Effect of Bloodletting Therapy at Local Myofascial Trigger

CLINICAL STUDYTOPIC Effect of bloodletting therapy at local myofascial trigger points and acupuncture at Jiaji (EX-B 2) points on upper back myofascial pain syndrome: a randomized controlled trial

Jiang Guimei, Jia Chao, Lin Mode aa Jiang Guimei, Physiotherapy Department, Guangdong Pro- control group (n = 33) were treated with a lidocaine vincial Hospital of Traditional Chinese Medicine, Guangzhou block at trigger points; one treatment course con- 510120, China sisted of five sessions of lidocaine block therapy Jia Chao, Tuina Department, No.1 Affiliated Hospital of with a 2-day break between each session. The sim- Guangzhou University of TCM, Guangzhou 510405, China plified McGill Scale (SF-MPQ) and tenderness Lin Mode, Department of Acupuncture and Moxibustion, Guangdong Provincial Hospital of TCM, Guangzhou 510120, threshold determination were used to assess pain China before and after a course of treatment. Supported by the Science and Technology Plan Project of RESULTS: After the third and fifth treatment, the Social Development of Guangdong Provincial Department of Science and Technology (Project name: Effect of Bloodlet- SF-MPQ values were significantly decreased (P < ting Therapy at Local Myofascial Trigger Points and Acu- 0.01) and the tenderness thresholds were signifi- puncture at Jiaji Points on Upper Back Myofascial Pain Syn- cantly increased (P < 0.01) in both groups com- drome, No. 2011B080701089) pared with before treatment. There were no signifi- Correspondence to: Associate chief physician Jia Chao, cant differences in pain assessments between the Tuina Department, No.1 Affiliated Hospital of Guangzhou two groups after three and five treatments (P > University of TCM, Guangzhou 510405, China. doctorji- 0.05). There were five cases with minor adverse re- [email protected] actions reported in the control patients, while no Telephone: +86-13535307000 Accepted: June 1, 2015 adverse reactions were reported in the treatment group.

CONCLUSION: Bloodletting therapy at local myo- Abstract fascial trigger points and acupuncture at Jiaji points was effective in treating upper back MPS. OBJECTIVE: To observe the clinical efficacy of Clinically, bloodletting and acupuncture therapy bloodletting therapy and acupuncture at Jiaji had the same efficacy as the lidocaine block thera- points for treating upper back myofascial pain syn- py, with fewer adverse reactions. drome (MPS), and compare this with lidocaine block therapy. © 2016 JTCM. Open access under CC BY-NC-ND license. METHODS: A total of 66 upper back MPS patients Key words: Myofascial pain syndromes; Acupunc- were randomly assigned to either the treatment ture; Bloodletting; Treatment outcome; Random- group or the control group in a 1∶1 ratio. The treat- ized controlled trial ment group (n = 33) were treated with bloodletting therapy at local myofascial trigger points and acupuncture at Jiaji (EX-B 2) points; one treatment INTRODUCTION course consisted of five, single 20-min-treatments Myofascial pain syndrome (MPS) is originally generat- with a 2-day break between each treatment. The ed within connective tissue such as muscles, tendons

JTCM | www. journaltcm. com 26 February 15, 2016 |Volume 36 | Issue 1 | Jiang GM et al. / Clinical Study and fascia. MPS is a common cause of neck pain, lum- tremely tender spot known as a TrP. (c) In addition to bar pain and pain around the major joints.1 Myofascial referring pain to the reference zone, TrPs may cause trigger points (MTrPs) are a major clinical feature of other sensory changes such as tenderness and dysesthe- MPS. sia. (e) Muscles with active MTrPs have a restricted pas- The most common treatment for MPS in Western sive (stretch) range of motion because of pain. (f) The Medicine is local block therapy, usually lidocaine.2 taut muscle band fibers respond consistently with a Muscle stretch therapy3,4 dry needle therapy5 and oral twitch response when the TrP is penetrated by a nee- non-steroidal anti-inflammatory drugs6 are also com- dle. (g) The patient feels pain when the muscle is monly used. However, there are limitations of these strongly contracted against fixed resistance. (h)Sleep treatments, such as adverse reactions to anesthetic and disturbance can increase pain sensitivity. oral medications, and intense pain associated with dry needle therapy and muscle stretch therapy.6-8 Traditional Chinese Medicine (TCM) syndrome The analgesic effect of acupuncture is recognized differentiation worldwide. Local acupuncture is mainly used in the According to the Criteria of diagnosis and therapeutic treatment of MPS; this relieves pain by damaging the effect of diseases and syndromes in TCM assigned by trigger points and improving local circulation. Howev- the State Administration of TCM,18 back myofasciitis er, there is a lack of specific treatment programs target- can be summarized into three syndromes: internal ing repeated pain caused by spinal segmental sensitiza- pathogen with wind, cold and dampness; stagnation of tion and central sensitization. Because Jiaji (EX-B 2) Qi and blood; and deficiency of Qi and blood. has special anatomic and physiologica functions, it was used in treating many diseases, especially in acupunc- Inclusion criteria ture analgesia.9-17 The skin over the trigger points (a) Diagnosed with MPS according to the above men- (TrPs) is pricked to release blood, and acupuncture is tioned diagnostic criteria. (b) Aged 20-60 years. (c) performed at the Jiaji (EX-B 2) points where the TrPs Provided written informed consent. are located. Exclusion criteria The purpose of this study was to evaluate the clinical (a) Comorbid diseases including cervical spondylosis, efficacy of bloodletting and Jiaji (EX-B 2) acupuncture cervical and spinal tuberculosis, ankylosing spondylitis, treatment for upper back MPS, and compare this with cervical tumor, severe pain caused by psychological fac- the efficacy of lidocaine block therapy. tors and other organic pathologic changes. (b) Hyper- sensitivity to drugs, injections, and/or acupuncture. (c) MATERIALS AND METHODS Severe cardiovascular and respiratory disease. (d) Tak- ing conflicting or related medicine during the study. This study was approved by the Ethics Committee of (e) Mental or psychiatric disease. (f) Pregnant women. Guangdong Provincial Traditional Chinese Medicine (g) Patients intolerant of or uncooperative with the Hospital. All participants provided written informed study. consent. A total of 66 participants were randomly divided into Treatment Treatment group: to locate the MTrPs, each patient two groups at a 1∶1 ratio of treatment group (n = 33) to control group (n = 33). All participants were outpa- pointed out their painful area, which the doctor then tients of the Physiotherapy Department of Guangdong pressed with their thumbs to confirm the presence of a Provincial Hospital of TCM from October 2011 to tense muscle band. The doctor pressed the TrP to bring June 2013. out the circumscribed pain and spasm, and then en- The random digits were generated by SPSS 11.0 soft- hanced the stimulus to induce referred pain. When the ware (SPSS Inc., Chicago, IL, USA) and were loaded pain was induced, patients were asked whether it felt in the envelopes. The corresponding envelopes were se- similar to the pain that usually occurs. To quantitative- 2 lected according to the sequence of the participants, ly evaluate the MTrPs, a tenderness meter with a 1 cm and the method in it was used in the research. spring end was placed on the major MTrPs. Pressure Because the treatment method is different, so the blind was applied, and the threshold of tenderness was mea- 2 method can't be used. Only in the data collation and sured. A threshold of tenderness of 2 kg/cm or below statistical analysis phase, there was a assign specific per- was regarded as abnormal. When the MTrPs were locat- son to manage the data. ed, an X was drawn on it with inerasable ink. Each MTrP was held steady with the doctor's non-dominant Diagnostic criteria of myofascial pain syndrome3,4 hand, and then the dominant hand was used to stab (a) Medical history of pain associated with some degree the triangle-edged needle (Hanyi triangle-edged nee- of mechanical abuse of the muscle in the form of mus- dle, 6.5 cm length, 0.5 mm tip length and 1.6 mm di- cle overload, which may have been acute, sustained ameter. Manufactured by Changchun AIK Medical De- and/or repetitive. (b) Palpation along the taut muscle vices Co., Ltd. Address: No. 25 karan Industrial park, band reveals a nodule exhibiting a highly localized, ex- jiutai Econimic Development Zone, Changchun.

JTCM | www. journaltcm. com 27 February 15, 2016 |Volume 36 | Issue 1 | Jiang GM et al. / Clinical Study

130507, China) into the MTrP about 0.2 mm deep, five times, with a 10-15 s break between each measure- and then quickly remove the needle. This was repeated ment; the mean value was recorded as the PPT and PTT. three times to bleed the MTrP. Adverse reactions we related to the therapy were record- After bloodletting, the glass cups were cupped on the ed, including subcutaneous hemorrhage and hemato- bleeding area for 10 min. The left hand held the hemo- ma, hypersensitivity, palpitations and dizziness. static clamping 95% alcohol cotton, right hand held glass cup. After the fire lighted alcohol cot, quickly ro- Data management and statistical analysis tated lighting cotton 1-3 turning in the cup, exited All clinical data were recorded on a specific clinical re- quickly, immediately covered the cup on the bleeding search form and managed by a specific person excluded sites. Ten minutes later, the cups were withdrew and from the researchers and therapists. Statistical analysis gore was abrased by disinfected cotton swab. was done using SPSS11.0 software (SPSS Inc., Chica- After cupping, acupuncture needles were inserted into go, IL, USA). Quantitative data were recorded as mean the MTrPs. When the patient felt radiating pain or oth- ± standard deviation and tested for normality. If the data were normally distributed, the independent t-testwas er unusual feelings on the acupoints, the needle was used; the paired t-test was used for comparing data be- lifted to the subcutaneous level and aimed toward the tween different treatment stages. Ranked data was test- tense muscle band or the string-like structure in the ed with the two sample Wilcoxon rank sum test. Val- muscle. To apply acupuncture to the Jiaji (EX-B 2) on ues of > 0.05 (two sides) and P < 0.05 were consid- the related spinal segment, the needle (Hanyi dispos- ered statisticallyα significant. able Acupuncture needle, 25 mm tip length and 0.25 mm diameter. Manufacturer and the place of manufacture is the same with above) insertion depth RESULTS was about 0.5 cun (25 mm equals to 1 cun) and the ma- The study was a randomized controlled trial. The re- nipulation was neutral. The patients had a sense of radi- search process is shown in Figure 1. In the treatment ating pain to other area, or acid or expansion at the group, nine patients were male and 24 were female, part of the needle. A treatment course consisted of with an average age of (35 ± 7) years and an average du- five, single 20-min-treatments with a 2-day break be- ration of illness of (2.9 ± 4.2) months. The TCM syn- tween each treatment. The MTrPs were relocated be- drome differentiations included internal pathogen with fore each treatment. wind, cold and dampness (10 cases), stagnation of Qi Control group: the MTrPs were located and marked and blood (20 cases), and deficiency of Qi and blood with an X as described above; no more than three dif- (2 cases). In the control group, 15 patients were male ferent points were chosen each time for lidocaine block and 18 were female, with an average age of (37 ± 9) therapy. The solution consisted of 2 mL of 2% lido- years and an average duration of illness of (5 ± 6) caine mixed with 6 mL of 0.9% saline, of which 2 mL months. The TCM syndrome differentiation included was injected at each TrP. Lidocaine was purchased from internal pathogen with wind, cold and dampness (7 Shanxi Jinxin Shuanghe Pharmaceutical Co., Ltd. (Yun cases), stagnation of Qi and blood (24 cases), and defi- Cheng City, Shanxi, China). ciency of Qi and blood (3 cases). There were no signifi- A treatment course consisted of five sessions of lido- cant differences between the two groups in age, sex, du- caine block therapy with a 2-day break between each ration of illness and prevalence of TCM syndrome dif- session. The MTrPs were relocated before each treat- ferentiation (P > 0.05 for all parameters). ment. Attention was paid to the angle and depth of needle insertion to prevent pneumothorax. Eligible subjects Inform and sign on the Outcome measurements informed consent (n = 66) The simplified McGill scale (SF-MPQ)19 consisting of Random the pain rating index (PRI), visual analog pain scale (VAS), and present pain intensity (PPI). Teatment group (n = 33) Control group (n = 33) Evaluation of the tendernessthreshold20 was performed using a push-pull force gauge (Fabrication Enterprises, Assessment before, Inc., New York city, USA) to measure the pressure pain after 3rd and 5th SF-MPQ Treatment threshold (PPT) and the pain tolerance threshold evaluation of the tender- (PTT). The PPT is the force value at which the patient ness threshold (n = 66) feels the pressure turn into pain. The PTT is the maxi- mum force value that the patient can tolerate. Because too much pressure also cause a noxious stimulation to Establish database (n = 66) the patients, so we also set a value. When the patient's PTT was higher than 10 kg/cm2, the measurement was Data analysis halted and this set value was recorded as the patient's statistical data (n = 66) PTT. In each case the threshold of pain was measured Figure1 Flow diagram of the study process

JTCM | www. journaltcm. com 28 February 15, 2016 |Volume 36 | Issue 1 | Jiang GM et al. / Clinical Study

Curative effect according to the simplified McGill reported in three cases. All cases finished the entire scale study and no further adverse reactions were reported There were no significant differences between the two during the study. groups before treatment regarding PRI, VAS and PPI (P > 0.05). Acupuncture and bloodletting at the Jiaji (EX-B2) and lidocaine block therapy both had a signifi- DISCUSSION cant effect on the SF-MPQ. The PRI, VAS and PPI af- An MTrP is a region on the affected muscle that causes ter the third and the fifth treatments were significantly pain; in most cases a taut band (string-like tubercle) is decreased compared with before treatment in both palpable on this region. Touching or pressing this re- groups (P < 0.01).The PRI, VAS and PPI after the gion can lead to local pain; and inferred pain or tender- fifth treatment were significantly lower than after the ness in a remote area and sympathetic phenomenon third therapy in both groups (P < 0.01). There were can also be induced. Stimulation of MTrPs can make no significant differences in PRI, VAS, and PPI be- the muscle feel soft and 'doughy', cause distraction of tween the two groups after the third and fifth treat- skeletal muscle, and decrease range of motion.2,3 ments (P > 0.05) (Table 1). The exact physiological mechanism of MTrPs has not Curative effect according to the tenderness thresholds yet been completely clarified. One theory is the energy 21 There were no significant differences between the two crisis hypothesis. Dysfunction of the motor endplate groups in PPT and PTT before treatment (P > 0.05). occurs in the affected skeletal muscle, which leads to ex- Acupuncture and bloodletting at the Jiaji (EX-B 2) cessive release of acetylcholine in the nerve terminal of points and lidocaine block therapy both had a signifi- the motor endplate, and continuous depolarization of cant effect on the tenderness thresholds. The PPT and cell membranes. More calcium is then released by the PTT after the third and fifth treatment were signifi- sarcoplasmic reticulum, resulting in continuous sarco- cantly increased in both groups compared with before mere contraction and the formation of a tense muscle 21 treatment (P < 0.01). The PPT and PTT after the fifth band and tubercle. The continuous sarcomere con- treatment were significantly higher than after the third traction increases the local energy consumption and de- treatment in both groups (P < 0.01). There were no creases the blood perfusion of the muscle. Hypoxia and significant differences between the PPT and PTT of ischemia of the muscle provokes the release of neural the two groups after the third and fifth treatment (P > vascular reaction substances, which are inflammatory 0.05) (Table 2). mediators including bradykinin, substance P, calcitonin gene related to peptide, tumor necrosis factor alpha, in- Adverse reactions terleukin(IL)-1 , IL-6, IL-8, and serotonin. These sub- No adverse reactions were observed in the treatment stances sensitizeβ the afferent nerve, resulting in painful group during the study. In the control group, transient TrPs. This process can also be defined as peripheral sen- hypertension that was relieved after a brief rest was re- sitization.21 The neural vascular reaction substances ported in two cases, and insomnia after treatment was cause the release of additional acetylcholine, and the

Table 1 Therapeutic effect according to the simplified McGill scale in the treatment and control groups (scores, xˉ ± s) PRI VAS PPI Group After 3rd After 5th After 3rd After 5th After 3rd After 5th Before Before Before therapy therapy therapy therapy therapy therapy Treatment 19.7±5.5 9.4±4.3a 2.7±2.5ab 7.7±0.9 3.4±1.3a 1.0±1.5ab 3.6±0.7 1.6±0.8a 0.5±0.8ab

Control 20.9±6.4 9.6±5.3a 3.4±4.3ab 7.6±1.1 3.6±1.4a 0.8±1.0ab 3.7±0.7 1.7±0.9a 0.4±0.6ab Notes: treatment group: treated with bloodletting therapy at local myofascial trigger points and acupuncture at Jiaji (EX-B 2) points; control group: treated with lidocaine block at trigger points. PRI: pain rating index; VAS: visual analog pain scale; PPI: present pain intensity. aP < 0.01, comparing values before and after treatment; bP < 0.01, comparing values after the third and fifth treatment. There were no significant differences between the two groups (P > 0.05).

Table 2 Therapeutic effect on the tenderness threshold in the treatment and control groups (kg/cm2, xˉ ± s) PPT PTT Group Before After 3rd therapy After 5th therapy Before After 3rd therapy After 5th therapy

Treatment 1.4±0.5 3.0±0.6a 4.6±0.8ab 1.9±0.7 3.7±0.7a 5.4±0.9ab

Control 1.4±0.6 3.1±0.7a 4.5±0.8ab 1.9±0.8 3.8±0.8a 5.3±0.9ab Notes: treatment group: treated with bloodletting therapy at local myofascial trigger points and acupuncture at Jiaji (EX-B 2) points; control group: treated with lidocaine block at trigger points. PPT: pressure pain threshold; PTT: pain tolerance threshold. aP < 0.01, comparing values before and after treatment; bP < 0.01, comparing values after the third and fifth treatment. There were no significant differences between the two groups (P > 0.05).

JTCM | www. journaltcm. com 29 February 15, 2016 |Volume 36 | Issue 1 | Jiang GM et al. / Clinical Study process forms a positive feedback loop.21 At the same the spinal nerves; 54.4% of the dorsal rami of spinal time, the concentration of noradrenaline rises and the nerves have a parallel location with the Jiaji (EX-B 2) pH decreases.21 points in a horizontal direction. Some dorsal rami of This peripheral sensitization can result in central ner- spinal nerves travel above or below the horizontal level vous system sensitization by provoking the sustained of Jiaji (EX-B 2) points, but the main area innervated discharge of nociceptors exiting the spinal dorsal horn by the spinal nerve covers the Jiaji (EX-B 2) points.9 through the C-fibers and A-delta fibers; through this The widely distributed nerve endings in the acupoint process, transformation in function and structure area, dorsal rami of spinal nerves, and the sympathetic evolves, causing spinal segmental sensitization.22 The nerve stem spreading from the centrum form the physi- clinical expression of spinal segmental sensitization in- ological basis of the therapeutic effects of acupuncture cludes hyperalgesia, pain at mild touch, referred pain, at Jiaji (EX-B 2) points.10 Our previous study con- and dysfunction of motor and autonomic nerve func- firmed the effectiveness and stability of acupuncture at tion.22 Sustained central nervous system sensitization Jiaji (EX-B 2) points for MPS.25 caused by pain enhances the excitation of neurons and Based on the clinic and experimental research, we enlarges the receptor pool of neurons, thus inducing in- think that acupuncture can relieve pain at three levels tractable referred pain.23 in the route of pain transmission: the local periphery, Relieving MTrPs is the main method for treating the spinal segment, and the central nervous system. MPS. Reversing spinal segmental sensitization and cen- The TrPs are damaged by bloodletting, which reduces tral nervous system sensitization are significant parts of the release of inflammatory mediators, and reverses the treatment. Injecting lidocaine into TrPs is universally sensitization of afferent nerves (peripheral sensitiza- accepted as an effective method for treating MPS; how- tion) to relieve myofascial pain. Afferent nerves protect ever, injecting local anesthetics intramuscularly may the spinal cord center from noxious stimulation. Acu- lead to myotoxicity.7,8 TrPs can also be treated by puncture at Jiaji (EX-B 2) points sends a signal bloodletting at MTrPs (also known as "Ahshi points" through the spinal nerves to the related spinal segment. in TCM theory). In the current study, bloodletting When the noxious stimulation and the acupuncture therapy had an instant analgesic effect. According to signalare sent to the same or nearby spinal segments, TCM theory, pain is due to the meridian blocked, in acupuncture significantly reduces pain, thus reversing which bloodletting dredges the affected meridian and spinal segmental sensitization. The acupuncture signal promotes the movement of Qi and blood; when the can be sent into the cerebrum through the ventrolater- meridian is dredged, pain is relieved. When local tissue al funiculus. In the frontal abdominal side of the me- is damaged by noxious stimulation, it releases several dulla oblongata, gray matter around the aqueduct of pain-producing substances, including K + ,H + , S-HT, the midbrain and the thalamus, noxious stimulation and bradykinin. The pain-producing substances affect and acupuncture signal gathers in the same cells and free nerve endings and induce pain impulses.24 To nuclear groups. When they take effect at the same block the pain-inducing process, bloodletting therapy time, noxious stimulation will be depressed by the acu- expels the blood with a high concentration of pain-pro- puncture signal, thus reversing central nervous system ducing substance, and draws fresh blood from a re- sensitization. mote area, thus lowering the concentration of pain-pro- To evaluate the therapeutic effect of bloodletting and ducing substances, improving the local circulation, and acupuncture, we adopted the universally accepted helping to repair damaged tissue.24 The treatment re- SF-MPQ and the threshold of tenderness. The duces neural vascular substances in the positive feed- SF-MPQ is one of the most widely accepted scales back loop of the energy crisis hypothesis, thus prevent- used for assessing all types of pain. The threshold of ing MTrPs from developing.24 tenderness includes the sensory and tolerance thresh- Jiaji (EX-B 2) points were chosen as acupoints in the olds of tenderness, which allows objective assessment current study. Many studies have used Jiaji (EX-B 2) of the severity of pain and improvement after therapy. points owing to their special anatomic and physiologi- In conclusion, bloodletting at TrPs and acupuncture at cal function, especially regarding pain treatment.9,10 Jia- Jiaji (EX-B 2) points lowered the SF-MPQ, and elevat- ji (EX-B 2) points are located between the Bladder Me- ed the patients' sensory and tolerance tenderness ridian of Foot-Taiyang and the Du Meridian, and con- thresholds. Moreover, no adverse reactions were report- nect the two meridians by a branch of the Du Meridi- ed in the treatment group. Acupuncture had a similar an. The Du Meridian gathers all the Yang Meridians, therapeutic effect to lidocaine block, with fewer ad- and the Bladder Meridian of Foot-Taiyang is primary verse reactions. Acupuncture is an effective and practi- to the Yang Meridians. Because Jiaji (EX-B 2) points cal method for MPS treatment. are located on two meridians, acupuncture at Jiaji (EX-B 2) points can modify the function of both me- REFERENCES ridians and inspire Yang Qi in the body. In terms of 1 Harden RN, Bruehl SP, Gass S, Niemiec C, Barbick B. their anatomical locations, Jiaji (EX-B 2) points and Signs and symptoms of the myofascial pain syndrome:a na- their surrounding area travel around the dorsal rami of tional survey of pain management providers. Clin J Pain

JTCM | www. journaltcm. com 30 February 15, 2016 |Volume 36 | Issue 1 | Jiang GM et al. / Clinical Study

2000; 16(1): 64-72. 15 Wang SX, Lai XS, He HT. Effects of Jiaji electro acupunc- 2 Lavelle ED, Lavelle W, Smith HS. Myofascial trigger ture on the expression of Strong peptide mRNA in spinal points. Anesthesiology 2007; 25(4): 841-851. cord in rats with adjuvant arthritis. Zhong Guo Zhong Yi 3 Travell JG, Simons DG. Myofascial pain and dysfunction: Yao Ke Ji 1999; 6(1): 1. the trigger point manual. Vol 1, upper half of body, 2nd 16 Lou ZC, Liu Y, Li XW. Electro acupuncture inhibits the ed. Baltimore：Williams & Wikins, 1983: 50-230. expression of FOS protein in beam side core induced by 4 Simons DG, Travell JG, Simons LS. Myofascial pain and wound. Di Yi Jun Yi Da Xue Xue Bao 1996; 16(2): 87. dysfunction: the trigger point manual. Vol 1, upper half of 17 Pang Y, Li XC, Li HD. The effects of electro acupuncture body,. 2nd ed. Baltimore：Williams&Wikins, 1999: and morphia on ACTH content and pain response in the 11-235. hypothalamus and bridge-medulla oblongata of rats with 5 Hsieh YL, Kao MJ, Kuan TS, et al. Dry Needing to a key chronic pain. Di San Jun Yi Da Xue Xue Bao 2000; 22(8): myofascial trigger point may reduce the irritability of satel- 720. lite MTrPs. Am J Phys Med Rehabil 2007; 86(5): 397-403. 18 State Administration of Traditional Chinese Medicine of 6 Mu WH, Sun J. Commonly used drugs for the treatment the People's Republic of China The Criteria of diagnosis of myofascial pain. Hai Xia Yao Xue, 2011; 13(B08): ． 76-77. and therapeutic effect of diseases and syndromes in TCM. 7 Zink W, Graf BM. Local anesthetic myotoxicity. Reg Nanjing: Nanjing University Publishing House, 1994: 200. Anesth Pain Med 2004; 29(4): 333-340. 19 Melzack R. The short-form McGill pain Questionnaire. 8 Amaniti E, Drampa F, Kouzi-Koliakos K, et al. Ropiva- Pain 1987; 30(2): 191-197. caine myotoxicity after single intramuscular injection in 20 Fisher AA. Algometry in diagnosis of musculoskeletal rats. Eur J Anaesthesiol 2006; 23(2): 130-135. pain and evaluation of treatment outcome: An update. J 9 Zhang WM, Guan Q, Chen CF. Study on locating Jiaji Musculoskelet Pain 1998; 6(1): 5-32. Points. Shanghai Zhen Jiu Za Zhi 1987; 6(4): 23. 21 Shah JP, Danoff JV, Desai MJ, et al. Biochemical associat- 10 Jin BR. Clinical appliance and theraputic mechanism of ed with pain and inflammation are elevated in sites near to Jiaji points. Shanghai Zhen Jiu Za Zhi 1987; 6(1): 16. and remote from active myofascial trigger points. Arch 11 Wang SX, Hong J, Lai XS.Effects of Jiaji electro acupunc- Phys Med Rehabil 2008; 89(1): 16-23. ture on spinal monoamine neurotransmitter content in 22 Vecchiet L, Vecchiet J, Giamberardino MA. Referred mus- rats with adjuvant arthritis. Zhong Guo Zhong Yi Yao Ke cle pain: clinical and pathophysiologic aspects. Curr Rev Ji 2001; 8(1): 1-3. Pain 1999; 3: 489-498. 12 Wang SX, Hong J, Zhou YL, et al. Effects of Jiaji electro 23 Coderre TJ, Katz J, Vaccarino AI, et al. Contribution of acupuncture on peripheral blood monoamine neurotrans- central neruoplasticity to pathological pain: review of clini- mitter content in rats with adjuvant arthritis. Zhong Guo cal and experimental evidence. Pain 1993; 52: 259-85. Zhong Yi Yao Ke Ji 2000; 7(5): 273-275. 24 Wang Zh, Ma W. Chinese Bloodletting Therapy. 2nd ed. 13 Wang SX, Hong J, lai XS, et al. Study on the effect of Jiaji electro acupuncture on spinal substance P in rats with ad- Anhui: Anhui Science & Technology Publishing House, juvant arthritis. Zhong Guo Zhong Yi Yao Ke Ji 2000; 7 2005: 53. (3): 131-132. 25 Jiang GM, Lin MD, Wang LY. Clinical research of the 14 Ruan HZ, Li XC, Li HD. Electro acupuncture inhibit the lumbar myofascial pain syndrome with acupuncture Jiaji expression of pain and c-fos in spinal cord caused by Sub- points treatment. Zhong Guo Zhen Jiu 2013; 33(3): stance P. Di San Jun Yi Da Xue Xue Bao 1997; (8): 332. 223-226.

JTCM | www. journaltcm. com 31 February 15, 2016 |Volume 36 | Issue 1 |