Combination Acupuncture and Cupping for Treating Adult Idiopathic Scoliosis

Abstract

Background: There is limited previous English-language literature on acupuncture's ability to treat idiopathic scoliosis. This report shows the potential effectiveness of a combination of acupuncture and cupping therapies to treat curvature progression and thoracic back pain in adult idiopathic scoliosis.

Intervention: A 34-year-old male veteran of the U.S. Armed Forces with thoracic back pain and muscle spasms originally presented to the chiropractic clinic at the Fargo Veterans Affairs Healthcare System, Fargo, ND. Per radiographs taken prior to the consultation, the chiropractor determined that the patient had an idiopathic right-convex scoliosis curve of ∼21°. Due to immobility of the thoracic spinal vertebra upon adjustment, he was referred to acupuncture care. After a clinical review, the acupuncturist hypothesized that a combination of utilizing acupuncture and cupping techniques would help relax the muscles along the thoracic spine, allowing correction of the patient's abnormal spinal curvature. Combination Traditional Chinese Medicine (TCM), using acupuncture with cupping therapy was given ∼2 times per week for several weeks, resulting in a total of 15 treatments.

Results: After 15 treatments, this patient's subjective pain decreased by 85%. Anecdotally, he reported “feeling a bit looser.” He continued to receive acupuncture and cupping treatments when his schedule allowed.

Conclusions: The combination therapy was effective for treating musculoskeletal pain but was inconclusive with respect to its ability to treat adult idiopathic scoliosis. More research is needed on the efficacy of TCM for treating adult idiopathic scoliosis.

Introduction

Idiopathic scoliosis is the most common type of spinal deformity of unknown origin and has a prevalence of more than 8% of adults over age 25.¹ The diagnostic criterion is a spinal curvature >10° on an anteroposterior (A/P) radiograph.² The curvature of a scoliotic spine can increase by 0.5°–2° per year. Adult idiopathic scoliosis typically is a continuation from adolescence but can also start in teenage years and continue into adulthood.³ The majority of adults with this condition are not disabled due to their symptoms and can manage their pain through over-the-counter medication, exercises, braces, or epidurals/nerve block injections.^2,3 For patients in whom these measures are not successful, surgical treatment might be recommended. An alternative approach to treating adult idiopathic scoliosis and managing musculoskeletal pain is acupuncture therapy.

Acupuncture is commonly used to manage pain throughout the world, although its ability to treat adult idiopathic scoliosis is still being determined.⁴ Research on acupuncture's ability to treat idiopathic scoliosis is in its infancy and has not been conducted on adults prior to this report, to the current authors' knowledge. A literature search, using the databases PubMed, ClinicalKey, and MEDLINE,^® using the keywords acupuncture and scoliosis resulted in a total of only 7 studies, none of which investigated acupuncture's effectiveness to treat adult idiopathic scoliosis.

Traditional Chinese Medicine (TCM), which includes acupuncture, is commonly used to address musculoskeletal pain and muscle tightness.⁵ Certain acupuncture-needle stimulation techniques can either tonify or sedate energy in meridians.⁶ It is believed that tonifying the areas of weak muscles and sedating the areas of overactive muscles can have a relaxing and balancing effect. TCM also includes cupping, a therapy that often uses fire inside of a glass cup to create a vacuum effect. This vacuum effect creates negative pressure on the areas of the body that it is applied to.⁶ Cupping is believed to increase blood and energy flow to the area cupped, relax muscles, and relieve pain.⁷

This case study evaluates the effectiveness of the combination of acupuncture with cupping and other TCM therapies to treat or halt the progression of the curvature of the idiopathic scoliotic spine by addressing the muscular imbalances of a patient's spine.

Case

Prior to being referred to acupuncture at the Fargo Veterans Affairs Health Care System (VA HCS), this 34-year-old male veteran of the U.S. Armed Forces was initially seen for chiropractic care to address pain in his thoracic spine that was affecting his ability to bend and sit. The patient's chief complaint was thoracic spinal pain. Anecdotally, he reported his pain to be “worse in the morning and alleviated later in the day,” with initial objective pain while stationary at 6/10 and upon bending at 7/10. He denied any trauma to the affected area. However, his duties in the U.S. Armed Forces required him to wear body armor daily, weighing ∼40 lbs. for long periods of time. Radiographs taken prior to his chiropractic care showed an idiopathic right-convex scoliosis of ∼21° (Fig. 1). The apex of the scoliosis was near the T-5 segment of the thoracic spine. The patient was unaware of his spinal curvature during his time in the military and prior to being treated at the Fargo VA HCS.

FIG. 1.

Radiographs prior and post acupuncture and cupping therapies. Initial radiograph showed a normal anteroposterior A/P thoracic spine view (left) 1 week prior to initial chiropractic consultation and before any interventions. Follow-up radiograph was taken after the fifteenth treatment with acupuncture and cupping therapy and showed A/P scoliosis (right). Preintervention Cobb angle was 21°; postintervention angle was calculated at 18°.

During the initial chiropractic consultation, the patient's thoracic-spine flexion was 20°, and his thoracic-spine extension was 5°, right-lateral flexion was 10°, and left-lateral flexion was 15°. Static palpation elicited pain over the right side of the T-5 segment. The patient objectively described his pain as “gripping and stiff” and reported that bending at the waist increased his pain near T-5/T-6. During the second and third chiropractic visits, the patient was adjusted for a spinal subluxation of the T-5 segment to the right and received 5 minutes of trigger-point therapy prior to adjustment. His objective pain was a 4/10 during both visits with no changes in range of motion. At that time, the chiropractor made the clinical decision to end the series of care due to the lack of movement in the thoracic spinal vertebra upon adjustment. He then referred the patient to acupuncture with the hope of relieving this patient's pain that was related to a muscle spasm in his thoracic spine due to the scoliosis.

After a clinical review, the acupuncturist hypothesized that a combination of acupuncture and cupping techniques would help relax this patient's muscles along his thoracic spine, thereby allowing correction of his scoliotic curvature. At this time, informed consent was signed by the patient to establish a case study. During a physical examination, tight, protruding, and tender muscles were discovered in the left upper-thoracic and right mid-thoracic regions. Specifically, the trapezius, rhomboid major, and rhomboid minor muscles were all taut and ropy upon palpation. Pain was also experienced by the patient upon palpation of these areas.

Acupuncture was performed on the patient, ∼2 times per week, for a total of 15 treatments. All needles used were 50-mm long and 32 Chinese gauge. During each treatment, the acupuncturist threaded the inner and outer Bladder meridian from C-7 to T-12 (acupuncture points needled were BL 11–BL 20, SI 14, and BL 41–BL 49). During threading, the acupuncturist inserted the needle transverse to transverse-obliquely 1–1.5 cun deep, aimed in the direction of the meridian flow, connecting the acupuncture points together.⁸ BL 11 (Dazhu, the Hui-Meeting point of Bones) was chosen for its use with diseases of the bone.⁸ The left BL 11 point was also a major Ah Shi, or tender point, on the patient.

Tonification techniques were used in the areas of muscle deficiency. These areas were on the right side of C-7–T-1 (on and superior to BL 11 Dazhu), and to the left of the largest scoliotic curve in the thoracic spine (T-4–T-19/BL 14 Jueyinshu–BL 18 Ganshu). Other acupuncture points of note were LI 4 Hegu (perpendicular insertion, 0.5-cun deep), SI 3 Houxi (perpendicular insertion, 0.25-cun deep), and BL 60 Kunlun aimed toward and connecting to KI 3 Taixi (see Fig. 2 for Bladder meridian points). During tonification, the acupuncturist inserted the needles into the deficient muscles, and then rotated clockwise with the thumb, slowly.⁶

FIG. 2.

Location of Bladder Meridian. Credit: Illustration reproduced from A Manual of Acupuncture⁸ by permission of the publishers: amanualofacupuncture.com

Sedation techniques were applied to muscles that were consistently tight and sore. When using sedation techniques, the needle was inserted into the tight, overactive muscles. The needle was then rotated counterclockwise, quickly.⁶ This technique was applied to 2 areas. One was to the right of the largest scoliotic curve in the thoracic spine (T-4–T-9/BL 14 Jueyinshu–BL 18 Ganshu). The other area was in the tight muscles near the largest scoliotic curve on the patient's upper left side (C-7–T-1, on and superior to BL 11 Dazhu).

Cupping was applied after removal of the needles to the areas of sedation (described above) to induce muscle relaxation, with the hypothesis that relaxing the indicated muscles would allow the spine to resume proper alignment. Cupping was utilized in 8 of the 15 total acupuncture treatments. Whether or not cupping was performed was determined by the time constraints of the appointment and the appearance of previous cupping marks. Cups remained stationary for 8 minutes at a time. Each cupping session was followed with a minute of t'ui na and the application of an herbal analgesic oil along the thoracic and lower cervical spine. T'ui na is a method of TCM massage and bodywork.⁸ On the days when cupping was not utilized, t'ui na was performed for a few minutes with a focus on relaxing the right side of the patient's mid-back and the left side of his upper thoracic and lower cervical areas.

Results

After 15 acupuncture treatments, the patient's follow-up radiographs were measured by the same VA chiropractor. He subjectively measured the thoracic spinal curvature to be 18° (Fig. 1). This was a potential reduction of 3° (14.29%) in the scoliotic curvature. However, this reduction could have been due to radiograph variation and observer calculation variability, as previous studies have found variations with single-observer measurements of up to 3.2°.⁹ The patient's self-reported pain since initiating acupuncture was 85% alleviated. Anecdotally, the patient also reported that “everything is feeling a bit looser” as a side-effect of his time spent on the acupuncture table.

Discussion

Adult idiopathic scoliosis with unknown origins usually begins during teenage years and can progress into adulthood.³ This patient was unaware of his condition prior to being seen at the Fargo VA HCS, which led researchers to believe that his time in the military could have increased the degree of his thoracic spinal curvature. In veterans, spinal deterioration is the leading cause of disability.¹⁰ The overall weight of the personal protective equipment (PPE, body armor and helmets) that troops are required to carry has increased over the past 20 years. This increase in weight could be correlated to the worsening rates of deterioration of the spinal column. In 2017, U.S. garrison troops carried an average of 27 pounds of PPE. Combat troops carry anywhere between 96 to 140 lbs. of PPE, with an average of 119 lbs. In 2003, the average combat load was 53–81 lbs. with an average of 67 lbs.¹¹ This is an average of a 67 lbs., more over the course of 14 years.

In the case of this veteran, he carried body armor that weighed 40 pounds alone. The military medical standards for enlisting states that soldiers can have a thoracic scoliotic curve of up to 30° (according to Cobb-angle measurement) as long as it is asymptomatic.¹² This patient did not have symptoms of pain until 7 months prior to being seen at the Fargo VA HCS.

The Cobb-angle measurement was used for the evaluation of the scoliotic curvature on this patient's A/P radiographs. This measurement was used to document curve progression initially with chiropractic care and after the combination TCM treatments. The Cobb angle is measured by taking the angle of lines perpendicular to the superior and inferior end plates of the most-angulated vertebrae involved in the scoliotic curve.¹³ The Cobb angle was calculated by the same VA chiropractor to avoid interobserver variations. It should be noted that the initial radiograph consisted of a normal A/P thoracic spinal view, and the follow-up radiograph consisted of an A/P scoliosis view. There was a slight difference in these 2 radiographs which could have increased the risk of intraobserver variations. This limited the ability to determine the effectiveness of acupuncture and cupping to decrease the scoliotic curvature.

This report added to the limited research available on acupuncture as a treatment option for managing adult idiopathic scoliosis. In addition, no previous literature was found on military body armor's effect on scoliotic curvature. Although this case study did not find conclusive evidence on the ability of combination TCM to treat adult idiopathic scoliosis, the potential decrease in this patient's adult idiopathic scoliotic curvature warrants a larger randomized controlled trial to understand the effectiveness of combination TCM therapies to treat adult idiopathic scoliosis.

Conclusions

This study demonstrated the effects of combination acupuncture and cupping therapy for a 34-year-old veteran of the U.S. Armed Forces with adult idiopathic scoliosis. While the overall pain of the patient was 85% alleviated, study of this patient did not yield conclusive evidence that the combination acupuncture and cupping therapies were effective for treating his curvature of the spine. For veterans, spinal deterioration remains the number-one disability.¹⁴ Future studies could help us understand fully how combination acupuncture and cupping therapies can help veterans.

Author Disclosure Statement

This material is the result of work supported with resources and the use of facilities at the Fargo VA Health Care System. The contents do not represent the views of the US Department of Veterans Affairs. No financial conflicts exist.

Funding Information

The authors received no specific funding for this work.