---

Corresponding author: Vasco Senna-Fernandes, M.D., M.Sc., Academia Brasileira de Arte e CiΓͺncia Oriental (ABACO), Rua Alice 1150, Rio de Janeiro, RJ, Brazil. CEP:22241-020. Fax/Phone: +5521-2205-9433. E-mail: vascosf888@yahoo.com.br or vascosf888@hotmail.com.

---

 Abstract

This paper introduces the concept of Kinetic Acupuncture (KA), a treatment that combines both acupuncture and physiotherapy. KA is a multidisciplinary therapy that synchronizes two simultaneous procedures, divided in 3 phases: (1) In the Pre-Kinetic phase, acupuncture needling is used at systemic, microsystemic or locomotor points. It aims to prepare musculoskeletal structures for physiotherapy by interrupting the pain-spasm-pain cycle. (2) In the Kinetic phase physiotherapy is used during acupuncture stimulation of relevant scalp points. It aims to promote synergism to restore mobility. (3) In the Post-Kinetic phase, mustard seeds are taped over ear acupoints of greatest pressure sensitivity. It aims to maintain prolonged stimulation for pain improvement. KA was used to treat patients (n=205; 147 women and 58 men, aged 16-96 years) with musculoskeletal disorders (MSD). The overall pain improvement (PI) was 18.8±15.8mm on a 100mm Visual Analogue Scale score. Functional mobility improvement (FMI) was 77.0±0.15%; therapeutic satisfaction related to the return to daily activities was 90.0%. On a 4-point scale, clinical improvement averaged 1.08. Most patients (76.6%) had "remarkable improvement". The results suggest strongly that KA is an effective method, and it may have a worthwhile role in the treatment of chronic conditions such as MSD in rehabilitation in order to improve pain intensity, functional mobility and performance of daily living activities, which is important for patients’ quality of life.

Keywords: Acupuncture, physiotherapy, kinesiotherapy, musculoskeletal-disorders, Kinetic-acupuncture

 

Introduction

Rehabilitation of musculoskeletal disorders (MSD) is a time-limited, goal-oriented and interdisciplinary process that aims (1) to decrease symptoms, (2) to optimize daily function and (3) to minimize disability¹. Kinetic acupuncture (KA) combines acupuncture and physiotherapy to rehabilitate MSD patients. Most patients with MSD complain of pain and restriction of functional mobility which can compromise their quality of life by a reduced ability to perform daily living activities, such as combing hair, dressing, eating and working. Physiotherapy plays an active role in preventing and treating several diseases, including MSD. In these cases, physiotherapy has a relevant role^{2, 3}. Complementary techniques, such as acupuncture, can also be used together to improve the treatment of MSD⁴.

Acupuncture is one of many therapies used in Traditional Chinese Medicine (TCM). It is useful to treat chronic pain syndromes and many pathological conditions^{5, 6} and scientific interest in this subject is also growing^{7, 8, 9}. It is suggested that acupuncture (1) releases of vasoactive substance due to aseptic inflammatory process from acupuncture micro trauma¹⁰; (2) improves cellular oxygenation^{11, 12} and metabolic exchanges, since increases local blood circulation^{13, 14}; (3) activates the immunological system to increase phagocytosis and inhibit inflammation; (4) stimulates the lymphatic system, since the acupoints and Channels often lie near the lymphatic ducts, influencing local lymph circulation.

Several authors reported that acupuncture efficiently treated patients with MSD who had received physiotherapy with limited success previously^{15, 16, 17, 18, 19, 20}. Several studies^{21, 22, 23, 24, 25, 26} suggested simultaneous combination of acupuncture and physical therapy or exercises for MSD rehabilitation, but that further research is needed to assess the benefits conclusively.

Acupuncture is relevant in MSD rehabilitation because it acts as an adjunct in the Pre-Kinetic phase²⁷ before use of physiotherapy. It acts by mechanisms that reduce the pain-spasm-pain cycle²⁷, such as analgesia and muscle relaxation²⁸, (a) increasing blood flow and tissue oxygenation²⁹, (b) increasing the ATP production³⁰, (c) stimulating antiinflammatory action²⁹, and (d) producing piezoelectric effects^{29, 31} from the induction of the aseptic inflammatory process¹⁰.

Acupuncture has specific action on muscles: (1) stimulating tendon and muscle spindles via proprioceptors³⁰, (ii) activating alpha and gamma motor neurons to regulate muscle tonus^{29, 32}. Other studies suggest that acupuncture may be helpful to treat fibrosis involving joints, tendons and muscles: (1) inducing piezoelectric effects by liberating alkaline phosphatase, which stimulates fibroblast activity and increases local metabolism, (2) causing temporary muscle distension followed by contraction, (3) improving muscle tone by increasing blood circulation and diluting toxins^{10, 30. In neurological disorders, besides peripheral stimulation, there is evidence that acupuncture helps nerve regeneration33, 34, 35, 36}.

KA treatment is based on synergism of acupuncture and conventional physiotherapy (kinesiotherapy), since acupuncture improves local blood circulation and muscle relaxation, and relieves of pain. KA treatment is carried out in three phases: Pre-Kinetic, Kinetic and Post-Kinetic.

In the Pre-Kinetic phase, needles are inserted in systemic points (body acupuncture)³⁷ or in microsystemic points (scalp acupuncture²⁶, ear acupuncture^{38, 39}, or hand acupuncture⁴⁰, or hand-foot acupuncture⁴¹ or wrist-ankle acupuncture⁴²). It aims to prepare the musculoskeletal system and to facilitate the response to the physiotherapy by interrupting pain-spasm-pain cycle.

In the Kinetic phase, microacupuncture (scalp acupuncture) is maintained while selected group exercises of physiotherapy were performed simultaneously. It aims to promote synergism to restore mobility. According to Chinese authors, simultaneous use of scalp acupuncture with exercises²² improved motor function during the treatment of hemiplegia^{23, 24}.

In the Post-Kinetic phase, placing mustard seeds on the ear acupoints of greatest sensitivity just after physiotherapy can maintain acupuncture stimulation for hours to weeks²⁷.

The purpose of this study was to determine the efficacy of KA to treat patients with MSD.

 

Methods

This study was carried out from 2000 to 2002 in the Acupuncture Research Clinic, Brazilian Academy of Oriental Science (ABACO), Sohaku-In Foundation for Oriental Medicine, Rio de Janeiro, Brazil. The patients (n=205; 147 women and 58 men, aged 16-96 years; Table 1) were volunteers. They were classified into 5 MSD categories: neck pain (58), upper back pain (30), low back pain (68), shoulder pain (28) and knee pain (21) (table 2).

An Ethical Committee (ABACO) approved the research protocols and the patients accepted them formally. The inclusion criteria in the selection of the patients were the presence of musculoskeletal pain and the difficult mobility. The exclusion criteria were psychiatric disorders, alcohol or drug users, endocrinopathies, pregnancy, cerebral trauma, tumour, infection and fracture.

After physiotherapy examination and TCM diagnosis, suitable Kinetic acupuncture treatments were performed following specific protocols.

In the Pre-Kinetic phase, each patient was treated with body acupuncture according to TCM and scalp acupuncture (YNSA)²⁶. In some cases, when these procedures were not successful, related and complementary techniques were used, such as electroacupuncture for severe pain^{44, 45}, cupping for muscle spasm and moxibustion in deficiency syndromes³⁷. Disposable stainless steel needles (0.2 x 40mm) were inserted in the body acupoints to a depth of 2-15mm. The acupoints were selected according to the TCM theory³⁷ (table 2). These points were combined with Yamamoto’s Kinetic points²⁶. Acupuncture needles were retained for 30 minutes, with a manual stimulation in each 15 minutes. For the scalp acupuncture, stainless needles of different length (5-7mm) were used. Needles were inserted and kept in the scalp acupoints (table 2), which were checked for stimulation with "hibiki" ²⁶ or "deqi"³⁷ (Table 2).

In the Kinetic phase, physiotherapy procedures were carried out with microacupuncture simultaneously, according to the condition of each patient. In joint stiffness or persistent segmental muscle spasm, tender spots were found and treated by Jiao’s technique²². Each treatment session lasted 30 minutes. According to the condition and response of each patient to the treatment, the physiotherapist used a selected group of physiotherapy exercises (Table 4). No medications or additional therapeutic exercises were prescribed during the trial.

In the Post-Kinetic phase, ear acupuncture was performed by placing mustard seeds, protected with micropore, on the ear acupoints according to each syndrome presented.

The patients were treated twice/week with the protocol as described above. The effects of treatment was evaluated by: (1) pain improvement (PI); (2) functional mobility improvement (FMI), (3) therapeutic satisfaction related to the return to the daily activities (TS); and (4) clinical improvement (CI). The PI was based on a Visual Analogue Scale (VAS) score⁴⁶ grading from 0 (no pain) to 100mm (worst possible pain). FMI and TS were based on a Numeric Rating Scale (NRS) from 0 (no improvement) to 100% (clinical resolution)⁴⁶. These parameters are supported by Neck Pain Questionnaire⁴⁷, Oswestry Back Pain Disability Questionnaire⁴⁸, DASH-Disabilities of the Arm, Shoulder and Hand Outcome Measure⁴⁹ and WOMAC Index⁵⁰. A 4-point verbal rating scale (FPVRS)²¹ was used to describe the patients’ clinical improvement as regards improvement of pain and functional mobility with daily living activities (DLA): (0) clinical resolution: no pain at rest, no pain with movement, no pain with DLA, (1) remarkable improvement: pain only with strong or forced movements, no pain with DLA, (2) simple improvement: pain and mobility improvement compared to before treatment, but pain and movement difficulty persist with DLA and (3) no improvement: no change in mobility or pain, pre-treatment functional persists after treatment. These parameters were assessed before treatment started and immediately after the end of the treatment.

Statistical analysis used t-test and ANOVA test by Graphpad Instat version 3.01⁵¹.

 

Results

Patient female:male ratio was 71.7:28.3% (2.5:1), with a mean age of 52.3±16.3 years; most were in the range from 41 to 60 years (Table 1).

MSD categories (Table 2) treated by KA were: neck pain 28.3, upper back pain 14.6, lower back pain 33.2, shoulder pain 13.7 and knee pain 10.2%. The most frequent diagnosis of pain was osteoarthritic (56.1%), of the lower back (the region most affected by this disorder; 19.5%), neck (16.6%), upper back (9.8%), knee (8.8%) and shoulder (1.5%).

Table 3 shows the acupoints chosen for KA treatment of the 5 MSD categories in the three phases. Table 4 shows the type of physiotherapy exercises used in Kinetic phase (Phase 2) according to the categories of pain disorder and mobility dysfunction. Besides of those standard exercises, massage also was used to resolve muscle nodules. To reduce pain and aid joint mobility, most of mobilization was performed below the pain tolerance limit in association to Jiao´s needling technique²².

Table 5 shows the number of KA treatments of MSD. The mean number of acupuncture sessions was 9.8±4.6; 9.8±3.7 to treat neck pain; 8.1±3.8 for upper back pain, 10.1±5.6 for lower back pain, 11.8±5.2 for shoulder pain and 8.5±3.1 for knee pain.

Table 6 shows the improvement of pain and functional mobility in the three stages of evaluation (pre-acupuncture, post-acupuncture and post-acupuncture plus physiotherapy). Table 6 also shows the mean and standard deviation (SD) of VAS score of pain improvement (PI) and NRS score functional mobility improvement (FMI) and therapeutic satisfaction related to the return to the daily activities (TS) of the patients with MSD treated by KA.

The global means and SD to PI, FMS and TS were 18.8±15.8mm, 77.3±0.15% and 89.5±0.06%, respectively. KA was effective in all MSD categories. In neck pain, the mean and SD improvement of the patients was PI=18.6±14.4mm, FMS=77.0±1.4% and TS= 89.0±0.07%. In upper back pain, PI was 16.3±12.2mm, FMS was 74.0±0.13% and TS was 90.0±0.05%. The patients with lower back had PI was 18.1±16.1mm, FMS was 80.0±0.16% and TS was 89.7±0.05%. While others with shoulder pain, the mean/SD of PI was 18.6±19.2mm, FMS was 81.4±0.16% and TS was 90.0±0.06%. Improvements in knee pain were less than in other groups: PI was 25.7±17.2mm, FMS was 67.9±0.21% and TS was 87.6±0.05% (Table 6).

There was statistically significant improvement in both PI and FMI among the evaluation stages: (1) pre-acupuncture and post-acupuncture (p<0.001), (2) pre-acupuncture and post-acupuncture plus physiotherapy (p<0.001) and (3) post-acupuncture and post-acupuncture plus physiotherapy (p<0.001). There was a statistically significant improvement in PI and FMI when the comparison was done in the first and last session for all patients of the 5 MSD categories (p<0.001) (Table 7 and Table 8).

Mean clinical improvement evaluated by FPVRS was 1.08; most (76.6%) patients had "remarkable improvement", 11.2% had "simple improvement", 9.3% had "clinical resolution" and 2.4% had "no improvement". Overall, 76.6% (157/205 patients) had spinal column disorders and 80.9% (127/157) of this subset achieved remarkable improvement. However, patients with knee pain had no statistically significant improvement in almost all stages of evaluation (Table 9).

 

Discussion 

David et al. (1998)¹⁵ reported that several studies have been performed to try to establish the current use of the acupuncture and conventional physiotherapy, since both methods are effective therapeutically¹⁵. Acupuncture has been reported to be superior to physiotherapy in the treatment of pain^{17, 52, 53}. However, further investigation is required to assess adequately the efficacy of acupuncture as a pain-relieving and movement rehabilitation modality^{25, 54}. Acupuncture combination with other therapies has been suggested^{22, 23, 24, 25, 26}. Clinical trials on the combination between acupuncture and physiotherapy are rare in literature^{27, 55}.

Our results suggest that KA significantly reduced pain intensity benefit and improved functional mobility in MSD patients. KA may be helpful to prevent fibrosis and stimulating motor activity, as described before¹⁰.

In general, cooling procedures (cryotherapy) are used in the Pre-Kinetic stage in physiotherapy^{56, 57. In KA Phase 1 (Pre-Kinetic), as an efficient preparation for physiotherapy, acupuncture was used to stimulate and warm the body, as thermography demonstrates}26. These effects are due to somatic sympathetic influences on musculoskeletal pain and modulation of sympathetic activity by acupuncture⁵⁸. In this phase, we used body acupuncture according to TCM principles⁵⁹ to treat the root ("ben") of the disease and scalp acupuncture-YNSA to reduce pain and motor dysfunction, because the clinical results are very fast and efficient to reduce the pain-spasm-pain cycle. After correct needling to induce the needling sensation - the "arrival of qi" ("hibiki" in Japanese²⁶; "deqi" in Chinese³⁷) - patients report that they feel warming, relaxing and anaesthetic effects during acupuncture stimulation. According to Kuo et al. (1994)¹³, blood flow at needled acupoints increases when the patient feels deqi (soreness, heaviness, numbness and paraesthesia). This often can be seen as an erythematous "flare" for 5-20mm around the responding acupoint. Increased blood flow may be one of the mechanisms accounting for Channel system responses during acupuncture. Therefore, patients are encouraged to do physiotherapy under this needling sensation in phase 2.

In KA Phase 2 (Kinetic), we suggest that acupuncture complements physiotherapy, due to the analgesic and muscle relaxing effects produced by scalp acupuncture. Because short needles are very light, have little drag and let the patients do their exercises freely without pain, we prefer short needles (5-7mm) for YNSA, although other authors^{22, 26} have used long needles (15 and 100mm, respectively).

In KA Phase 3 (Post-Kinetic), we suggest that the efficient action is due to prolonged stimulation of ear acupoints, which maintains analgesia and muscular relaxation. Because mustard seeds taped to the ear acupoints are easy to use and can be changed in every week, we used them instead of inserting semi-permanent needles.

In this study, KA was effective in spinal column disorders, in almost all the stages of the evaluation and better than in other MSD categories. According to White et al. (2004)⁶⁰, acupuncture can reduce neck pain and produce a statistically, but not clinically, significant effect compared with placebo. Kung et al. (2001)⁶¹ has suggested that acupuncture is a somewhat effective method for pain relief of patients with chronic myofascial pain syndrome in the cervical and upper back regions, but its pain relief may not last long enough.

In our study, clinical improvement in the period after acupuncture plus physiotherapy was not significant (p>0.05). However, important pain relief and improved mobility of neck and upper back regions were found after performing cervical mobilization⁶² in the Kinetic phase. Patel et al. (1989)⁶³ reported that meta-analysis showed that acupuncture was effective in low back pain. Molsberg et al. (1997)⁶⁴ concluded that real acupuncture is an important supplement in the management of chronic low back pain. Meng et al. (2002)⁵² verified that acupuncture was an effective, safe adjunct treatment for chronic low back pain in older patients. In our work, patients with low back pain had statistically significant results in almost all stages of the evaluation (p<0.001) (Table 9).

KA also was an effective treatment in shoulder pain. Guerra et al. (2003)²¹ reported that acupuncture alone gave clinical resolution (59.7%) among 201 patients with soft tissue shoulder pain. Dyson-Hudson et al. (2001)⁶ found that 88.9% of patients treated with acupuncture reported significant improvement in shoulder pain after the treatment, and 77.8% reported maintained improvement after the follow-up period. These findings related to chronic disorders that are difficult to cure, such as frozen shoulder, osteoarthritis and trauma sequels. In our study, most patients with this category of disease achieved "remarkable improvement" (60.7%, 17/58), but only a small number (2/28, 7.1%) had "clinical resolution" (Table 9).

Acupuncture has reported as an effective complementary treatment for patients with knee pain syndrome. Some authors also reported that acupuncture is an effective treatment to reduce pain and improve joint mobility in patients with knee pain syndrome^{65, 66}. Tillu et al. (2002) ⁶⁷ suggested that acupuncture may be used in the management of the advanced knee osteoarthritis. However, in contrast to other MSD categories, our results in the knee pain category failed to reach statistical significance for those parameters.

Also, because acupuncture is safe and effective in improving MSD symptoms that physiotherapy alone could not improve, this study suggests that acupuncture could be an adjunct therapy in rehabilitation.

 

Conclusion

While the use of acupuncture for MSD rehabilitation continues to increase, rigorous studies to examine its efficacy are needed before definitive recommendations regarding the application of this procedure. Our results strongly suggest that KA is effective and it may have a worthwhile role in the treatment of chronic conditions such as MSD in rehabilitation in order to improve pain intensity, functional mobility and performance daily living activities. These benefits are important for patients’ quality of life. Further research is needed to assess fully the efficacy of this treatment.

 

Acknowledgements 

The authors thank Dr Sohaku Bastos, OMD, PHD, Dr Elisa Bastos and Dr Liege Brunini from the Brazilian Academy of Oriental Science/ Sohaku-In Foundation for Oriental Medicine, and Dr Li Rui, OMD, PHD from Beijing University of TCM & Pharmacology for their help, support, encouragement and valuable suggestions through the course of this study, and Phil Rogers MRCVS, Dublin, for help in editing the manuscript.

 

References

1.      Hanada EY (2003). Efficacy of rehabilitative therapy in regional musculoskeletal conditions. Best Pract Res Clin Rheumt. 17:151-166.

2.      Magee DS (2000). Orthopedic physical assessment. W D Saunders Co.

3.      Cailliet R (1991). Shoulder pain. FA Davis Company.

4.      Lohya PB (1987). Role of acupuncture in locomotor disorders in: compilation of the abstracts of acupuncture and moxibustion papers – The First World Conference on Acupuncture-Moxibustion. Beijing, China; 62-63.

5.      Biella G, Sotgiu ML, Pellegata G, Paulesu E, Castiglioni I, Fazio F (2001). Acupuncture produces central activations in pain regions. Neuroimage 14:60-66.

6.      Dyson-Hudson TA, Shiflett SC, Kirshblum SC, Bowen JE (2001). Acupuncture and tager psychophysical integration in the treatment of wheelchair user’s shoulder pain in individual with spinal cord injury. Arch. Phys. Med. Rehabil. 82:1038-1046.

7.      Ernst E (2004). Musculoskeletal conditions and complementary/alternative medicine. Best Pract Res Clin Rheumatol. 18(4):539-56.

8.      Keuler H (1998). Nurse to acupuncturist: a personal transition. Nurse Pract Forum;.9(4):202-8.

9.      Santos-Filho SD, Bastos SRC, Pereira FAO, Senna-Fernandes V, França Daisy, Guilhon S, Bernardo-Filho M (2003). An evaluation of scientific papers about acupuncture. J AusTrad Med Soc. 3(4):1-3.

10.  Draehmpaehl D, Zohmann A (1998). Akupunktur bei hund und katze-wissenschaftliche grundlagen und praxis. Enke Ferdinand.

11.  Wu Y, Shen Q, Zhang Q (1992). The effect of acupuncture on high oxygen pressure-induced convulsion and its relationship to the brain GABA concentration in mice. Zhen Ci Yan Jiu. 17(2):104-9.

12.  Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E (1998). Effects of acupuncture on the oxygenation of cerebral tissue. Neurol Res. 20 Suppl 1:S28-32.

13.  Kuo TC, Lin CW, Ho FM (2004). The soreness and numbness effect of acupuncture on skin blood flow. Am J Chin Med. 32(1):117-29.

14.  Litscher G, Nemetz W, Smolle J, Schwarz G, Schikora D, Uranüs S (2004). Histological investigation of the micromorphological effects of the application of a laser needle--results of an animal experiment. Biomed Tech (Berl). 49(1-2):2-5.

15.  David J, Modi S, Aluko AA, Robertshaw C, Farebrother J (1998). Chronic neck pain: a comparison of acupuncture treatment and physiotherapy. Br J Rheumatol, 37(10):1118-1122.

16.  Ene EE, Odia GI (1983). Effect of acupuncture on disorders of musculoskeletal system of Nigerians. Am J Chin Med. 11:106-111.

17.  Haslam R (2001). A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip: a randomized controlled trial. Acupunct Med. 19:19-26.

18.  Kerr DP, Walsh DM, Baxter GD (2001). A study of the use of acupuncture in physiotherapy. Complement Ther Med. 9(1): 21-27.

19.  Tukmachi ES (1999). Frozen shoulder: a comparison of western and traditional Chinese approaches and a clinical study of its acupuncture treatment. Acupunct Med. 17(1): 9.

20.  Wedenberg K, Moen B, Norling A (2000). A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy. Acta Obstet. Gynecol. Scand. 79:331-335.

21.  Guerra J, Bassas E, Andres M, Verdugo F, Gonzalez M (2003). Acupuncture for soft tissue shoulders: a series of 201 cases. Acupunct Med. 21:18-22.

22.  Jiao S (1997). Scalp acupuncture and clinical cases. Beijing, Foreign Languages Press.

23.  Kong YQ, Ren XS, Lu SK (1996). The acupuncture treatment for paralysis. Beijing/ New York, Science Press.

24.  Lo Chi-Kwong (1981). Nose, hand and foot acupuncture. Hong Kong Commercial Press Ltd.

25.  Sun KO, Chan KC, Lo SL, Fong DY (2001). Acupuncture for frozen shoulder. China. Hong Kong Med J; 7:381-891.

26.  Yamamoto T. (1998) Yamamoto new scalp acupuncture – YNSA. Tokyo, Axel Springer Japan Publishing Inc.

27.  Senna-Fernandes V, França D, Cortez C, Silva D (2003). Acupuntura Cinética: tratamento sistemático do aparelho locomotor e neuromuscular da face por acupuntura associada à cinesioterapia/ Kinetic Acupuncture: systematic therapy of face neuromuscular and locomotor system by acupuncture associated to kinesiotherapy. Fisioter Bras. 4(3):184-195.

28.  Pomeranz B (2001). Acupuncture Analgesia - Basic Research. In : Stux G, Hammerschlag R, editors Clinical Acupuncture – Scientific Basis, Berlin/ New York: Spring-Verlag, p.1-21.

29.  Athenstaedt H (1974). Pyrolectric and piezoelectric of vertebrates. Ann. New York Acad Sci. 238: 68-110.

30.  Silbernagl S, Despopoulos A (1991). Taschenatlas der physiologie. 4. Augleg, Georg Thieme, Stuttgart-New York.

31.  Auerswrald W (1982). 1^st Akupunktur naturwissenschaft? Neue chinesische grundlagenforschungen mit internationalen literaturangaben. Teil B: Zur Praxis der Akupunktur. Velarg Wilhem Maudrich, Wien-München-Bern.

32.  Deininger T (1992). Sind die therapiemethoden der traditionellen chinesischen medizin objektivierbar? vortrag anläßklich der verlnihung des bachmann-preises durch die deutsche Ärztegesellschaft für Akupunktur in Freudenstadt am 5.9.

33.  Chen YS, Yao CH, Chen TH, Lin JG, Hsieh CL, Lin CC, Lao CJ, Tsai CC (2001). Effect of acupuncture stimulation on peripheral nerve regeneration using silicone rubber chambers. Am J Chin Med. 29:377-385.

34.  Kong T, Fan T, Han X, Guo Z, Lei L, Zang J (1993). Electroacupuncture promotes the regeneration of different fibers in rat's tibial nerve Zhen Ci Yan Jiu; China 18:232-235.

35.  Samoilov NG (1991). Structure of skeletal muscles in combined conditions of denervation, physical load and laser acupuncture Arkh Anat Gistol Embriol; USSR, 100:81-85.

36.  Wei YE, Pei ZS (1988). Acupuncture promote regeneration of rat's peripheral nerve China. Zhen Ci Yan Jiu, 13:358-361.

37.  Cheng Xin-Nong (1987). Chinese acupuncture and moxibustion. 1^sted, Beijing, Foreign Languages Press.

38.  Nogier PMF (1972). Treatise of auriculotherapy. Maisonneuve, Moulins-les-Metz.

39.  Huang LC (2001). Auricular treatment – formulae and prescriptions. Auricular medicine international research and training centre. Florida.

40.  Tae YW (2001). KHT-koryo hand therapy: Korean hand acupuncture 2^nd revised edition. Eum Yang Mek Jin Publishing Co. Seoul, Korea.

41.  Park JW (1999). Sujok therapy. vol.1. Moscow: Onnuri - Sujok Academy Publishers.

42.  Zhou QH, Ling CQ, Zhang XS (2002). Wrist-ankle acupuncture. Publishing House of Shanghai University of Traditional Chinese Medicine, Shanghai, China.

43.  Zhu MQ (1992). Zhu´s scalp acupuncture. Hong Kong, San Francisco, California: 8 Dragons Pub.; Chinese Scalp Acupuncture Centre of USA.

44.  Bastos RS (1993). Tratado de eletroacupuntura – perspectivas científicas, teoria e prática Rio de Janeiro: Numen.

45.  Han JS (2001). Opioid and antiopioid peptides: a model of yin-yang balance in acupuncture mechanism of pain modulation. In : Stux G, Hammerschlag R, editors Clinical Acupuncture – Scientific Basis, Berlin/ New York: Spring-Verlag. p.51-68.

46.  White A (1998). Measuring Pain. Acupunct Med.16(2)

47.  Leak AM, Cooper J, Dyer S, Williams KA, Turner-Stokes L, Frank AO (1994). The Northwick Park neck pain questionnaire, devised to measure neck pain and disability. British Journal of Rheumatology. 33: 469-74

48.  Fairbank JCT, Couper J, Davies JB, O’Brien JP (1980). The Oswestry low back pain disability questionnaire. Physiotherapy. 66: 271-3.

49.  Hudak PL, Amadio PC, Bombardier C (1996). The Upper Extremity Collaborative Group (UECG): Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). Am J Ind Med. 29:602-608.

50.  Bellamy N, Buchanan WW, Goldsmith CH (1988). Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. Journal of Rheumatology. 75: 1833-40.

51.  Graphpad Software, INC. GraphPad 3.01. Copyright© 1992-1998.

52.  Meng CF, Wang D, Ngeow J, Lao L, Peterson M, Paget S (2002). Acupuncture for chronic low back pain in older patients: a randomized, controlled trial. Rheumatology. 30:137-148.

53.  König A, Radke S, Molzen H, Haase M, Müller C, Drexler D, Natalis M, Krauss M, Behrens N, Irnich D (2003). Randomised trial of acupuncture compared with conventional massage and sham laser acupuncture for treatment of chronic neck pain - range of motion analysis. Z Orthop Ihre Grenzgeb.141(4):395-400.

54.  Jin D, Li Z (2003). Acupuncture and the elevation manipulation of massage for treatment of frozen shoulder. J Tradit Chin Med. 23(3):212-3.

55.  França D, Senna-Fernandes V, Cortez C (2004). Acupuntura Cinética como efeito potencializador dos elementos moduladores do movimento no tratamento de lesoes desportivas / Kinetic Acupuncture as potential effect of movement modulation elements in treatment of sport injuries. Fisioter. Bras. 5(2):111-118.

56.  Kitchen S, Bazin S (1996). Clayton’s Electrotherapy. 10^th ed. W.B.Saunders Company Ltd.

57.  Swenson C, Swärd L, Karlsson J (1996). Cryotherapy in sports medicine. Scand J Med Sci Sports. 6:193-200.

58.  Thomas D, Collins S, Strauss S (1992). Somatic sympathetic vasomotor changes documented by medical thermographic imaging during acupuncture analgesia. Clin Rheumatol. 11(1):55-9.

59.  Geng JY, Su ZH (1990). Practical Traditional Chinese Medicine and Pharmacology - Basic Theories and Principles. Beijing, New World Press.

60.  White P, Lewith G, Prescott P, Conway J (2004). Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Comment In: Ann Intern Med. 141(12):957-8.

61.  Kung YY, Chen FP, Chaung HL, Chou CT, Tsai YY, Hwang SJ (2002). Evaluation of acupuncture effect to chronic myofascial pain syndrome in the cervical and upper back regions by the concept of Meridians. Acupunct Electrother Res. 27(1):59.

62.  Coppieters MW, Stappaerts KH, Wouters LL, Janssens K (2003).The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. J Orthop Sports Phys Ther. 33(7):369-78.

63.  Patel M, Gutzwiller F, Paccaud F, Marazzi A (1989). A meta-analysis of acupuncture for chronic pain. Int J Epidemiol. 18:900-906.

64.  Molsberg A, Bowing G (1997). Acupuncture for pain in locomotive disorders. Critical analysis of clinical studies with respect to the quality of acupuncture in particular. Schmerz. 11:24-29.

65.  Bizzini M, Childs JD, Piva SR, Delitto A (2003). Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 33:2-20.

66.  Jensen R, Gothesen O, Liseth K, Baerheim A (1999). Acupuncture treatment of patellofemoral pain syndrome. J Alten Complement Med. 5:521-527.

67.  Tillu A, Tillu S, Vowler S (2002). Effect of acupuncture on knee function in advanced osteoarthritis of the knee: prospective , non-randomized controlled study. Acupunct Med. 20(1):19-21.