Analgesic Effect of Manual Acupuncture and Laser Acupuncture for Lateral Epicondylalgia: A Systematic Review and Meta-analysis
Wen-Dien Chang*, Ping-Tung Lai†, and Yung-An Tsou§‡
* Department of Sports Medicine, §Graduate Institute of Clinical Medical Science, China Medical
University and Hospital. No. 91, Hsueh-Shih Road, Taichung City 404, Taiwan (R.O.C)
† Department of Physical Therapy and Rehabilitation, Da-Chien General Hospital. No. 6, Shin
Guang Street, Miaoli City, Taiwan (R.O.C).
‡Department of Otorhinolaryngology, China Medical University and Hospital. No. 91, Hsueh-Shih
Road, Taichung City 404, Taiwan (R.O.C)
Running Title: LASER AND MANUAL ACUPUNCTURE ON LATERAL EPICONDYLALGIA
Correspondence to: Wen-Dien Chang, Department of Sports Medicine, China Medical University. No. 91, Hsueh-Shih Road, Taichung City 404, Taiwan (R.O.C), Fax: 4-22061724, Tel: (886)-4-22053366 ext. 7605, E-mail: [email protected]
acupuncture is often used for treating lateral epicondylalgia. Laser acupuncture, compared with manual acupuncture, has more advantages because it is painless, aseptic and safe. However, the analgesic effect of manual acupuncture and laser acupuncture on lateral epicondylalgia has rarely been explored. We conducted a systematic review and meta-analysis to compare the analgesic effect of laser acupuncture and manual acupuncture for treating lateral epicondylalgia. We investigated studies in the Medline, PubMed, and CINAHL databases, published from January 1980 to December 2013. This review included 9 randomized articles. Six of them examined manual acupuncture and the others focused on laser acupuncture. We analyzed the meta-analysis results regarding the analgesic effect of the treatment, and observed substantial differences in 4 articles related to manual acupuncture. Manual acupuncture is effective in short-term pain relief for treating lateral epicondylalgia; however, its long-term analgesic effect is unremarkable. A suitable acupuncture point and depth can be used to treat lateral epicondylalgia. Manual acupuncture applied on lateral epicondylalgia produced stronger evidence of an analgesic effect than did laser acupuncture, and further study on the analgesic effect of laser acupuncture is required.
Key words: Lateral epicondylalgia; Laser acupuncture; Acupuncture point
Lateral epicondylalgia, also called tennis elbow, is an orthopedic disorder the commonly occurs in the elbow. The overuse of repetitive wrist extension while engaging in tennis or typing can lead to this disorder (Moon et al., 2013). The symptoms of lateral epicondylalgia include pain in the lateral epicondyle when performing resistance movements with the forearm, and tenderness when lifting heavy objects (Lucado et al., 2012). The pain recurs within 3 to 6 years and affects functional movements and activities (Viola, 1998; Shiri et al., 2006). Hence, patients typically receive therapy within 6 to 24 months (Viola, 1998; Coombes et al., 2009). A previous systematic review produced strong evidence that treatment strategies for lateral epicondylalgia, including physical therapy, exercise therapy, and Chinese medicine, provide the positive effects of pain relief or the functional improvement of upper extremities (Trudel et al., 2004). Chinese medicine practitioners treat acute lateral epicondylalgia by recommending that patients stop overusing their hands and rest periodically during activities that require their hands to move repetitively, use an ice pack for pain relief, apply ointment to activate blood circulation and thereby dissipate blood stasis, and undergo acupuncture through the use of several acupuncture points following Gok Ji (LI-11) and Su Sam Ni (LI-10) (Trinh et al., 2004; Shin et al., 2013). Subacute and chronic lateral epicondylalgia is treated with massage, acupuncture, and traditional Chinese medicine to activate blood circulation and thus dissipate blood stasis, and to nourish Qi and blood (Bisset et al., 2005; Shin et al., 2013).
Acupuncture is commonly used for treating lateral epicondylalgia (Webster-Harrison et al., 2002). The acupuncture theory for pain relief is that the related acupuncture point stimulates endorphin secretion and increases the quantity of 5-hydroxy tryptophan in the brain to relieve pain
(Hsieh, 2012; Zijlstra et al., 2003). Furthermore, traditional Chinese medicine postulates that acupuncture releases the stasis at the acupuncture point and recovers the balance of energy inside the body to relieve pain (Melzack et al., 1977). Traditional Chinese medicine practitioners use the theory of syndrome differentiation and treatment to diagnose lateral epicondylalgia and determine whether it belongs to Heat Bi or Cold Bi to apply various acupuncture points (Lee, 2000). The tender point of lateral epicondylalgia is similar to the Ashi point (Xu and Li, 2005). Melzack et al. suggested that the tender point has 71% relevance to the acupuncture point at the same site, which differs from acupuncture theory (Melzack et al., 1977). Manual acupuncture often inputs Qi or energy flow at the acupuncture point to reduce symptoms (Trinh et al., 2004). Low-level laser therapy applied to laser acupuncture irradiates the injured tissue to induce biological stimulation (Viola, 1998). Low-level laser therapy for laser acupuncture has been recently used for treating orthopedic diseases (Chang et al., 2010). Compared with manual acupuncture, laser therapy applied to the acupuncture point has more advantages because it is painless, aseptic, safe, dosage adjustable, and user friendly (Schüller and Neugebauer, 2008). The application of laser acupuncture for reducing the symptoms of lateral epicondylalgia is controversial (Johnson et al., 2007; Schüller and Neugebauer, 2008). However, studies in which the analgesic effect of manual acupuncture and laser acupuncture on lateral epicondylalgia is discussed are rare.
The National Institutes of Health asserted that acupuncture can be a therapeutic substitute for treating several orthopedic disorders such as low back pain and lateral epicondylalgia (National Institutes of Health, 1998). The systematic review conducted by Trinh et al. indicated that
acupuncture can provide short-term pain relief in the treatment of lateral epicondylalgia (Trinh et
al., 2004). However, published research reports in which the analgesic effect of manual acupuncture
and laser acupuncture is discussed are lacking. The aim of the present study was to analyze the analgesic effect of manual acupuncture and laser acupuncture on lateral epicondylalgia. This result may improve their application in traditional Chinese medicine.
Methods
In this study, 2 researchers conducted a search for articles published between January 1980 and December 2013 by using the electronic databases of Medline, PubMed, and CINAHL. Low-level laser therapy, lateral epicondylalgia, tennis elbow, acupuncture, and laser acupuncture were used as keywords to search for related articles that were subsequently included in the study. In the systematic review of the articles, the analgesic effects of manual acupuncture and laser acupuncture on the treatment of lateral epicondylalgia were investigated. Hence, articles that reported randomized controlled trials (RCTs) were included based on the following criteria: patients with a diagnosis of lateral epicondylalgia and pain in the lateral epicondyle when extending the elbow (a positive Mill’s test); patients who received manual acupuncture or laser acupuncture treatment; and the control group underwent a sham procedure or treatment using a placebo laser and needle acupuncture.
The researchers used the physiotherapy evidence database scale (PEDro) to assess the quality of the articles (Moseley et al., 2002). The PEDro scale is an 11-item scale that has strong interexaminer reliability. This scale is used to assess methodological quality such as randomization procedures and blind statistical comparisons of results, and the total score for the scale ranges from 0 (lowest
quality) to 11 (highest quality). Rosenthal’s file drawer method was used to calculate a fail-safe
number and to determine the publication bias (Madden and Paul, 2011; Rosenthal, 1979). The fail-safe number: 19S－N (S is the number of articles that reported a statistically significant difference in pain relief; N is the number of article that reported no statistically significant difference in pain relief). We considered publication bias to influence the result of meta-analysis when the fail-safe number is greater than the tolerance level, which is calculated using the equation 5k + 10, where k is the number of articles that underwent meta-analysis.
Data Analysis
All the included articles were coded and data were collected. First, the characteristics of the studies, including authors, publication date, number of participants, average age of the participants, and quality of the studies, were recorded. Second, the differences among the studies, such as treatment time, treatment options, acupuncture points, assessment times, and assessment results, were recorded. We compared the results of analgesic effects between experimental and placebo groups in the included studies, and collected the success rates of inducing analgesia following the treatments. Based on these statistics, we calculated the experimental event rate (EER), control event rate
(CER), absolute risk reduction (ARR), and relative risk reduction (RRR) of the studies and analyzed the number needed to treat (NNT) as an effective treatment index for the experimental groups. Meta-analysis was performed using MedCalc software (MedCalc, Mariakerke, Belgium). The odds ratio (OR) was used an index of the validity of the analgesic effect, and was presented as a 95% confidence interval (CI). If the 95% CI did not include the value of 1, a null hypothesis was considered and statistically significant differences existed in the treatment results. The total effect was calculated by a total random effect model to assume the analgesic effect of laser acupuncture and manual acupuncture. If no significant heterogeneity occurred, a total fixed effect model was used. When P > 0.05 or I2 < 50%, homogeneity was used in a Q statistic test, and was considered significant. The comparison of analgesic effects was discussed using a recommended grade based on the Philadelphia Panel Classification System (Harris and Susman, 2002).
Results
We investigated the analgesic effect of laser acupuncture and manual acupuncture in the treatment of lateral epicondylalgia. After applying the exclusion and inclusion criteria, 9 articles were determined to be relevant to this study, as shown in Fig. 1 (Lundeberg et al., 1987; Haker and Lundeberg, 1990a; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991; Fink et al., 2002a; Fink et al., 2002b; Gu and Shan, 2007; Molsberger and Hille, 1994; Wang, 2011). The PEDro score for all of the studies ranged from 3 to 9. Table 1 indicates that 6 studies investigated the effect of manual acupuncture (Haker and Lundeberg, 1990a; Molsberger and Hille, 1994; Fink et al., 2002a;
Fink et al., 2002b; Gu and Shan, 2007; Wang, 2011). In those articles, Molsberger et al. chose the Yang Neung Cheon (GB-34) in the lower limb as the treatment point (Molsberger and Hille, 1994), whereas the others adopted an acupuncture point near the lateral epicondyle, based on the theory of syndrome differentiation and treatment (Haker and Lundeberg, 1990a; Fink et al., 2002a; Fink et
al., 2002b; Gu and Shan, 2007; Wang, 2011). In comparing the articles that reported on the use of
other acupuncture points (Molsberger and Hille, 1994; Fink et al., 2002a; Fink et al., 2002b; Gu and Shan, 2007), Hacker et al. used a superficial needle at the acupuncture point for the control group (Haker and Lundeberg, 1990a), and Wang chose the anti-Ashi point to perform acupuncture on the control group (Wang, 2011).
Assessment Outcome
The studies generally investigated 3 fields: pain, muscle strength, and self-report questionnaires on the effect of receiving manual acupuncture or laser acupuncture. To measure pain, the patients were evaluated during motion and when static. The visual analog scale (VAS) was commonly administered to assess the experience of pain in patients. The VAS is a 10-point rating scale ranging from 0 (no pain) to 10 (severe pain), which is similar to the 11-point box scale (EPBS) (Molsberger and Hille, 1994). Certain studies assessed the pain of wrist extension, pronation, and supination, and recorded the number of recovered participants or the frequency and time of pain. To measure muscle strength, participants were asked to perform forearm movement against resistance, such as wrist extension, pronation, and supination to determine whether pain affected their strength (Haker
and Lundeberg, 1990a; Haker and Lundeberg, 1991). A weight test in which various weights, from 1 to 4 kg, were used was conducted to examine the pain of wrist extension (Lundeberg et al., 1987; Haker and Lundeberg, 1990a; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991). A vigorimeter was used to test the participants’ grasp strength, which represented functional movement strength (Lundeberg et al., 1987; Haker and Lundeberg, 1990a; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991). We used the disabilities of the arm, shoulder, and hand questionnaire (DASH) to evaluate upper limb function (Fink et al., 2002b) ; the DASH includes 30 questions, the responses to which are measured using a 5-point ordinal scale. A high score represents a severe effect of lateral epicondylalgia on upper limb function. The posttreatment and follow-up measure was examined using a self-satisfaction questionnaire (Haker and Lundeberg, 1990a; Haker and Lundeberg, 1991). Participants answered the questionnaire items by using a range of options, comprising excellent, good, improved, slightly improved and unchanged/worse, based on their subjective feelings regarding general health status.
Laser Acupuncture
Of the 3 studies in which laser acupuncture was used as the treatment option for lateral epicondylalgia (Lundeberg et al., 1987; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991), 2 applied laser therapy to the acupuncture point (Lundeberg et al., 1987; Haker and Lundeberg, 1990b), and the other study applied it to both the acupuncture point and the tender point (Haker and Lundeberg, 1991). These 3 studies adopted 904-nm-wavelength laser acupuncture (Lundeberg et
al., 1987; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991), and Lundeburg applied a
632.8-nm wavelength for the control group (Lundeberg et al., 1987). All of the studies involved the use of a GaAs laser, and the average power ranged from 0.07 to 12 mW (Lundeberg et al., 1987; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991). Regarding the power output of the laser, only Lundeberg et al. used a continuous wave, whereas the others used a pulse wave, with frequencies ranging from 70 to 38700 Hz (Lundeberg et al., 1987). All of the studies recorded the laser dosage only at the J/ point, and did not document observations of the area of the laser projector (Haker and Lundeberg et al., 1987; Lundeberg, 1990b; Haker and Lundeberg, 1991); therefore, the laser energy density was not calculated. We observed that the laser acupuncture dosages used in these studies ranged from 0.004 to 0.9 J.
Manual Acupuncture
Table 2 indicates that the manual acupuncture groups took 25–30 minutes for each treatment session, whereas the laser acupuncture groups took 30 seconds to 2 minutes. Except for Wang, Gu
et al., Molsberger et al., and Lundeberg et al., who conducted 1–5 sessions of acupuncture
(Lundeberg et al., 1987; Molsberger and Hille, 1994; Gu and Shan, 2007; Wang, 2011), other studies contained a total of 10 sessions of acupuncture treatment (Haker and Lundeberg, 1990a; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991; Fink et al., 2002a; Fink et al., 2002b). The treatment effect was primarily assessed using the degree of pain relief. In all of the manual acupuncture studies, a statistically significant difference existed between the experimental group
and the control group after intervention (Molsberger and Hille, 1994; Fink et al., 2002a; Fink et al., 2002b; Gu and Shan, 2007; Wang, 2011). After performing calculations by using the results reported in the 9 articles (Table 2), the fail-safe number (value = 111) was greater than the tolerance level (value = 55). Therefore, the publication bias did not influence the result of meta-analysis, which had a high degree of confidence. In the meta-analysis of analgesic effect presented in Fig. 2, a statistically significant difference existed between the results reported by Wang (NNT: 2.12, OR: 9.24, 95% CI: 2.87–29.75), Gu et al. (NNT: 4.34, OR: 8.87, 95% CI: 1.27–61.9), Molsberger et al. (NNT: 1.85, OR: 11.28, 95% CI: 2.93–43.47), and Haker et al. (NNT: 3.50, OR: 3.43, 95% CI: 1.32–8.87) (Haker and Lundeberg, 1990a; Molsberger and Hille, 1994; Gu and Shan, 2007; Wang, 2011).
Discussion
The mechanism of acupuncture in relieving pain remains unclear (Viola, 1998). In the present study, among the 6 studies that investigated the analgesic effect of manual acupuncture (Haker and Lundeberg, 1990a; Molsberger and Hille, 1994; Fink et al., 2002a; Fink et al., 2002b; Gu and Shan, 2007; Wang, 2011), Molsberger et al. suggested that manual acupuncture increases endorphin secretion to relieve pain (Molsberger and Hille, 1994); and Fink et al. asserted that manual acupuncture affects the pathway of the Aδ nerve fiber to inhibit painful sensation and relieve pain in certain body regions (Fink et al., 2002b). Their research indicated a substantial difference between acupuncture administered at the acupuncture point and that administered at other points within the
same dermatome in the activation of the Aδ nerve fiber. However, they did not clarify whether the acupuncture point had a high density of Aδ nerve fiber (Fink et al., 2002b); consequently, the analgesic effect of Aδ nerve fiber on pain relief remains uncertain. Haker et al. posited that manual acupuncture causes a De Qi sensation (Haker and Lundeberg, 1990a) and a sour and warm feeling at the acupuncture point, which is critical in pain relief because it activates the descending pain inhibitory system in the central nervous system. In an animal study, Park et al. observed that manual acupuncture can provoke the activation of extracellular signal-regulated kinase (Park et al., 2014). The molecular change can increase the fibroblasts and keratinocytes in the skin and produce an analgesic effect. Fink et al. indicated that an optimal acupuncture point and acupuncture depth are key factors in the benefits provided by this effect (Fink et al., 2002a), but which specific acupuncture point relieves pain remains unclear. When treating lateral epicondylalgia, Molsberger
et al. observed that acupuncture administered on the same side of the lower limb relieved pain
immediately, but they did not determine whether the acupuncture point in the lower limb was the specific point for treating lateral epicondylalgia (Molsberger and Hille, 1994). Haker et al. demonstrated that a suitable acupuncture depth can relieve pain through De Qi sensation, but they did not describe how to determine using the acupuncture point (Haker and Lundeberg, 1990a). The 2 studies conducted by Fink et al., and the studies performed by Wang, Gu et al., and Molsberger et
al. applied acupuncture to the acupuncture point of the forearm muscle and the tendon, which is a
widely used technique in the field of traditional Chinese medicine, and observed immediate pain relief (Molsberger and Hille, 1994; Fink et al., 2002a; Fink et al., 2002b; Gu and Shan, 2007;
Wang, 2011). Based on the Philadelphia Panel Classification System, we assigned the short-term effect of manual acupuncture on the relief of pain caused by lateral epicondylalgia a Level B score because it exhibited a substantial difference in treatment and was clinically meaningful. Molsberger
et al. posited that pain is a subjective sensation, and that only an evaluation performed immediately
after treatment instead of a long-term follow up can be used to determine the effect on pain relief (Wang, 2011). Furthermore, in the other 3 studies, follow up was conducted 3 to 12 months after treatment and no substantial effect on pain relief was observed (Fink et al., 2002a; Fink et al., 2002b; Wang, 2011). Fink et al. observed no considerable difference because the disorder recurred over time (Fink et al., 2002a). Therefore, based on the Philadelphia Panel Classification System, we assigned the long-term effect of manual acupuncture of the relief of pain caused by lateral epicondylalgia a Level C+ score because manual acupuncture did not exhibit a substantial difference in treatment outcomes, but it proved that manual acupuncture did not demonstrate clinical meaning on long-term pain relief.
The output power of low-level laser therapy used in clinical settings was lower than 500 mW (Chang et al., 2008), and the treatment mechanism was photobioregulation, instead of hot thermal therapy (Wu et al., 2009; Chang et al., 2010). Three studies in which low-level laser therapy was used in laser acupuncture to treat lateral epicondylalgia were conducted (Lundeberg et
al., 1987; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991), and these studies
investigated the use of laser therapy on acupuncture points. Table 2 indicates that laser therapy was ineffective when applied to acupuncture points. To determine a suitable dosage of laser
acupuncture, Haker et al. compared studies in which laser acupuncture dosage was used (12 mW; 30 s/point; 0.36 J/point; 10 acupuncture points) with their most recent study (0.07 mW; 60 s/point; 0.004 J/point; 5 acupuncture points) (Lundeberg et al., 1987; Haker and Lundeberg, 1991), and observed that 0.36 J/point was more suitable than the other points were. Furthermore, they indicated that a long treatment time did not enhance the effect (Haker and Lundeberg, 1991). In the follow up of the other studies in which laser acupuncture was used, participants indicated that their lateral epicondylalgia symptoms remained “unchanged” or became “worse” (Haker and Lundeberg, 1990b). Hence, Haker et al. reported that because lateral epicondylalgia is inflamed muscle tissue and low-level laser therapy is photobioregulated, therapy is limited by the Arndt-Schultz law (Haker and Lundeberg, 1990b). A dosage of low-level laser therapy that is insufficiently high induces no activation; conversely, a dosage that passes the threshold activates biological stimulation (Ohshiro, 1988; Chang et al., 2008). Furthermore, a dosage that is excessively high inhibits the effect. Acupuncture activates the Aδ nerve fiber that processes pain by providing mechanical stimulation to connective tissue, by which the acupuncture point creates a signal to the meridian (Fink et al., 2002b; Viola, 1998). However, Haker et al. indicated that the penetration depth of the 632.8-nm HeNe laser was 0.62 nm, whereas that of the 904-nm GaAs laser was 1.4 nm (Haker and Lundeberg, 1990b). Whether laser acupuncture can reach the depth of manual acupuncture requires further investigation. Therefore, according to the Philadelphia Panel Classification System, we assigned the analgesic effect of laser acupuncture in treating lateral epicondylalgia a Level D score because it did not exhibit a substantial difference in treatment outcomes, and the treatment method
was unclear.
In the effect analysis presented in Table 3 and Fig. 2, the NNT of the manual acupuncture studies was lower than that of the laser acupuncture studies. The results reported by Wang (NNT: 2.12, OR: 9.24, 95% CI: 2.87–29.75), Gu et al. (NNT: 4.34, OR: 8.87, 95% CI: 1.27–61.9), Molsberger et al. (NNT: 1.85, OR: 11.28, 95% CI: 2.93–43.47), and Haker et al. (NNT: 3.50, OR: 3.43, 95% CI: 1.32–8.87) indicated that manual acupuncture exhibited a substantial difference in treatment effect (Haker and Lundeberg, 1990a; Molsberger and Hille, 1994; Gu and Shan, 2007; Wang, 2011). Thus, manual acupuncture produced an enhanced effect compared with that achieved using laser acupuncture. In the 6 studies of manual acupuncture, the NNTs of Fink et al. (Fink et
al., 2002a; Fink et al., 2002b) were higher than those of the other studies (Haker and Lundeberg,
1990a; Molsberger and Hille, 1994; Gu and Shan, 2007; Wang, 2011). Fink et al. posited that the design of the control group affected the results (Fink et al., 2002b), such as sham acupuncture applied on participants’ backs, and a shallow depth used in sham acupuncture (Haker and Lundeberg, 1990a; Molsberger and Hille, 1994), which emphasized the treatment effect exhibited in the experimental group. To examine the effect of manual acupuncture, establishing a suitable experimental group design and excluding psychological effects were crucial (Haker and Lundeberg, 1990a; Fink et al., 2002a). The 6 studies of manual acupuncture revealed an improvement in pain, muscle strength, and function after treatment (Haker and Lundeberg, 1990a; Molsberger and Hille, 1994; Fink et al., 2002a; Fink et al., 2002b; Gu and Shan, 2007; Wang, 2011). Haker et al. confirmed that applying manual acupuncture on lateral epicondylalgia can increase blood flow in
partial muscle tissue and block the activity of the sympathetic nerve, which can inhibit inflammation (Haker and Lundeberg, 1990a). Fink et al. asserted that the effect of manual acupuncture does not occur unless the optimal acupuncture point is determined and used (Fink et
al., 2002b). According to the Philadelphia Panel Classification System, we assigned the analgesic
effect of manual acupuncture on the treatment of lateral epicondylalgia a Level B score because it exhibited a substantial difference in treatment outcomes and was clinically meaningful.
Previous studies have reported that pain relief achieved using low-level laser therapy is related to the metabolism of adenosine triphosphate, because it encourages the myofascial trigger point to absorb energy and thereby cause local hypoxia to increase blood circulation, which subsequently decreases the pain caused by lateral epicondylalgia (Lam and Cheing, 2007; Emanet
et al., 2010). However, the 3 parameters of laser application (wavelength, power, and energy
density) (Wu et al., 2009; Chang et al., 2010), and their arrangement also influence laser penetration into muscle tissue [30], all of which exert a critical effect. Haker and Lundeberg combined laser acupuncture with wavelength of 940 and 632.8 nm in treatment in a series of studies (Lundeberg et al., 1987; Haker and Lundeberg, 1990a; Haker and Lundeberg, 1990b; Haker and Lundeberg, 1991). They also combined laser irradiation at the tender point and laser acupuncture with a wavelength of 940 nm (Haker and Lundeberg, 1991). However, neither treatment method exerted a significant effect (P > 0.05). They believed the differences in the laser dosage and type influenced the effect. Because laser acupuncture and manual acupuncture differ, further investigation is required to clarify whether laser acupuncture can penetrate to a sufficient depth at
the acupuncture point.
Conclusion
Manual acupuncture immediately relieves the pain of lateral epicondylalgia, but its long-term analgesic effect is unremarkable. Applying it at a suitable acupuncture point and to an optimal acupuncture depth can effectively treat lateral epicondylalgia. The reviewed articles indicated that manual acupuncture applied to lateral epicondylalgia produces stronger evidence of pain relief than does laser acupuncture.
Acknowledgement
The authors are grateful for financial support from China Medical University under the contract No. CMU100-N2-05.
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