Medical Acupuncture

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Acupuncture Improves Flexibility: Acute Effect of

Acupuncture Before a Static Stretch of Hip Adductors

Medical Acupuncture

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Journal:

Manuscript ID:
Manuscript Type:

Complete List of Authors:

Original Article
15-Oct-2010

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Date Submitted by the

Author:

ACU-2010-0773.R1

Carvalho, Alessandro; Universidade Federal do Rio de Janeiro

Cabral, Leonardo
Rubini, Ercole

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Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Abstract

Background: Acupuncture has been used for many years to treat illnesses, and
seems to have benefits when combined with other interventions such as exercise,
though still little investigated. Objective: Investigated the acute effect of
acupuncture on traditional acupoints, local no-acupoints (adductor magnus muscle)
and sham acupuncture before static stretching exercise on the maximum range of
motion of hip abduction. Design, Setting, and Subjects:

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This study was a

randomized controlled trial carried out on 44 healthy and untrained undergraduate

students at a university located in Rio de Janeiro, Brazil. Intervention: Subjects

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were randomly assigned to four groups and receive 1 session with a acupuncture
treatment followed by 4 sets of static stretching of the hip abductors. Group 1 (G1)

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were treated with acupuncture in five points (acupoints) followed by stretching of

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the hip abductors (N=10). Group 2 (G2) had the acupuncture treatment in the
adductor magnus muscle (no-acupoints) and stretching of the hip abductors

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(N=12). Group 3 (G3) the control group, used a placebo acupuncture and

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stretching of hip abductors (N=10). Group 4 (G4) just the acupoints, with no
stretching (N=12). Main Outcome Measure: Maximum range of motion of hip
abduction was evaluated before and after intervention with a flexometer. Results:
There was a significant increase in the amplitude of hip abduction when measures
before and after the intervention were compared in G1 (p = 0.007; CI95% = -7.46
to -1.54) and G2 (p = 0.009; CI95% = -13.14 to -2.36). There was no significant
difference in the comparison between groups (p = 0.399). Conclusions: The
results have demonstrated that the accomplishment of an acupuncture application

Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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in acupoints and no acupoints before exercises of static stretching can generate an
acute significant increase on hip range of motion.

Keywords: Acupuncture, Range of Motion, Muscular Relaxation.

Introduction

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Acupuncture is a therapy that has been used by the ancient Chinese

Traditional Medicine (CTM) for approximately 2500 years, and has been practiced
in the West for a few decades, where it has become well-known for its analgesic

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and anesthetic effects and in the treatment of a certain number of orthopedic,

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rheumatic, respiratory and neurological diseases.1 According to CTM, there is a

network of meridians (jingluo) connecting functional organs in the human body.

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Acupuncture at specific acupoints along the meridians exerts therapeutic effects on

nearby and/or distant regions. The physiological effects is yet to be well explained 2

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and some studies have observed the interaction between the effects of

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acupuncture and physical exercise, showing that acupuncture appears to improve

exercise performance though the mechanisms of how it does so are not well
understood.2,3,4,5,6
Stretching is an activity included in most training programs7 and practiced by
professional atheletes and practitioners of recreational exercises for flexibility
training.

Some of the physiological effects of stretching in the musculoskeletal

complex are similar to those of acupuncture, mainly in relation to the decrease in

Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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pain perception and analgesia. The main physiological effects of muscular
stretching are the viscoelastic accommodation in the tendon-muscle unity,9,10,11
increase of tolerance to stretching,12,13 decrease of -motoneuron excitability and
that

of

1a

fibers,14,15,16

and

these

effects

generate

mechanical

and

neurophysiological responses of which the most commonly observed results are

muscular relaxation and gain in range of motion, induced by an increase in
nociceptors threshold and by a decrease in passive tension in the muscle. 17

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The analgesia caused by acupuncture seems to occur through the change

in the perception of pain, which is generated by the nociceptive inhibitory action in

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the spinal cord, as well as by the activation of several cortex areas, such as
somatosensory area, hypothalamus and limbic system.18,19,20 Some studies have

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observed the effects of acupuncture in the central nervous system (CNS) in areas

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such as the hypothalamus, nucleus accumbens, and descending nociceptive

structures.

18,21,22

A theory presented by Langevin (2001) about one of the

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traditional acupuncture techniques, the De-Qi, i.e. sensation of shock after

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inserting the acupuncture needle, showed this to be essential to the effectiveness

of acupuncture therapy, for it generates a biomechanical response which involves
the connective tissue.22,23 The sensation of the De-Qi seems to activate nervous
fibers, generating inhibition of pain in the spinal cord and in the brain.24,25

Both methods, acupuncture and stretching exercises, present similar

physiological effects in relationship of analgesia caused by nociceptive inhibitory
action. Our hypothesis is that acupuncture given prior to passive stretching of hip

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adductors will enhance abduction range of motion more than stretching exercises
alone.

This study aims to compare the acute effects of acupuncture on adjacent

traditional acupoints (LR 1, LR 3, LR 8, REN 2, GB 34), local no-acupoints
(adductor magnus muscle) and sham acupuncture before static stretching exercise
on the maximum range of motion of hip abduction.

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Materials and Methods

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Participants

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A convenience sample of 44 healthy male subjects aged of 18-45 years

were from the University Estcio de S were invited to participate in this study. The

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exclusion criteria included presence of orthopedic injuries in the lower limbs,

needle

phobia,

skin

lesions,

use

of

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anti-inflammatory

drugs,

nutritional

supplements or anabolic androgenic steroids. All subjects signed an informed

consent containing all information about the procedures, as well as possible risks
and discomfort involved in studies of this nature. The Committee of Ethics in
Research at University Estcio de S approved the study methods and
procedures.

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Medical Acupuncture

Study protocols

Subjects visited the laboratory twice and drawn randomly into four groups. The

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choice for each group was made through the drawing of lots (numbers) from a
previously sealed envelope.

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In their first visit, subjects were familiarized with the experimental treatment
according to the group to which they were assigned and a morphologic evaluation

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was conducted (Table 1). Measures taken were: stature (cm), body mass (kg), and

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skinfold thickness. From the measures of skinfold thickness, body density was
predicted through the chemical model of two compartments, using the equation

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proposed by Jackson and Pollock.26 After body density prediction, fat (%) was
determined by Siris equation. 27

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In the second visit the procedures were: (I) pre-test, which corresponds to
the measure of maximal hip abduction range of motion; (II) experimental treatment
(acupuncture); (III) post-test, the new measure of maximal hip abduction range of
motion being taken immediately after the treatment.

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All subjects in the four groups were eyes covered during the any
acupuncture treatment, in order to minimize the possibility of any kind of motivation
which might affect the results.

Experimental procedures

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In G1, as a pre-test, the measure of MRM was taken, and immediately

after that, the subjects receive treatment with acupuncture in five traditional
acupoints:

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Dadun (LR 1), located on the ungual lateral angle of the hallux;

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Taichong (LR 3), in instep, on the space between the first and second metatarsals,
1,5cun28 from the web between the toes; Ququan (LR 8), just superior to the medial

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end of the popliteal crease, in the depression anterior to the tendons of

semitendinosus and semimembranosus muscles; Qugu (REN 2), in pubic region,

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on the superior edge of the pubic symphysis , on the mid-line of the body. These

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four points give origin to an extra meridian called "Jue Yin Liver Tendinomuscular
Channel (Chanel of the Liver Tendon-muscle Energy). Besides these points, the
Yanglingquan (GB 34) was also selected. This acupoint located in the depression
anterior and inferior to the fibular head, and is traditionally recommended for
treatment of decreased joint mobility. Immediately after the acupuncture treatment,
subjects were given four sets of static stretching of the hip adductors, each lasting
30 seconds and having an interval of 1 minute between them. The post-test with a
new measure of MRM was performed immediately after stretching.

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In G2 the pre-test was done, followed by the acupuncture on no-acupoints,
then the static stretching of the hip abductor muscles, then the post-test. Five
needles were inserted along the muscular belly of the adductor magnus muscle
(bilaterally); the distance between the points was of 6 cm, starting from the point of
origin of the muscle up to the point of insertion, taking into consideration the
anatomical and morphological characteristics of the individual.

In G3, which was the control group, subjects had the pre-test and then

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received a superficial stimulus on the same no-acupoints used in G2, where the
needle was inserted in the skin and immediately taken off (Sham acupuncture),

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similar to the studies of Vincent et al30 and Goddard et al.

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Right after that

subjects were submitted to the stretching protocol and the post-test.

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In G4, subjects had the pre-test and then were submitted to a treatment in

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which the same acupoints used in G1, followed by a new measure of MRM (posttest), without the stretching exercises protocol.

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Acupuncture

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The acupuncture treatment was conducted on a mattress, at the same hour

of day, room temperature of 21 degrees Celsius. Individual disposable needles of
0.25x30 mm (HUA-TUO - Korea) were used. The trained acupuncturist conducted
all procedures. All acupoints selected were fixed according to muscle and bone
anatomic references, and the measures recommended by CTM theory.

Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Before

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insertion of needles, the skin was cleaned with 70% alcohol. The needles were
inserted perpendicularly, bilaterally, with stimulus of unilateral clockwise rotation for
attainment of the De-Qi18 and depth varying from 8 to 50 mm according to the
anatomic location of the points.

Stretching

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Static stretching of hip abductor muscles was done in the same position of

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the test for maximum range of motion (MRM). Four sets of stretching were done

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with the duration of 30 seconds3 each and an interval of one minute between them.
None of the subjects performed any kind of exercise involving the adductor

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muscles of the hip joint, from 24 hours preceding the beginning of the study to the
end of it.

Flexibility outcome measure

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Two flexometers (FL) (Fleximeter, Instituto Code de Pesquisas - Code

Institute of Research - Brazil) were used for the measure of joint range of motion.
Three trained evaluators applied the tests. The first evaluator performed the
maximum passive stretching on the subjects. The second and third evaluators

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were responsible for reading the amplitude of movement, in degrees, in the
fleximeters.

The FLs were fixed right below the head of fibula, having their faces placed
right below the tibial tuberosity. The subjects stayed lying with his back on the
ground, with the hip flexed at approximately 90 degrees, knees totally extended,
the gluteus and lower limbs leaning against the wall. Both FLs started from zero
degrees, which is the angle associated with the position in which the feet touch

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each other. The feet of subjects stayed united and in slight abduction, leading the
hip to a slight external rotation during the test (Figure 1). After putting the subject in

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the right position, the first evaluator calibrated the FLs to zero degrees and then
performed the stretching of the hip adductor muscles, pressing the subjects thighs

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down with the hands touching them right above the knees, preventing the knees

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from flexing (Figure 2). MRM was measured when the subject reported discomfort
(pain). This position was sustained for about three seconds, so that the evaluators

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could read the measure. The second and third evaluators took place on each side

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of the subject, reading the measures for each leg when the point of MRM of the hip
adduction was reached.

The final measures read on both FLs was added up, and the result was
considered the maximum range of motion. A pilot study performed with 45
volunteers showed that these measurement procedures have 95% limits of
agreement

of -10.1 to 17.3 degrees and high intraday reliability (ICC=0.91;

CI95%=0.80 to 0.95).

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Statistical Analysis

A paired t test was used to determine the effect of the treatment on the
amplitude of hip abduction, from pre to post-intervention situation. A one-way
analysis of variance (ANOVA) of the percent rates of change from the moment of
pre-intervention to the moment of post -intervention was used to determine the

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effects of the different types of treatment on hip range of motion. Tukeys post hoc
test was used when F was significant. All analyses were done by the statistic pack
SPSS v.13.0 (SPSS Inc., Chicago, IL, USA). The level of significance used was P

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0.05.

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Results

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In the intra-group analysis groups G1 (P = 0.007; CI95% = -7.46 to -1.54)

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and G2 (P = 0.009; CI95% = -13.14 to -2.36) showed significant differences from

pre to post-intervention. There was no significant difference from pre to postintervention in groups G3 (P = 0.115; CI95% = -12.39 to 1.59) and G4 (P = 0.079;
CI95% = -9.08 to 0.58) (Figure 3). The ANOVA showed no significant difference in
the delta (%) between the groups (P = 0.399).

Discussion

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The results have shown that, in an acute form, there was significant
difference in degrees of flexibility in hip abduction in subjects treated with static
stretching preceded by acupuncture either in acupoints (G1) and no-acupoints
(G2).

Our hypothesis was that the acupuncture treatment before performing

stretching exercises would be improve flexibility of hip abduction more than
stretching exercises alone. Such fact could be observed in groups G1 and G2, but

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not in the comparison between groups.

Up to this moment, no study specifically investigating the effect of

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acupuncture on flexibility has been published, which makes the comparison of

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these results more difficult. Experimental study results have shown combining
acupuncture treatment with exercise therapy is beneficial. In the few studies that

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measured the effect of acupuncture on the flexibility, Huguenin (2005) found no

significant differences in range of motion for internal rotation or flexion of the hip

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after treatment with acupuncture intervention. Among the limitations of this study is

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the evaluation of the flexibility that was made through pictures and treatment with
acupuncture (needles were inserted only superficially into the skin)32.Another study
by Edwards and Knowles (2003) showed a significant improvement in myofascial
pain in the group treated with an intervention that combined acupuncture and
active stretching exercises as compared with a group treated only with active
stretching exercises, and a control group33.

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There is a consensus about the alteration in the perception of pain and in
the analgesia caused by the stimulus of acupuncture needles, either in acupoints
or in no-acupoints.

2,17,32,33

Chu34 reports that insertion and intramuscular

manipulation of acupuncture needles may generate depolarization of single muscle

fibers and electromyographic alterations classified as micro-twitches which, in turn,
are capable of causing a micro stretching effect in the shortened fibers adjacent
to the stimulated muscle and reduce the effect of mechanical traction of those

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fibers in nociceptive structures, including nerves and intramuscular blood vessels.

As a result, muscular relaxation may occur in the stimulated area through the
increase of blood circulation, which may induce the relief of local muscular pain,

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which in turn may have an effect on the gate of pain in the spinal cord.

Two

studies

confirm

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this

hypothesis,

as

they

observed,

through

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photoplethysmography, evidence of local increase of blood circulation after

acupuncture treatment in the tibialis anterior muscle in healthy subjects, and in the

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trapezoid muscle in subjects with fibromyalgia.

35,36

Other studies, however,

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demonstrate that there is a possible controversy about the hemodynamic alteration

caused by acupuncture. 37,38 Knardahl (1998) observed an increase of 15% to 20%
in muscle electrical activity and increased tolerance of pain immediately after 30
minutes of treatment with electroacupuncture, and this effect remained high,
between 10 and 30% after the intervention37. Kimura (2006) conducted a stimulus
with acupuncture for two minutes in 12 volunteers and found similar results
regarding the increase of muscular activity and decreased skin perfusion during

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acupuncture stimulation38. Both studies found a negative correlation between the
hemodynamic and autonomic responses that occurred during acupuncture.
One comprehensive literature review39 describes that the alterations of the
nociceptive system occur from noxious stimulus, chemical, mechanical or thermal
in their nature, in the skin or in the muscular and visceral tissues, and that those
are perceived primarily by the afferent free nerve endings ( fibers C and A). Fibers

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C and some fibers A innervate areas near the vascular wall in the muscular tissue
in the zones of muscle-tendon insertions and in the tendons themselves. These
fibers are susceptible to noxious mechanical stimulus such as stretching, torsion

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and compression. 39 Pea et al.40 also corroborated this hypothesis in their study.
High thresholds of tensive or compressive stimulus generate a mechanism of

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transduction, and this implicates in the activation of cation channels in the free

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nervous endings and also neurochemical alterations in their neural membrane

(increase in the influx of Na+, K+ and Ca+, for example). The activation of cation

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channels occurs from the distortion of the collagen bridge between the free nerve

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endings and in adjacent tissues. The depolarization of the nociceptors membrane

occurs from their neurochemical alterations, and as a consequence there is an
increase in their thresholds.

39,40

Making the translation between knowledge, we

can consider that the stimulation with acupuncture needles (harmful) and stretching
exercises (mechanical) fits in here and they both have a lot in common
physiological pathway.

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In the acupuncture case, one study about the remodeling of fibroblast in the
subcutaneous tissue and the possible mechanisms of mechanotransduction
brought about by acupuncture through the connective tissue, report that alterations
in the extracellular matrix caused by the manipulation of acupuncture needles may
generate modulation in the entrance of sensory stimuli in afferent nociceptors41.

Another hypothesis of our study is about the relation between tissue

alterations and the neurophysiological responses caused by acupuncture and

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stretching exercises. There is a possible increase of the articular amplitude

promoted

by

the

stimulus

of

acupuncture,

through

the

mechanism

of

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mechanotransduction, i.e. mechanical alterations in the connective tissue

generated by the insertion and rotation of the needles and, in the case of

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stretching, the mechanotransduction promoted by the pulling of the muscular

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tissue; common to both interventions is the alteration of nociceptive thresholds and

the increase of tolerance to pain. Although it has not been investigated in a direct

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way, the improve of flexibility after acupuncture and stretching exercise in the

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comparison in to groups that received the treatment with different techniques,

which had only stretching exercise or only acupuncture demonstrate the viability of
this hypothesis, but other studies must be carried out to investigate objectively this.

Conclusion

To the best of our knowledge this is the first study to show that the use of
acupuncture before performing a static stretching exercise for the hip adductors,

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can generate a significant acute increase in flexibility. In the comparison between
the groups that received acupuncture and static stretching with the control group
(stretching exercises only), the first intervention proved to be significant in the
comparison of pre and post-intervention results.
The use of acupuncture associated to stretching exercises is a clinical
practice employed by acupuncture specialists, and it may become useful in the
treatment of injuries and/or training of athletes or practitioners of recreational

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exercises who need an acute increase of flexibility to perform a specific activity.

Some of the physiological effects of acupuncture and of skeletal muscle stretching
are similar, such as muscular relaxation and the increase of pain tolerance, which

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can justify the association of these methods for greater flexibility.

Acknowledgements

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The authors would like to thank the Fundao de Amparo Pesquisa do

Estado do Rio de Janeiro (FAPERJ) for their financial support.

Author Disclosure State

No competing financial interests exist.

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Medical Acupuncture

299x388mm (72 x 72 DPI)

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Figure 1 - Initial position of measure of flexibility and stretching exercise
135x101mm (300 x 300 DPI)

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Figure 2 - Final position of measure of flexibility and stretching exercise

135x101mm (300 x 300 DPI)

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299x388mm (72 x 72 DPI)

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