Lateral Elbow Pain in Mainstream Medicine: A Challenge Today, A Breeze in 200 BC
Mainstream medicine (MSM) is defined as “Medicine practiced by holders of M.D. or D.O. degrees and by their allied health professionals, such as physical therapists, psychologists, and registered nurses" (Melissa C Stoppler, 2021). Similar definition is given by National Cancer Institute of NIH of the US, where “mainstream medicine” is a system in which medical doctors and other healthcare professionals (such as nurses, pharmacists, and therapists) treat symptoms and diseases using drugs, radiation, or surgery.
MSM is also called allopathic medicine, biomedicine, conventional medicine, orthodox medicine, and Western medicine. The term "mainstream" implies that other forms of medicine are outside the mainstream.
This post talks about the difference between today's MSM and the counterpart in ancient China 2000 year ago (at latest prior to 100 BC), with a simple health condition - lateral elbow pain (LEP) as an example case.
Best-Evidence Practice in Today's MSM
Lateral elbow pain (LEP), commonly known as tennis elbow, is a musculoskeletal disorder mostly affecting working people between 35 and 54 years of age, with a prevalence of between 1% and 3% (Brattberg G., 1983)
Recently in Dec. 2022, the Journal of Orthopaedic & Sports Physical Therapy published a clinical guideline for treatment of LEP. The guideline was authored by 10 PT, 1 MD and 1 OD researchers (Ann M. Lucado et al, 2022) from the US and Canada, and was based on the scientific literature published prior to November 2021.
The background of creating this guideline is that the Academy of Hand and Upper Extremity Physical Therapy (AHUEPT) and Academy of Orthopaedic Physical Therapy (AOPT) of the American Physical Therapy Association (APTA) have an ongoing effort to create evidence-based practice guidelines for management of patients with musculoskeletal impairments. LEP is one of commonly seen such impairments.
As stated in the guideline, two purposes of this APTA guideline for LEP, among others, are:
This APTA guideline could give us healthcare practitioners a rough idea about what seems to be the most current practice and the best evidence for LEP treatment in MSM today.
The guideline provided 17 RCT-tested interventions for LEP and the level of evidence for each intervention:
As shown above, none of the 17 interventions has a strong level of evidence. The highest level of evidence is “moderate” for 5 interventions (exercise, strengthening combined with manual therapy, joint mobilization, rigid taping and dry needling). The remaining 12 interventions have either weak evidence or conflicting evidence (uncertainty).
Conflicting Evidences
As mentioned earlier, the APTA guideline for LEP was based on the scientific literature published prior to November 2021. Soon after the APTA guideline established, in March 2022, a more recent systematic review and meta-analysis by 6 MD researchers (led by Peter Lapner) from Canada and the US compared physiotherapy (strengthening), corticosteroids (CSIs), platelet-rich plasma (PRP), and autologous blood (AB) with no treatment (or placebo control) in patients with lateral epicondylitis. The results were as below.
This 2022 literature review concluded: The available evidence does not support the use of nonoperative treatment options including physiotherapy (strengthening), CSI, PRP, or AB in the treatment of lateral epicondylitis.
While the literature review for establishing ATPA guideline was conducted on behalf of the American Physical Therapy Association (APTA), the more recent (March 2022) systematic review and meta-analysis was conducted on behalf of the Canadian Shoulder and Elbow Society (CSES).
Note that the ATPA guideline recommended strengthening (combined with manual therapy) with moderate evidence to support, but the more recent CSES guideline does not support “strengthening” due to insufficient evidence.
So a moderate level of evidence at this moment may soon turn out to be a weak or conflicting one just a moment later, if different RCTs are included in the literature review. There is another possibility that this conflicting may indicate that strengthening alone does not work unless combined with manual therapy.
At least in the last few decades, conflicting evidence has constantly been a commonly seen phenomenon particularly in medical researches. The words “may”, “possibly”, “seem to be”, “unclear”, “uncertain”... are among the most frequently used terms or phrases in the medical research papers when a conclusion, if any, is made.
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Inconclusive Researches
In 2019, the International Journal of Rehabilitation Research published a systematic review authored by 8 PT researchers from Japan (Momosaki R et al, 2019). The review was based on the Cochrane Database of Systematic Reviews in the Cochrane Library from 2008 through 2017 in the field of physiotherapy.
The Cochrane reviewers found 283 CRs in the field of physiotherapy, and among which only 16 (5.7%) were conclusive. Almost all reviews recognized the need for additional studies. Most CRs in physiotherapy are inconclusive, and most emphasize the need for further research (Momosaki R et al, 2019).
The Magic Consistency & Certainty in Ancient Healing Art
While a simple pain on the lateral elbow defeated the entire modern medicine world, few healthcare practitioners today are aware that there was a healing art 2000 years ago in China which could instantly knock out or greatly relieve any pain on the body including elbow pain.
The efficacy of the acupuncture in ancient China as described in Chinese medicine classic Huangdi Neijing was indeed marvelous: the symptom relief happens the instant the needle is in. More importantly, such instant efficacy was highly consistent, reliable and reproducible.
By at latest 100 BC, acupuncture in China had already developed into such a point that it was widely practiced as mainstream medicine. It was so popular and successful that the authors of Huandi Neijing strongly proposed that the herbs, most of them are poisonous, should be replaced by needles (LS 1 of Huangdi Neijing). I call this ancient acupuncture in China “Neijing Acupuncture” (NA).
When you read Neijing, you can always feel intensely the strong confidence of the Chinese physicians in that era with the efficacy of their needling: If the symptom relief is not instant, you just have not done the job correctly. The Lingshu 1 says:
Knock out LEP in A Breeze
If you understand the “hidden” principles of Neijing acupuncture, elbow pain relief is just a breeze (not just lateral elbow pain but pain anywhere on the elbow, even anywhere on the body). The “secret” of the magic Neijing acupuncture is very simple and straightforward: where to insert needles for a best cure is exclusively determined by the site of the illness.
In case of LEP where the site of pain is at lateral epicondyle, there are at least 10 body regions where you can find a spot which once pricked using a needle could produce an instant pain relief. Among these immediately effective spots, one of the most convenient ones is located at the plantar side of the MTP joint of the second toe. The practitioner can identify a tiny tender spot somewhere in this small area on the foot opposite of the painful elbow.
For the details of how to knock out LEP in a breeze, read “Lateral Elbow Pain: A Myth Bafling Modern Medicine World, A Breeze for Ancient Chinese Doctors”.
References
Ann M. Lucado et al. From US and Canada, Lateral Elbow Pain and Muscle Function Impairments. Journal of Orthopaedic & Sports Physical Therapy Dec. 2022 Volume 52 Issue12 Pages 1-111
Melissa Conrad St?ppler, MD Definition of Mainstream medicine, 3/29/2021, rxlist.com
Keith M Smart et al, Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II . Cochrane Review, 2022
Olivia Willis, 2017, Physiotherpy, chiropractic, and osteopathy: What's the difference? abc.net.au
Peter Lapner et al, Nonoperative treatment of lateral epicondylitis: a systematic review and meta-analysis, JSES International Volume 6, Issue 2, March 2022, Pages 321-330
Ryo Momosaki?et al, Conclusiveness of Cochrane Reviews in physiotherapy: a systematic search and analytical review. Int J Rehabil Res. 2019 Jun;42(2):97-105.