Acupuncture to Treat Brachial Plexopathy and CRPS
Complex regional pain syndrome (CRPS) can occur with or without injury or noxious stimuli. Patients commonly present with a clinical syndrome of pain, autonomic dysfunction, trophic changes, and functional impairment.1 Diagnosing CRPS at its early stages and utilizing a multidisciplinary approach with aggressive physical therapy have been shown to alleviate pain and increase function in the affected limb. Acupuncture may be an adjuvant treatment option that may provide additional benefits for patients with CRPS.
Gunshot Wound Leading to CRPS
A 21-year-old woman with no past medical history presented to the pain clinic. Five months earlier, she sustained a gunshot wound to the left shoulder/chest with a resultant brachial plexus injury.
At the time of the injury, she was evaluated at John H. Stroger Jr. Hospital of Cook County Trauma Center, in Chicago, Illinois, where it was determined that surgical intervention was not indicated. After a couple days of observation, she was discharged with a prescription of gabapentin (starting dose 300 mg tid; titrated up to 1,200 mg tid) and immediately enrolled in occupational/physical therapy, which included therapeutic exercises, manual therapy, orthotic management, and desensitization therapy. [Editor's Note: Prescribing information for gabapentin recommends a starting dose of 300 mg/d; Day 2, 600 mg/d; Day 3, 900 mg/day).
During our initial evaluation in the pain clinic, she presented with the following symptoms: a disabling burning sensation, hyperesthesia of the left forearm, and a decrease in active range of motion (wrist flexion 0 degrees, extension 0 degrees, pronation 0 degrees and supination 0 degrees). Her average daily visual analog pain score (VAS) at the time of presentation was 5 to 6/10. On physical examination, the patient exhibited allodynia and atrophy of the left upper extremity. Electromyography (EMG) conducted after the injury confirmed severe left brachial plexopathy.
Along with her current therapy, we offered a stellate ganglion block and intravenous lidocaine infusion. However, the patient did not desire any intervention at this time, and opted to try acupuncture. She attended biweekly acupuncture sessions for 3 consecutive months, in combination with weekly session of biofeedback and cognitive behavioral therapy with our pain psychologist.
The acupuncturist targeted two points specifically on the contralateral lower extremity: Gall Bladder 34 and Stomach 38 (see Figures 1 and 2). Electrostimulation was used on these points, with the red electrode (cathode) on Gall Bladder 34 and the black electrode (anode) on Stomach 38. After 3 months of therapy, the patient’s active range of motion (wrist flexion/extension, supination and pronation) had significantly improved. In addition, she was able to obtain satisfactory pain control, measuring an average VAS of 3-4/10 with activity. (See Figures 1 and 2)
CRPS is a pain syndrome that frequently affects the upper and lower extremities. Patients may present with a constellation of symptoms that include neurosensory, sudomotor, vasomotor, and trophic findings.2 Although the exact mechanism have not been fully elucidated, the postulated mechanisms of CRPS include: (1) somatosensory reorganization at the cortical level; (2) neurogenic inflammation caused by release of calcitonin gene-related peptide (CGRP); (3) substance P producing nociceptors sensitization; and (4) overactive sympathetic nervous system.3
In 2003, the previous criteria for diagnosis of CRPS set by the Inter-national Association for the Study of Pain was replaced by the Budapest Research Criteria. The new criteria were developed to increase the specificity for identifying CRPS. To make a diagnosis of CRPS, the Budapest Research Criteria requires at least 3 of the 4 symptoms and 2 of the 4 signs at the time of evaluation from the following categories: sensory, vasomotor, sudomotor, and trophic changes.3
CRPS progresses through 3 stages: acute (usually 1-3 months); dystrophic (usually 3-6 months); and atrophic (>6 months). Therefore, the ultimate goal for treatment is to reduce pain effectively, improve motor function, and prevent progression to the atrophic stage (when tissue atrophy and bone demineralization becomes irreversible). The success of treatment increases with early diagnosis and implementation of physical therapy and rehabilitation, as well as psychological support, pharmacologic therapy, and interventional therapies.4
At the initial clinic visit, the patient was prescribed the maximum recommended dose of gabapentin (1,200 mg tid) as well as tramadol (100 mg tid), yet still failed to complete physical therapy due to uncontrolled pain. The patient elected to proceed with acupuncture before proceeding with interventional treatment options.
And after a 3 month trial of acupuncture, the patient reported a decrease in pain score allowing her to fully participate in physical therapy, with a subsequent improvement in motor function. Bowsher et al theorizes that the analgesic effect of acupuncture is brought on “by both a generalized neurohormonal mechanism, involving the release of free β-endorphin and by two descending neuronal mechanisms, the first of which is serotonergic and the second adrenergic.”5
CRPS is a challenging disease that requires early recognition and multimodal therapy to better facilitate rehabilitation of the affected extremity in order to prevent long-term disability. Acupuncture is an emerging alternative treatment option for CRPS patient. However studies and cases reports are sparse due to the cost and difficulty recruiting patients for randomized control trials. Although this case study involved only one subject, the results of the acupuncture treatment showed improvement in pain control and improved motor function. Our case report aims to generate more interest and research in defining the role and efficacy of acupuncture in CRPS.