Trigger Point Acupuncture (Dry Needling) and Associated Fecal Incontinence in Multiple Sclerosis: A Case Report

Presenting Complaint

A 57-year-old woman presented for treatment of persistent thoracolumbar pain, which had been ongoing since a lifting injury some 12 months previously. As a result of the lifting injury, the patient had sustained a compression fracture of the T12 vertebra. Pain control had deteriorated over the past 4 months, with subsequent weight gain due to an inability to walk for greater than 10 minutes without significant back pain. Significant levels of stress and long hours at work were also considered to contribute to the patient's clinical presentation.

Past History

MS was diagnosed in 1981. The disease initially presented as numbness in the feet along with altered bowel and bladder function. The patient had experienced intermittent optic neuritis, speech difficulties, and coordination and balance changes since 1983. She had previously sought advice from a women's health consultant regarding increased urinary urgency and episodes of “variable bowel function,” including fecal leakage. At the time of her presentation the patient considered her MS condition to be relatively stable without the need for medication. The patient reported that most of her MS plaques were of central and cervical origin.

The patient had responded well to previous acupuncture treatments during the acute and subacute postfracture phases, which had incorporated sustained needling styles, using classical points (BL 60, SI 3, and BL 26) and targeted muscle trigger points, dry-needling the local paravertebral muscles from T12 to L5 and quadratus lumborum.

On Examination

The patient reported pain in the low lumbar spinal region symmetrically “in a tight band”; pain radiated into the upper gluteal area and also the right calf, with an average pre-treatment verbal Numerical Pain Rating Score of 6 of 10. ¹⁴ Supine lying also aggravated her lumbar symptoms, and the patient reported concurrent right-sided neck tension and occipital headaches. Patient Specific Functional Scales ¹⁵ recorded before treatment began were 9 of 10 for walking 100 meters, 8 of 10 for sitting longer than 10 minutes, and 4 of 10 for lifting duties at work (with 10 being optimal function).

On physical examination, the patient's lumbar spine range of motion was reduced by 25% in all planes of motion with lumbar pain reproduced at the limits of right side flexion and rotation. All reflexes were brisk, but calf power was equal and the patient was able to walk on her toes indicating no functional loss of plantarflexor strength. She had a positive result on an active straight leg raise test ¹⁶ on the right, which improved with bilateral compression of the anterior superior iliac spines. The patient demonstrated generally poor core strength (grade I on the Oxford scale, transversus abdominis) and had positive Trendelenburg signs bilaterally. Trigger points were also palpably tender bilaterally over the erector spinae, gluteal, and the right upper trapezius muscles.

Treatment

Treatment included bilateral needling of trigger-point acupuncture (dry-needling) ¹⁷ in the following: multifidus at L4 (equivalent to the Huatuo jiaji point); ¹⁸ gluteus maximus, medius, and minimus; and right upper trapezius (middle fibers and the right occipital insertion points). ¹⁹ The patient was placed in the prone position for the needling with flat palpation and insertion at the spinal and gluteal trigger points, using a “sparrow pecking” vertical technique until one fasciculation was achieved each. The occipital point was achieved with a flat-needle insertion parallel to the skin surface towards the nuchal line of the skull with one fasciculation. The middle fibers of the upper trapezius were palpated in a pinch grip with the soft tissue lifted off the chest wall. The needle was angled obliquely superior to the chest wall and above the therapist's thumb and index finger. Five fasciculations were achieved with a single insertion and multiple vertical manipulations. Spinal and trapezius points were treated with 0.22×40-mm and gluteal 0.22×75-mm-long single-use sterile Medic acupuncture needles, respectively (WuXi Jiajian Medical Instrument Co Ltd, Wuxi City, China). As part of the informed consent process, the patient was verbally warned about the potential for soreness over the subsequent 7–8 hours after treatment.

Evolution and Outcome

The patient presented again 8 days later and reported that she had experienced a bout of fecal incontinence with an associated loss of any sense of bowel evacuation following the previous acupuncture session. The patient also reported that her legs felt like “cotton wool” when getting out of the car. This feeling persisted for 24 hours and then settled into a “heavy leg” sensation bilaterally from the knees down. She consulted her general practitioner 3 days later, who prescribed a 1-week course of prednisone. It was the patient's opinion that, because of the immediacy of the reaction following the treatment session, the acupuncture had “flared” her MS; consequently, further acupuncture was discontinued. Investigations by the patient's neurologist subsequently confirmed a loss of sensation to one third of her anal sphincter. Verbal consent was obtained from the patient to undertake her clinical profile for the purposes of this case report.

Clinical Hypotheses

It is well established that bowel dysfunction—constipation, fecal incontinence, or a combination of both—may occur in 39%–73% of individuals with MS. ²¹ Normal bowel function depends on competence of the internal and external sphincters, pelvic floor musculature (puborectalis), and anorectal sensation and is supplemented by executive control, all of which may be disrupted by lesions associated with MS. Fecal incontinence is a heterogenous condition because it is often due to the presence of more than one deficit. ²² Dysautonomia secondary to MS may also influence bowel function, causing changes in stool consistency and frequency, flatus, and explosive diarrhea; if sphincter control is compromised, further sudden stool incontinence may occur. ²³

It is possible that the L4 and gluteal trigger points needled within the region of the L4–S1 dermatomes ²⁴ may have, via dichotomizing spinal nerve viscerosomatic connections (namely the superior hypogastric plexus and inferior mesenteric ganglion supplying the distal colon), modulated the autonomic homeostasis of the enteric system. The additional symptoms of reported loss of anorectal sensation in this patient's profile, along with altered sensation bilaterally in the lower limb, suggest the possibility of dorsal spinal column involvement; however, loss of proprioception was not confirmed clinically. Sustained needling of the paraspinal area (Governing Vessel and Bladder points) in combination with ashi points (the equivalent classical trigger point) ¹⁸ have previously resulted in two adverse acupuncture reactions, but urinary rather than fecal incontinence was reported. ²⁵

The addition of needling of the upper trapezius in the regions of BL 10 and GB 21 was a notable feature that had been added to this patient's usual treatment regimen. It is not known whether this supplementary intervention disrupted normal bowel function. According to Traditional Chinese Medicine theory, GB 21 is an acupuncture point with strong descending actions causing the drawing down of Qi (i.e., influencing a drawing down action in the body). ²⁶ Notably, Deadman et al., ²⁶ in quoting Gao Wu, states that “so strong is the action of GB21 in the descent of qi that you must also needle ST36 to regulate and tonify to counter any effects of the excessive qi descent.”

The relapse of MS symptoms may also be explained by changes in the inflammatory cytokines, such as tumor necrosis factor-α and interferon-γ, ² and some evidence, based on the skeletal muscle of rabbits, suggests that the tissues may be sensitive to different myofascial trigger point dosage levels. ²⁷ It is argued that whereas a single treatment with myofascial trigger points may produce a short-term analgesic effect due to changes in biochemical levels, an increase in dosage may induce tissue damage with associated increased levels of tumor necrosis factor-α. 2⁷ In the case study under discussion, the patient had single-twitch responses to the thoracolumbar and pelvic areas but a multiple-twitch response to the trapezius trigger point, which possibly accounts for systemic changes in the general metabolic homeostasis of the patient, and the ensuing fecal incontinence episode.

Mann ²⁸ considers patients with MS as potentially “strong reactors” to acupuncture who, if overtreated, may experience temporary but extremely unpleasant reactions, which then aggravate their MS symptoms. Patients with MS have been reported to experience autonomic dysreflexia,^29–32 which is a condition attributed to unregulated sympathetic discharge,^29–32 with symptoms ranging from hypertension, headache, anxiety, visual changes, altered heart rate, and nasal congestion to flushing, diaphoresis, and piloerection. ³⁰ Any needling associated with acupuncture may lead to a sympathetic reaction with an initial increase in sympathetic tone followed with a corresponding decrease after the removal of the needles, which may persist for up to 18 hours afterward.^33,34 In the case of patients with CNS lesions, almost any noxious stimulus may precipitate a massive sympathetic response, resulting in vasoconstriction of all the vascular beds below the spinal cord injury level of needling.

Patients with MS may have defects in peripheral immune regulation with a lowered threshold for activation of autoreactive T cells, which are responsible for initiating the inflammatory cascade. ³⁵ It is thought that there may be a relationship between MS fatigue and the overproduction of inflammatory cytokines systemically or within the CNS. ²¹ The work-related stress experienced by the patient may have also been a comprising factor leading to increased vulnerability on an existing compromised nervous system.

Implications

This case study highlights that treatment of patients with MS requires judicious and careful history taking, including details of urinary and or fecal incontinence independently of whether dry-needling or sustained-needling acupuncture treatment is planned. Systemic and local physiologic responses are likely to be altered, and special care should be taken when needling a patient with MS. Minimal acupuncture (superficial, few points, and with single-dose fasciculation in the case of dry-needling) would seem prudent to avoid potential immune or autonomic driven responses that may exacerbate MS symptoms. It is recommended that patients be forewarned of the potential for transient worsening of symptoms and homeostatic changes associated with acupuncture as part of the informed consent process before treatment.