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Short Communication
Experimental Pathology and Health Sciences
2016;8 (2): 85-92
Effect of Acupuncture on delayed onset muscle sore-
ness: series of case studies
Cardoso R1,2,3; Lumini-Oliveira J 3,4; Santos MJ1,5., Bruno Ramos1, Machado J1,6; Greten HJ1,5
Abstract
Delayed onset muscle soreness (DOMS) is a common form of muscle soreness, experienced by individu-
als who perform unaccustomed exercise as a result of exercise induced muscle damage (EIMD) (Aminian-
Far et al., 2011). Scientic studies have shown contradictory results on the effects of acupuncture on
DOMS.
The aim of this study was to evaluate acupuncture effects on DOMS. For this preliminary study, 3 healthy
participants, after completing a screening questionnaire and providing written informed consent, were
randomly distributed into three groups (verum acupuncture group (VA), sham acupuncture group (SA)
and a control group CG). Pressure pain threshold (PPT), vertical jump (VJ) and an isokinetic evaluation
were performed before and after (immediately and after 24h) an EIMD protocol which subjects performing
a ve sets of 20 drop jumps from a height of 0,6m step, with a 10 seconds interval between jumps and 2
minutes rest period between sets.
The present protocol of EIMD showed success in inducing DOMS. When VA, SA and CG groups were
compared, it was found that VA had better results in all outcome measures. However, SA group showed
better results than CG, when PPT was compared.
As a conclusion, the results showed that acupuncture applied after an EIMD protocol, had a positive effect
on PPT, VJ and Average Peak Torque.
Key words: Acupuncture, Traditional Chinese Medicine, delayed onset muscle soreness, exercise induced
muscle damage.
Introduction
Delayed onset muscle soreness (DOMS) is a com-
mon form of muscle soreness, experienced by in-
dividuals who perform unaccustomed exercise as a
result of exercise induced muscle damage (EIMD)
(Aminian-Far et al., 2011). It results in symptoms
such as: tenderness, edema, muscle stiffness, and
typically involves an eccentric component, and has
a peak between 24 and 48 hours post-exercise and
spontaneously disappears within 5 to 7 days (Amin-
ian-Far et al., 2011; Torres et al., 2012).
Research commonly suggests that DOMS is the
result of an inammatory process caused by micro-
tears in the muscle bers during unaccustomed
repetitive activity and/or eccentric contractions
(Barbe, Barr, 2006;Barr, Barbe, Clark, 2004) but it
has also been suggested that muscle soreness can
occur without micro-trauma (Zainuddin, Newton,
Sacco, Nosaka, 2005).
While western medicine attributes DOMS to local
inammation, due to either mechanical damage or
swelling, leading to ischemia and muscle spasms,
Traditional Chinese Medicine (TCM) views DOMS
as localized “Qi” and “Xue” stasis that manifests
as pain and soreness of the joints, muscles and/
or tendons. Collectively, this is known as muscle
Bi-syndrome (Xinnong, 1987).
Acupuncture has shown to increase of muscular
power (Huang, et al., 2007; Hubscher, et al., 2010;
Ozerkan, et al., 2007; Yang, et al., 2006; Zhou, et
al., 2012), to improve microcirculation (Kuo, Lin,
Ho, 2004), to decrease inammatory processes
(Moon et al, 2007), to inhibit spinal and supraspi-
nal nociceptive transmission (Ikeda, Asai, Murase,
2000), as well as to improve vertical jump (Sousa,
2012). Therefore, from a theoretical standpoint
acupuncture might be an attractive, benecial,
low-cost, quick and low-risk treatment strategy for
DOMS treatment, improving performance on ath-
letes and productivity in workers.
The major aim of this study is to evaluate the ef-
fects of acupuncture on DOMS.
1 ICBAS - Institute of Biomedical Sciences Abel Salazar, University of Porto
2 Hospital-School of Fernando Pessoa University
3 UFP - Fernando Pessoa University – Faculty of Health Sciences
4 CIAFEL - Research Centre in Physical Activity, Health and Leisure, University of Porto, Porto
5 Heidelberg School of Chinese Medicine, Heidelberg, Germany
6 LABIOMEP - Porto Biomechanics Laboratory, University of Porto
Ricardo Cardoso
rcardoso@ufp.edu.pt
Jorge Machado
jmachado@icbas.up.pt
Experimental Pathology and Health Sciences
86
Materials and Methods
Ethics - All research was undertaken at Hospital-
School of Fernando Pessoa University and was
previously approved by the Ethical Committee of
Fernando Pessoa University. All participants signed
an informed consent form in accordance with the
Helsinki Statement being informed that they could
quit at any moment without consequences and
guaranteeing them anonymity.
Recruitment - The sample of this study was only
comprised of a total of three university students
volunteers. The subjects were randomly divided
in three groups using a software available at www.
graphpad.com/quickcals: in a verum acupuncture
group (VA), a sham acupuncture group (SA) and
a control group (CG) with no loss in the follow up
period.
Treatment Protocol - Participant in the VA was
submitted to an acupuncture treatment using the
“Leopard spot” technique (Greten, 2010) in the
acupuncture points of S34 (liangqiu), S36 (zusanli),
and H3 (taichong), on the non-dominant limb with
an insulin needle, in the SA he received the same
technique but in three other points also on the non-
dominant lower limb, but that were not associated
with any conduit (with no therapeutic evidence).
The CG didn´t received any type of treatment.
For the execution of acupuncture protocols, all par-
ticipants were positioned in the supine position and
received treatment at total rest. All participants were
blinded regarding the treatment and didn`t know to
which group they were allocated (Witt, et al., 2005).
Once properly disinfect the skin, the participants
were intervened in points according to the group.
The points were selected by experts’ practitioners.
The selection of points in VA was based on the
Heidelberg model of Traditional Chinese Medicine
(Greten, 2010). The “Leopard spot” technique con-
sisted in 5 quick penetrations on skin (Hauer, et al.,
2011; Nabeta, and Kawakita, 2002) in the selected
points. The penetration depth was controlled by the
size of the blade of the insulin needles (Hauer, et
al., 2011).
Outcome measures
Biometric data collection - After the biometric data
collection, weight and height of participants was
accessed to calculate body mass index (BMI) and
age in order to guarantee the homogeneity of the
participants. Leg dominance was then assessed by
asking the participant to kick a ball to the research-
er, after having received it the same way (Lucena
et al., 2010).
Pressure pain threshold - Pressure pain thresh-
old (PPT) was assessed using a pressure algom-
eter (Wagner Fdix®, USA). Constant pressure
was exerted until the participant felt the lowest
stimulus intensity at which an individual perceives
mechanical pain at one reference point, marked
on the thigh, along a line drawn from the anterior
superior iliac spines to the superior pole of the
patella. The point was at 5 cm above the superior
pole of the patella (representing the musculotendi-musculotendi-
nous junction) (Sellwood et al., 2007). The PPT re-
cordings were carried out in a seated position with
a 90˚ angle in the hip and knee joint and performed
three times. The best result of PPT of the 3 record-
ings at each location was used in further analysis.
During PPT recordings, the algometry was applied
perpendicular to the skin (Aminiain-Far et al., 2011;
Law et al., 2008). The subjects were instructed to
say “yes” as soon as the pressure exerted by the
algometer became “slightly unpleasant”, as has
been proposed in similar studies (Vanderween et
al. 1996; Dhondt et al.1999) and was preferred to
using the expression “pain” alone.
The vertical jump -Vertical jump (VJ) performance
was performed using the ErgoJump® dynamom-® dynamom-dynamom-
eter (Globus®, Italy), which participants assumed
a squat-jump test position. The subjects were then
asked to perform 3 jumps with 2 to 3 minutes be-
tween jumps and it was chosen the best of the 3.
Isokinetic strength - After the above mentioned
measurements, participants warmed-up in the cy-
cle-ergometer (BH Fitness®, Confort Evolution) for
5 minutes, with a resistance equivalent to 2% of
body weight, at a moderate power (50W) to avoid
fatigue (Aminiain-Far et al., 2011).
This evaluation was assessed using an isokinetic
dynamometer (Biodex System 4®, Biodex Medi-®, Biodex Medi-Biodex Medi-
cal Systems, Inc., Shirley, NY, USA). Participants
performed the evaluation which consists of 1 set of
10 maximal concentric contractions of the quadri-
ceps and hamstrings, unilaterally and in the non-
dominant limb, at a running speed of 60º/s, with
90s intervals between sets, in a range between 90º
and 0º. Visual biofeedback, verbal commands and
patient positioning were uniform for all groups in
the study during the protocol (Barroso et al., 2010;
Drouin et al., 2004).
Study Design - The study was divided in 3 phases:
Pre-intervention phase, Exercise induced muscle
damage (EIMD) protocol phase, and an Interven-
tion phase
In the Pre-intervention phase the subjects, after
being informed about the study design and pro-
cedures, sign a consent form. After completing a
screening questionnaire for biometric and personal
data, as well as, for detection of possible exclusion
criteria (history of hamstring or quadriceps muscle
injury, previously medical diagnosed musculoskel-
etal pathologies in the lower limb or renal, cardiac,
metabolic, and endocrine disorders which might
inhibit the performance of physical exercise, use
of anti-inammatory AID‟s, pain and muscle relax-
2016:8 (2)
87
ants, and individuals who had performed vigorous
physical exercise within seven days prior to the
protocol (Abad et al., 2010; Milias et al., 2005). We
excluded women with menstruation, pregnant, par-
ticipants with intense fear of needles and any type
of drugs consumption (Itoh et al., 2010) and partici-
pants who drank beverages containing caffeine or
alcohol in a period of less than 12 hours prior to the
measurements (Hübscher et al., 2008).
After being randomly assigned to one of three
groups (VA vs. SA vs. CG), leg dominance was de-
termined and baseline values established for the
3 separate main outcome measures on the non-
dominant leg (Newton et al., 2012) in the following
order: pressure pain threshold, isokinetic (average
quadriceps peak torque) [Time 0 (T0)]. Vertical
squat jump test was also performed using both legs
to access muscle power.
In the EIMD protocol phase the participants per-
formed the same EIMD protocol of the Miyama and
Nosaka (2004a), that has been previously shown
to cause signicant elevation in muscle damage
indices and produce DOMS (Miyama and Nosaka,
2004a; Goodall and Howatson, 2008; Howatson et
al. 2012). In this protocol subjects dropped from a
height of 0.6m step and jumped upward maximally
immediately after landing from the box and landed
on the surface again after the vertical jump. To per-
form the next drop jump, subjects had to climb two
steps of stair into the platform. Five sets of 20 drop
jumps were performed with a 10 s interval between
jumps, and a 2 min rest period was given between
sets. Subjects performed drop jumps with barefoot,
because it has been reported that biomechanical
factors are inuenced dramatically by shoes (Wit
et al., 2000; Ogon et al., 2001), and comparisons
between bouts were thought to be easier by elimi-
nating the effect of shoes.
In the intervention phase, a second [Time 1 (T1),
prior to the intervention], third [Time 2 (T2), 20 min
after the intervention], a fourth [Time 3 (T3), 24h
after, 10 min before the second intervention] and
a fth [Time 4 (T4), 24h after, 20 min after the sec-
ond intervention] assessments were performed.
In the T1, T2 and T3 assessments, only PPT was
performed, as measures as VJ and isokinetic might
exacerbate the muscle injury. In the T4 assess-
ment, all T0 baseline measures were repeated.
Acupuncture was performed or not, for 2 minutes
immediately after T1 and T3 assessment moments,
according the group they belong. In the CG they
didn´t underwent acupuncture but a 2 minutes pe-
riod of rest between assessments were assured as
it was the necessary time to apply the acupuncture
technique in the VA and SA groups.
Results
All groups showed different results in all outcome
measures along the time. When PPT data was ana-
lyzed we found signicant differences along the dif-
ferent moments for the different groups.
While in the CG we see a progressive decrease in
PPT from a mean initial value (T0) of 4,61 Kgf/cm2
to a nal value of 2,02 Kgf/cm2 (T4), the SA and VA
groups showed an increase in PPT between T1/T2
and T3/T4, suggesting an immediate and a longer
term effect of acupuncture, as the VA group was the
only group that showed an increase of PPT com-
paring T0-T4 (Table 2, Fig 2).
When we compared the VJ in the different groups
in the different moments, we observed a decrease
along the different moments in all groups. However,
Experimental Pathology and Health Sciences
88
comparing VJ values between T0 and T4, the VA
group showed a smaller decrease of VJ values,
comparing to the other groups (Table 3, Fig. 3).
When we compared the AVG PT in the different
groups in the different moments, VA group was the
only one that increased AVG PT values along the
time (T0-T4). The other groups showed a progres-
sive decrease in AVG PT values from a initial value
(T0) to nal value (T4) (Table 4, Fig 4).
Discussion
In the literature, the few studies referring acu-
puncture effects on DOMS, present contradictory
results, probably due to the kind of methodologies
used in the different studies. However, in the thera-
peutic use of acupuncture, standardization of treat-
ment protocols concerning the acupuncture dura-
tion, technique and the number and type of points
used is not consensual or even desired, as each
patient, despite subject to the same stimulus, will
always present its own specic homeostatic imbal-
ance and energetic compensation. Moreover, the
muscular groups in which it was applied, the model
of EIMD, and respective intensity, as the evalua-
tor experience, varies among acupuncture studies
(Barroso et al., 2010; Barroso et al., 2011; Lin and
Yang, 1999; Barlas et al., 2000; Hübscher et al,
2008; Itoh et al., 2010).
In this study, was shown that DOMS worsens the
PPT values like literature refers (Miyama and No-
saka, 2004a; Goodall and Howatson, 2008; Howat-
son et al., 2012, Jay et al., 2014). It was also found
that VA improve PPT values, immediately and 24
hours after EIMD. It is important to point out that
the VA results were better than the ones of the SA
and the CG in PPT. This fact might suggest that
acupuncture might be a factor to take into account
on DOMS, especially in PPT.
Itoh et al. (2010) corroborates the results of this
study showing signicant differences in VAS for
pain between the control group and acupuncture
group immediately after treatment and three days
after exercise. In the investigation of Hübscher et
al (2008), there were no signicant differences be-
tween groups in outcome measures at the baseline
(T0). After 72 hours, muscle soreness was signi-
cantly lower in the acupuncture group compared to
the sham acupuncture and control subjects. How-
ever, the mean PPT scores were not signicantly
different between groups. Another study which
had similar results to the present study, Lin and
Yang (1999) demonstrated signicant reductions
in muscle tenderness through acupuncture versus
no acupuncture, whereas CK activity remained un-
changed. These results could not be conrmed in
a study by Barlas et al. (2000), who reported insig-
nicant changes in tenderness and perceived mus-
cle soreness when acupuncture was compared to
sham acupuncture and no acupuncture. In addition,
these last two studies did not include any measures
of muscle function that might be, besides muscle
soreness, tenderness, and inammation, consid-
ered an important outcome when the objective is
to appraise the efcacy of acupuncture in DOMS.
Literature analysis as shown several evidences
that show the acupuncture effectiveness on the
increase of muscular power (Huang, et al., 2007;
Hubscher, et al., 2010; Ozerkan, et al., 2007; Yang,
et al., 2006; Zhou, et al., 2012). However, regarding
VJ, some demonstrate controversial results when
compared to the results in this study.
However, the present study showed the capacity of
an acupuncture protocol to increase muscular pow-
er or more correctly to avoid a decrease in muscle
performance when performing a functional task
like a VJ. Some studies that show that after EIMD,
muscle power decreases (Miyama and Nosaka,
2004a; Goodall and Howatson, 2008; Howatson et
al. 2012, Jay et al. 2014) its attenuation constitutes
a more important nding than AVG PT as it is more
applicable to real life situations. This study conrms
these ndings because VJ decreased in all groups
(VA, SA and CG) as the other muscle power mea-
surements (AVG PT). These results are in line with
the study by Sousa (2012), where in VA group at
the point S34 with the same technique used in this
study, had better results in increased vertical jump
in volleyball players than a SA group. The authors
concluded that VA group signicantly improved the
VJ, while in the SA group, there was a slight loss of
vertical jump.
A model of acupuncture mechanism on musculo-
skeletal pain conditions proposed by Gunn (1996)
refers to the process of intramuscular stimulation.
Muscle strength training has been shown to rehabili-
tate painful muscles as induces adaptation of meta-
bolic and stress-related mRNA and protein respons-
es in painful muscles (Sjøgaard and Søgaard,
2014) and is also one the treatment mechanisms
proposed in trigger point treatments.
Eccentric and concentric exercise and trigger
points have been associated with localized hypoxia
which leads to the release of multiple algogenic
substances like bradykinin (BK), calcitonin gene-
related peptide (CGRP), substance P (SP), tumor
necrosis factor-α (TNF- α), interleukin-1β (IL-1β),
serotonin, and norepinephrine. Shah et al (2005)
analyzed latent and active trigger points on affect-
ed muscle and, comparatively to normal muscles,
found signicantly increased concentrations of
these substances in active trigger points, which
in turn stimulate the muscle nociceptors and bind
to specic receptor molecules decrease energy
supply and possible increased metabolic demand
which affects voltage-gated calcium channels of
the sarcoplasmic reticulum and increases the in-
tracellular calcium levels, which triggers sustained
muscle contractures (Dommerholt, 2006). A similar
effect can be proposed to be present in DOMS, al-
though in this study active trigger points were not
the target of treatment but could also explain the
results observed when SA was used.
Conclusions
Acupuncture has been studied as a treatment for
many causes of pain, being a promising treatment
for DOMS because it showed that can reduce MS
2016:8 (2)
89
and improve PPT and VJ, yet with limited results in
muscular power and ROM.
Acknowledgements
Authors acknowledge all the work team of the Ap-
plied Physiology Laboratory - ICBAS UP, for logis-
tic, technical and revision support.
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