care or when electroacupuncture was provided compared with usual care
alone. Acupuncture was found to be slightly superior to medications
(NSAIDs, muscle relaxers, analgesic medications) and usual care, but
differences were small.
Two large-scale studies presenting level I evidence showed acupuncture
was not significantly better than sham acupuncture but was significantly
better than the usual care of physical therapy and medications in patients with
chronic low back pain.
19,20
In a more recent study, 638 patients were
randomized to receive individualized acupuncture (in which different points
were specifically chosen for each patient based on individual symptoms and
presentation), standardized acupuncture (in which the same back pain
protocol was used on every patient), simulated acupuncture (using a
toothpick and guide tube), or usual care.20 The outcomes were measured with
the Roland-Morris Disability Questionnaire score (0 to 24) and symptom
bothersomeness scale (0 to 10). At 8 weeks posttreatment, the mean
dysfunction scores for individualized, standardized, and simulated
acupuncture groups had improved by 4.4, 4.5, and 4.4 points, respectively,
compared with 2.1 points for patients receiving usual care (P < 0.001).
Symptoms improved by 1.6 to 1.9 points in the treatment groups compared
with 0.7 points in the usual care group (P < 0.001). The results also appeared
durable at 1 year for function but not for symptoms. Individualized
acupuncture was not found to be better than standardized acupuncture.
20
There also is some evidence that acupuncture can be helpful in nonspecific
acute low back pain disorders.
21
A recent Cochrane review on acupuncture for neck disorders (whiplashassociated disorders, chronic myofascial neck pain, arthritic neck pain,
chronic nonspecific neck pain, and neck pain with radicular symptoms)
reported overall moderate-quality evidence in favor of acupuncture.
22
Specifically, acupuncture is beneficial at immediate-term follow-up
compared with sham acupuncture for reducing pain intensity, at short-term
follow-up (1 day to 3 months) compared with sham or inactive management
of pain intensity, at short-term follow-up compared with sham management
of disability, and at short-term follow-up compared with a waitlist control
group for pain intensity and neck disability. In a randomized controlled
multicenter trial plus nonrandomized cohort study from general practices in
Germany, 14,161 patients with chronic neck pain were randomized to
acupuncture treatment or a control group receiving no acupuncture but
including usual care.23 At 3 months, neck pain and disability improved by
16.2 to 38.3 points in the acupuncture group on the Neck Pain and Disability
Scale by Wheeler, compared with 3.9 to 50.5 points in the control group, with
an average difference of 12.3 (P < 0.001). Treatment success was maintained
through 6 months.
Several difficulties exist when analyzing acupuncture studies. What is the
best control group to use when studying acupuncture? Some studies use sham
acupuncture as the control, whereas others use usual treatment or no
treatment. If sham treatment is used, what is the most appropriate treatment
method? Some studies have used superficial needling in nonacupuncture
points as a sham treatment, but superficial needling in nonacupuncture points
may not be a true sham treatment because there are physiologic effects from
any type of needling. Another difficulty in analyzing acupuncture studies on
low back pain is that most of the studies involve nonspecific chronic low
back pain, and a structural diagnosis is not given. The lack of a diagnosis
may limit the use of the literature in helping clinicians decide whether
acupuncture is appropriate for a particular patient. New literature is emerging
about acupuncture treatment of specific spinal conditions such as spinal
Figure 2
stenosis; however, results currently are inconclusive.24 Another issue
regarding acupuncture is whether it is a placebo effect, because some of the
major studies showed it was not better than sham acupuncture. Acupuncture
undoubtedly has a large placebo effect, as do other treatments. However,
there is likely a true acupuncture effect. Using the Cohen effect size d index
in which 0.8 is a large effect, 0.5 is a medium effect, and 0.2 is a small effect,
one study estimated the acupuncture effect on chronic neck and low back
pain was 0.55, with 0.22 the result of placebo or nonspecific effects and 0.23
the result of verum or specific effects.
25
Illustration depicts the point shape of a hypodermic needle,
a strand of human hair, and an acupuncture needle. An
acupuncture needle has a pencil-like tip compared with the tip of a
hypodermic needle.
Dry Needling
Dry needling uses acupuncture or hypodermic needles to treat myofascial
pain (nothing is injected), and often is performed by physical therapists or
physiotherapists, whereas acupuncture is typically practiced by physicians or
licensed acupuncturists. The safety profile for dry needling is nearly identical
to that of acupuncture.26 In many ways, dry needling can be thought of as a
westernized form of acupuncture with a more limited indication. The points
used in dry needling are tender points in the muscle or trigger points and are
called ah shi points by acupuncturists. Trigger points are discrete
hyperirritable nodules felt within skeletal muscle that have altered motor end
plate activity.27 Until recently, the only way to identify a trigger point was by
palpation. However, in a recent study using ultrasound imaging and
elastography, palpable myofascial trigger points were found to have nodular
regions of hypo-echogenicity and show diminished vibration amplitude on
external vibration, which is consistent with local regions of increased
mechanical stiffness.
28
A number of studies have reviewed the physiologic effects of needling a
muscle. In a 2008 study observing trigger points, it was found that the
chemical milieu at trigger points is abnormal with a decreased pH level and
an increased number of inflammatory markers such as substance P, calcitonin
gene-related peptide, bradykinin, 5-hydroxytryptamine receptors,
norepinephrine, tumor necrosis factor-α, and interleukin-1b.29 After needling
the trigger point and eliciting a local twitch response, there is an immediate
decrease in substance P and calcitonin gene-related peptide, but the duration
of the decrease is unknown. It is thought that it is important to achieve a local
twitch response after dry needling because it may cause a decrease in local
inflammation and also normalize abnormal end plate activity.
Many published studies on efficacy of dry needling for low back or neck
pain have been grouped with acupuncture studies, but there are several
separate dry needling studies as well. A study of 66 patients with low back
pain who responded positively to multifidus dry needling, defined as an
improvement in Oswestry Disability Index at 1 week, found that these
responders exhibited greater improvements in lumbar multifidi muscle
contraction (as measured by the percent change in muscle thickness on
ultrasound) and nociceptive sensitivity (as measured by assessing the
pressure pain threshold) 1 week after treatment, but not immediately, when
compared with nonresponders.30 A separate study by the same author also
found that increased low back pain with the multifidi lift test (P = 0.01) and
no aggravation with standing (P = 0.01) were the two best predictors of
improved disability with dry needling of lumbar multifidus.
31
Cupping
Cupping is an ancient medical treatment that applies suction to the skin by
use of a glass or plastic cup. A negative suction is created by heating the air
in the glass cup, or using a manual pump to draw air out of the cup. There are
two main techniques used: wet cupping, in which skin incisions are made to
allow blood and other body fluids to escape, and dry cupping, in which no
incisions are made. Cupping can be helpful for numerous pain conditions,
including neck pain and low back pain, and is thought to increase local blood
circulation and thereby relieve painful muscle tension. Cupping also can be
combined with massage techniques in which the cups are dragged along the
skin while suction occurs.
32,33
Although cupping is considered safe, adverse
events including vasovagal reaction, generalized body ache, increased local
pain after cupping, pain during the procedure, skin laceration, and worsened
headache and tinnitus have been reported.
32-34
Cupping was shown to be more effective than waitlist control for
managing pain and disability in the immediate term for chronic neck pain
(moderate evidence). Several small and lower-quality studies showed a small
clinical significance that cupping was more effective than medications
(NSAIDs) in reducing pain and disability at immediate term for chronic low
back pain (low evidence). Findings of large clinical significance indicated
that cupping was more effective than usual care in treating pain and disability
in the short term for chronic low back pain (moderate evidence).
33
Chiropractic Care
Chiropractic care is one of the most widely used complementary health
therapies for patients with spine-related pain. Some similarities exist between
chiropractic and osteopathic treatments. Both treatments have philosophies
that spinal alignment influences whole body health. Chiropractors tend to use
more spinal manipulation techniques, whereas physical therapists or
osteopathic physicians may use mobilizations and other techniques as well.
Manipulation is active facilitation of a joint with the goal of movement
beyond the physiologic barrier, whereas mobilization is active facilitation of
a joint with the goal of movement to the physiologic barrier but not through
it. Different types of treatments can accomplish either manipulation or
mobilization. Approximately 8% to 9% of patients with low back pain seek
chiropractic care.
35
In general, chiropractic spinal manipulation is well tolerated and typically
has mild side effects. Local discomfort occurs in more than 50% of
patients.36 Of those who experience discomfort, most report the severity as
mild or moderate. Other common side effects include headache, tiredness,
radiating discomfort, dizziness, nausea, and hot skin.
Although severe adverse events are rare after manipulation, such
occurrences have been estimated to occur in 1:400,000 adjustments and may
result in devastating injury. The greatest concern is the potential risk for
cervical dissection of the vertebral artery or internal carotid artery after
cervical manipulation therapy (CMT), which may result in stroke or death.
37
Several case-control studies have demonstrated an association between
cervical spinal manipulations and cervical dissection, but critics argue that
manipulation does not prove causation. Many investigators have sought to
clarify the ambiguity between incidence and causation regarding cervical
spinal manipulation, but studies are often flawed by reporting bias, selection
bias, and the challenges associated with studying rare outcomes. A 2014
consensus statement from the American Heart Association and the American
Stroke Association recommends that “although the incidence of CMTassociated cervical dissection in patients who have previously received CMT
is not well established, and probably low…patients should be informed of the
statistical association between cervical dissection and CMT prior to
undergoing manipulation of the cervical spine.”
38
In a 2016 Cochrane review, 51 trials with 2,920 collective participants
with chronic neck pain were reviewed.39 For acute and subacute neck pain,
the review found that cervical spine manipulation may result in greater
improvements in pain relief than medications such as NSAIDs, opioids, or
muscle relaxers. Cervical spine manipulation resulted in immediate pain
relief, but not at short-term follow-up (up to 1 month) when compared with
results of inactive control participants. There were similar results in
improvements in pain relief, function, quality of life, and satisfaction when
comparing cervical manipulation with mobilization. A 2016 randomized
controlled trial reported improved cost-effectiveness of spinal manipulation
with home exercise for adults older than 65 years with chronic neck pain
compared with supervised exercise and home exercise or home exercise
alone.
40
In a 2011 Cochrane review, 12 randomized controlled trials with 2,887
collective participants with low back pain were reviewed.41 For acute and
subacute low back pain, chiropractic care improved short- and medium-term
pain (less than 1 month and 1 to 6 months’ duration, respectively), but no
statistical difference was found in long-term pain (more than 6 months). In
addition, short-term improvement in disability was seen in chiropractic care
compared with other therapies. For chronic low back pain, there was no
significant difference between chiropractic care and other treatments
regarding improvement in pain or disability.
Massage Therapy
Massage therapy is the manipulation of superficial and deeper layers of
muscle and connective tissue using various techniques to enhance function,
aid in the healing process, decrease muscle reflex activity, inhibit motorneuron excitability, and promote relaxation and well-being.42 There are many
types of massage therapies. In Swedish massage, the therapist uses long
strokes, kneading, deep circular movements, vibration, and tapping.
Petrissage and effleurage, techniques used to treat lymphedema, involve
various ways of kneading and rolling and picking up the skin and muscles.
Friction includes using the thumb, fingertips, or knuckles to apply deep,
direct pressure to one site of muscular tension. Tapotement involves fast,
stimulating, and percussion-type movements and can include cupping,
hacking, and pounding. Sports massage combines techniques of Swedish
massage and deep tissue massage to release chronic muscle tension, and it is
adapted to the needs of athletes. Myofascial trigger point therapy focuses on
trigger points.
Recent investigations undertaken to better understand the fascial system
have led to the development of massage therapy techniques that incorporate
more anatomic knowledge. Fascia has traditionally been thought of as a
passive structure that envelops muscles; however, it is now evident that fascia
is a dynamic tissue with complex vasculature and dense innervation. There is
little consistency when referring to fascia; terms such as aponeurosis,
retinaculum, fascia, and ligaments refer to some form of fascia. Fascia can be
categorized as superficial or deep. Superficial fascia is formed by loosely
packed interwoven collagen fibers mixed with abundant elastic fibers, is
tightly connected with superficial veins and lymphatic vessels, and has
functions of thermoregulation. Deep fascia refers to all the well-organized,
dense fibrous layers that interpenetrate and surround muscles, bones, nerves,
and blood vessels and bind them together into a continuous mass. When it
covers bones, deep fascia is termed periosteum; around tendons it forms
paratenon; and around vessels and nerves, it forms the neurovascular sheath.
There are two types of deep fascia: aponeurotic and epimysial.
Aponeurotic fascia contains collagen fiber bundles that align along the main
axis of the limbs in both longitudinal and oblique directions and function
similar to a tendon by allowing force transmission along the limbs.
Thoracolumbar fascia, which is considered aponeurotic fascia, has dense
sensory innervation and is thought to be an important link in nonspecific low
back pain.43 Epimysial fascia is tightly adhered to underlying muscles via
multiple fibrous septa that originate from the inner aspect and penetrate the
muscle; therefore, it is impossible to separate the function of epimysial fascia
from that of muscle44 (Figure 3).
Figure 3
Illustrations and ultrasound images show the organization
of subcutaneous layers in the limbs (A and B) and in the
trunk (C and D). The superficial fascia divides the subcutaneous
tissue into two adipose layers in the body: the superficial adipose
tissue and the deep adipose tissue. Fibrous septa connect the
superficial fascia to skin and to deep fascia, which form a threedimensional network around fat lobules. The deep fascia shows
different features according to the region. In the limbs, it is formed by
two or three fibrous sublayers separated by hyaluronic acid, and in the
trunk, the deep fascia only consists of one fibrous layer and thus, is
thinner. (Adapted with permission from Stecco C, Tiengo C, Stecco A,
et al: Fascia redefined: Anatomical features and technical relevance in
fascial flap surgery. Surg Radiol Anat 2013:35[5]:369-376.)
Disorders of the fascia can account for many conditions that otherwise
may be difficult to explain. Myofascial pain has been termed the great
mimicker and can cause symptoms of numbness, tingling, and radiating pain
in nondermatomal or myotomal distributions. Because superficial fascia is
closely linked with lymphatics and blood vessels, alterations of superficial
fascia can result in lymphedema, venous dilatation, changes in skin color, or
chronic ischemia of the skin in the absence of measurable vascular or
circulation problems. Disorders of aponeurotic deep fascia can result in
myofascial pain.44 Etiology of myofascial pain is typically thought of as
multifactorial, with a notable contribution from peripheral tissues,
specifically fascia. One functional characteristic of fascia is the sliding
capability of fascial sublayers. Hyaluronic acid is commonly found between
the fascial layers and provides a lubricating surface for fascia to glide
smoothly over muscles and tendons. The biologic properties of hyaluronic
acid vary depending on the size of their molecular chains. With a decreased
pH level that can be seen after muscle exhaustion and lactic acid buildup, the
molecular chains increase in size, and the viscosity of hyaluronic acid in the
endomysium and perimysium can increase considerably.45 This increased
viscosity of hyaluronic acid can result in stiffness throughout the muscles and
surrounding areas, which in normal situations disappears after rest. However,
this same increased viscosity can result in dysfunction, poor gliding of the
fascial layers, and myofascial pain.
Manipulation and massage of muscles and their associated fascia can
increase local temperature and catalyze an inflammatory reaction, both of
which facilitate breakdown of larger chains of hyaluronic acid, resulting in
decreased hyaluronic acid viscosity and restoration of normal gliding of
fascial layers. These results can be accomplished with a massage technique
called fascial manipulation, which is deep compression and friction over
specific points in the body that are thought to be commonly dysfunctional
and densified. This technique can be performed with a knuckle or an elbow
and is performed along a functional myofascial sequence.
A gentler massage technique called myofascial release involves applying
low pressure and long-duration stretches to the myofascial complex that are
intended to break up fascial adhesions, restore optimal length, decrease pain,
and improve function.
46,47
Myofascial release can be performed directly at
the site of restricted fascia with the use of knuckles, elbows, or tools to apply
tension with a few kilograms of force to stretch the fascia. Alternatively, it
can be performed indirectly by applying gentle pressure of a few grams,
using the hands to follow the direction of fascial restriction, and holding the
stretch to allow the fascia to unwind itself.
Images of the fascia reveal that increased thickness (specifically, an
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