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

Jessica Lucia Neves Bastos1, Elisa Dória Pires1, Marcelo Lourenço Silva3, Fernanda Lopes Buiatti de Araújo1,2, Josie Resende Torres Silva3*


Acupuncture specialization course, Instituto Paulista de Estudos Sistêmicos (IPES), Praça Boaventura Ferreira da Rosa 384, CEP 14049-900, Ribeirão Preto, SP, Brazil.

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


Department of Pharmacology, Faculty of Medicine of Ribeirão Preto-USP, Av. Bandeirantes, 3900, CEP 14049-900, Ribeirão 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 Ribeirão Preto-USP, Av. Bandeirantes 3900, CEP 14049-900, Ribeirão Preto, SP, Brazil. Tel: 55-16-3602 3184; Fax: 55 16 3633 2301; E-mail: No financial supports.

acupuncture treatment was performed at five tender points. Over a two month period. diffuse and widespread musculoskeletal pain. 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. Conclusions The results pointed for clear effectiveness of the tender point acupuncture treatment in providing improvements on the individuals overall framework. but also an improvement in the tables of anxiety and depression. whose pathogenesis is still unknown. BDI and BAI. Results The results pointed not only to a reduction in pain threshold sensitivity. for its analgesic effects. but not in HAQ. tender points.Abstract Background Affecting more women than men. trapezius. not only in their life quality. which were demonstrated through questionnaires FIQ. fibromyalgia. pain. but also in reducing the painful sensitivity of FMS. Key-words: Acupuncture. followed by the treatment. rhomboid. upper chest and lateral epicondyle. and in quality of life. located bilaterally at the occipital. the acupuncture. once a week. Fibromyalgia (FMS) is a rheumatic syndrome characterized by chronic. At the end of the treatment. stands like an effective option when the reduction of painful sensitivity and improvement of life quality is aimed. the subjects were submitted to a reassessment for final review of the applied methods. . BDI and BAI). Among the recommended treatments. Therefore. this research aimed to investigate whether the acupuncture at tender points could be effective for the management of fibromyalgia syndrome. HAQ.

treatments are based on global stretching. a total of 18 points distributed throughout the body. with consequent improvement of the affected individual life quality is aimed. stress. whose pathogenesis is still unknown [1]. depression. affected individuals also have musculoskeletal pain lasting more than three months. In general. Acupuncture treatment involves both stimulation of systemic specific points (points of therapeutic action) and the simple deactivation of tender points (Ashi points .90% of cases). determined by the American College of Rheumatology (ACR) in 1990. and the individual diagnosed with FMS has a great sensitivity to pressure (~ 4Kgf) in at least 11 of these points [2]. All these features aim to provide the individual some pain relief and restore its functionality. cognitive-behavioral work and some systemic medications like antiinflammatory drugs. and dyspnea [3 – 5]. headaches. physical conditioning exercises with light aerobic exercise. with a higher incidence on individuals aged between 45 and 64 years [6 – 9].Background The Fibromyalgia (FMS) is a rheumatic syndrome characterized by chronic. The diagnosis. antidepressants and opioid and non-opioid analgesics [10 – 12]. is given by the so-called tender points. Affecting eight times more women than men (80 . In addition to the painful points. generalized and diffuse musculoskeletal pain disorder. intestinal disorders and psychological characteristics such as anxiety. This ancient art uses needles and moxas to relief pain and other symptoms related to several diseases [13]. morning stiffness.referred . for its analgesic effects. is also an effective treatment option when the reduction of painful sensitivity. Acupuncture.

14]. dryness and humidity) which blocks the Qi movement. Despite of all these positive results with systemic acupuncture treatment. and allowing a faster and more effective recovery of injuries and contractures [13. heat. causing pain. and feel motivated to continue treatment. the purpose of this . These effects are of great importance for the treatment of FMS once with a reduction in pain. providing an improvement in pain to the affected individual [25 – 27]. For Traditional Chinese Medicine (TCM) the body illness occurs as a result of a vacuum energy (Qi) in the meridians. improve their life quality. wind. rebalancing the body and reducing pain conditions. reducing the pain symptoms [15 – 19]. 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. The acupuncture practice restores energy flow through the meridians. 25].pain). the individual is able to resume their activities of daily living (ADL). thus allowing the penetration of perverse energy (external factors such as excessive cold. In fact. it would be also important to consider the possibility of applying acupuncture at Ashi points. Therefore. which in the case overlap with the fibromyalgia tender points [24. restoring the Qi (energy) and Xue (blood) flux. A TCM based treatment aims to remove the excess of damp and disperse the cold. contractures and injuries to the individual body. this rheumatic syndrome is characterized in TCM as an emotional disorder which affects the Liver. The direct puncture of the tender points could lead to a stimulation of the local circulation of Qi and Xue. Many studies have shown the effectiveness of acupuncture in the treatment of FMS [20 – 24].

Before enrollment. All candidates were informed beforehand about the project. being approved through the process number 2011-0001. NY). 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. 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). and those who were willing to participate in the experiments signed an informed consent in two ways. each patient was asked to give an informed consent to participation in the study. followed by the treatment itself. bellow side bone at elbow . All the treatment procedures were submitted to the ethics committee from Instituto Paulista de Estudos Sistêmicos (IPES).study was to evaluate the effectiveness of acupuncture performed at tender points for the management of FMS symptoms. New York. Evaluation The classification and recording of FMS tender points were performed using the pressure algometer (Pain Diagnosis and Treatment Inc. according to resolution 196/96 of National Health.

0. assessment of anxiety by Beck Anxiety Inventory (BAI). trapezius. allowing the easy access to the selected points. At the end of the follow up. and upper inner shoulder (rhomboid) tender points (Figure 1). rhomboid. All needles were manipulated by combined rotating and twisting with lifting thrusting manipulation each five minutes in session. All the individuals were placed in a sitting position. Aiming to investigate any possible effects on the life quality questionnaires were applied: assessment of life quality through Fibromyalgia Impact Questionnaire (FIQ). with the upper body unclothed. base of the skull (occipital).25 x 30 mm).(lateral epicondyle). evaluation of ADL by the Heath Assessment Questionnaire (HAQ). Treatment Acupuncture was performed bilateral at the occipital. These five tender points were chosen considering theirs easier accessibility for the application of the acupuncture treatment. subjects were submitted to a reassessment for final review of the . A lower score indicates that the individual is healthier. were inserted in a perpendicular position to a depth of ~ 2. while high scores indicates the worst results. Each session last for 20 min and the sessions were carried out once a week over a two month period. The needles (Dong Bang. assessment of depression by the Beck Depression Inventory (BDI).0 cm. upper chest and lateral epicondyle tender points. The treatments were all carried out by a trained licensed specialist and there were no adverse events related to the applied treatment. neck and shoulder (trapezius).

the mean at left and right rhomboid was enhanced by 68% and 83%. patients reported significant improvement in pain symptoms with mean FIQ scores dropping from 66 to 31.applied method (Figure 1).98 to 4. a 24% reduction not statistically significant.36). a 52% reduction. respectively (from 4.2 to 7).94 to 5. a 55% reduction.16).4 and 2. Table 1 In addition. Table 1 presents the results of the FMS tender points pressure sensibility before and after acupuncture treatment.8 (Origin Lab Corporation).67. The results were submitted to analysis of variance (ANOVA) with a confidence level of 95%.67 to 18. the mean at left and right upper chest was enhanced by 61% and 71%.4 to 4. left and right trapezius was enhanced by 70% and 74%. mean HAQ scores from 24.14 to 6.33 to 9.66 to 6. and the mean at left and right epicondyle was enhanced by 72% and 83%.34 to 3.3 and 2. respectively (from 3.26 to 6.94). all reported some improvement in their major FMS symptoms. using the Origin software v.5.76). the mean at left and right occipital was enhanced by 84% and 98%. mean BDI depression scores dropping from 21. respectively (from 2. After 8 weeks. respectively (from 4.8. Figure 1 Results Among the 8 subjects who completed the treatment and assessments.18 to 5.38 and 4.9 and 2.8 and 4. respectively (from 3.78 to 3. and the mean BAI anxiety scores dropping .

high levels of substance P and neurotrophins. Figure 2 Discussion The etiopathogeny of fibromyalgia syndrome (FMS) remains unknown. The results pointed not only to a reduction in pain threshold sensitivity. We also observed significant decreases in other symptoms including gastrointestinal complaints and fatigue. central sensitivization. The improvement in pain tolerance may be related to the local action of the punctured . a 78% reduction (Figure 2). and in quality of life. The present study demonstrated a statistically significant difference before and after the treatment of acupuncture at tender points eight weeks after the first treatment. dispersing cold and restoring the flow of Qi (energy) and Xue (blood) in the affected body [32 – 34]. but also an improvement in the state of anxiety and depression. BAI and FIQ. thus. 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. although current hypotheses centre on anomalous peripheral nociception caused by windup. The studies reporting the acupuncture effectiveness for FMS treatment show that positive results have been achieved by removing excess moisture. Levels of anxiety and depression among patients with musculoskeletal pain are known to be related to FMS [30]. which were demonstrated through questionnaires BDI. 29].from 36 to 8. and alterations to the hypothalamus-hypophysis-adrenal axis [28. the prevalence of patients with FMS and severe depression varies from 20-80% [31].

possibly obtained through the simple application of needles at points of referred pain (ashi). but also to improve. the life quality of each woman. Table 2 Beyond these points and their effects.needles through the ashi points technique. gall bladder and triple burner. On the other hand. . 35]. stimulating the local circulation of Qi (energy) and Xue (blood). but also a removal of excess moisture and cold dispersion in treated women. melancholy. data analysis demonstrates that the puncture of these 5 tender points was effective not only to increase the pain tolerance of the volunteers. which were balanced. presented in Table 2 [36]. These effects were possibly achieved through balancing the meridians of the lung. Such actions can also be identified as responsible for causing an overall improvement in quality of life of treated women [14]. the data showed not only a restoring in the flow of Qi and Xue. and a local release of anti-pain substances. in general. which can coincide with systemic acupuncture points whose effects. this improvement in the overall framework of the subjects may be related to the selected tender points. leading to an improvement in pain and comfort feeling [25. which were fueled by points that coincided with the used tender points. depression. bladder. In general. Thus. fear and lack of courage to follow through with the treatment of FMS until the end. providing an improvement in the condition of sadness. there are also the emotional matrices related to the used meridians.

FLBA helped to design the project and data analysis. not only in reducing the painful sensitivity. JRTS and MLS participated of study coordination and helped to draft the manuscript. Acknowledgements The authors wish to thank Prof. Although more research clearly needs to be done. . made the data collection. but also in their life quality. Patricia Driusso for having ceded his laboratory at Federal University of São Carlos (UFSCar) to perform the data collection of this research. providing improvements in the individuals overall framework.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. Competing interests The authors declare that they have no competing interests. these results do seem promising. Authors' contributions JLN and EDP performed the experimental design of the project. performed the statistical analysis and drafted the manuscript.


Wolfe F.References 1. Alboukrek D. Michalek JE. Kreck T. Albert RK: Dyspnea resulting from fibromyalgia. Weiss DJ. Scand J Rheumatol 2000. Han JS: Acupuncture and endorphins. Bogduk N: Classification of chronic pain. Orr MD. 14. 5. 6. Vipraio GA. Rheum Dis Clin North Am 1999. Chest 1998. Buskila D: Fibromyalgia. Gran JT: The prevalence of fibromyalgia among aged 20-49 years in Arendal.12:113-123. Bradley LA. Curr opin Rheumatol 2000. Scand J Rheumatol 1992. Arthritis Rheum 1990. 7. Han S. Seattle: IASP Press. Merskey H. Zautra AJ. Arthritis Rheum 1994. Wen TS: Acupuntura clássica chinesa.361:268-261. 13. Davis MC.25:215-232. 15. Yunus MB.62:1575-1582.21:74-78. 3. 2 Ed. Sauer JF. Russell IJ. Chalot SD. Millea PJ. Goldenberg DL: Criteria for the classification of fibromyalgia: Report of the Multicenter Criteria Committee.113:246-249. Sppchley M: Chronic widespread musculoskeletal pain with or without fibromyalgia: psychological distress in a representative community adult sample. J Rheumatol 2002. 1 ed. 11. Harth M.33:160-172. Bombardier C E. 16.29:588-594. Nielson WR. Am Fam Physician 2000.46:40-48. Smythe HAA.29:3-7. Ulett GA. chronic fatigue syndrome and myofascial pain syndrome.44:129-138. 9. Pongratz DE.37:1593-1601. Han JS: Electroacupuncture: Mechanisms and Clinical Application. Assumpção A. Reich JW: Vulnerability to stress among women in chronic pain from fibromyalgia and osteoarthritis. 2o. 4. 10. Yamamura Y: Acupuntura tradicional: A arte de inserir. Biol Psychiatry 1998. 12. . Description of chronic pain syndromes and definitions of terms. MacKillp F: Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Bennett AM. Matsutani LA: A prevalência de fibromialgia: uma revisão de literatura. Lage LV. 1994. 2006. Ver Bras Reumatol 2006. 8. Alberts KR: Psychological and behavioral approaches to pain management for patients with rheumatic diseases.Symptom or diagnosis: a definition of the positon. São Paulo: Cultrix. 2. White KP. Littman B. Lopes Y. Norway.23:215-226. Holloway RL: Treating fibromyalgia. Ostbye T. 2001. São Paulo: Roca. Neuroscience Letters 2004. Sievers M: Fibromyalgia . Forseth KO. Ann Behav Med 2001. Cavalcante AB.

Chantraine A. Giles DE: Psychosocial stress and anxiety in musculoskeletal pain patients with and without depression. Sprott H. 29. Damush TM. Ji CN. 31. Arthritis Rheum 1994. Littman B. Sletten CD. Zirbs A. Jeschonnek M.31:116-122. Clinical Considerations. Wien Kin Wochenschr 2000.17. Vischer TL: Electroacupuncture in fibromyalgia: results of a controlled trial. Vipraio GA.78:88-95. Bosia L. 20. KJ. Kroenke K. MacKillip F: Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Bair MJ. Wu F. 19. Orr MD.16:157163. 26. Fietta P. Yang GF. Yuan SO: Modern Medical Explanation on Ashi Points.37:1593-1601. . 24. 23. Deluze C. Xiong P. Prog Neurobiol 2008. Buchwald D: A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. BMJ 1992. Anesth & Analg 2008. Russell IJ.85:355-375. Tu W. Staud R: Fibromyalgia pain: do we know the source? Curr Opin Rheumatol 2004. 25. 18. Assefi NP. Zhongguo Zhen Jiu 2011. Ohio State Med J 1977. Grohmann G. 21. The American Journal of Chinese Medicine 2008. Lin JG. 28. Ann Intern Med 2005. Alboukrek D. Zhongguo Zhen Jiu 2012.305:1249-1252.73:299-302. Goldberg J. White PF: Acupuncture Analgesia: II.32:180-182. 27. Smith WR. Williams BA. Xiong J: Clinical randomized controlled trials os treatment of neck-back myofascial pain syndrome by acupuncture of Ashi-points combined with moxibustion of heat-sensitive points. Martin DP. Kain ZN. Michalek JE. Gen Hosp Psychiatry 2009. Sherman. Wang SM.106:611-621. Poleshuck EL. Fietta P. Kang MF. Berger IH: Improvement of fibronyalgia symptoms with acupuncture: results of a randomized controlled trial. Acta Biomed 2007. Zhen Cie Yan Jiu 2011.36:635-645. Chen WL: Acupuncture Analgesia: A Review of Its Mechanisms of Actions. Mayo Clin Proc 2006. Wu J.143:10-19. 22.81:749-757. Zhao ZQ: Neural mechanism underlying acupuncture analgesia.31:1078-1080.36:116-120. Lopez Y. Jacobsen C. 30. Hein G: Changes in microcirculation above tender points im patients with fibromyalgia mediated by acupuncture. Manganelli P: Fibromyalgia and psychiatric disorders. Wang X: Comparative study on therapeutic effect of Ashi-points and anti-ashi-points on external humeral epicondylitis.112:580-586. Waylonis GW: Long term follow-up on patients with fibrositis treated with acupuncture. Krebs EE.

Rheumatology 2007. Cologne.237:46-48. Konemann. Wang ZH. Kolster BC. Elkin PL. Ding XJ.31:333-335. Mayo Clin Proc 2005. Hammes M. Zhongguo Zhen Jiu 2011. Seirin Pictorial Atlas of Acupuncture. Yang JJ: A survey of acupuncture for fibromyalgia syndrome. Vincent A. Zhang ZF. 2000. Shanghai J Acupunct Moxibustion 2004. Ernst E: Acupuncture for fibromyalgia—a systematic review of randomized clinical trials. 35. 36.80:55-60. Ashi method and pressing reaction. Li Y. Fu XY. Thompson JM: Use of complementary and alternative medical therapies by patients referred to a fibromyalgia treatment program at a tertiary care center. Wahner-Roedler DL. Legends . Zhou CL: Ashi points.46:201-204. Mayhew E.32. 33. 34. Chen CY. Lian YL.

Figure 2: Averages and standard deviations of the volunteers questionnaires. before and after the treatment. before and after treatment. followed by the percentage increase tolerance to pain after applying the acupuncture at tender points. . Table 1: Average obtained through pressure algometer (kgf).Figure 1: Flow chart of process and disposition of patients.

26 2.98 Means After 6.94 Increase % 84% 98% 70% 74% 68% 83% 61% 71% 72% 83% Table 2: Punctured tender points and corresponding acupuncture points and function according TCM [36].4 3. .78 2.Points Right Occipital Left Occipital Right Trapezius Left Trapezius Right Rhomboid Left Rhomboid Right Upper Chest Left Upper Chest Right Lateral Epicondyle Left Lateral Epicondyle Means Before 3.38 7 3.66 4.2 2.16 6.14 4.18 4.36 4.76 5.34 3.4 2.8 6.9 4.94 4.3 5.

Leads the wind and moisture out of the chest. Filter out the heat. treat all upper extremity problems. expels wind. Enforces. Conducts heat out of the ends. lung back shu point. Trapezius Triple heater 15 (TH15) Urinary Bladder 13 (BL13) Rhomboid Upper Chest Lung 2 (LU2) Lateral Epicondyle Large Intestine 11 (LI11) .Tender Points Occipital Acupuncture points Gallbladder 20 (GB20) Function according TCM Eliminates the wind. improves pain in upper limbs and neck stiffness. make permeable the channel power. frees the senses. nourishes yin and filters the lungs heat. becomes permeable channel energy. improves headache and stiff neck. distributes and reduces lung Qi.