16: Using the Integrative Neuromuscular Acupoint System for Acupoint Injection Therapy

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CHAPTER 16 Using the Integrative Neuromuscular Acupoint System for Acupoint Injection Therapy

INTRODUCTION

The purpose of this chapter is to present the Integrative Neuromuscular Acupoint System (INMAS) to healthcare professionals who have already used injection therapy for pain management.

In the late 1960s, traditional Chinese medicine (TCM) was experiencing an extraordinary period of development, and the leading direction of research in the field, sponsored by the Chinese government, was the integration of TCM with modern medicine. Many new methods were explored to improve the effectiveness of traditional needling and were referred to as “innovative needling-method therapy” (xin zhen liao fa). These new techniques included electrical acupuncture, scalp acupuncture, acupoint implant therapy (surgically implanting foreign material at the acupoints), acupoint tissue extraction therapy (surgically removing fatty tissue from the acupoints), and acupoint injection therapy. In addition, practitioners of Chinese folk medicine were using more than 80 types of needling methods such as eye, nose, wrist-and-ankle needling, and so on.

For injection therapy the Chinese doctors injected about 1cc of a vitamin solution (but not vitamin C, which creates a very painful reaction), and various Chinese herbal extracts at the location of acupoints, and they claimed very good therapeutic results. Like acupuncture anesthesia, this was developed as a move toward the integration of traditional Chinese and modern medicine.

In the United States, Dr. Janet Travell, without previous knowledge of Chinese acupuncture, discovered and published the patterns of pain trigger points in 32 skeletal muscles in 1952.¹ The locations of these trigger points basically matched most acupoint locations in the ancient Chinese system. Dr. Travell injected anesthetics (0.5% procaine in physiologic saline) into these trigger points to treat myofascial pain symptoms such as lower back pain. Today the solutions used for injection may include isotonic saline, procaine, lidocaine, Botulinum toxin A (BTA), corticosteroids, and other longer-acting local anesthetics. Some of these injected solutions have some myotoxic effects.

Both the innovative Chinese acupoint injection method and Dr. Travell’s system have their merits. INMAS is a simple and comprehensive method that integrates the Chinese acupuncture channel (meridian) system with Western neuromuscular understanding. All the 20 (or 21) injectable homeostatic acupoints (HAs) that are specified in INMAS match the major acupoints of the ancient 10 channels (meridians) (large intestine, small intestine, stomach, gallbladder, urinary bladder, liver, kidney, lung, spleen, and governor) as well as the major trigger points of the modern neuromuscular system.

THE BENEFITS OF INMAS FOR ACUPOINT INJECTION THERAPY

The Chinese acupoint injection system is based on the traditional concept of yin-yang balance and “channel (meridian) theory,” whereas Dr. Travell’s system focuses on intramuscular trigger points whose locations are based on modern pathology, anatomy, and physiology. INMAS combines the benefits of both because the majority of the 24 HA points are at the same time major channel (meridian) points and trigger points.

Of the 24 HAs that are specified in INMAS all but three are suitable for injection therapy, the exceptions being the facial HAs (H2 great auricular, H19 infraorbital, and H23 supraorbital), with H3 spinal accessory being a unique case requiring special caution on account of the lungs beneath. Note also that:

1. Symmetrical points are injected to prevent spasm in the antagonistic muscles

2. Distal points are injected for treatment of referred pain

INMAS AND CHRONIC MYOFASCIAL PAIN

The area to be injected should contain no damaged tissue, swelling, bruises, or scar tissue. Chronic myofascial pain usually develops around one or more HAs, and the location of these is a guide to the location of the other secondary tender points. Some of the HAs may also be related to referred pain.

For example, in patients with lower back pain, all the 7 HAs associated with the lumbosacral plexus may be tender: H14 superior cluneal, H15 posterior cutaneous of L2, H16 inferior gluteal, H22 posterior cutaneous of L5, H18 iliotibial, H11 lateral popliteal, and H10 sural. In addition to these major points, secondary tender points can develop around:

1. H15, if the pain is in iliopsoas, the lower part of latissimus dorsi, or multifidus in the L2 region

2. H22, if the pain is related to sacroiliac (SI) joints, L4 and L5 region, or multifidus in the S1 region

3. H16, if the pain is felt in the gluteal region in gluteus maximus or piriformis

4. H14, if the pain is felt in the iliotibial band, gluteus minimus, or medius

5. H18, if the pain is palpable in the iliotibial band down to the knee

6. H11 and H10 if the pain is felt in the leg

The HAs specified by INMAS can serve as a map for finding the secondary tender points because the INMAS system traces the interaction between the major nerve trunks and the major muscles of the neuromuscular system.

INMAS AND ACUTE MYOFASCIAL PAIN

Acute pain is a localized symptom, and wherever it occurs some tender HAs can be found around the painful area. Injection can be applied to the painful muscle(s) and the neighboring HAs.

If acute pain is accompanied by tissue injury, swelling, or ecchymosis (bruising), we suggest that injection should not be made into the injured tissue, but acupuncture needles can be used to reduce swelling and bruising, and to promote tissue repair.

TECHNICAL CONSIDERATIONS OF INJECTION THERAPY

Both acupuncture needling and injection share the same mechanism, which is to create healing-promoting lesions and a harmless temporary foreign body–immune reaction to treat myofascial pain. Injection needles are thicker than acupuncture needles so some technical safety factors should be taken into consideration.

Skin Cleaning

Injection needles make large lesions, so an aseptic area of skin should be carefully prepared for injection. Any common antiseptic can be used for cleaning the skin. Avoid any inflamed, swollen, or infected skin.

Bleeding

Injection may cause more bleeding than do the fine needles used in acupuncture. To avoid excessive capillary bleeding, patients can be advised to take vitamin C to decrease capillary fragility for 1 week before the injection. Patients also should not take any blood-thinning drugs such as aspirin for 3 days before the injection.

Needle Sizes

The purpose of the injection is to stretch the contracture inside the muscles, so the needles should be long enough to reach the depth where the contracture is situated. Thinner needles are less painful to patients, but they are liable to bend inside the muscles. Deep, thick muscles may unexpectedly contract and cause the needle to detach from the syringe if it is not firmly held. A large-diameter needle gives a better sense of tissue penetration and is therefore easier for the practitioner to use; however, the needling is more painful, so the practitioner has to find the appropriate diameter and length to suit the patient’s level of tolerance.

Injection Volume

The process of injection physically pushes the muscle tissue aside to stretch the contracted muscle fibers. The needling itself first breaks some muscle contracture and stretches the contracted muscle fibers, then the hydraulic tension of the injected liquid reinforces the muscle stretching. A large volume of injected liquid may create excessive tissue lesions and increase the chance of liquid being unintentionally forced into a blood vessel, and clinical experience shows that a volume less than 1 cc (1 ml) is both safe and effective, and reaches the right compromise between tissue healing and tissue destruction.

Commonly Used Solutions for Injection Therapy

Since the late 1960s Chinese doctors have used vitamins B1, B6, and B12 for injection into acupoints. U.S. doctors use isotonic saline; local anesthetics such as procaine, lidocaine, and other long-acting anesthetics; corticosteroids; BTA; and epinephrine. Some of these substances are more myotoxic than others.

Isotonic saline can be injected into the HAs for pain relief. A controlled, double-blind comparison between isotonic saline and a myotoxic, long-acting anesthetic (0.5% mepivacaine) showed that isotonic saline offered the same or even better efficacy than mepivacaine.²

Procaine is the least myotoxic among the local anesthetics and is hydrolyzed in the blood. A 1% solution is suitable for injection therapy. This anesthetic blocks nerve conduction by binding to the calcium sites of the cellular membrane of the neuron.

A 1% solution of lidocaine is also used for injection. This anesthetic is longer-acting than procaine but more toxic because it is fat-soluble and is metabolized primarily in the liver.

Corticosteroids are antiinflammatory agents. There is no known controlled study on the effectiveness of steroid injection in comparison with other injected substances, but repeated injections of steroids should be avoided due to known side effects such as atrophy of skin and subcutaneous tissue.

Patients should be told that they may experience loss of sensation for up to 30 minutes after injection.

In general, procaine and lidocaine are the least myotoxic when used at 1% or lower concentrations. Solutions stronger than 1% become significantly myotoxic. Dr. Travell recommended a procaine concentration of 0.5% in physiologic saline, and she found that higher concentrations gave no additional pain relief.³ Longer-acting anesthetics are more myotoxic without appreciable clinical advantage in treating myofascial pain. Local anesthetics at a lower concentration (0.25%) will selectively block small fibers, while higher concentrations will also block the larger A-δ (IIIb and IIIa) fibers.⁴

Local anesthetics definitely reduce the sensation of soreness and other discomfort immediately after injection. However, evidence shows that the efficacy of injection therapy in pain relief does not depend on any specific properties that these injected substances may possess, but rather on the stimulation effect of the needling used for their injection.⁵

Postinjection Maintenance

After injection the patients should not physically overload the injected muscles for a few days. Mild physical exercise such as walking would be appropriate for the first 3 days.

Avoiding Reactions to Needling

As with acupuncture, injection may cause a harmless but alarming reaction like a short syncope. This is completely preventable. The practitioner should inform patients that they should not be hungry or overfull at the beginning of treatment. It is better to eat no more than a light snack 1 hour before the treatment. If patients are physically exhausted, sweating excessively, very cold, or nervous, they should rest to regain their normal condition before having injections. Finally, patients should be positioned comfortably and securely. We suggest using a recumbent posture (supine, prone, or on the side). If the sitting position has to be used, patients should be well secured so that they will not fall if there is a syncope.

Syncope is most often seen in healthy male patients in their twenties, or female patients from 20 to 50 years of age, usually with lower blood pressure (110/70 or lower).

HISTOPATHOLOGIC EFFECT OF INJECTION THERAPY

A classic experiment using intramuscular injection in rats showed that injection of low volumes (1 cc or less) and low concentration (1% or less) caused only occasional, minor damage to muscle fibers. A temporary inflammatory reaction developed in 24 to 72 hours: a mild infiltration of neutrophils, lymphocytes, and macrophages was observed during this time. The damaged fibers was eventually phagocytized. No changes could be detected beyond 7 days.⁶ These established data match our clinical observations.

SUMMARY

INMAS provides a map for finding the most effective points for intramuscular injection for both chronic and acute myofascial pain. In addition, it is an easy and reliable procedure for restoring homeostasis, or yin-yang balance, which helps to restore general health as well as give local pain relief.

1 Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med. 1952;11:425-434.

2 Frost FA, Jessen B, Siggard-Anderson J. A control, double-blind comparison of mepivacaine injection versus saline injection for myofascial pain. Lancet. 1980;1:499-501.

3 Travell J. Temporomandibular joint pain referred from muscles of the head and neck. J Prosthet Dent. 1960;10:745-763.

4 Bekkering R, van Bussel R. Segmental acupuncture. In: Filshie J, White A, editors. Medical acupuncture: a Western scientific approach. Edinburgh: Churchill Livingstone; 1998:109.

5 Baldry P. Trigger point acupuncture. In: Filshie J, White A, editors. Medical acupuncture: a Western scientific approach. Edinburgh: Churchill Livingstone; 1998:39.

6 Pissolato P, Mannheimer W. Histopathologic effects of local anesthetic drugs and related substances. Springfield, Ill: Charles C. Thomas, 1961;40. 41, 60, and 71.

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