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

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

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.

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: two needles were inserted into each lateral side of the neck where the most tender areas were palpated. There were no SAs in the lumbar area because HAs are both PAs and SAs in this case.

PAs: one needle was inserted on both sides of C4 level because these areas were more tender than other areas on the neck. There were no PAs in the lumbar area because HAs are both PAs and SAs in this case.

Treatments were administered twice a week for the first 2 weeks and then once a week. Prior to each treatment, the neck was carefully palpated to identify the new SAs and the treatment was adjusted accordingly. The lower back acupoints remained unchanged. CG felt improvement in both the neck and the lower back after the fourth treatment. After the seventh treatment, she no longer felt pain in the neck and felt only a slight pain in the lower back, and resumed her work as a dentist. Because of her busy medical practice, CG comes once a week for treatment to prevent recurrence of the lower back, neck, and shoulder pain.

Group C: Average Results

Case 11: Lower Back Pain

LR is a 40-year-old housewife. She presented with severe lower back pain that she had felt all day long for many months. At night she could not sleep on her back. An MRI showed that she had a severe disk herniation at the L4-L5 level. LR’s spine surgeon told her that she needed immediate surgery or her pain would not only disable her but would cause further nerve degeneration. LR came to our clinic to find an alternative approach.

After reading her medical evaluation, we could not make any promises in this case, but did our best to treat her for 1 month. We told her that she should consider surgery if no progress was achieved after this time. LR has high blood pressure, which is controlled by medication, and occasionally she experiences cramping pain during the first day of her menses. Quantitative evaluation placed LR in group C.

Upon palpation, her lumbar acupoints were very tender (H15, H22, H14, H16), especially the left H22. The left leg acupoints (H18, H11, H10, and H6) were more sensitive than those on the right. Neck and shoulder acupoints were tender but not as sensitive as lumbar and leg acupoints. LR has low tolerance to the pain of needling so we had to design treatments that used a minimal number of points. Due to the severity of the symptoms, her poor health, and low tolerance to needling, the patient was not given any prognosis, but she decided to commit to the treatments in any case.

Treatment Plan

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

HAs: lumbar (H14, H15, H16, and H22) and leg (H18, H11, and H10).

SAs: two needles were inserted into each lateral side of L5 and S2 because this area was very tender.

PAs: no PAs were used, because PAs are SAs in this case.

Treatments were administered twice a week for 4 weeks and then once weekly. The same treatment was used each time. After the fourth treatment, LR felt better and decided to continue receiving treatments in order to avoid surgery. She experienced severe pain after the fifth treatment because of the onset of her menses. After the eighth treatment she felt more than 50% pain relief. We continued to use the same procedure for each treatment. After the sixteenth treatment, she felt very little pain and could walk and do most household chores with little pain. After the 24th treatment, she did not feel pain anymore, only occasional discomfort in the lumbar area. Whenever she experienced discomfort, she came for one or two sessions.

Case 12: Neck/Hip Pain (Whiplash/Arthritis)

AA is a successful 52-year-old businesswoman. She was involved in three car accidents that left her with severe neck pain. Her whole body was very weak. If she lay in the prone position for more than 10 minutes she would experience unbearable pain. Sitting for more than 15 minutes also caused her pain because of arthritis in her hip. She experienced pain while walking even a short distance. She had steroid injections, which helped for a short time. Surgery for neck pain was recommended.

Quantitative evaluation placed AA in group C. Upon palpation, all of her neck muscles on the lateral sides and back were very tender; the right shoulder muscles and the muscles right to the region of T1-T7 were also tender. AA has arthritis in the right hip, which causes pain in her right hip and leg. Based on her medical history, the prognosis was that more than 16 treatments were needed.

Treatment Plan

Treatments were administered in the prone position. Since AA could lie prone for only 10 minutes because of neck pain, we focused on the neck first. The acupoints selected were:

HAs: neck (H7), shoulder (H3, H7, H13, and H8), lumbar (H14, H15, H16, and H22), and leg (H18, H10).

SAs: one needle was inserted into each lateral side of the neck where the most tender areas were palpated.

PAs: two needles were inserted on both sides of C3 and C5 level because these areas were more tender than other areas on the neck. Three needles are used on each side along T1-T5.

Treatments were repeated twice a week. After the sixth session, AA felt less neck pain and was able to lie prone for 20 minutes.

Starting from the seventh session, we continued to repeat the same treatment plan but also added two needles on the right hip and two needles on the right IT band where very tender areas were palpated. We continued administering these treatments twice a week. AA was getting stronger and reported a reduction in the pain level. After receiving treatments for 2 months, AA felt very little occasional pain in the neck, hip, and leg and could walk for 40 minutes every day, which accelerated her recovery. After 3 months of treatments, her neck pain was completely gone, and she felt only some hip and leg discomfort if she walked for more than 2 hours.

Case 13: Lower Back Pain

BM, a 74-year-old woman, complained of chronic lower back pain. BM used to run a farm with her late husband and continued to run the family business. She had had 16 surgeries including four on her lower back. The most recent lower back surgery was 2 years ago for L2-L3 disk herniation. After a short relief, her lower back pain had returned and she was recommended to have no more lower back surgery.

BM looked strong for her age, but had had several strokes and atrial fibrillation. She told us that she had lumbar spinal stenosis at L2-L4 and foraminal stenosis at L4-S1. Scars from the previous four surgeries were observed on her lower back. Because of the multiple lower back surgeries and stenoses, it was difficult to estimate how many treatments, if any, could benefit this patient. However, BM insisted on starting acupuncture treatment. She told us, “Please take me, I am a fighter.”

Quantitative evaluation placed BM in group C but close to D. She was placed in group C due to her strong willpower and determination to regain her normal life (“I will do everything needed. I am a fighter.”). Upon palpation, her lower back was sore on both sides along L1-S2; all of the lumbar and leg acupoints (H15, H22, H14, H16, H18, H11, and H10) were tender; and there were secondary tender acupoints appearing around some of the primary acupoints. (At present it is not clear how multiple surgeries change the physiology of acupoints.)

Treatment Plan

BM could not lie prone because of her shoulder pain. Thus, treatments were administered when BM was lying on her left side. The acupoints selected were:

HAs: lumbar (bilateral H15, H16 and H22, right H14), and right leg (H18, H11, and H10).

SAs: two needles were inserted into each lateral side of the L5 and S2 because these two points were more sensitive upon palpation.

PAs: PAs were not needed because lumbar HAs are PAs and SAs in this case.

Treatments were administered once a week. After the fourth treatment, BM felt better and was able to walk without a walker. After 12 treatments, BM reported that she experienced more than 70% pain relief. She still felt pain but was able to do many things, including gardening, that she was not able to do before the acupuncture treatment. Encouraged by the results, BM continues to receive treatments once every 2 weeks.

Group D: Low Responders

Case 14: Lower Back Pain

RM is an 85-year-old woman who used to run a construction business with her late husband. She presented to the clinic with such severe lower back pain that she could not walk upright and had to lie in bed most of the time.

She has arthritis in most of her fingers and toes. These affected joints were swollen. She used to be a very strong and healthy woman but now the lower back pain was practically disabling her. Quantitative evaluation showed that RM belongs to group D. As a friend of BM of the previous case, she was encouraged by BM’s example, and was very hopeful and optimistic. RM was determined to follow the treatment regimen, had a strong support group at home, and was not willing to let the pain control her any more.

Upon palpation, her body had many tender acupoints, especially on the lower back area, and every lumbar acupoint was a tender area. Our prognosis was that she needed more than 16 treatments and that she should use transcutaneous electrical nerve stimulation (TENS) to treat herself at home for 20 minutes every day. Fortunately, RM has a granddaughter who is a massage therapist. We suggested that RM should receive light massage three times a week and acupuncture treatments once weekly.

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: two needles were inserted into each lateral side of the L5 and S2 because these two points were more sensitive upon palpation.

PAs: PAs were not needed because lumbar HAs are PAs and SAs in this case.

Treatments were repeated weekly, with the locations of SAs periodically changed according to the tenderness of the points in the lumbosacral region. After the first month, RM started to feel improvement. Two months later, she felt some pain but her back became more flexible and she could walk 30 minutes a day with only a little pain. She received a total of 18 treatments in our clinic. Five months later she informed us that she was taking all her children and grandchildren on a boat cruise to Alaska.

Case 15: Lower Back Pain

KK is a 69-year-old businessman who appeared very tall and emaciated. He presented to the clinic for severe lower back and right leg pain. The pain was more prominent on the right side, especially exactly on the right buttock muscle gluteus maximus where H16 inferior gluteal is located. The pain radiated to the lateral side on the IT band and front thigh. Sometimes he felt pain in both thighs.

A computed axial tomography (CAT) scan showed multilevel degenerative and postoperative changes in this patient who had undergone a wide laminectomy between the L1-2 disk space and the L3-4 disk space. There was also a large disk herniation with material prolapsing behind the posterior lower half of the L3 vertebral body. The disk herniation to the left of midline appeared to be causing a mass effect on at least one root that passed over it. There was also evidence of a possible arachnoiditis, particularly to the right of midline at the L2-3 disk space level and at the L3-4 disk space level and a small neuroma at the L3-4 level.

KK used to be physically fit and active, a mountain climber. Four years ago, he started to feel lower back pain and some signs of Parkinson’s disease. He had lower back surgery 15 months ago but it did not help. He received one steroid injection, which reduced the pain for only 1 week. He was taking about twenty different drugs daily for various reasons. His muscles were weak because he could not exercise sufficiently.

Quantitative evaluation placed KK in group D. We warned KK that his case was not easy and that he should make a commitment to work with us for a while. He would also have to regularly use TENS, receive massages, and walk with a walker for at least 30 minutes daily.

We used the INMAS protocol with minor adjustment of the SAs according to his pain during every session. KK received two treatments a week for the first 2 weeks, then one session a week. He felt some improvement after each treatment, but the pain would come back the following day. After the eighth session, KK decided to stop acupuncture treatment and to have another surgery.

Some possible reasons why treatment was not successful were that KK was too weak to follow the home routine; his family and friends did not believe in acupuncture and thus did not adequately support him; and only a few treatments were delivered. It is also possible that acupuncture simply does not work in his case.

NECK AND UPPER LIMB PAIN

Case 16: Neck and Upper Limb Pain

ML is a 42-year-old artist. He presented to the clinic with right shoulder and arm pain. He had a tingling sensation radiating from the right shoulder down to the tip of the right index finger. He had felt occasional tingling sensations for 1 year, but the tingling had become constant about 1 month previously. He had not consulted his medical doctor.

ML had bursitis in the same shoulder 20 years ago. He quit smoking 5 years ago. Also 5 years ago he was involved in a car accident that resulted in chronic neck pain.

ML is a healthy man and quantitative evaluation placed him in group B. Upon palpation, his neck and shoulder acupoints were sore (H7, H3, H13, H8), especially on the right side. The right arm acupoints H9 and H1 were also painful upon palpation, as were the lower back acupoints (H15, H22, H14, and H16). Acupoints on the right side of his body were more sore than those on the left. Sensitive points had appeared on the shoulder around H3 on the trapezius muscle, teres minor and major muscles, deltoid muscle, and the tendons of both heads of the biceps. ML’s pain was considered chronic because it lasted for more than 1 year. However, given that the patient was healthy the prognosis was that about eight treatments would be needed.

Treatment Plan Prone position.

The acupoints selected were:

HAs: neck and shoulder (H7, H3, H13, and H8), lower back (H15, H22, H14, and H16).

SAs: tender points on both lateral sides of the neck, palpable tender points close to the attachment to the humerus on the muscles supraspinatus, latissimus dorsi, teres major and minor. A few tender points were selected from these locations in every session.

PAs: three needles on each side along C5-T1.

Supine position. The acupoints selected were:

HAs: upper limb (H9, H1, and H12).

SAs: tender points on the deltoid muscles and biceps, especially the tendons of both heads of the biceps.

Both prone and supine positions were used in every session to desensitize all the affected muscles and soft tissues. Treatments were administered once a week. ML felt better after the second treatment. After six treatments, ML felt no more pain and tingling.

Case 17: Neck, Shoulder, and Upper Limb and Lower Back Pain

TB is a 34-year-old financier who works long hours in front of a computer. For 3 months prior to presenting to the clinic she experienced pain on the right side of the neck, in the right elbow, and in the right wrist while she was working. She was referred to the clinic by a spine surgeon.

TB suffered lower back pain 8 or 9 months previously. Physical therapy and chiropractic manipulation reduced the lower back pain but now the pain had come back and spread to the neck, shoulder, elbow, and wrist. In the last 15 years, she had three car accidents; two of them left her with whiplash and one caused a minor concussion. She used to be physically active until 3 months previously when severe pain greatly reduced her physical activity.

TB has no other medical problems. Quantitative evaluation placed her in group B. Upon palpation, her neck, right shoulder, and right arm muscles were very tender and her lower back acupoints also were very tender. The prognosis was eight treatments.

Treatment Plan

Prone position. The acupoints selected were:

HAs: neck and shoulder (H7, H3, H13, and H8), lower back (H15, H22, H14, and H16).

SAs: tender points on both lateral sides of the neck, tender points palpable close to attachment of the humerus on the muscles supraspinatus, latissimus dorsi, teres major and minor. A few tender points were selected from these locations in every session.

PAs: three needles on each side along C5-T1.

Supine position. The acupoints selected were:

HAs: upper limb (H9, H1, and H12).

SAs: tender points on the deltoid muscles, biceps, and muscles of the forearm extensors and flexors, especially the tender points right on the top of the carpal tunnel (palm side, between the base of the metacarpal and the wrist crease). During each session, one or two tender SAs on each part of the right upper limb were selected.

Both prone and supine positions were used in every session. Treatments were administered twice a week for the first 2 weeks then once a week. TB felt better after the fourth treatment. After six treatments, TB felt a drastic reduction in all of her neck, shoulder, arm, and lower back pain. TB received a total of nine treatments to obtain total relief from her pain symptoms.

Case 18: Finger Pain from Mountain Climbing

MT, a 32-year-old avid mountain climber, presented to the clinic for finger pain. During the previous 4 weeks he experienced sharp pain in the right middle finger when he grasped a rock during climbing.

MT is very healthy and quantitative evaluation placed him in group A. Physical examination revealed a tender area that was palpable on lateral sides of the joint between the proximal and middle phalanges. The pain was possibly caused by inflammation of the tendon of flexor digitorum superficialis. Usually tendinitis is caused by the tight muscle. We suggested that MT stop climbing until the injured tendon was completely healed. The prognosis was six treatments (between four and eight treatments).

Treatment Plan

Treatments were administered in the supine position. Local symptomatic treatment can provide complete healing of an acute inflammation. The SAs selected were:

1. Two small needles were inserted on each side of the joint between proximal and middle phalanges of the right middle finger.

2. Five tender points were palpated on the flexor muscles of the right forearm and were deeply needled.

Treatments were repeated once every 5 days. Finger pain was reduced upon palpation after the second treatment. After four treatments the pain was completely gone. MT waited for another 2 weeks before starting to climb again.

Case 19: Rotator Cuff Injury

AS is a 42-year-old social worker. She came to the clinic with a left rotator cuff injury. Three weeks previously she felt pain on the left shoulder after exercising in the gym. Her doctor diagnosed the shoulder pain as a rotator cuff injury, but no further medical evaluation was ordered. AS was prescribed an antiinflammatory drug, which she preferred not to take.

AS is athletically active and has no previous injuries. Quantitative evaluation placed her in group B. Upon palpation, tender points were found in the left lateral side of the neck, on the trapezius, the muscles of the scapula, the deltoid, and the pectoralis major and minor, especially on the front of the head of the humerus. Lumbar acupoints were also tender. Without data from a medical evaluation, such as magnetic resonance imaging (MRI), we could not assess the injury, but we were able to reduce pain and inflammation. The prognosis was that six to eight treatments would be needed.

Treatment Plan

The patient was positioned on the right side, so that both the front and back of the left shoulder were accessible. Treatments focused on the shoulder, neck, and lower back. The acupoints selected were:

HAs: neck (left H7), shoulder (left H3, H13, H8, and H17), lower back (H15, H22, left H14, and left H16).

SAs: the shoulder area was carefully palpated, especially on the head of the humerus, and five to eight tender points were selected to needle.

PAs: three needles on each side along C5-T1.

Treatments were administered once every 5 days, with the same protocol being used for every session. After seven treatments, AS felt completely pain-free.

HIP, LOWER LIMB AND FOOT PAIN.

Case 20: Foot Fasciitis

ST is a 37-year-old businessman. He had experienced pain on the sole and lateral side of the right foot for almost 1 year prior to presenting at the clinic. ST could not walk for more than 30 minutes because of debilitating pain in the right foot.

Thirteen months before presenting at the clinic, ST had surgery on the tendon of the right peroneus longus because he had torn the tendon during a basketball game. After the surgery ST began to feel foot pain.

ST is healthy and used to be athletic, but could not exercise since the foot problem. Qualitative analysis placed ST in group A. Palpation showed that the pain might have been caused by an inflammation of the plantar fascia (fasciitis). To supplement the acupuncture treatments, we suggested that ST wear an orthopedic shoe as often as possible. Considering the prior surgical intervention, the prognosis was that 8 to 12 treatments would be needed.

Treatment Plan

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

HAs: lumbar and leg (H15, H22, H15, H16, H18, H11, and H10).

SAs: three to five needles were inserted on the painful area on the sole and lateral side of the right foot. The needles were inserted all the way to the bone.

PAs: two needles were inserted on both sides of L5-S1, where tender points were detected.

Treatments were performed twice weekly for the first 2 weeks, then once a week. The same treatment was used each time. ST started to wear an orthopedic shoe and felt better after the third treatment. After nine treatments, he did not feel foot pain even when wearing a normal shoe. At this point ST discontinued his treatments. One month later, he told us that his foot felt normal and he started to play basketball again, but with caution.

Case 21: Pain in the Achilles Tendon

MR is a 48-year-old schoolteacher who played tennis 2 to 3 times a week. Six months ago, he heard a snapping noise on the left Achilles tendon during a tennis game. The next day he experienced pain in the Achilles tendon and found that the middle portion of the tendon was swollen. He was prescribed a nonsteroidal antiinflammatory drug by his medical doctor, learned stretching exercises from his physical therapist, and visited a massage therapist. The pain became more severe and he walked with a limp. He decided to try acupuncture.

MR is a healthy man without any history of previous injuries. Because quantitative evaluation placed MR in group A, we thought it possible to achieve healing through symptomatic treatment. Since there had been an insufficient blood supply to the Achilles tendon, the prognosis was that about eight sessions would be needed because tendinitis in a physically active person takes longer to heal than do muscular disorders.

Treatment Plan

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

HAs: all lumbar and leg HAs (H15, H22, H14, H16, H18, and H11).

SAs: H10 and the two tender points that were palpated around it; four to six needles were inserted into the swollen part of the Achilles tendon.

PAs: two needles were inserted on both sides of L5-S1, where nerve fibers are sent to the Achilles tendon.

The treatment was repeated every 5 days. After three treatments, MR felt significant pain relief. After seven treatments, the pain was completely gone, although the injured portion of the tendon was still slightly enlarged. MR gradually resumed his exercise routine without feeling any pain.

Case 22: Bursitis

KR, a physical therapist, just turned 26. She likes skiing and hiking during weekends. For the last 3 months, she experienced lower back pain, which was relieved after physical therapy. However, after some time she felt the pain again, around the attachment area of the left hamstring muscles. She felt the pain if she sat or walked for more than 1 hour. She told us that she believed the pain was caused by bursitis.

KR is healthy and has no previous injuries. Quantitative evaluation placed her in group B. During physical evaluation, pain was felt upon pressure on the left proximal attachment of the hamstring muscles. Upon palpation, the left lumbar and leg HAs were more tender than the right ones. Since KR’s pain was acute, the prognosis was that four to eight treatments would be needed to achieve healing.

Treatment Plan

Prone position. The acupoints selected were:

HAs: lumbar and leg (H15, H22, H14, H16, H18, H11, and H10).

SAs: four to five needles were inserted into the tender attachment area of the hamstring muscles.

PAs: two needles were inserted on both sides along L5-S2.

Supine position. The acupoints selected were:

HAs: leg (H4, H24, H6, and H5).

SAs: the medial, anterior, and lateral thigh areas were palpated to find tender points. One to three tender points were selected for needling in each session.

Treatments were administered once every 4 to 5 days. After five treatments, KR felt complete relief from the bursitis.

Case 23: Knee Pain

YY is a 49-year-old research scientist. He came to the clinic complaining of right knee pain, which he had felt for 2 weeks. The knee pain partially disabled him—he could walk with a tolerable level of pain on flat ground but could not climb stairs.

YY is healthy, living a sedentary lifestyle, although he walks about 2 miles a day. He had no previous medical problems. Quantitative evaluation placed him in group B. Since YY did not have a knee injury or arthritis, the knee pain was mostly caused by the tightening of the thigh muscles, which pull on the knee tendons. Upon palpation, the adductor muscles on the medial side of the thigh, and the lower part of sartorius, harbored several tender points. The area just below the medial condyle of the tibia was also very sensitive. Given that the pain was acute and that YY had no other medical problems, the prognosis was that four to eight treatments would be sufficient to achieve pain relief.

Treatment Plan

Prone position. The acupoints selected were:

HAs: lumbar and leg (H15, H22, H14, H16, H18, H11, and H10).

SAs: no SAs in this position.

PAs: two needles were inserted on both sides along L2-L5 (in addition to H22).

Supine position. The acupoints selected were:

HAs: leg (H4, H24, H6, and H5).

SAs: the medial, anterior, and lateral thigh areas were palpated to find tender points, and one to three tender points were selected for needling in each session. One needle was inserted into the dimple area on each side of the patellar tendon. The area around the medial condyle of the tibia was palpated and one to two points were selected for needling in each session.

Treatment was administered every 5 days. YY felt complete pain relief after the second session. He came for the third session and then discontinued the treatments. Four months later, the knee pain returned. He received two more treatments and the pain was completely relieved.

Case 24: Hip Pain

RV is a 66-year-old retired office manager who came to the clinic for right hip pain. She has arthritis on the right hip, which makes walking very difficult, so she walks very little. Both of her legs were swollen.

RV was taking medications for a cardiovascular problem (aneurysm) and high blood pressure. She also experienced some difficulty breathing. She had smoked for 30 years and quit 10 years previously. Quantitative evaluation placed RV in group C. Upon palpation, her hip area, especially around the greater trochanter, was very sore and resistant to touch. Considering the nature of the hip pain and RV’s general health, our prognosis was that she would need long-term treatment.

Treatment Plan

RV cannot lie prone, so treatments were administered with the patient lying on her left side. In this position, the posterior, lateral, and anterior sides of the hip are accessible.

HAs: lumbar (H15, H14, H22, H16 [right], H18 [right], and H10 [right]).

SAs: Five to six needles were inserted around the greater trochanter where the area was tender.

PAs: Five needles were inserted on each side of the thoracic spine along T1-T7. These needles help to improve shortness of breath.

For swollen legs, RV resumed the supine position. A cushion was propped behind the knee to raise the knee. H24, H6, and H5 were needled on both sides.

This treatment plan was repeated weekly. The swelling of the legs improved with each treatment, and the hip pain was gradually reduced to a tolerable level of soreness. RV started to walk more with the help of a cane or walker. The shortness of breath also was improving with each treatment, although it would get worse with weather changes. RV’s hip was becoming stronger after 10 treatments, allowing her to take increasingly longer walks, although the hip soreness persists. She continues to come for a treatment from time to time, whenever she feels she needs one.

SHINGLES

Case 25: Shingles

YZ is a 26-year-old graduate student. Five days before presenting to the clinic she felt itching in the left hypochondrium and lumbar region and the next day shiny blisters appeared on the skin. She felt excruciating burning pain in the infected area. She took Advil to reduce the pain but obtained little relief.

YZ is healthy and has no previous medical problems. Quantitative evaluation placed her in group B. Given that her shingle eruption was acute, our prognosis was that eight treatments would be needed.

Treatment Plan

Treatments were administered with the patient lying on her right side. The acupoints selected were:

HAs: shoulder and neck (H7 [left], H3 [left], and H8 [left]), left arm (H9, H1, and H12), lumbar (H15, H22, H14, and H16 [left]).

SAs: no SAs at this stage.

PAs: the infected dermatomes are supplied by spinal nerves T7-T10; thus, five needles were inserted on each side along spine T7-T10.

This treatment plan was repeated for every session. Treatments were administered every day for 5 days.

From the sixth treatment, in addition to the above HAs and PAs, 25 to 30 small needles (15 mm in length) were inserted into the infected skin. This treatment was repeated once every other day. After the eighth treatment, YZ felt recovered but continued for two more sessions.

The efficacy of acupuncture in treating postherpetic neuralgia is very controversial. The basic mechanism of acupuncture therapy should here be mentioned again: acupuncture does not target particular symptoms but just activates the healing potential of the body. The efficacy of acupuncture treatments for postherpetic neuralgia (shingles) or trigeminal neuralgia mostly depends on the healing capacity of the body. In the case presented above, YZ is young and healthy, so recovery was expected. In cases with low self-healing potential, such as patients of group D, acupuncture efficacy drops as the number of passive acupoints in the body increases. This is why acupuncture, in cases of postherpetic neuralgia, offers good healing for some but little or no results for others.

HEADACHE

Case 26: Headache

NH is a 46-year-old lawyer. She had experienced headaches for 5 years, mostly with pain in the left temple or behind the left eye. The headaches were not severe but persistent. She did not visit her family physician for the headaches but diagnosed them herself as tension headaches. An ophthalmologist examined her eyes and did not find any abnormalities. She tried homeopathic medications and chiropractic manipulation, which did not provide relief. Massage provided some relief for 1 or 2 days.

NH works very hard. She gets up at 5 am and goes to bed at 9 pm. She practices yoga every day and exercises twice a week in a gym. She has no history of previous injuries but had a urethra surgery 30 years ago. Quantitative evaluation placed NH in group B. Visual examination showed that her left shoulder was higher than her right, and she said that it had been this way for years. Upon palpation, HAs on the neck, shoulder, and lower back were very sore, especially on the left side. Given that the headache was chronic because it had persisted for 5 years, the prognosis was that at least eight treatments were needed to provide pain relief that might last for months.

Treatment Plan

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

HAs: neck (H7); shoulder (H3, H13, and H8), lumbar (H15, H22, H14, and H18).

SAs: one needle was inserted into each lateral side of the neck where the most tender spot was palpated. Two to three tender points were identified and needled around H3. One tender point on the muscle supraspinatus was needled.

PAs: two needles were inserted into each side along C5-T1; three needles were inserted into each side along T2-T7.

Treatments were repeated every 4 to 5 days. NH felt increasingly better with each treatment. After six treatments she felt no pain for an entire week. After the eighth session, she decided to stop treatments. She came back about 2 months later because she started to experience headaches again due to a stressful project. We repeated the same treatment plan for another four sessions. We believe that as long as her left shoulder is higher than the right, headaches can be triggered by any stressful situation or by cumulative daily stress.

Case 27: Headache

CC is a 31-year-old homemaker. She had experienced a severe headache one to three times a week on the left half of the skull for almost 6 years. This headache is often accompanied by nausea and stomach upsets. She does not take any pain medication because it irritates her stomach.

CC had a car accident 7 years ago, which resulted in severe lower back and neck pain for several months. CC also suffered from severe constipation. She ate vegetables, meats, and beans but had bowel movements about once or twice a week.

Quantitative evaluation placed CC in group C. Upon palpation, tender acupoints were found around every HA. We believed that her headache was related to her homeostatic condition and suggested that she drink fresh vegetable juice several times a day to cure the constipation. Our prognosis was that she needed 2 to 3 months of acupuncture treatments.

Treatment Plan

Prone position. The acupoints selected were:

HAs: all HAs accessible in this position.

SAs: one or two needles were inserted on each lateral side of the neck during each session according to the palpated tender points.

PAs: no PAs were selected because there were no local somatic symptoms.

Supine position. The acupoints selected were:

HAs: all HAs accessible in this position.

SAs: one needle was inserted bilaterally into the point about 2 inches lateral to the umbilicus. These two points, Stomach 25 in the classic acupuncture system, may help to relieve constipation.

Each session included treatments in both the prone and supine positions. Treatments were administered once every week. After the fourth treatment, CC experienced headaches less frequently. She drank juice regularly and had more frequent bowel movements. After the eighth treatment she went on vacation for 2 weeks and did not experience a headache. She continued with four more treatments after returning from vacation. Because CC belonged to group C, we warned her that her headache may recur after a while and that she should continue with maintenance treatments once every 2 weeks to stabilize her improvement. We also advised her that special attention should be paid to maintaining regular bowel movements.

NON-PAIN SYMPTOMS

Please note that the prediction of non-pain symptoms is less reliable than pain symptoms, and therefore the prediction is omitted in these cases.

Case 28: Bell’s Palsy (1)

Bell’s palsy is the paralysis of the muscles on one side of the face caused by neuropathy of the facial nerve. It can result from injury to the facial nerve, tumor, in rare cases, or unknown causes. The symptom is often no more than a temporary condition for a few days or weeks. However, it is not uncommon to see patients who take months or longer to recover if there is no treatment. If the symptom lasts too long, branches of the facial nerve can degenerate.

Acupuncture therapy will accelerate the healing process. However, if paralysis has persisted for a long time, acupuncture can do little or nothing.

RS is a 27-year-old computer programmer. Six months prior to presenting to the clinic he was involved in an accident that caused pain on the C5-C7 level. One week later he suddenly had paralysis on the left side of the face: the left corner of his mouth was sagging; the left eye could not be closed; and it was difficult to drink, chew, and swallow. This paralysis had persisted for 6 months without any improvement.

RS is healthy and exercises in a gym everyday. He has no previous medical problems.

Quantitative evaluation placed him in group B. However, since the palsy had lasted for 6 months, recovery was expected to be slow.

Treatment Plan

Prone position. The acupoints selected were:

HAs: all HAs accessible in this position.

SAs: no SAs were selected.

PAs: two needles were inserted on each side along C5-C7.

Supine position. The acupoints selected were:

HAs: facial and arm (H2, H23, H19, H9, H1, and H12). Leg HAs were not selected because of no symptoms in those areas.

SAs: on the affected facial muscles except orbicularis oculi: zygomaticus major and minor, orbicularis oris, levators labii.

The treatment plan was repeated every session twice weekly for the first 2 weeks, and then once a week. After six treatments, RS felt that the muscles were strong enough to bring up the drooping mouth corner and that eating and drinking had become easier. RS had a total of 16 treatments over 3 months, at the end of which the facial paralysis was no longer noticeable, although the left eye still did not close well at night. Subsequently, RS came to treatment irregularly and 4 months later the muscle orbicularis oculi could blink and close.

Case 29: Bell’s Palsy (2)

AS, a 65-year-old woman, came to the clinic with Bell’s palsy. She retired from her job in a bank 5 years previously. She started to have shingles on the left foot, leg, and hip. One month later, in the morning, she suddenly felt paralysis on the left side of the face. She was told that the paralysis would resolve itself in a few days. She waited for 2 months and still did not experience any improvement.

She has a complicated medical history. Thirty five years ago she broke two left ribs and damaged her neck (whiplash) in a car accident. Thirty years ago a complete hysterectomy was performed. She got hepatitis C from a blood transfusion. Ten years ago she had surgery on both wrists for carpal tunnel syndrome. She takes medication to control diabetes and occasionally experiences migraine headaches. She has a rotator cuff tear so she cannot lie in the prone position.

Quantitative evaluation placed AS in group C, very close to group D. Our prognosis was that her health and energy might not be able to sustain intensive acupuncture treatment and thus the treatment process might take longer.

Treatment Plan

Treatments were administered in the supine position because AS can only lie on her back. The acupoints selected were:

HAs: facial and arm (H2, H23, H19, H9, H1, and H12), leg (H4, H6, and H24).

SAs: on the affected facial muscles except orbicularis oculi.

The treatment plan was repeated in every session. AS received treatments once a week. After 10 treatments, she felt that the muscles were strong enough to bring up the drooping mouth corner and that eating and drinking had become easier. RS received a total of 16 treatments in 4 months. At the end of the treatments her facial paralysis was no longer noticeable but the left eye still did not close well at night and she needed to use eye drops to keep her eye moist.

One year later, AS felt a sharp pain for a few hours in the right shoulder area and experienced paralysis on the right side of her face the next morning. This time she received a total of eight treatments to bring the paralytic muscles back to normal.

Case 30: Sinusitis

NC is a 22-year-old student of architecture who came to the clinic with very painful chronic sinusitis. Her medical doctors suggested surgery. She recently had an ear infection and she thought it was caused by the sinusitis.

NC is reasonably healthy but has had chronic sinusitis and bronchitis since childhood. She is allergic to milk. Quantitative evaluation placed NC in group B.

Treatment Plan

Prone position. Acupoints selected were:

HAs: all HAs accessible in this position.

SAs: no SAs.

PAs: five needles on each side along T1-T7 for bronchitis.

Supine position. Acupoints selected were:

HAs: all HAs accessible in this position.

SAs: one needle was inserted into the nasion (midline between the eyes), and 1 needle on each ala nasi of the nose.

This treatment plan was repeated once every week. Immediately after the first treatment, NC said she felt better. After three treatments, she felt a significant improvement. Since her sinusitis was not related to the seasons (allergies), NC decided to come for an additional four treatments to stabilize the result. The additional treatments were administered once every 2 weeks.

Case 31: Urticaria or Neurodermatitis

KV just turned 48 and is an office manager. She experienced itchy and burning red wheals over her entire body 1 hour after she had finished working in her garden, where she was doing yard work under the sun for 3 hours.

KV is healthy and athletic. She had experienced similar urticaria two to three times many years ago but not in the previous 5 years. Quantitative evaluation placed KV in group B.

Treatment Plan

Prone position. The acupoints selected were:

HAs: all HAs accessible in this position.

SAs: no SAs were selected at this stage. Her problem was not pain related.

PAs: five needles were used on each side of the thoracic spine along T1-T7.

Supine position. The acupoints selected were:

HAs: all HAs accessible in this position.

The treatment plan was repeated once every day for 2 days. Most skin wheals subsided after the third treatment except the skin on the medial sides of the thigh and on the cubital fossa. After the third treatment the same needling was repeated with the addition of 5 to 10 needles inserted into the itchy skin on the medial thighs and cubital fossae. After the fifth treatment, the skin completely cleared up and the itching stopped.

Neurodermatitis can be treated in the same way. Apply needles to the following acupoints:

HAs: all HAs over the body.

SAs: insert several needles in itchy areas.

PAs: PAs are selected according to the dermatome relationship with SAs. For example, if itchy skin is located on the arms, PAs along C5-T1 should be selected. If itching appears on the lower limb, S1-S4 should be used.

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17: Case Studies

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