Thus the number of tender homeostatic acupoints (N_HAs; see Chapter 5) shows the interaction between the self-healing potential (HP) and the severity of the symptoms (SS). This relationship can be roughly expressed in the following linear formula:

This formula expresses the condition that the number of HAs is proportional to the severity of the symptoms (SS) and inversely proportional to the self-healing potential (HP); f represents a factor that varies for each individual.

A healthy person maintains optimum homeostasis, which results in the best self-healing and produces a fast, complete cure of most pain symptoms. Such a person will have only a few tender acupoints. If a healthy person suffers from acute pain symptoms, they can usually be relieved by two to four acupuncture treatments.

When chronic disease or chronic pain is affecting the body, homeostasis declines, the healing potential is reduced, and additional tender HAs gradually appear in a predictable sequence and in predictable locations. Patients with chronic pain usually need 8 to 16 acupuncture treatments to achieve pain relief. The same symptoms may return after about 4 to 6 months, and then additional acupuncture treatments will be needed to keep the pain under control for another 4 to 6 months.

If homeostasis deteriorates beyond a certain physiologic limit, the mechanism of self-healing is severely impeded. No matter how many treatments are administered, these patients will feel little or no relief.

Dr. H.C. Dung classified patients into four groups (see Table 6-1) according to their self-healing potential and treatment prognosis, after studying more than 15,000 cases.

Classification of patients is important because it allows prediction of the efficacy, duration, and prognosis of acupuncture therapy. To classify patients into groups, it is not necessary for a practitioner to count every passive HA in the body. Because HAs appear in an anticipated sequence and at highly predictable locations, it is sufficient to check a few landmark acupoints to obtain a clear picture about the group to which a patient belongs at the time of the treatment.

The selected landmark acupoints for patient evaluation are the H1 deep radial on the forearm (Figures 6-1 and 6-2) and H4 saphenous (Figure 6-3). The deep radial nerve and the saphenous nerve are similar to one another. Both emerge from deep tissues at similar locations just below the elbow and knee and start to branch to innervate other muscles. Figures 6-1 and 6-3 show that more HAs can appear distally to both H1 and H4. These additional points are located along the deep radial and saphenous nerves, about 2 to 3 cm apart. We call these points H1-2, H1-3, H1-4 (located on the deep radial nerve) and H4-2, H4-3, H4-4 (located on the saphenous nerve). Thus the total number of points is 16 bilaterally.

Figure 6-1 Acupoint used for quantitative evaluation. H1 deep radial is the first tender acupoint appearing in every person. As homeostasis declines, more tender points (H1-2, H1-3, and H1-4) gradually develop along the deep radial nerve distally from H1. So the number of tender points appearing on the deep radial nerve provides reliable information about the level of homeostasis; this information reflects the patient’s self-healing potential.

(Modified from Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002, WB Saunders.)

Figure 6-2 Surface location of H1 deep radial and its derivative tender points H1-2, H1-3, and H1-4 used to evaluate the self-healing potential.

(Modified from Lumley J: Surface anatomy: the anatomical basis of clinical examination, ed 3, Edinburgh, 2002, Churchill Livingstone.)

Figure 6-3 Surface location of H4 saphenous. The saphenous nerve is a cutaneous branch of the femoral nerve and supplies the skin of the medial side of the leg and foot. Just below the medial condyle of the tibia, the saphenous nerve emerges from the deep fascia and forms an important acupoint H4 saphenous. As homeostasis declines, more tender points appear along the course of the saphenous nerve distal from the H4 location. Thus these tender points on the saphenous nerve, if they appear, provide valuable information about the degree of homeostasis. These points, in order from proximal to distal, are termed H4-1, H4-2, H4-3, and H4-4. The distance between two points is about 2 to 3 cm (varying according to the length of the leg).

(Modified from Lumley J: Surface anatomy: the anatomical basis of clinical examination, ed 3, Edinburgh, 2002, Churchill Livingstone.)

The two points, H1 and H4, are tender in almost all patients. When the self-healing potential of a patient declines, the second points, H1-2 and H4-2, appear tender. If the self-healing potential continues to decline, the third points, H1-3 and H4-3, also become sensitive. When the self-healing potential is minimal, the fourth acupoints, H1-4 and H4-4, become tender.

When examining a patient we palpate all these 16 diagnostic points on the forearms and legs on both sides of the body. Using the results of this examination we can classify our patients into four groups, as shown in Table 6-2.

Table 6-2 Classification of Patients According to 16 Evaluation Points (H1−1, −2, −3, −4) + (H4−1, −2, −3, −4)

By combining data from Tables 6-1 and 6-2, we can predict the efficacy, duration, and outcome of acupuncture treatments. Statistical analysis shows that about one third of patients belong to group A (28%). The effects of acupuncture can seem miraculous for this group. Group D accounts for about one tenth of patients (8%), and these are least able to benefit from acupuncture therapy. Most patients, about 64%, belong to groups B and C and represent an average or slightly below average health level. Acupuncture treatments can successfully control chronic pain for patients in groups B and C for some time. In some cases the pain will recur in about 4 to 6 months (see Table 6-1); some patients may enjoy longer pain relief if they take appropriate measures for health maintenance. The mechanism of pain relapse was explained in Chapters 3 and 5. Age and genetic factors may influence the self-healing potential. The age of most group A patients is below 40, and most group D patients are above 60 years of age. Nevertheless it is not uncommon to see older patients in group A and younger patients in group D. We should not assume that older patients are necessarily sick or weak.

When checking acupoints, the practitioner must be able to apply correct and consistent pressure to each acupoint, which is not a difficult skill to learn. As a general rule, apply 2 to 3 pounds of thumb pressure on each diagnostic point. Applying insufficient pressure may cause underestimation of the tenderness of the acupoint, and applying excessive pressure may cause overestimation of the sensitivity of the acupoint.

The following simple guidelines facilitate the evaluation procedure:

1. The practitioner should adjust the thumb pressure to the pain threshold level of each patient. For example, when pressure is applied to H1-1 and H4-1, some patients will jump because of intolerable pain, whereas others will feel only a little tenderness. The practitioner should adjust the level of thumb pressure accordingly.

2. Less experienced practitioners can use the color change in their thumbnail as an indicator. When pressing acupoints H1-1 and H4-1, simply look at the nail of the thumb: when the pink color turns to white, the pressure is about 2 to 3 pounds. Care must be taken when treating patients who have a lower tolerance for pressure.

CLINICAL TECHNIQUES

The following section describes how to apply the quantitative evaluation method to acupuncture treatment.

Definition of Efficacy of Acupuncture Treatments

Acupuncture efficacy is measured by (1) the number of treatments needed for maximal relief and (2) the duration of the pain relief. It depends on the interaction between a patient’s self-healing potential and the severity and nature of the symptoms. In Tables 6-1 and 6-2, we classify pain patients into four groups: A, B, C, and D. Accordingly we can classify acupuncture efficacy into four groups: excellent for group A, good for group B, average for group C, and poor for group D. Different groups need a different number of treatments and experience different durations of pain relief.

With two to four treatments, patients in group A enjoy complete pain relief for at least 1 year or even for years if proper preventive measures are taken.

Group B patients need about four to eight treatments to obtain pain relief of about 4 to 6 months’ duration or longer if they adopt appropriate preventive maintenance.

Acupuncture treatments achieve average efficacy in group C patients. Patients in this group need more than eight treatments to obtain pain relief for an average of 5 months. After the symptoms relapse these patients need another session of acupuncture treatments to keep the pain under control for another 5 months (5 ± 1 months). Patients in this group can upgrade to group B by continuing preventive acupuncture treatments even after the pain symptoms are relieved.

Acupuncture generally demonstrates poor efficacy in group D patients. Acupuncture treatments may offer patients in this group pain relief for only a few days. Our clinical evidence shows that, with help from other supportive procedures such as diet, exercise, massage, and change of lifestyle, some of the group D patients may upgrade to group C. Sometimes remarkable results can be achieved for group D patients who demonstrate a strong desire to be healed and who are well supported by their practitioner and family members.

Collecting Information to Evaluate a Patient’s Healing Potential

In acupuncture therapy for soft tissue pain, understanding the full capacity of a patient’s self-healing potential is more important than understanding the mechanism and nature of the pathologic symptoms or diseases afflicting that patient. This is why acupuncture is able to treat with success symptoms that originate from what might be labeled mechanism unknown by health care professionals.

Thus QAE is not meant to differentiate diseases or to investigate the mechanism of diseases. The goal of QAE is to provide the information necessary for evaluating the self-healing potential of a patient and the projected efficacy of acupuncture treatments.

Before making a plan for acupuncture treatment, a practitioner should create the patient’s complete medical profile, and to do this the following information should be obtained.

Syncope or “Needle Fainting”

Dr. Chen, of the Center for Traditional Chinese Medicine of Veterans General Hospital in Taipei, Taiwan, reported 55 syncope events in 28,285 clinical acupuncture visits (0.19%).¹ These data are similar to our own clinical evidence. According to Dr. Chen’s statistical analysis, 28,285 visits account for about 3,235 patients, with each patient having an average of eight acupuncture treatments. Thus an acupuncture practitioner may encounter one syncope event in about every 500 treatments; in other words about 2% of patients in an acupuncture clinic will experience syncope. Fortunately syncope, or “needle fainting” as it is called in China, can be predicted and prevented.

In most cases syncope or “needle fainting” refers to the sudden loss of consciousness as a result of temporary low blood supply to the brain. Syncope occurs within 2 to 10 minutes of initial needle insertion. When only a few needles are inserted into the body, a syncope-prone patient complains of feeling dizzy and light-headed, the eyes become crossed, the muscles become rigid, and syncope follows.

Syncope usually happens in the early phase of the treatment; however, older patients may develop syncope in the middle or even at the end of the treatment. Close care should be taken throughout the course of a treatment when dealing with older patients.

Handling Syncope

When a patient experiences syncope during acupuncture treatment, the practitioner should remain calm and use the following procedures:

1. Immediately remove all needles from the patient. Have the patient lie down on his or her back with the head lower than the feet by elevating the feet on a cushion. This position helps to maintain the blood flow to the brain. If the patient is going to vomit, position the person on his or her side to prevent choking.

2. Needle the following regions: the middle part of the philtrum, just below the nasal septum on the vertical groove in the median portion of the upper lip (Figure 6-4), and the tip of the index or middle fingers.

Figure 6-4 The point on the philtrum to be needled in cases of syncope. It is just below the septum of the nose.

(Modified from Jenkins D: Hollinshead’s functional anatomy of the limbs and back, ed 8, Philadelphia, 2002.)

This procedure is clinically proven and effectively brings the patient back to consciousness. The physiologic mechanism of this centuries-old prescription is still unclear; possibly needling these points increases blood pressure.

Usually this type of needling terminates syncope quickly, almost immediately. As a rule, after “needle fainting” a patient feels tired and experiences slight discomfort all over the body, partly caused by psychological panic. If the patient does not wake up in a few minutes, an emergency call to a hospital is advised, although the acupuncture literature has never recorded a syncope of such prolonged duration.

Prevention of Syncope During Acupuncture Treatment

Acupuncture syncope happens mostly to patients when needles are inserted in the body in a seated or upright position. Prone, supine, or side positions of the body during acupuncture treatment are the most secure.

The following types of patients are more likely to experience syncope, and practitioners should always be prepared when treating patients in these categories:

1. A new patient without previous acupuncture experience or one who has not had acupuncture treatments for more than 6 months. Acupuncture provides a new stimulus to the physiologic activity of these patients, and their bodies need to adjust to this new modality.

2. Young, healthy, athletic males who may have a strong vasovagal reaction to needling.

3. Thin, middle-aged women with blood pressure lower than 120/70.

4. Older or weak patients who have a low energy level and multiple medical problems. In this group of patients, syncope may occur at any time during the acupuncture treatment.

5. Patients who are hungry, dehydrated, or exhausted after intense physical activities, or who eat just before the treatment.

As a preventive measure, inform new patients that they should eat no more than a light meal at least 1 hour before acupuncture treatment.

Bleeding and Bruising Caused by Needling

The estimated probability of bleeding from needling is about 10%, and the estimated probability of bruising after needling is less than 10%. Bleeding and bruising at needling sites do not cause any adverse effects to the patient’s health. As a preventive measure, a practitioner should avoid needling visible veins or palpable arteries below the skin surface, although ancient practitioners purposely needled the pulsing arterial points to treat diseases.

Bleeding caused by needling produces a tiny drop of blood on withdrawal of the needle and can be stopped by pressing with a cotton swab. Bruises caused by needling may take 5 to 7 days to disappear. Before a patient’s first acupuncture treatment, a practitioner should explain to the patient the possibility that harmless bleeding or bruising may occur.

Patients who have capillaries close to the skin surface, who have blood vessel problems, or are using a blood-thinning medication may experience bleeding or bruising more often. In this case the practitioner may press a cotton ball to the needle site immediately after withdrawing the needles. The practitioner should avoid needling directly on the joint capsule.

Pneumothorax

If an acupuncture needle perforates the pulmonary pleura (the serous membrane investing the lungs and lining the chest wall), the needle may cause a local lesion to the pleura or in some cases to the lung. As a result air could penetrate the lesion-damaged tissue of the thoracic wall and accumulate in the pleural cavity, which prevents lung expansion and results in difficult breathing accompanied by chest pain. This condition is called pneumothorax. Special attention to thoracic anatomy is needed (see Chapter 9 and Figure 9-12, p. 137) to avoid pneumothorax when needling points on the anterior, lateral, or posterior thorax.

No medical record exists to indicate that pneumothorax caused by needling has led to a life-threatening condition, but improper acupuncture needling will produce a severe traumatic effect on the patient. If an acupuncture needle perforates the pleura, the patient may suddenly feel pain radiating from the needling site. Usually the patient starts coughing about 30 minutes later and experiences short breaths, pain in the chest area, and tingling or numbness in the arms. When pneumothorax is suspected, the patient should be hospitalized for emergency aid. To prevent pneumothorax, we suggest using needles 25 to 30 mm (about 1 inch) long for paravertebral points (see Chapter 5) and 15 mm long for the lateral and anterior thorax.

When needling acupoints such as the H3 spinal accessory and H13 dorsal scapula (see Chapter 5), we recommend the following procedure: insert a needle (40 mm long) skin deep, and then grasp and hold up the muscle tissue between the fingers and the thumb. After the muscle is raised, continue inserting the needle until it reaches the nodule in the muscle and then immediately withdraw the needle without loosening grasp of the tissue. This safe procedure can be repeated a few times to achieve better muscle relaxation. This needling method should be performed only by experienced practitioners who are familiar with the gross anatomy of this region. Inexperienced practitioners may use an alternative procedure by inserting a few shorter needles (25 mm long) around H3 and H13 to achieve desirable results.

Special care should be taken when treating patients with a thinner body wall, especially patients with a spine problem, such as scoliosis, or a history of heavy smoking, because these patients have thinner, less elastic, weaker thoracic muscles. They may require more time to recover from the needle-induced lesions.

Acupuncture lesions may produce possible pneumothorax symptoms even after treatment. The hole from a needle-induced lesion in less elastic muscles may reopen when patients in the high-risk group simply breathe or do physical exercises. For safety reasons, when needling PAs in the thoracic region of patients in the high-risk group use only shorter needles tilting to the midline.

Needling Reaction

Physiologic reactions to acupuncture needling can be observed in some patients. The reaction may appear during treatment (immediate reaction) or a few hours after treatment (latent reaction).

Immediate Reaction

An immediate reaction manifests through the phenomena of syncope, sweating, brief hot or cold flashes, and in rare cases an anxiety attack. Among these reactions, only syncope needs a special procedure as described.

Latent Reaction

About 10% of patients feel more pain within 24 or 48 hours after acupuncture treatment. This pain may be “wandering” or appear in a new location. For instance, a patient complaining of lower back pain might experience shoulder pain, knee pain, or a headache for 1 or 2 days after acupuncture treatment.

This latent reaction occurs mostly in two different groups of patients: very healthy (group A) or very unhealthy (group D). The reaction in group A is referred to as a positive latent reaction and the reaction in group D as a negative latent reaction. A majority of patients experience none of these temporary side effects.

In older or weaker patients with multiple chronic health problems, the negative latent physiologic reaction can be induced by overstimulation from needling. During the first few treatments of weaker or older patients, no more than 10 needles should be used to avoid a negative latent reaction. After patients adjust to the needling and become physically stronger, more needles can be introduced if necessary.

The negative latent reaction can be explained as follows. Each acupuncture needle creates a tiny lesion or trauma to the soft tissues, including peripheral nerve endings. The healing of the needle-induced lesions is an energy-consuming process. A physically weak body with multiple injuries or symptoms can accept only a limited number of new needle-induced lesions because a weak body does not have enough healing energy to heal many of them. Patients who experience a negative latent reaction are mostly women 40 years of age or older.

Another group of patients, mostly young, healthy, athletic males in their twenties or thirties, may feel more pain within 24 hours after their first acupuncture treatment. This positive latent reaction does not indicate overstimulation but is a positive sign showing that the patient is having a strong response to acupuncture therapy. This type of patient usually requires fewer treatment sessions and recovers faster than most other patients.

What to Do When a Patient Experiences a Latent Reaction

A latent reaction, whether negative or positive, is not dangerous and can be easily relieved. When a patient experiences a latent reaction, a practitioner may insert a few needles in the painful area for about 5 to 10 minutes to cause the pain to subside. Usually we use one or two needles in a patient experiencing a negative latent reaction and four needles in a patient experiencing a positive latent reaction. Mild and light massage or moist heat also can help to calm down latent reaction pain.

More than 30% of patients feel tired and fatigued for a day after the treatment. This tiredness forces patients to sleep more and to perform fewer physical activities. Subsequent to the fatigue phase, patients usually experience a feeling of improvement and relief of symptoms. Thus the fatigue phase should be interpreted as positive body language convincing the patients to conserve the energy needed for healing of the symptoms after stress is removed.

A few patients complain of soreness at needle sites for 2 to 5 days after treatment. We suggest two explanations for this phenomenon. The first possibility is that needling interrupts the contracture structure deep in the muscle and/or other tissues and causes an antiinflammatory reaction. The needle-induced lesion continues to stimulate the tissues for a few days after the needle is removed. The second possibility is that a needle may perforate the deep blood vessel slightly and cause tiny internal bleeding, which stimulates the tissues for a few days. Usually massage or moist heat will reduce the soreness.

Drowsiness

Most patients feel relaxed or sleepy during treatment. Immediately after treatment, a few patients feel a little drowsy, possibly because of temporary lower blood pressure. These patients should lie down and rest until their drowsiness is gone and before they drive a car or go home.

Skin Reaction

Small red spots on the skin commonly appear at needle sites. The redness is most likely caused by local histamine release in reaction to the needle-induced lesion. This transient erythema lasts from a couple of minutes to 2 or 3 days after treatment. The erythema disappears once the needle-induced lesion heals. There is definitely neuroimmune reaction at the needling sites.

Pregnancy

Pregnant women frequently consider acupuncture to reduce lower back pain and treat other problems. Classic acupuncture texts list several acupoints that might induce abortion during the first trimester or even later. These acupoints are the H12 deep radial and H6 tibial (see inside cover). Some practitioners in China believe that needling any point in the body of a pregnant woman when she is 30 years old or older may induce abortion. A practitioner should fully understand the risk when working with pregnant patients.

Needling Skill

We highly recommend using disposable needles with individual guide tubes to minimize any possibility of infection. To insert this type of needle, hold the tube with one hand and lightly and swiftly tap the top of the tube with a finger of the other hand. Subsequently a practitioner can continue to insert the needle by either “pistoning” up and down or rotating clockwise and counterclockwise. These manipulation techniques help to relax the muscle contracture (see Chapter 3) and increase stimulation. Some patients might not tolerate the manipulation and will experience excessive pain, in which case the practitioner should use a finer needle and insert it with minimal twisting or rotating.

How Many Needles Should Be Used for Each Treatment?

Understanding the needling mechanisms and the physiologic strength or weakness of a patient permits a practitioner to decide how many needles should be used during an acupuncture treatment.

Each needle creates a microlesion in the tissues. In most patients it takes 2 days or longer for the needle-induced lesions to be replaced by fresh cells, and this process takes longer in weak patients. Thus, as indicated earlier, acupuncture-induced healing is an energy-consuming process.

Because the healing of needle-induced lesions usually takes longer for weaker and older patients because of their low energy level and low self-healing potential, a practitioner should use fewer needles during acupuncture treatments for these patients. As a reaction to overneedling, some patients may feel tired after treatment; they may feel soreness on the needled spots, or experience more pain for 1 or 2 days.

Healthier and younger patients have enough energy to heal the needle-induced lesions faster, and a practitioner could use more needles during an acupuncture treatment for these patients. As a rule of thumb, up to 30 needles can be used in one session.

For first-time patients without any previous experience of acupuncture treatments, fewer acupoints should be needled because these patients’ bodies need time to adjust to this new modality. A patient should be treated as a first-time patient if he or she has not received acupuncture treatments for longer than 6 months.

To provide effective acupuncture treatments, practitioners are encouraged to modify the protocol and to adjust it to each patient’s level of homeostasis, severity of pain symptoms, and tolerance to needles.

Frequency of Acupuncture Appointments

A successful acupuncture therapy should be administered with proper treatment “dosage” and treatment timing. Acupuncture “dosage” refers to the number of needles used in each treatment and to the timing of treatment. “Underneedling” may slow the healing process in most patients, whereas “overneedling” may cause strong “postneedling” reaction in a few patients.

For most patients, about 2 days are needed to heal the needle-induced lesions. For weaker and older patients, more than 2 days will be needed to heal the same lesions. Sufficient time should be allowed to heal the needle-induced lesions between treatments, especially for weak and older patients. Therefore the timing of acupuncture appointments depends on the following three factors.

General Health

Healthier patients need about 2 or 3 days between treatments, whereas weaker and older patients need 4 to 7 days between treatments. Keep in mind that the success or efficacy of acupuncture therapy depends not only on the skills of the practitioner but also on the general health of the patient.

Number of Needles Used During Treatment

The more needle-induced lesions that are made during an acupuncture treatment, the longer the time required between treatments.

Severity of Pain Symptoms

A severe symptom usually requires more treatments. When working with weaker patients who are experiencing a severe pain symptom, sufficient postneedling recovery time between treatments should be allowed. In practice a healthy patient can receive a treatment every day or every 2 to 3 days, whereas a weak or older patient needs 4 to 7 days between treatments. In China, weaker patients may receive daily treatment with minimal needling.

Types of Pain Relief

Three types of recovery are observed:

1. Immediate relief. This can usually be expected in young, healthy patients (group A) with simple acute pain symptoms.

2. Cumulative relief. Most patients feel some improvement after each treatment (groups B and C), and major or complete relief can realistically be expected after several treatments.

3. Delayed relief. Sometimes pain reduction is not obtained from the first few treatments but may be suddenly experienced 2 to 3 weeks after the first treatment.

If a patient has not experienced pain relief after the first four to six treatments, allow the patient to stop treatments for a week before resuming treatment again. Patients usually feel an improvement during the break.

Treatment Protocol

Acupuncture therapy by its nature (nonspecific) does not directly treat any particular symptoms or diseases; rather, it activates the process of self-healing for “healable” symptoms or diseases, either completely or partially. Our treatment protocol reflects the nature of acupuncture therapy and is clinically proven to be effective and applicable to every pain patient.

As we know, no two patients are identical. They have different homeostasis states, medical histories, lifestyles, and genetic makeup. The treatment protocol should be adjusted to the needs and health of each patient.

Our Integrative Neuromuscular Acupoint System (INMAS) protocol is standardized to be applicable to all pain symptoms and is individualized to be adjustable for each patient and each treatment. Please note that even the same patient could be treated differently at different sessions.

Explanation of the General Protocol

The general protocol consists of two parts: the standardized protocol and the individualized protocol.

1. Standardized protocol. The standardized protocol uses all or some of the 24 HAs for all pain symptoms (Chapter 5).

2. Individualized protocol. The individualized protocol uses symptomatic acupoints (SAs) and paravertebral acupoints (PAs), which are adjustable to each patient’s pain symptoms.

The following is a technical description of the general protocol and presents clinical examples of its practical applications.

Body Positions During Acupuncture Treatment

The body positions used during treatment depend on the location of the symptoms and the patient’s condition. Some patients, for example, cannot lie prone. A practitioner can decide whether to use one body position—prone, supine, or on the side—for a whole treatment, alternating for each successive treatment, or to use two or three positions in one treatment.

Use the prone position first in cases of pain in the neck, shoulder, back, hip, or knee. Note that knee pain often involves back muscles. For facial, elbow, or abdominal problems the supine position is preferable during the first treatment.

The sitting position should be used with discrimination and only for patients who cannot lie down. A practitioner should be alert and remember that a patient with lower blood pressure (lower than 120/70) may be susceptible to syncope while in the sitting position.

Standardized Protocol for the Prone Position

The patient lies comfortably in the prone position. The practitioner, using a finger or a thumb, palpates all 13 accessible HAs. All HAs are bilateral except H20 spinous process of T7. The forearms are not included.

Head (2):	H2 great auricular, H7 greater occipital
Shoulder bridge (1):	H3 spinal accessory
Shoulder (2):	H8 infraspinatus, H13 dorsal scapula
Upper back (2):	H20 spinous process of T7, H21 posterior cutaneous of T6
Lower back (3):	H14 superior cluneal, H15 posterior

Clinical Notes

During the treatment of a patient from one of the healthier groups (groups A, B, and some of group C), all 13 HAs can be needled, a total of 25 acupoints bilaterally (H20 is not bilateral).

When treating a weak or older patient, a practitioner should use fewer needles, as mentioned already, usually less than 20. The principle for selecting HAs in weak patients is as follows: All HAs should be needled in the main area of pain, but only the most tender HAs are needled in other regions. For example, when treating a weak patient with lower back pain, all lower back HAs (H14, H15, H16, and H22) should be needled first. Then the practitioner should palpate the lower extremities and find one or two more tender HAs and needle them. One or two HAs may also be selected in the neck, shoulder, and upper extremities, but these regions can be ignored if the patient is too weak to accept more needles. Weak patients need more treatments than those who can tolerate more needles at one time.

Standardized Protocol for Supine Position

The patient lies comfortably in the supine position. Using the thumb or other finger, the practitioner palpates the 11 accessible HAs.

Face (2):	H19 infraorbital, H23 supraorbital
Upper limbs (3):	H1 deep radial, H9 lateral antebrachial cutaneous, H12 superficial radial
Chest (1):	H17 lateral pectoral
Lower limbs (5):	H4 saphenous, H5 deep peroneal, H6 tibial H18 iliotibial, H24 common peroneal

Clinical Notes

When treating a patient from one of the healthy groups (groups A, B, and some of group C), all of the previously mentioned 11 HAs can be needled, bilaterally a total of 22 HAs. Sometimes it is necessary to avoid using the facial acupoints H19 and H23 because the feeling of needles being inserted into the face makes some patients uncomfortable.

For older or weaker patients, the same principles apply as were described in the previous section.

Individualized Protocol

The individualized protocol combines SAs and PAs to customize acupuncture treatments to the patient’s needs and pathologic symptoms.

Locating Symptomatic Acupoints

As explained in Chapter 5, HAs appear in a similar pattern in every patient. Each HA also serves as a “road map” for locating SAs. Finding and treating the right SAs greatly enhances the efficacy of the treatment. The following is an explanation of the general procedure of locating SAs.

Most symptomatic SAs emerge around local HAs. SAs are affected by a patient’s individual pain symptoms and therefore have an individual pattern. Some SAs are predictable, and some are not.