The DO Points

One thing that emerged from our reviews was a clustering of points on the hand used (separately) to treat pain in the heel, usually on the contralateral side.  I have grouped these together, as the Diagonally Opposite points (DO points for short).  They are illustrated above.

A significant subgroup of our sources used these points, all from China, yet quite disparate in their rationales.  Some simply say “use upper for lower”; e.g. Chen 1 used SI6; Liu 2 used PC7; Ouyang 3 used “corresponding points on the palm” without giving details.

Some go with the notion of specific efficacy.  Heel pain is given 4 as a specific indication for using the points Muguan and Guguan (a pair of points located approximately where I have indicated on the diagram, and located by finding tenderness).  Zhang et al 5 hypothesise that “PC7 had a better effect than LI4 in relieving pain due to plantar fasciitis” and claim to have demonstrated that “acupoint PC7 has a specific effect for treatment of plantar fasciitis …”

Others apply the ‘principle of opposites’ in terms of meridian theory, in a variety of ways:

  • Reaves6 suggests HT8 as “shaoyin corresponding point” although he doesn’t say what it is corresponding with. I wonder why this point, rather than HT7?
  • Nie et al7 also invoked Shaoyin, but then used different logic (along the lines of: Bone pain – Kidney – Leg Shaoyin – Arm shaoyin – branches to Pericardium) and recommended a “newly discovered” point, Zhangen.
  • The connection between KI, BL and SI via Taiyang is invoked in papers by Gao 8 and by Feng 9, leading to the use of SI3, which they choose (as the command point for GV) to raise yang in cases of deficiency.
  • The Yangqiao meridian was given 10 as a rationale for choosing GB20 (because Yangjiao “originates in the heel” and GB20 is the “corresponding point” to the heel). As the command points for Yangqiao are BL62 and SI3, I might have expected this combination to have been used, but this has not appeared in the research to date.
  • I would like to add Taiyin into the mix, from my own experience. When I had PF, I had a trigger point on the SP meridian (Leg Taiyin) in Abductor hallucis, and the point of most tenderness on the hand was on the LU meridian (Arm Taiyin) near LU10 (RC point on the diagram).

This ‘principle of opposites’ was perhaps first articulated in the Ling Shu as “use upper for lower” (or vice versa) but its intuitive use is widespread today among acupuncturists of all schools, in my experience.  How can we build on this?  How should we choose between these points, in any given case? 

Hopefully, if a pattern differentiation has been done for the individual patient, a clear choice might be apparent.  But that is not what was done in the research reviewed. Instead a categorical approach was taken, where the approach is generalised to a cohort of patients shoe-horned into a diagnosis.

I wonder – are there safe generalisations we could make?  We could debate finer points of Shaoyin v Taiyin v Yangqiao but maybe we don’t need to.  Zhang et al 5 introduce the idea of anatomical mirroring of the heel in the hand.  This brings to mind Sherrington’s classic ‘The Integrative Action of the Nervous System’. 

We know that locomotory reflexes are organised so that the movements of opposite limbs are coordinated (as the right leg flexes, the left leg and right arm extend, and so on), so I wonder if a similar pattern underlies our sensory pathways too.  Could it be that a pain in the heel is somehow related to a change in the sensory function of the ‘heel of the hand’?  And that sensory input on the hand could influence (in some specific way) pain pathways from the heel?  I have not seen anything published on this; have you?

Following this hypothesis, one might expect to find physiological changes to help identify the most useful points, such as electrical conductivity, or localised hypersensitivity.  Tenderness of points is often given as a rationale for choosing them. 

So what is the bottom line?  For practice: there are some tactics that fit naturally into certain strategies:

  • If you must stick to EBM, the DO point to consider is PC7.
  • If using the local Ashi, search for tender points also at the ‘heel of the hand’ in the vicinity of Zhanggen, Muguan or Guguan.
  • If you found tender points along the SP meridian, or a trigger point in Abductor hallucis, consider Taiyin and look for a tender point near LU10.
  • If you are sure the KI meridian is involved and are using KI3, you might consider HT8 as a distant point along the Shaoyin meridian.
  • If working with Yangqiao, using BL62, then adding the other command point SI3 may enhance the effect, particularly if there is a need to raise KI yang.
  • SI3 also makes sense as a distant point along Taiyang, in combination with BL62 or, indeed any other BL points on the leg.

Finally, here are some suggestions for research projects:

  • Mapping tenderness of DO points in patients and controls would be an interesting study.
  • Similarly, mapping other parameters could be useful, such as: electro-conductivity, thermography or the ‘active points test’ 11.
  • It may be tempting to design an RCT to compare the effectiveness of these points against one another but I would be wary of the assumption that any single point is ‘the’ point for heel pain. Please remember that patients vary and these DO points traditionally have different functions; then be very clear about what hypothesis you are testing.
  • If the aim is to build on Zhang et al’s work on PC7, any of the other DO points might make a better comparator than LI4. Perhaps one could compare PC7 with whichever point was indicated by tenderness in each patient.  And, of course, it would be ideal to include a proper no-treatment control group (waiting list, or dummy needling) to give us a measure of natural remission, etc.

References:

  1. Chen C. Using Yanglao (SI6) as the main acupoint to treat heel pain by acupuncture. Zhong Guo Zhen Jiu 2002; 22: 400.
  2. Liu ZA. Hand needling treatment for painful heels: a clinical observation of 20 cases. International Journal of Clinical Acupuncture 1999; 10: 95-97.
  3. Ouyang Q and Yu G. Acupuncture at upper limb points for pain of the sole: a report of 73 cases. International Journal of Clinical Acupuncture 1996; 7: 499-501.
  4. Borten P. Tung Points and Unique Applications of Points on the 14 Main Channels as Presented by Wei Chieh Young, Richard Tan & Steven Rush, http://peterborten.com/wp-content/uploads/2012/12/Tung-Point-Compilation1.pdf (accessed 26/2/14).
  5. Zhang SP, Yip TP and Li QS. Acupuncture Treatment for Plantar Fasciitis: A Randomized Controlled Trial with Six Months Follow-up. Evid Based Complement Alternat Med 2009; 23: 23. DOI: 10.1093/ecam/nep186.
  6. Reaves W. Plantar Fasciitis: Acupuncture Treatment of Heel Pain., https://www.jadeinstitute.com/posts/plantar-fasciitis-acupuncture-treatment-of-heel-pain/   (2015, accessed 14/05/2021).
  7. Nie H. Puncturing Zhanggen in treating 106 cases of calcanodynia. International Journal of Clinical Acupuncture 1993; 4: 201-202.
  8. Gao H. Analysis of 30 cases of heel pain in middle age and elderly patients by acupuncture in HouXi (SI3) acupoint. J Henan Univ (Med Sci) 1998; 17: 54-55.
  9. Feng J. Acupuncture treatment of heel pain using Houxi [SI3] point. Ch Ac & Moxib 2002 22: 400
  10. Chen SC. Needling Fengchi in treatment of pain in the heel: a report of 17 cases. International Journal of Clinical Acupuncture 1996; 7: 209-210.
  11. Marcelli S. The Active Points Test. London: Singing Dragon, 2015.

2020 overview

While I was trying to complete the book, I kept getting interrupted by new publications coming out, stimulating new lines of thought.  I had to draw a line somewhere, so I chose the end of 2019.  Now 2020 is complete, it seems appropriate to look back at what was new during that year.  There were four RCTs comparing various types of acupuncture or dry needling with other interventions.  I will feature each of them on separate pages in the AcuPHPedia section of the site; here are some general observations. 

True to form, we’re keeping up the tradition of heterogeneity.  Although all four are RCTs, and two are in the same journal, they have little else in common.  Two of them use DN to MTPs but even they use different rationales, different techniques and different muscles!

The conclusions, in short, are:

  • Dry needling MTPs in the calf gave added benefit to patients receiving Extracorporeal Shock Wave Therapy (ESWT) [commentary]
  • Percutaneous Needle Electrolysis (PNE) gave no added benefit to DN of MTPs [commentary]
  • Adding EA to manual needling of Ashi, KI3, BL60 and BL57 gave no added benefit [commentary]
  • Electroacupuncture with Warm Needling (EAWN) gave significant benefit compared to waiting list [commentary]

 I would like to pick up on the issue of effect sizes.

One of the recent studies (Ho et al) gives us a comparison between the treatment group and a waiting list group.  This is the first to have done so, of all publications I have seen on this subject.  It gives us some insight into the natural history of the condition, and a baseline against which to compare the outcomes of other studies.  Of course, they are not directly comparable, as they come from different populations, in different contexts, yet it is possible to form an impression. 

To do so, setting aside the variety of tools and time-frames used, I have focussed on a single measure that they all have in common (morning/first-step pain VAS) and a narrow time frame (baseline to end of treatment/4 weeks).  From the data available, I have extracted the group mean scores (ignoring their variance) and calculated the percentage improvement.  This is what we get:

(in both charts, the papers are identified by initials, as follows:   B = Bagcier & Yilmaz; A = Al-Boloushi et al; W = Wang et al; H = Ho et al.)

What strikes me here is the overall similarity.  All of the interventions, assessed after 4 weeks, were associated with improvements of about the same magnitude (50% improvement +/- 10).  This is in clear contrast to the waiting list group that showed no improvement, which seems to suggest that the improvements seen are indeed related to the interventions used.  Now we need more studies with waiting list or placebo controls, to back this up.

Please remember this is indicative, not definitive; you need to view the individual papers, to appraise the results properly and to see them in context (e.g. long-term follow-up, etc).

So now let’s look at what new questions have arisen.

1 – Combined strategies. Dry needling to gastro-soleus MTPs gave significant added benefit to an ESWT/cold/stretching/orthosis protocol; how should we build on this?

a – Was the benefit of DN due to facilitating stretching, as intended in this study, or could it have been due to deactivation of MTPs, regardless of stretching?

b – Was the benefit additive, or would DN have achieved the same outcome (or even better) without the ESWT? An earlier study by Eftekhar-Sadat, (needling 2-4 gastro-soleus MTPs, weekly for four weeks) the reduction of pain VAS at 4 weeks was 68.3% – a comparable result, without the use of ESWT.

2 – Interventions at the Ashi point. In the ESWT group the reduction in VAS was about 50%.  This is perhaps better than the results of steroid injection (e.g. 45% in Li et al) but seems rather less than the reduction with various other interventions:

This raises the question whether these differences are real, or are due to confounding contextual variables. I guess only direct comparisons will tell us for sure.

3 – EAWN. The paper by Ho et al clearly shows significant benefit of EAWN, compared to waiting list.  However, the effect size is small (42%) relative to other studies and this procedure relatively laborious.  Also, there are many practitioners who don’t use moxibustion (or are not allowed to, in some hospital contexts).  They might ask:

a – what are the relative benefits of different components of this intervention? Is it necessary to include needling, electrostimulation AND warming, or could similar benefits be obtained with less labour-intensive approaches?

b – Are there sub-groups of patients (e.g. with Cold syndromes) for whom moxibustion is particularly indicated?

4 – Practitioner attitudes to invasiveness of interventions. Here is an idea for psycho-sociological research: why do some practitioners (and, indeed, some patients) choose interventions that are inherently painful and invasive, given the existence of benign alternatives?  Have they not heard that ‘less is more’?

Anachronistic categorisations

Following on the theme of KI3, let’s take a look at one of the favourite rationales given for using it: the zang-fu concept that ‘Kidney governs Bone’. 

Viewed from this perspective, PHP is seen as pain in the bone (“calcanodynia”) or pain caused by bony growths (calcaneal spurs).  Within this frame of reference, some authors reported on the presence or absence of spurs on X-ray and some even went so far as to use the disappearance of spurs from X-rays as an outcome measure.  With this diagnosis, in zang-fu theory, it follows logically to address Kidney dysfunction. 

“Calcanodynia is mostly due to bone disease resulting from Kidney Deficiency … .” 1

However, there seems to be consensus these days that bony pathology is NOT the cause of heel pain 2.  Many sufferers have no spurs and, conversely, many people with spurs on X-ray have no pain.  Instead, the problem is explained in terms of soft tissues: pathology in the fascia, or trigger points in the muscles.  In this case, perhaps we should invoke the TEAM notion that ‘Liver governs Sinews’ and expect Liver dysfunction rather than Kidney.  Some practitioners are already aware of this, e.g. ‘Duncan’ in the BAcC forum, said: “people I have treated have more often had a liver pattern” 3.

The thing is you only find patterns if you perform syndrome differentiation.  Many of the papers we found did not do so.  Instead, they used a Categorical approach (as defined in my book), which magnifies the problem of using possibly erroneous nosology. 

Usually, in RCTs and in case series studies, the problem of heel pain is slotted into the category of ‘kidney deficiency’ and treatment protocol is predefined on that basis.  This is done before subjects are recruited into the study.  Then the criteria for inclusion are based on an abstract set of characteristics, such as the defining features of PF.  The pattern differentiation of each individual is never done, so we cannot know whether they had ‘kidney deficiency’ at all.  If they did not, clearly their treatment would be suboptimal and the research invalid. 

Maybe there is a subset of PHP sufferers who DO have ‘Kidney deficiency’, and others who have Liver patterns, or mixed patterns, or something else, such as traumatic stagnation.  We’ll never know, until researchers pay attention to the realities in front of them, rather than abstract categories.

Of course, there are issues around the reliability and reproducibility of TEAM diagnoses4.  This in itself deserves further study and I suggest that PHP offers an ideal focus for such studies.  It seems to me that this condition is inherently less complex than (e.g.) dysmenorrhoea, which may make it simpler to explore.

The problem of outdated categorising terminology also affects biomedical approaches to PHP.  The terms ‘fasciitis’ still prevails, presumably due to normative pressure and institutional inertia, in spite of general understanding that degeneration, not inflammation, is the relevant pathology (except perhaps in some acute cases).  Indeed there may be no local pathology at all (as indicated by relevant scans) if the PHP is related to the presence of MTPs further up the leg.

Yet there are many practitioners still recommending the use of ice, or NSAIDs, or injected corticosteroids, as strategies to counteract inflammation.  How are these interventions justified in the absence of inflammation?  What harm might they be doing?  Some (even the guy who originally promoted it, Gabe Mirkin 5) argue that the use of cold (‘icing’) is likely to be harmful 6-8.  Yet, a glance at social media shows that PF sufferers are still being advised to do it.

From a TEAM perspective, the patient with PHP is more likely to have a ‘cold’ condition (Cold Bi, or Yang deficiency) particularly after the acute phase.  In this case coldness would be expected to make the pain worse, and warming treatment (moxibustion) may be indicated.  This also makes physiological sense – the application of warmth will enhance local blood flow, which in turn will aid tissue healing. 

So which approach is right?  I contend that we do not know yet and I would not expect that one approach fits all.  We need to conduct patient-centred research to find out. 

References

  1. Nie H. Puncturing Zhanggen in treating 106 cases of calcanodynia. International Journal of Clinical Acupuncture 1993; 4: 201-202.
  2. Kadakia AR. Plantar Fasciitis and Bone Spurs, https://orthoinfo.aaos.org/en/diseases–conditions/plantar-fasciitis-and-bone-spurs/ (2010).
  3. Laura R and others. Plantar Fasciaitis [sic] – any experience!, Practitioners’ forum, British Acupuncture Council [no longer available] (2007) .
  4. Schnyer RN, McKnight P, Conboy LA, et al. Can Reliability of the Chinese Medicine Diagnostic Process Be Improved? Results of a Prospective Randomized Controlled Trial. J Altern Complement Med 2019; 25: 1103-1108. DOI: 10.1089/acm.2019.0260.
  5. Mirkin G. Why Ice Delays Recovery, https://www.drmirkin.com/fitness/why-ice-delays-recovery.html (2015).
  6. Dubois B and Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med 2020; 54: 72-73. DOI: 10.1136/bjsports-2019-101253.
  7. Mannix L. Putting ice on injuries could be doing more damage than good, https://www.theage.com.au/national/putting-ice-on-injuries-could-be-doing-more-damage-than-good-20191011-p52zw0.html (2019).
  8. Wood Z. To Ice Or Not To Ice An Injury?, https://www.physio-network.com/blog/ice-for-acute-injury/ (2021).

The many facets of Taixi (KI3)

Recently I was alerted by a tweet to a paper1 on the ‘heterogeneous effect of Taixi (KI3)’ showing that fMRI responses to needling this acupoint in healthy volunteers were different in older and younger age groups. 

I don’t find this surprising.  One of the key findings reported in our earlier publications2 was heterogeneity in all aspects of the studies, and KI3 was no exception.  It was a commonly used acupoint in the treatment of Plantar Heel Pain syndrome (PHP, aka plantar fasciitis or heel spur syndrome).  Although we were looking only at the treatment of this single condition a variety of different reasons were given for choosing KI3.  Which of the following list, do you think?

 

·         Evidence in journal
·         Textbook recommendation
·         Analgesic point
·         Proximity of point to affected area
·         Point on local meridian
·         Expel Wind
·         Clear Heat
·         Dispel Cold
·         Circulate Blood
·         Move stagnant Qi 
·         Tonify deficient Qi
·         Anchors Qi
·         Replenish KI Yin
·         Tonify KI Yang
·         The Eight Principles
·         No reason
·         All of the above
·         None of the above

 

 

  

Congratulations if you chose ‘All of the above’; this is indeed what we found. 

While, on the face of it, using KI3 in the treatment of PHP may appear simple, it is seen to be far from it when you stand back and take a broader view.  The complexity is compounded when you take into account:

·         the variety of stimulus methods used (needling, electroacupuncture, TENS, moxa, laser, magnet)
·         the other points used together with KI3 and 
·         the rationales underpinning those choices.   

You might think all this heterogeneity reflects a bespoke approach to a lot of different patients and this is partly true; however, in about ¾ of the studies the approach was prescribed in advance, with no concession to the individuality of the subjects in the trials.  Therefore the heterogeneity is inherent in the models in use, not just in the patients.

Does this matter?  From the point of view of a postmodern practitioner using a bespoke, exploratory approach (as I described in Section 3 of my book) the answer is no.  But many researchers seem to start from the assumption of homogeneity; some even make it explicit: “heel pain of plantar fasciitis is a homogenous pathological condition characterized by local inflammation”.3  Yet, clearly, this assumption is not supported by the evidence.  My concern is that it is continuing to undermine the research effort.

The problem is that the heterogeneity is hidden.  Researchers searching for a simple ‘truth’ design their studies to reduce it as much as possible, by means of inclusion and exclusion criteria and statistical generalisations.  Then others come along and generalise further with systematic reviews and even meta-analyses.4  The ‘truths’ thus constructed are then enshrined in official guidelines for evidence-based practice, as if they are uniformly relevant to real patients. 

The paper by He et al is a reminder that we should adopt these guidelines with caution.  It alerts us to the existence of variants, even in the healthy population; I have proposed that the population of PHP patients is probably divided along several dimensions (e.g. age, duration of complaint, internal v external aetiology, etc).  This has significant implications for practice and I have made recommendations for research to explore this.  I will come back to that point in a future blog.

Meanwhile the recent study leaves us with more questions than answers:

·         How would patients with PHP compare to normal, in fMRI scans?
·         Would different subgroups emerge?
·         What differences would be seen in fMRI responses to other interventions at KI3 (laser, moxa, etc)?
·         What differences would be seen in fMRI if other points were stimulated together with KI3?

References

1.                      He L, Chen G, Zheng R, et al. Heterogeneous Acupuncture Effects of Taixi (KI3) on Functional Connectivity in Healthy Youth and Elder: A Functional MRI Study Using Regional Homogeneity and Large-Scale Functional Connectivity Analysis. Neural Plasticity 2020; 2020: 8884318. DOI: 10.1155/2020/8884318.

2.                      Clark MT, Clark RJ, Toohey S, et al. Rationales and treatment approaches underpinning the use of acupuncture and related techniques for plantar heel pain: a critical interpretive synthesis. Acupunct Med 2017; 35: 9-16. DOI: 10.1136/acupmed-2015-011042.

3.                      Zhang SP, Yip TP and Li QS. Acupuncture Treatment for Plantar Fasciitis: A Randomized Controlled Trial with Six Months Follow-up. Evid Based Complement Alternat Med 2009; 23: 23. DOI: 10.1093/ecam/nep186.

4.                      He C and Ma H. Effectiveness of trigger point dry needling for plantar heel pain: a meta-analysis of seven randomized controlled trials. Journal of pain research 2017; 10: 1933-1942. 2017/09/02.  DOI: 10.2147/jpr.s41607.