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Complementary and Alternative Medicine

Individuals with SCI experience a wide range of secondary complications including pain, urinary tract infections, bowel problems and spasticity. Unfortunately, standard medical care is not always successful in managing these complications (Pannek et al., 2015). As a result, many patients turn to complementary and alternative medicines (CAMs) (Pannek et al., 2015). In a recent study, it was found that 19.1% of SCI patients had used CAM, with pain being the most common reason for use (86.4%) (Carlson et al., 2006).

Acupuncture is an ancient Chinese therapy that has been practiced for more than 4000 years to prevent and treat diseases (Lee & Liao 1990; Fan et al., 2018). When a patient undergoes acupuncture, a hair-thin needle is inserted into an acupoint and manipulated manually or electrically (Fan et al., 2018). To date, more than 361 acupoints, which form a network of 14 channels (meridians) have been identified. It has been speculated that acupuncture therapy, when applied to acute SCI, assists in minimizing cord shrinkage and spares ventral horn neurons (Politis & Korchinski 1990; Ran et al., 1992; Tsay 1974; Wu 1990). However, there are few clinical studies to support the therapeutic efficacy of acupuncture in SCI.

Trager psychophysical integration (Trager) is a form of bodywork and movement re-education developed by Milton Trager. It is based off the theory that the brain, through the nervous system, contributes to pain by maintaining muscles and other soft tissues in a chronically contracted and inflamed position (Dyson-Hudson et al., 2001). Trager therapy aims to induce relaxation and release tension through the use of gentle, rhythmic, non-intrusive movements and touch. Patients are taught to identify and correct movement patterns that may lead to pain and as a result it is often considered a form of movement re-education (Dyson-Hudson et al., 2001). Interestingly, several case studies found Trager improves range of motion and decreases pain in a number of musculoskeletal disorders (Blackburn, 2003). However, there are few clinical studies reporting the therapeutic efficacy of Trager in SCI.

The methodological details and results from two studies investigating acupuncture and Trager as a rehabilitative therapy for spinal cord injured individuals are listed in Table 26.

Table 26 Complementary & Alternative Medicine

Author Year

Country

Research Design

Score

Total Sample Size

Methods

 

Outcome
Dyson-Hudson et al., 2001

USA

RCT

PEDro=7

N=21

Population: Age: 28-69 yr; Gender: males=18, females=6; Time since injury: 5-33 yr; Length of shoulder pain: 4 mo -22 yr.

Intervention: Subjects received either acupuncture treatments (sessions lasted 20-30 min) or Trager Psychophysical Integration – sessions lasted approx 45 min. Consisted of both table work and Mentasticâ exercises (easy, natural movement sequences to enhance relaxation and decrease pain during table work).

Outcome Measures: Intake questionnaire (demographics and medical history), Weekly log, Wheelchair users shoulder pain index (WUSPI), Numeric rating scale (NRS), Verbal rating scale (VRS), Range of Motion (ROM).

1.     There was a significant effect of time for both treatments on performance corrected (PC)-WUSPI (Acupuncture p<0.001 and Trager p=0.001).

2.     Overall a reduction of the PC-WUSPI could be seen when looking at the data from the beginning of treatment to the end for both groups (p<0.05)

3.     There was a significant effect of time for both acupuncture and Trager groups for average pain & most severe pain (p<0.01, p<0.001 respectively), for the least severe pain the acupuncture group showed a significant reduction (p<0.01) compared to the Trager group.

4.     Verbal response scores- there was a statistically significant treatment effect for both groups (p=0.001).

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data.
Wong et al., 2003

Taiwan

RCT

PEDro=5

N=100

Population: Mean age: 35 yr; Gender: males=80, females=20; Level of injury: paraplegia=63, tetraplegia=37; Severity of injury: AIS A-B; Chronicity: acute.

Intervention: Acupuncture was administered to the treatment group via 4 x 5 cm adhesive surface electrodes at the acupoints of bilateral Hou Has (S13) and Shen Mo (B62). Frequency was set at 75 hz with a pulse duration of 200 usec and the magnitude of stimulation was set at 10 mV. Sessions were 30 min, 5x/wk.

Outcome Measures: ASIA Impairment Scale (AIS) (sensory + motor), Functional Independence Measure (FIM).

1.     Acupuncture group – sensory, motor + FIM scores improved significantly day of D/C + one yr after injury (p<0.05). Control group – only motor score significant improvement at 1yr post injury F/U p=0.023.

2.     Comparison of AIS + FIM scores of both groups not at admission; D/C + one yr post significant improvement AIS + FIM in acupuncture versus control p<0.05.

3.     More patients in acupuncture group improved to AIS grade B + C or better at D/C + one-yr post p<0.05.

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data.

 

Discussion

Upon review of the literature, there are very few studies which investigate the use of CAM within the SCI patient population. Wong et al. (2003) investigated the neurologic and functional recovery of acute traumatic SCI patients when treated with electrical acupuncture. They found significant improvements in AIS and FIM scores upon discharge from the hospital and one year after injury in the acupuncture group. Although, an inherent bias may have been present as the reviewer who assessed the participants was not blinded to the group assignment.

Dyson-Hudson et al. (2001) found that traditional acupuncture therapy was no more effective than Trager for the treatment of shoulder pain. This suggests that traditional acupuncture and Trager therapy may be used interchangeably depending on patient preference.

To date, the only CAM techniques that have been evaluated in the SCI population are acupuncture and Trager; however, these studies do not provide conclusive evidence of effectiveness. As the most common reason for CAM use is dissatisfaction with conventional medicine for treatment of pain, it is important to find a therapy which is safe and efficacious. In order to do this, more research is necessary. Future research should focus on determining the long-term effects of acupuncture therapy, as well as functional and neurological outcomes in larger clinical trials.

Conclusion

There is level 1b evidence (from one randomized controlled trial; Dyson-Hudson et al. 2001) that general acupuncture is no more effective than Trager therapy in reducing post-SCI upper limb pain.

There is level 2 evidence (from one randomized controlled trial; Wong et al., 2003) that use of concomitant auricular and electrical acupuncture therapy may improve the neurological and functional recovery of acute spinal cord injured individuals.

Acupuncture and Trager therapy may reduce upper limb pain post-SCI, however, there is limited evidence that acupuncture improves neurological and functional recovery in SCI.