Electro-acupuncture in orthopedic rehabilitation—integration without redundancy

Orthopaedic and sports rehabilitation services are offered through a variety of outlets. More often than not they are multidisciplinary.  This fact is a testament to the complexity of the rehabilitation process. It takes an entire team of health care providers to restore a patient after a serious injury. The team may include an orthopaedic surgeon who runs tests, makes a diagnosis and a referral; a physical and/or occupational therapist; a chiropractor; and, lately, a massage therapist and an acupuncturist. While each team member brings his or her own expertise to the table, there can be a redundancy in their offerings, especially on the hands-on end of the treatment spectrum. For example, some acupuncturists may also be trained in Tui Na -– a form of Chinese manipulative therapy that combines therapeutic massage with joint mobilization, traction, and assisted stretching through PNF (proprioceptive neuromuscular facilitation). Many of these techniques fall squarely into the domain of physical therapy.

How should we leverage the skills of different members of the treatment team to assure speedy and safe recovery for our patients? How do we choose from the assortment of treatment modalities? And in what order should we implement them? Therapeutic exercises, which are an essential part of the rehabilitation process, may not be applicable immediately after surgery or injury. Pain and inflammation at that time may still be too acute to permit exercises. Therefore, pain-reducing techniques and anti-inflammatory measures are called for.

This is when and where electro-acupuncture, otherwise known as percutaneous electrical nerve stimulation (PENS), can be handy. PENS is a lesser-known sibling of TENS, which stands for a Transcutaneous Electrical Nerve Stimulation. The latter technique is usually performed by physical therapists, the former by acupuncturists. Both techniques are used to control pain. While we still need well-designed large-scale clinical studies to prove the efficacy of both modalities, some studies favor PENS over TENS in the treatment of pain. Look at the PENS for Low Back Pain randomized crossover study:


I think that there are several advantages of using PENS over TENS to treat acute pain:

  1. During PENS procedure at least two acupuncture needles penetrate skin. They deliver electrical stimulation directly to the targeted tissues under the skin, bypassing the skin’s electrical resistance. The skin’s electrical resistance can be as high as 450,000 Ohms when dry, less when wet. In contrast, electrical resistance of the internal body is much lower, typically measured at several hundreds of Ohms. TENS procedure is carried out with the external electrodes that are placed on the surface of skin. Electrical current always seeks a path of the least electrical resistance. With TENS, the electrical current spreads over the surface of skin but does not go underneath.
  2. Acupuncture needles can be positioned with greater precision—in comparison with the surface electrodes—in the proximity of the treated anatomical structures. The electrical current flows trough the areas that are otherwise difficult to reach. For example, after a repair of the meniscus acupuncture needles can be inserted medially and laterally along the joint lines of the knee. The electrical current will flow from the one side of the knee to the other through the meniscus and the joint itself.
  3. Although somewhat speculative:  in addition to a segmental analgesia, PENS may work systemically, through the pituitary hypothalamic system. http://www.ncbi.nlm.nih.gov/pubmed/9330669

PENS is an example of a useful non-redundant technique that brings acupuncture into the rehabilitation process.

Leave a Reply