17: Case Studies

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CHAPTER 17 Case Studies

INTRODUCTION

The cases presented here illustrate two principles:

1. Applying the quantitative acupuncture evaluation (QAE) method to predict the result and duration of treatment
2. Applying and individualizing the standardized Integrative Neuromuscular Acupoint System (INMAS) protocol to each particular patient and symptom

Quantitative Acupuncture Evaluation

The principle of QAE is discussed in detail in Chapter 6 and we provide only a summary here.

Quantitative evaluation is based on the following factors:

1. The homeostatic status of a person is the same as the self-healing potential of that person in acupuncture therapy
2. The number of tender (passive) points in the body is an indicator of the healing potential—the more tender points, the lower the expected healing potential
3. As homeostasis declines, tender points appear in a predictable sequence in predictable anatomic locations

We selected 16 acupoints as evaluation points: palpating 4 points on the deep radial nerve on both arms and 4 points on the saphenous nerve on both legs enables us to divide patients into four groups: A, B, C, and D (Table 17-1).

Table 17-1 Quantitative Evaluation of Patients with Soft Tissue Pain

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Practitioners should understand that there is no drastic pathological difference between patients in groups A and B, and within each group there are differences between patients. For example, some group B patients may need 6 to 8 treatments, whereas others may need 8 to 10 treatments. Furthermore, the self-healing capability of some group A patients may be very close to that of some group B patients. For example, it is possible that some group A patients may need 7 to 8 treatments, whereas some group B patients may need only 5 to 6 treatments.

Standardized but Individualized INMAS Protocol

The INMAS treatment protocol ensures that every patient receives appropriately standardized treatment that is also adjusted to the patient’s personal condition. The INMAS protocol is described in detail in Chapter 5 and we provide only a summary here.

INMAS comprises three types of acupoint: homeostatic acupoints (HAs), symptomatic acupoints (SAs), and paravertebral acupoints (PAs). The HAs form the standardized part of the protocol and the SAs and PAs are used to adjust the protocol to each patient’s individual condition. For safety reasons, all patients are treated in recumbent positions: prone, supine, or on one side. All or some of the HAs available in the selected position are needled. The determination of whether to needle all or only some HAs depends on the patient’s needle tolerance and health. Fewer HAs will be used if the patient is less tolerant to needles, or is very weak and lacks sufficient energy to support the self-healing of a large number of needle-induced lesions. However fewer needles will also be appropriate for a patient who is very healthy, since in such a case a small number of needles will be sufficient for effective treatment. Weaker patients may feel very tired for a day or two after treatment.

About 5 to 10 SAs are commonly used for each treatment. The practitioner should palpate the symptomatic area carefully to find the most tender points.

PAs and SAs should be in the same segment. For example, PAs along C5-T1 are used for symptoms on the arm, whereas PAs along L3-L5 are used for knee pain.

The principles of quantitative evaluation and individualization of the standardized INMAS protocol are depicted in every case presented below. All of these cases involved real patients but their names have been changed to protect their privacy.

NECK AND BACK PAIN

Group A: Excellent Results

Case 1: Lower Back Pain

JK, a 42-year-old man, is a manager in a construction company. He is physically active and enjoys outdoor activities such as boating and hiking. One-and-a-half years ago, JK felt lower back pain after moving heavy furniture. After this episode, he was in constant pain that became more severe when he would sit down for about 30 minutes to work on his computer. The pain was more tolerable in the morning when he got up but sometimes became severe in the evening. He visited a chiropractor and several massage therapists, and obtained some relief for a short period following each treatment. A CT scan did not show any detectable problems.

Before the furniture-moving episode, JK occasionally felt soreness and stiffness in the lower back for a few days after heavy work. He had not had any accidents or severe injuries except for slightly hurting his biceps while doing weight lifting 6 years previously.

Quantitative evaluation placed JK in group A. Visual evaluation showed that his right shoulder was about 1 inch lower than his left. During physical examination, the right acupoints H14, H15, H16, and H22 were very tender upon palpation. The skin around right H15 was shiny, suggesting some swelling and inflammation. The impression was that the pain was caused by lumbar muscle strain. Considering that the pain had persisted for one and a half years, the prognosis was that it would take 4 to 8 treatments to achieve optimal recovery of the lumbar muscles for this group A individual.

Treatment Plan

Treatments were administered in the prone position. The acupoints selected were:

HAs: all of the HAs accessible to this position.
SAs: lumbar HAs are in fact SAs in this case.
PAs: lumbar HAs are in fact PAs in this case.

Treatments were scheduled every 5 days. After the second treatment, JK felt much better and his lumbar muscles were much more relaxed. After the fourth treatment, JK felt almost no pain. He was told not to resume his strenuous exercise routine because his injured muscles were still weak. After the sixth treatment, JK cancelled the remaining two treatments because he felt pain-free and returned to his usual physical activities.

At present, JK has resumed his vigorous lifestyle, coming to our clinic about once a month for maintenance treatments, which prevent his back and neck muscles from becoming tight and sore.

Case 2: Lower Back and Neck Pain

AB is a 20-year-old male bluegrass guitarist and a sophomore at a university. He came to the clinic with complaints of severe lower back pain, which he experienced after performing in the national bluegrass contest several days prior to visiting the clinic.

AB is fit and healthy and has no previous physical injuries. Quantitative evaluation placed him in group A. Visual examination showed that his left shoulder was higher than his right. Upon palpation, acupoints on the left of the neck and the left shoulder area (H7, H3, H13, and H8) were more tender than acupoints on the right side. Left lumbar acupoints (H14, H15, and H16) were sore upon palpation. The impression was that the pain in the lower back and neck was of an acute nature. The prognosis was that pain relief could be achieved within four treatments.

Treatment Plan

Treatments were done in the prone position. The acupoints selected were:

HAs: all accessible HAs in this position.
SAs: two tender points on left lateral neck, and two points on right lateral neck.
PAs: three points along T1-T3.

Treatments were scheduled every 3 days. Immediately after the first treatment, AB felt much more relaxed, his left shoulder moved lower, and his lower back pain subsided. The following day AB felt much better, the pain still lingered but was less disturbing. Two days after the second treatment, AB felt no pain and was able to continue to perform with his band.

Case 3: Lower Back Pain

YS was referred to the clinic by a local spine surgeon. She is 70 years old, in good health, active, and a world traveler. Three months prior to visiting the clinic she experienced lower back pain; she felt better after taking Advil but the pain would soon come back. She felt better in the morning but the pain became more severe as she engaged in her daily routine. At the same time she was experiencing a swelling of the left hypochondrium. Her medical doctor did not detect any abnormal condition in the spine.

YV was a smoker for more than 30 years but had quit 20 years previously. She had three children. At 40 years of age she had a left ovariotomy; at 50 she experienced mild whiplash from a low-speed car accident; at 55 she was hospitalized for lower back pain but was discharged without surgery. She adhered to a healthy low-carbohydrate and low-fat diet and prior to the current back pain she used to walk 3 to 4 miles a day.

YS is a healthy individual with only a few tender points on the body. Quantitative evaluation placed YS in group A. Visual examination showed that her left shoulder was a little lower than her right. Palpation revealed no tender points on the neck but very tender left lumbar acupoints (H14 and H15). The impression was that YS had lumbar muscle strain. The prognosis was that four to six acupuncture treatments would be needed.

Treatment Plan

Prone position:

HAs: lumbar HAs (H14, H15, H16, H22).
SAs: lumbar HAs are SAs in this case.
PAs: considering that the swollen left hypochondrium was on dermatomes T6-T10, four needles on each side along T6-T10 were used.

Supine position:

SAs: 15 small needles (15 mm in length) were inserted into the swollen skin

Treatments were administered every 4 days. After the second treatment, YS felt much better. After the fourth treatment, YS felt no pain and no swelling and discontinued the treatments, although she continues to come in periodically for maintenance treatments.

Case 4: Neck Pain Caused by Whiplash from a Car Accident

JL is a 17-year-old male high school senior who experienced whiplash after his car was hit from behind. One day after the accident he experienced neck and upper back pain. He hoped that the pain would resolve itself but after the pain had continued for 2 months his mother brought him to the clinic.

JL is healthy, without any previous medical problems. Quantitative evaluation placed him in group A. Upon palpation, his neck muscles on the sides and back were very tender, especially at the levels of C1-C2 and C4-C5. Also the muscles along T1-T10 were painful to palpation. The lumbar acupoints H15 and H22 were tender because the lower back muscles were also sensitive. Since the muscle pain extended from the cervical spine down to the sacral spine, the prognosis was that eight acupuncture treatments would be needed.

Treatment Plan

The treatments were administered in the prone position. The acupoints selected were:

HAs: neck (H7), shoulder (H3, H7, H13 and H8) and lumbar (H14, H15, H16, and H22).
SAs: two needles were inserted into each side of the cervical spine at C4-C5 level where the most tender points were palpated.
PAs: two needles were inserted on both sides of C5; five needles were inserted on each side along T1 to T8.

Treatments were administered every 4 days. JL felt sore one day after the first treatment but felt much better the next day. After the fifth treatment, the pain in the neck, upper back, and lower back completely disappeared.

Group B: Good Results

Case 5: Lower Back Pain

DS is a 36-year-old female school teacher. She experienced lower back pain about 5 months before coming to the clinic. The CT scan showed severe degenerative changes in the vertebrae L4-L5-S1. Two months prior to her visit she had received steroid injections but they did not provide relief. She does not have a history of injury or accident and lives a sedentary lifestyle.

Quantitative evaluation placed her in group B. Upon palpation, her lumbar acupoints H14, H15, H16, and H22 were tender and the area along L4-S4 was very painful. The neck and shoulder acupoints were also sensitive. Given that DS is a group B patient, the prognosis was that she would need about eight treatments to achieve stable relief.

Treatment Plan

Treatments were administered in the prone position. The acupoints selected were:

HAs: neck (H7), shoulder (H3, H7, H13, and H8) and lumbar (H14, H15, H16, and H22).
SAs: four needles were inserted into each side along L4-S4.
PAs: none because PAs along L4-S4 are in fact SAs.

Treatments were repeated every 4 to 5 days. After three treatments, DS felt that the pain was starting to subside. After the sixth treatment, she did not feel any pain and left for a 2-week vacation. After coming back from vacation, she felt some pain when working in the kitchen (she is a tall woman and the sink seems to have been too low for her) and resumed treatments. After a total of eight treatments, she did not feel any pain. One year later, DS is still pain free.

Case 6: Neck Pain

RF is a 62-year-old retired accountant. He experienced neck pain for at least 3 years prior to coming to the clinic. He had a very limited range of motion in the neck and always had to turn his whole body in order to look to the side. RF took prescribed pain medications but the pain came back when he stopped taking the pills and it was recommended that he “learn to live with the pain.” He has arthritis on C5. An MRI of the lumbar spine showed a large prolapsed disk herniation to the left of midline at L4-L5 associated with retrolisthesis at that level. In addition, he experienced pain on both IT bands.

Twenty years ago his car was rear ended in a car accident at a speed of 10 mph and he was diagnosed with whiplash. After the accident he started to experience neck pain. At the time of his first acupuncture appointment, he had been in pain for 3 years. He has asthma and uses a steroid inhalant in small dosages every morning. He is a little underweight but maintains a good appetite.

Quantitative evaluation placed RF in group B. Upon palpation, he had tender muscles in the back and on both sides of the neck from C1 to C7 and tender lumbar and leg acupoints (H14, H15, H16, H22, H18, H11, and H10). The prognosis was that 8 to 12 treatments would be needed.

Treatment Plan

Treatments were administered in the prone position. The selected acupoints were:

HAs: neck (H7), shoulder (H3, H7, H13, and H8), lumbar (H14, H15, H16, and H22) and leg (H18, H11 and H10).
SAs: three needles were inserted into each side of the cervical spine at C3, C5, and C6 levels where the most tender points were palpated.
PAs: two needles were inserted on both sides of C5.

Treatments were repeated every 5 days. Routine neck exercises were suggested. After the fourth treatment, RF felt sufficiently better to go on a long strenuous hike in the mountains, which required frequent head movement. The next day after the hike, RF experienced severe pain and came to the clinic for an emergency treatment. After six treatments, his lower back and leg pain were gone and his neck pain was subsiding.

During subsequent treatments, the leg acupoints were no longer used. After the twelfth treatment, RF did not feel any more neck pain even after going for a long hike, and he could rotate his head more than 60 degrees to both sides without turning his body. RF decided to continue acupuncture treatments to improve the range of motion of his neck and for general maintenance.

Case 7: Lower Back Pain

BG is a 52-year-old banker. He had experienced lower back stiffness, especially in the morning, for 30 years prior to presenting at the clinic. He runs three times a week for about 2 miles and is an avid golfer. Six months before his first appointment, his back stiffness became painful. Medical evaluation revealed disk degeneration at L4-L5.

BG had no previous medical problems. Quantitative evaluation placed him in group B. Upon palpation, his left lumbar muscles were more sensitive than those on the right, and the left lumbar acupoints (H15, H14, H22, and H16) were tender, especially H22. The neck area was healthy, without any tender points. Given the foregoing, treatments were concentrated on the lower back. The back pain was treatable because of its acute nature. The prognosis was that about eight treatments should be enough to reduce the present pain and, given 30-years-worth of lower back stiffness, about four more treatments would be needed to prevent lower back pain in the future. Thus, the prognosis was that initially eight treatments would be necessary.

Treatment Plan

Treatments were administered in the prone position. The acupoints selected were:

HAs: neck (H7), shoulder (H3, H7, H13 and H8), lumbar (H14, H15, H16, and H22), and leg HAs (H18, H11 and H10).
SAs: three needles were inserted into each side of levels L4-S1 where the most tender points were palpated.
PAs: none because PAs and SAs are the same in this case.

Treatments were repeated every 5 days. After the third treatment, BG no longer felt pain but he continued the treatments to reduce the morning stiffness of his lower back. BG comes for treatment once a month to prevent lower back pain and to improve his golf game due to better muscular coordination.

Case 8: Neck Pain

CH is a 55-year-old business manager. For 20 years she experienced tight shoulder muscles, especially the trapezius muscle. Six months prior to presenting to the clinic she felt neck pain that restricted her head rotation to the right. Medical evaluation suggested facet arthritis of C4-C5 and disk C4-C5 herniation. Her family physician prescribed steroid medication for 3 months. The medication did not relieve her pain but she experienced vasoconstriction in the skin area left to C7-T1, puffiness in the face, and left shoulder and arm pain.

CH is generally healthy. She has three children and had a hysterectomy at the age of 30. Fourteen years ago, she sustained whiplash from a car accident and experienced neck pain one hour after the accident. She continued to walk 3 miles a day even with the recent constant neck pain.

Quantitative evaluation placed CH in group B. Upon palpation, her neck muscles, especially the left side, were found to be very tender and warmer than normal, suggesting inflammation. Also tender were her shoulder and arm acupoints (H2, H7, H3, H13, H8, H9, H1, and H12) and the lumbar acupoints (H14, H15, and H16). Considering the severe neck pain as the results of arthritis and disk herniation, the prognosis was that 8 to 16 treatments would be needed.

Treatment Plan

Treatments were administered in the prone position. The acupoints selected were:

HAs: neck (H7), shoulder (H3, H7, H13, and H8), arm (H9, H1, and H12), and lumbar (H14, for two months, H15, H16, and H22).
SAs: three needles were inserted into each side of the cervical spine at C3, C5, and C6, where the most tender areas were detected.
PAs: two needles are inserted on both sides at C5 and C6.

Treatments were administered every 4 to 5 days. CH experienced improvement after the fifth treatment. After the seventh treatment, she went on vacation and to her surprise did not feel any neck, shoulder, or arm pain during the vacation. She continued to receive preventive acupuncture therapy treatments weekly until the twelfth treatment and was advised to continue acupuncture treatments once a month for 6 months.

Case 9: Lower Back Pain

YM is a 43-year-old computer engineer. He had suffered lower back pain for 2 years prior to presenting at the clinic. Medical evaluation revealed disk herniation at L4-L5. YM felt back pain whenever he stood or sat. At night he felt better only when sleeping on his side in the fetal position. His neurosurgeon advised him that he should delay surgery for several more years, until the disk herniation would become severe enough to justify it.

YM had no previous medical problems. Qualitative evaluation placed him in group B. Upon palpation, slightly tender HAs were found in the neck and shoulder areas and his left lumbar muscles were more sensitive than those on the right. The most tender tissue palpated was in the lumbosacral region left of L4 and S4. All of the lumbar acupoints (H15, H22, H14, and H16) also were very tender, especially on the left side. Considering the herniation of disks L4-L5 and the nature of this patient’s work, which required many hours in front of the computer, the prognosis was that eight treatments, with subsequent maintenance treatments, would be needed.

Treatment Plan

Treatments were administered in the prone position. The acupoints selected were:

HAs: neck (H7), shoulder (H3, H7, H13, and H8), lumbar (H14, H15, H16, and H22), and leg (H18, H11, and H10).
SAs: three needles were inserted into each side at the L3-S2 levels, where the most tender areas were palpated.
PAs: none, because PAs and SAs are the same in this case.

Treatments were administered once a week. After the fourth treatment, YM did not feel pain, only a tightness on the left side. Considering the L4-L5 herniation, YM decided to continue receiving maintenance treatments every 2 weeks. At present, YM has been receiving treatments at the clinic for 3 years. He feels slight pain sometimes after a long working day but the pain disappears after a maintenance treatment.

Case 10: Neck and Lower Back Pain

CG is a 55-year-old dentist. She had no history of pain problems during her 20 years of practice, until a sudden onset of neck and lower back pain about 5 months before she presented to the clinic. After the onset, she continued to work for 2 months but eventually was no longer able to tolerate the pain and had to leave her practice. An MRI did not reveal any problems.

Fifteen years ago CG experienced minor whiplash from a low-speed car accident; three years ago she tore her right ACL ligament and underwent corrective surgery. CG started menopause at the age of 51.

Qualitative evaluation placed CG in group B. Upon palpation, all of her neck and shoulder acupoints (H2, H7, H3, H13, and H8) were very tender and the lateral sides and back of the neck were very painful. All the back and leg acupoints (H15, H22, H14, H16, H18, H11, and H10) were tender, and swelling skin was observed on the lumbar area. Considering the extensive pain in both neck and lower back, the prognosis was that 8 to 16 treatments were needed.

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