The Foundation of the Spine: The Coccyx and the Sacrum

An analogy between the spine and a big tree will help to illustrate why many patients experience pain in this area. The trunk of a big tree (like the spine) has to support the canopy (the head) and numerous heavy branches (the upper limbs, ribs, and internal organs) that sprout from the trunk. This construction subjects the trunk to continuous mechanical stress and eventually the stress will affect the root system (the coccyx and sacrum bones).

The root system must be very strong and practically immovable to give adequate stability to the trunk and heavy branches of the tree. In calm weather, the tree ensures its symmetrical balance by having its branches spread in all directions and by evenly distributing gravitational stress among all the roots, which also spread in all directions. When a strong wind tilts the tree to one side, the symmetrical balance is lost and the roots from the opposite side of the tree sustain huge stress, which is many times higher than the weight of the tree (Figure 9-2). Using the physical principle of leverage, we can calculate the stress applied to the root system on the affected side of the tree. For example, if a tree weighs 500 pounds at its center of gravity, the affected part of the root system will sustain a stress of more than 5000 pounds.

Figure 9-2 Mechanical force sustained at the sacroiliac joint to balance the body is about 3 to 6 times the weight of the luggage if the spine is bent to pick up luggage. A similar mechanical stress occurs at the roots when the wind bends a tree.

The tree analogy explains why the foundation of the spine—the coccyx and sacrum—is so easily stressed and liable to be painful. Bending and twisting in an asymmetric manner are the predominant causes of lower back injury. The leverage described in the analogy with the tree is also applicable to our spine. For example, when a mother bends forward to pick up a 30-pound baby with both hands symmetrically, the stress on the spine and its foundation (sacrum and coccyx) could be 300 pounds. If the mother uses a correct bending posture, such as bending the knee first and staying close to the baby, the stress can be reduced to 100 pounds, which is distributed evenly between the muscles and joints on both sides of the body.

If our right hand picks up a 30-pound package (asymmetric action), the stress on the left sacroiliac joint and lumbar muscles on the left side can be more than 300 pounds, which will be distributed along the whole spine from the neck to the lower back. These are examples of the kind of potentially damaging stressful situations that our spine is exposed to daily, without our conscious awareness, in the workplace, at home, and during sports activities.

To correctly apply INMAS to the coccyx and the sacrum, an understanding of the anatomic structure of this area is important. The coccyx, which is also called the tailbone, is located at the base of the back. It consists of three to five fused bones. If we lose our balance and fall, the coccyx can break and a condition called coccygodynia may occur. We will discuss coccygodynia later in this chapter.

Above the coccyx are five more fused bones, the sacrum (S1-S5). The sacrum is a spade-shaped structure that is fixed between the two halves of the pelvis, which is the only structure that connects the spine to the lower limbs. Referring to the tree analogy, the two fused, relatively immovable bones—the coccyx and the sacrum—represent the roots of the tree. The two bones called ilium on either side of the pelvis make a joint on either side of the sacrum, and these are called the sacroiliac joints.

The sacroiliac (SI) joints differ from other joints. They are thicker and stronger and can move only a few millimeters (Figure 9-3). This relative immobility of SI joints stabilizes the spine against gravitational forces. The SI joints are also subject to the tremendous stresses and strains created by the forces of asymmetric imbalance as discussed in the above examples. The SI joints have to support the trunk, shoulders, arms, and head and to ensure a full range of motion.

Figure 9-3 Sacroiliac (SI) joints. A and B, Anterior and posterior views of the SI joints. C, Schematic horizontal section through the SI joints.

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

During locomotive activity such as walking, running, carrying weights, raising the arms, or dancing, the joints transfer weight from the spine to the hip bones. The pathological effect of excessive or overextended stress will accumulate in the joints and result in soft tissue disease.

These joints are innervated by the lower lumbar and sacral nerves, as a result of which pathological conditions in the joints can produce lower back pain and sciatica. For example, when the SI joints are inflamed, movement of the spine in any direction causes pain in the lumbosacral part of the spine. Usually the pain is more pronounced at the limit of forward flexion, since the hamstring muscles hold the hip bones in a relatively fixed position while the sacrum is rotating forward as the spine bends down.

INMAS is effective in treating painful symptoms related to the SI joint region. Most SI joint pain is caused by inflammation of the soft tissues such as nerves and ligaments. When needles are inserted into inflamed tissues, the needle-induced lesions break the blood vessels, thus stimulating the local defense immune reaction. As a result of the immune reaction, inflammation of the soft tissues of the SI joint is reduced. The needle-induced secretion of endorphins from the spinal cord and the brain reduces the physiological stress caused by the joint pain, thereby accelerating tissue healing. Eventually, this process restores normal SI joint function. The degree of recovery of SI joint function depends on the degree of the injury and the self-healing capability of the body.

The INMAS protocol for treating SI joints is provided at the end of this chapter.

Lumbar Spine (L1-L5)

The lumbar part of the spine is situated above the sacrum. The lumbar spine has five large vertebrae, and each vertebra has two upper facets (superior articular facets) that emerge from the top and two lower facets (inferior articular facets) that descend from the bottom (Figure 9-4).

Figure 9-4 Representative vertebrae from the spinal column. A, Cervical region. B, thoracic region. C, Lumbar region.

The functional unit of the lumbar spine consists of two adjacent vertebrae with an interposed intervertebral disk. The disk is a hydrodynamic structure that permits weight bearing and ensures the mobility of the unit itself and the mobility of the entire vertebral column. The two inferior facets of the vertebra above are loosely joined to the two superior facets of the vertebra below. During forward-and-back motion such as in fast dancing, the facets slide across each other. A side view shows that the lumbar spine is concave relative to the back of the body, and this is termed the lordotic curve.

The lumbar spine is located between two different and functionally conflicting parts of the spine and therefore is always subjected to substantial stress. Below the lumbar spine is the immobilized stability of the sacrum and above it are the heavy but flexible structures of the thoracic and cervical spine, which are required to be able to maintain a full range of spontaneous and rapid movement. This is why the lumbar spine is constantly engaged in trying to mediate an acceptable compromise between two conflicting functions, providing enough of both strength and flexibility at the same time.

Additional stress on the lumbar spine is created when a person holds weight in their hands with the arms extending away from the center of gravity of the body. In an upright posture the lumbar spine is supporting the axial compressive forces from the weight of the head, which is about 10 to 15 pounds, the weight of the upper limbs, and any additional loads that the upper limbs are carrying. When this compressive force is greater than half the body weight, particularly, the spine becomes unstable.

Because of these factors the lumbar spine is subject to a greater amount of constant stress than any other part of the spine, due to:

Thoracic Spine (T1-T12)

The thoracic spine has 12 vertebrae, and each vertebra has a pair of ribs attached to it. The ribs form a cage that holds open a space for creating a partial vacuum for inflating the lungs. The rib cage also protects the heart, lungs, and liver. The upper 10 ribs arise from the spine and are joined at the front. This allows the spine only a limited range of motion. Side views show that this part of the back is slightly concave relative to the front of the body, and this is termed the kyphotic curve.

The two lower ribs are short and are called floating ribs. They do not enclose anything, but they allow a broader range of motion than the first 10 thoracic vertebrae. The joints between the last thoracic vertebra and the first lumbar vertebra (between T12 and L1) also facilitate side-to-side rotation of these relatively immobile regions. This rotation implies a significant amount of wear and tear on these lowest two thoracic vertebrae and may result in various pain syndromes and degenerative diseases like osteoarthritis.

Cervical Spine

The cervical spine has seven vertebrae. These vertebrae get progressively smaller as they approach the bottom of the skull (see Figure 9-4). The cervical spine is the upper part of the spine and is capable of a great range of motion, in contrast to the foundation of the spine, the sacrum and coccyx, which has fused bones and almost immovable sacroiliac joints. For instance, the cervical spine allows the neck to turn 90 degrees in either direction, the ear to almost touch the shoulder, and the head to lean backwards more than 70 degrees.

The cervical spine differs from other parts of the spine in its agile motion and its ability to perform other important tasks; for instance, in addition to supporting the head, the neck provides a passage for air, food, nerves, and blood vessels.

The cervical spine is composed of two major complexes: the upper cervical segment (C1 and C2) and the lower cervical segment (C3 to C7). The occipital bone of the skull sits on the ring-shaped bone C1, which is called the atlas. The joint between them (0-C1), which is the first joint of the cervical spine, is called the atlantooccipital (AO) joint. This joint provides a very important function by anchoring the skull to the spine, and it is therefore necessarily the most immobile joint of the neck spine.

The second cervical vertebra, the axis, is the strongest of the cervical vertebrae. C2 has two large horizontal flat bearing surfaces called the superior articular facets. The atlas, C1, bearing the skull on top of it, rotates on these articular facets.

The distinctive feature of C2 is a blunt toothlike process called the odontoid process, or dens, projecting superiorly from the body (Figure 9-5). C1 uses the dens of C2 as its pivot for rotation. The front inner surface of the ring-shaped C1 is attached to the dens of C2, allowing C1 with the skull on top of it to rotate against the dens.

Figure 9-5 Posterosuperior views of the atlas (A) and axis (B). C, Superior view of the atlantoaxial joint.

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

The joint between C1 and C2, called the atlantoaxial (AA) joint, is the most mobile part of the spine. Fifty percent of all cervical rotation occurs at the AA joint.

The first two vertebral joints differ from all other vertebral joints because their main function is to allow head rotation. C1 and C2 are jointed by ligamentous integrity, and not by bony facets as are all other typical vertebrae.

Among all vertebral joints the AO joint is the most immobile, whereas the AA joint is the most mobile. This functional characteristic makes the AA joint more vulnerable to wear and susceptible to pathological conditions like inflammation and arthritis.

The use of homeostatic acupoints (HAs) to implement functional restoration, as well as reducing or eliminating pain, makes it an effective modality in reducing inflammation, rebuilding the function of the joints, and relieving and controlling related pain syndromes.

The facet joint between C2 and C3 is a transitional structure located between the rotation joint above C3 and the flexion-extension joints below C3. The cervical spine from C3 to C7 is organized such that it can rotate and simultaneously flex forward or laterally, or extend backward. The cervical vertebrae have to maintain enough stability to support the head, which weighs 10 to 15 pounds, while providing enough flexibility to perform these motions.

The peripheral nerve network in the neck region is some of the most complicated nervous wiring in the body. Eight cervical nerves emerge from the intervertebral foramen to form the cervical plexus from C1 to C4, and brachial plexus from C5 to T1. The intervertebral foramen is the passage from which the spinal nerve emerges. The neck is also the passage for the autonomic nervous system, which balances the physiological activities of the majority of the internal organs. Thus, pathological neck problems will affect not only the head and the arms but many different organs ranging from the brain to the large intestine.

A functional unit of the spine consists of two neighboring vertebrae: one above and one below. Examination of what happens to a typical cervical functional unit during a car accident will help to explain how excessive motion of the neck or exposure to sudden external forces can cause neck problems and pain.

In a car accident a sudden external force causes the head to bend forward (forward flexion) and the upper vertebra slides forward about an axis of rotation. The anterior intervertebral disk space narrows, the posterior intervertebral disk space widens, and the intervertebral disk deforms. As a result of this excessive narrowing of the anterior intervertebral space, there may be damage to the cartilage of the anterior joint surface, and the intervertebral disk may be broken and pushed backward. The widened posterior joint may break the joint capsule or even cause tearing of the ligaments. The broken intervertebral disk becomes herniated and the damaged joint surface produces pain and can cause arthritis in the future.

Rotation of the cervical spine is a coupling motion that involves both rotation and lateral flexion. For example, when the head turns to the left, the upper vertebra rotates to the left while its left intervertebral disk space narrows and its right intervertebral disk space widens. When this rotation is caused by violent force, the sudden closure of the left intervertebral disk space will cause damage to the cartilage of the joints, break the intervertebral disk, and force it to the right. Rotation caused by violent force also may cause injury to the spinal nerves: the left intervertebral foramen becomes smaller and pinches the left spinal nerve, and the broken intervertebral disk bulges to the right and pushes the right spinal nerve.

During a whiplash accident, the horizontal force from the back causes the neck to overextend and overflex (Figure 9-6), which causes damage to both posterior and anterior joints. In addition, the translational back-and-forward movement of the upper vertebra closes the vertebral canal, which causes injury to the spinal cord. Understanding the basic mechanical structure of the spine and the nature of pathological damage sustained by the spine during an accident is the key to effective acupuncture treatment for back pain.

Figure 9-6 Overextension and overflexion during a “whiplash” injury.

(From Wall P, Melzack R: Textbook of pain, ed 4, Edinburgh, 1999, Churchill Livingstone.)

The INMAS protocol for treating whiplash will be provided in the end of this chapter. Please note that in the case of whiplash, pain symptoms such as neck pain, lower back pain, and upper back pain are all closely related because functionally and anatomically all three parts of the spine—the neck, the upper back, and the lower back—are interrelated structures that should be understood as one whole entity and treated as such.

All the components of the back are so dependent upon each other that a problem in one structure can damage all the others. For example, a mechanical neck injury causes inflammation in spinal joints, which will strain muscles, and chronic muscle strain can contribute to arthritis in the spinal joints. Neck pain and back pain are clinically coupled.

Muscle strain can lead to disk displacement, and displaced disks can further strain the muscles. Motions such as excessive forward flexion, excessive backward extension, or excessive lateral rotation cause injuries to bony joints that involve cartilages, disks, capsules, and ligaments. These injuries strain the muscles, and strained muscles irritate the spinal nerves. All these pathological changes to the basic mechanical structure of the spine produce pain, and eventually this pain can trigger chronic problems such as arthritis and degenerative diseases.

The Shortened Muscle Syndrome

Muscles become shortened for protective reasons, to prevent further damage to healthy muscle tissue when it is subjected to pathologic factors, such as cold, fatigue, repetitive overuse or overstretching, low oxygen, or deficient blood circulation. When a muscle becomes shortened a domino effect is initiated that can generate many painful conditions. Muscular shortening gives rise to tension in the tissues by pulling tendons and their attachments and by offering resistance to healthy stretching. Thus, the shortened muscles and the stressed tendons and attachments eventually cause such symptoms as neck and back pain, epicondylitis, tendinitis, and tenosynovitis. All of these symptoms share the same etiology, although they appear dissimilar and occur at different anatomic sites.

Shortened muscles limit the range of motion of joints. For instance, a pathological condition called “frozen shoulders” is a result of shortening of all the muscles around the shoulder joint in addition to a capsular problem like inflammation. The shortened muscles increase pressure on the articular surface of a joint, which results in joint pain (arthralgia). Muscle shortening is also often responsible for joint misalignment. For example, the shortened muscle (extensor hallucis longus) of the foot causes angulation of the great toe (hallux vulgus) and a painful bunion. Muscle shortening contributes to pathologic conditions of joints, such as restriction of the range of motion and misalignment, and eventually leads to degenerative arthritis and osteoarthritis. Shortened muscles also put pressure on the nerves and produce an entrapment syndrome. For example, carpal tunnel syndrome is a result of shortening in the pronator teres or pronator quadratus muscles.

The paraspinal muscles, when shortened, draw two adjacent vertebrae closer together, which narrows the intervertebral space and foramen (Figure 9-7). The results are a bulging disk and a compressed nerve root. A vicious circle is gradually built up: shortened muscles cause compressed nerve roots (radiculopathy), and compressed nerve roots lead to further muscle shortening.⁴

Figure 9-7 Shortened paraspinal muscles across an intervertebral space compress the disk and nerve root.

(From Filshie J, White A: Medical acupuncture: a Western scientific approach, Edinburgh, 1998, Churchill Livingstone.)

Acupuncture treatments can break this vicious circle by using needles to produce a minimal tissue injury, which stimulates the relaxation of muscle stress. The primary goal in the treatment of muscle shortening is relaxation of the affected muscle, and acupuncture needling achieves this goal more swiftly and precisely than any other medical modality. When a fine acupuncture needle pierces a muscle, it pushes aside tissue, disrupts the cell membrane, and inflicts a minute tissue injury, which mechanically creates a brief outburst of microcurrents (injury potentials). The microinjury that results from needling generates relatively longlasting currents that stimulate the mechanism of repair and regeneration of the affected tissue (see Chapter 3). Thus, acupuncture treatment eliminates the pathological condition responsible for muscle shortening. After treatment a patient feels either no pain or a significant alleviation of pain.

This mechanism explains the efficacy of acupuncture treatment in addressing pain syndromes resulting from radiculopathy or pathological conditions of the joints such as osteoarthritis.

Bursitis

A bursa is a small fluid-filled sac that reduces friction between tissues. Excessive or repetitive use of a joint irritates the bursa and causes it to swell, resulting in pain during movement. The principal symptom of acute bursitis is sudden severe pain resulting in limitation of motion of the affected joints. A chronic bursitis condition may develop if an attack of acute bursitis is left untreated. Acupuncture needling is a very effective modality for treating acute bursitis but its effectiveness decreases proportionally to the degree of development of the chronic stage of the disease. Bursitis causes pain in the bursa and also in the muscles. The affected muscles become shortened and blood circulation is reduced. Needling is able to relax the muscles and increase blood circulation as well as stimulating an immune reaction and thus reducing the inflammation of the bursa.

Spinal Stenosis

Lumbar spinal stenosis is defined as a condition involving any type of narrowing of the spinal canal, nerve root canal, or tunnels of intervertebral foramina.⁵ Spinal stenosis can be either congenital or acquired. Acquired stenosis may be due to degenerative conditions (spondylolisthesis, see below), failed medical procedures (postlaminectomy, postfusion, postchemonucleolysis), or posttraumatic injuries, or it may be secondary to disk herniation (see below). Narrowing can occur in one or several locations of the same vertebral segment or it can affect several segments. The canal space can be narrowed by pathological changes in the soft tissues, scar tissue, or bony tissue impingement (bone spurs). Severe stenosis results in nerve compression. Soft tissue encroachment or abnormal bone growth such as osteophyte formation reduces the size of the intervertebral foramen and causes foraminal stenosis.

Twenty percent of patients diagnosed with spinal stenosis show no pain symptoms. The majority of sufferers experience lower back pain and some impairment of sensory or motor function in the leg(s) when walking or standing. Patients with spinal stenosis are more comfortable sleeping in the fetal position but they still experience a stiff back upon awakening. This stiffness is diminished in the course of daily activities but increases with prolonged standing and walking.

Some patients with spinal stenosis experience numbness or a burning sensation in both legs. Narrowing of the spinal canal or nerve root canal causes the painful condition known as a pinched nerve, which also irritates muscles and causes muscle pain. Acupuncture needling can relax the groups of erector spinae muscles from the neck to the sacral regions, thus reducing tension and increasing blood circulation between vertebral joints, which alleviates the pressure on the nerve roots and may help reduce swelling or inflammation of soft tissues in the affected region. Based on this mechanism, acupuncture therapy is helpful in mild cases of spinal stenosis especially when applied in combination with proper physical exercise. For example, one of our patients developed both spinal and foramenal stenosis at age 74 after four lumbar surgeries. Acupuncture therapy was able to reduce the pain to a very tolerable level and this patient now resumes normal life, including home office work and some gardening. Acupuncture therapy is not effective for severe cases of stenosis. When the cause of pain is not physiologically repairable such as in severe stenosis, acupuncture provides limited or no relief.

Radiculopathy

Radiculopathy is a common pain pattern seen in both the neck and the lower back. A spinal nerve leaves the spinal cord through the intervertebral foramen to innervate the skin, muscles, joints, or organs. The spinal nerve root or its membrane (dura) becomes inflamed and painful when the intervertebral foramen becomes reduced in its size due to herniated disks, bone spurs, osteoarthritis, or pathological changes in the soft tissues. The pain from the narrowing nerve root causes pain anywhere along the course of this spinal nerve to its target organs, especially the arm or the leg. This pathological condition is called radiculopathy.

In the case of radiculopathy, pain is manifested along the distribution of the painful nerve trunk. This condition also results in decreased muscle strength or a loss of sensation or reflex. Some radiculopathic pain may be referred pain and may manifest itself in an area distanced from the affected nerve because of cross communication between the nerves. For example:

Both radiculopathy and spinal stenosis (see above) can reduce blood circulation and cause one or more of the affected limbs to become a little cooler or paler than the healthy one. Some patients with lumbar radiculopathy may experience changes in bowel or bladder habits, with more frequent nighttime urination or leakage of urine when coughing or laughing.

Needling of the HAs and symptomatic acupoints (SAs) in cases of radiculopathy and stenosis reduces pain as a result of:

Spondylosis

Spondylosis refers to an acquired immobility of the joints caused by pathological conditions such as traumatic injury, infection, inflamed joint coverings, or degenerative spinal changes due to osteoarthritis. The majority of spondylosis cases are related to chronic rheumatoid arthritis, when the affected joint tends to assume the least painful position and may become more or less permanently fixed in this position. Pain from the affected joint spreads to the adjacent muscles and can cause extensive soft tissue pain and inflammation.

Application of needling relaxes the muscles and reduces soft tissue pain and inflammation. Relaxation and reduced inflammation of the muscles result in relaxation of the joint. The efficacy of acupuncture therapy in the treatment of spondylosis directly depends on the severity of the condition and the general health of the patient. If the spondylosis is caused by acute soft tissue injuries, needling will provide fast and significant relief due to the localized and restricted nature of the symptoms. If the spondylosis is of a chronic nature, which involves extensive tissue damage and even degenerative destruction, acupuncture can provide only limited, temporary, or no pain relief. In healthier patients a quicker and more complete recovery can be expected, and conversely recovery is slower in patients with greater medical problems.

Spondylolisthesis

Spondylolisthesis is the forward displacement of a vertebra over a lower vertebra. Usually this out-of-alignment condition happens at the fifth lumbar vertebra over the sacrum, or the fourth lumbar over the fifth. The forward slippage of the vertebra can lead to spinal stenosis and radiculopathy, which result in muscles that are tight and painful in response to movement, especially movement in the back and buttocks area.

Usually, acupuncture provides only temporary relief for this condition by reducing the muscle pain. It cannot secure stable pain relief because in this case reducing muscle spasm does not result in realignment of the affected joints.

Sciatica

Sciatica is one of the three main clinical manifestations of lower back pain. The other two are pain caused by spinal stenosis and nonspecific back pain symptoms that are often related to problems with various back muscles.

The term “sciatica” is used to describe a number of disorders directly or indirectly affecting the sciatic nerve. Patients with sciatica often feel pain along the anatomic path of the sciatic nerve and its branches: along the lumbar spine through the gluteal area, down along the back of the leg and calf to the sole of the foot or the big toe. Sciatica pain can have a constant or intermittent character. The sharpness of the pain sensation varies and may increase and decrease over a short period of time. The character of the pain can be described as an unpleasant electric shock, heat, tingling, or a stabbing or almost unbearable pain sensation.

Because of its significant size and length (it is the biggest nerve in our body), the sciatic nerve is subject to many types of injuries and inflammations. For example, sciatic pain can be caused by a herniated disk, arthritis of the spine, and pressure on the nerve from certain types of exertion. The sciatic nerve also can be damaged by toxic substances such as lead or alcohol. Occasionally diseases such as diabetes mellitus, gout, or vitamin deficiency contribute to sciatica pain.

In the majority of sciatica cases, where pain and inflammation are caused by soft tissue injury, a proper combination of HAs and SAs produces the optimum pain relief by reducing the inflammation of nerves and muscle. Nerve inflammation is liable to cause pain in the muscles it innervates. Needling and its resulting lesions activate an antiinflammatory reaction that reduces nerve sensitization. Needling also relaxes the painful muscles and increases blood circulation. The general effect of the acupuncture needling is to reduce the inflammation of nerves, muscles, and other soft tissues, and this results in relief from the pain of sciatica.

When patients have sciatica of unknown etiology, and do not experience significant relief after sufficient acupuncture sessions (Chapter 6), they should be referred for further medical evaluation.

Piriformis Syndrome

The piriformis muscle arises from the anterior surface of the sacrum, then is distributed through the greater sciatic foramen and is surrounded by neurovascular structures that enter the buttock. The piriformis muscle is attached to the upper border of the greater trochanter of the femur. Functionally, it is a lateral rotator of the thigh at the hip. Its task is to ensure, in concert with other muscles, a lateral rotation of the femur, and this is very demanding. When the piriformis muscle is fatigued, it becomes tight and generates pain when forced to stretch.

Current medical opinion holds that lower back pain with sciatic radiation may be caused by a compression of the sciatic nerve by the piriformis muscle as the nerve emerges from under the muscle in the buttock (Figure 9-8). The piriformis syndrome is characterized by pain along the sciatic nerve. The pain is usually more severe in the sitting position than in the standing position, and it is often more troublesome early in the morning if patients sleep on their backs. Tenderness in the buttock area, especially at the center of the gluteus maximus muscle, can be palpated. This tenderness is located at acupoint H16 inferior gluteal in our INMAS. This acupoint is sensitive in most healthy people but this does not mean they all have piriformis syndrome.

Figure 9-8 Piriformis syndrome: some experts believe that the piriformis muscle compresses the sciatic nerve as it emerges from under the piriformis muscle in the buttock.

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

Patients with piriformis syndrome experience pain and a restricted range of motion when trying to cross the affected leg over the healthy leg because this action demands stretching of the piriformis muscle. After a prolonged period in a sitting position, patients may experience numbness, tingling, weakness, loss of reflexes, strange discomfort sensations, and even a temperature difference in the parts of the body served by the sciatic nerve, which starts from the roots of L4, L5, and S1. In a few cases, patients with piriformis syndrome experience a tingling sensation in the testicles or labia majora.

Some in the medical profession believe that the piriformis syndrome cannot trigger such a significant amount of pain because the piriformis muscle is too small to have such a powerful impact on the sciatic nerve. Regardless of whether this opinion is justified, patients with piriformis syndrome can be benefited by acupuncture needling. The practitioner can easily find the tender acupoint H16 inferior gluteal and needle it deeply with a long needle all the way to the piriformis muscle. This needling of the piriformis muscle itself reduces tension and inflammation. If there are other tender points around H16, they should be located by palpation and needled for complete pain relief.

Herniated Disk (Herniated Nucleus Pulposus)

A herniated disk may cause pain because of anatomic abnormality and chemical irritation.

Excessive and nonphysiologic motion of the functional unit of the spine, especially rotation (twisting), damages the annular fibers. The centrally located nucleus is thus allowed to herniate outward through the disrupted annular fibers. This outward bulging, the herniation, may encroach on the posterior longitudinal ligament and the dorsal root ganglion and its dural sheath within the intervertebral foramen, thus creating a radiculopathy or spinal stenosis, affecting multiple nerve roots.

In addition to mechanical encroachment, the injured disk releases nociceptive chemicals of the matrix, leading to inflammation of the dural sheath, ligament, and nerve roots. Inflammatory cells such as macrophages, lymphocytes, and fibroblasts are found in surgically removed disk material. Recent research shows that cytokines and chemokines also play a role as pain triggers.⁷

In cases of a mild herniated disk, acupuncture needling relaxes the tight back muscles, thereby reducing the pressure applied to the joint by these muscles. The relaxed muscles are enabled to obtain sufficient blood circulation, which causes an increase in nutrition, oxygen supply, and removal of toxins, allowing the self-healing potential to bring under control the biochemical irritation to the nerves. According to some researchers, the body tissues are even able to absorb the herniated materials.⁸

Self healing of a herniated disk is a very important concept as described by the well-known neurosurgeon Dr. Frank T. Vertosick, Fellow of the American College of Surgeons¹⁰:

When our body can absorb the herniated disk in mild cases, acupuncture will accelerate this process.

In cases of a severely herniated disk, the large mass of the herniated material occupies the space and passage of the spinal cord or nerves and constantly irritates the sensory nerves. The irritated nerves cause pain and inflammation in muscles and other soft tissues. In this case acupuncture needling relaxes the tight and painful muscles. In the presence of persisting neuropathologic irritation, pain relief by means of acupuncture is possible but temporary. However, even temporary pain relief is beneficial to patients because it slows down the degenerative or necrotic process as well.

Constant pain causes constant tightness of the muscles, which results in reduced blood circulation and aggravates the process of degeneration. When the tight muscles are relaxed, the blood circulation is increased, which leads to increased supply of nutrients and oxygen to the affected tissues, removing metabolic wastes, and activating tissue regeneration. Thus, needling mechanisms will slow down the tissue degeneration. Unfortunately, because of the herniation, the needle-induced muscle relaxation will not last long, so acupuncture will serve only as a supplementary therapy for this condition.

Several patients with severe lower back pain and MRI-confirmed herniated disks came to our clinic for pain relief before making a decision about whether or not to have surgery. After treatment in our practice some of these patients experienced a reduction in or total relief of pain and decided to delay surgery indefinitely.

Tendinitis

Tendinitis means inflammation of tendons and of tendon-muscle attachments. It is frequently associated with a calcium deposit (calcific tendinitis), which may also involve the bursa around the tendon or near the joint, causing bursitis (see below).

Overstretched tendons, whether strained or sprained, will be inflamed. Many professional and amateur athletes have experienced tendinitis, such as pain in the region where the hamstring originates on the ischial tuberosity, or the insertion area on the medial side of the knee, or the upper part of the medial surface of the tibia. In upper limbs, lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow) are very common tendon injuries. These types of tendinitis are caused by repeated and excessive extension-flexion motions and, in the upper limbs, by rapid pronation-supination. These repeated motions first make muscles tight and fatigued so they cannot relax fast enough or to a sufficient extent. Then the tight muscles start to exert force on the tendons, which results in tendinitis. Upon examination of the affected muscles, tender points are found in the affected tendons and muscles as well. In most repetitive injuries, tendinitis is clearly caused by tight, shortened, and fatigued muscles (Figure 9-9).

Figure 9-9 A fatigued, tight, and shortened muscle can cause tendinitis.

(From Filshie J, White A: Medical acupuncture: a Western scientific approach, Edinburgh, 1998, Churchill Livingstone.)

To treat tendinitis, both the affected muscles and the inflamed tendons should be needled simultaneously. Focusing only on inflamed tendons is a common mistake in treating tendinitis. The inflammation of the tendon is the effect, and the cause is the tight and fatigued muscles. We get very good results in treating tendon and ligament inflammation by proper simultaneous needling of both tight muscles and inflamed tendons. Practitioners should carefully palpate the sore muscles and inflamed tendons to detect all the tender points, and all these points should be needled.

Note that in cases of tendon or ligament inflammation caused by overstretching from athletic activities, patients should take complete rest or perform only mild exercise during the course of the first few acupuncture treatments.

Facet Syndrome

The majority of joints in the spine have smooth surfaces of cartilage. Each joint is bathed in a slippery lubricating liquid and enclosed in a rough pleated capsule. Facet joints have a rich nerve supply from the medial branch of the dorsal ramus of the spinal nerve.

Facet joints of the spine, like all joints in the body, are mechanically aligned to sustain and secure movement. For example, due to the mechanical design necessary to meet the functional demands of the body, the cervical spine is more mobile but less stable while the lumbar spine is less mobile and more stable. Therefore the facet joints of the cervical spine are designed to allow flexion (bending forward), extension (bending backward), and rotation to the side while the lumbar facet joints resist rotation.

High-tech medical equipment such as X-rays, CAT, and MRI scans often provide the necessary data for identifying the underlying cause of a patient’s pain, but medical doctors are aware that the source of pain cannot always be detected by these means. In some cases patients feel pain when their joints appear normal on X-rays, CAT, or MRI scans. Alternatively, the joints can appear damaged while no pain is experienced by the patient. Thus, acupuncture practitioners should keep in mind that high-tech data presented to them by a patient may be valuable, but the underlying cause of the pain can be much more complicated than the data can reveal.

Pathology of facet joints may result in neck and back pain. For instance, in chronic whiplash cases, disturbed facet joints are the single most common cause of neck pain. Once a facet joint is injured in an accident or through excessive motion, a patient experiences pain even when performing tasks within their normal range of motion.

In young people, strong or abrupt movement can cause the lumbar facet joints to slip out of normal alignment. When this happens, the facet joints become locked and extremely painful. With aging many minor traumas are accumulated at the joint surface. The accumulated effect of these injuries gradually produces permanent swellings and deformities on the joint surfaces, which are no longer smooth. When such joints are forced to move or to support weight, the deformities bear the full impact of pressure that is normally evenly distributed over the entire joint surface. This pathological condition chemically and mechanically provokes the nerves to create pain.

Acupuncture needling relaxes tight muscles, increases blood circulation, activates the secretion of endorphins, and stimulates immune reactions, thus reducing the pain and inflammation associated with muscles, nerves, tendons, and ligaments and restoring normal physiology. This process is likely to contribute to a slowing of the degeneration of the facet joints. However, when facet pain is related to degeneration caused purely by aging, acupuncture is helpful in reducing pain but cannot cure the cause of the pain.

Acupuncture is very useful in treating misaligned joints because it relaxes the shortened muscles that pull the joints out of alignment or immobilize them. Relaxing the tight muscles and ligaments loosens the joints and thereby allows them to realign. In addition, the effect of needling in promoting blood circulation and stimulating the immune reaction, which reduces swelling and inflammation of soft tissues of the joints, helps to restore the physiologic structure of the affected joint.

This mechanism of needling plays a significant role in preventing the traumas that accumulate on the surface of facet joints as a result of aging. Regular acupuncture maintenance treatments and proper exercise help to develop healthy, strong paraspinal muscles and an enhanced blood supply. With the increased nutrition and oxygen that this brings, aging-related degeneration slows down, and the possibility of trauma in this region is greatly reduced.

Sacroiliac Joint Derangement

The erect position of the human body makes it prone to SI joint derangement. The entire spine and all related structures such as the head, ribs, arms and the weight of the inner organs are resting on the spade-shaped sacrum bone. Both sides of the sacrum form immovable SI joints with the iliac bones. Therefore the entire weight of the body above the waist is supported by these two joints. As noted at the beginning of this chapter, daily movements such as twisting, bending, running, pulling, pushing, and lifting, as well as improperly carrying heavy loads, subject the SI joints to an enormous amount of stress.

The surfaces of the two joints are very rough and irregular, with numerous notches and tabs that must fit exactly into each other. The joints are stabilized by the strongest ligaments of the body. The normal range of motion for this part of the spine is only a few millimeters, which means that the SI joints are practically immovable.

Pain from SI joint derangement can be different on the left and right sides of the body. The pain is increased while performing certain movements, such as lifting the feet when getting in or out of a car, getting out of bed in the morning, or bending down with the knees locked. Usually twisting to one side hurts more than twisting to the other. The pain can be felt in the area of the SI joint and the iliac crest and also along the pathway of the sciatic nerve. Changing position or shifting body weight may help to alleviate the pain for a short time.

There is a difference of opinion in the medical profession as to whether SI joint injuries are a common cause of back pain. Some believe that SI joint injuries account for many cases of lower back pain because the mechanical stress of the spine converges on the SI joints. When a person flexes forward asymmetrically or rotates the body, most of the stress of supporting the motion is borne by one of the two SI joints. In a study on two hundred patients with “workmen’s compensation” type of injuries of the lower back, it was found that more than 80% of the patients could localize their pain to one or both SI joints while injuries involving the spinal ligaments, muscles, iliolumbar ligaments, facet joints, ribs, or protruding disks were less common.⁴

Others believe that SI joint injuries are rarely the source of lower back pain except in unusual types of arthritis or pelvic dislocation,¹¹ and the reasons usually given are that SI joints form a very stable intersection, that SI joints are very well fused in adults, and that the ligaments on either side of the SI joints are among the strongest in the body. It is interesting to note that SI joint derangement does not show up on X-rays, MRIs, or electromyography (EMG).

The theoretical disagreement on SI joint etiology does not affect the good results achieved by acupuncture therapy in most patients diagnosed with SI joint problems. In the case of lower back pain, an acupuncture practitioner should carefully examine and palpate the lumbar, sacral, and iliac crest areas including the surface just on the top of the SI joints. Usually, if the SI joint area is sensitive, the iliac crest area, buttock muscles, and iliotibial band area are also sensitive and tight. In this case the acupoints H14, H15, H16, and H18 are very sensitive or even painful upon palpation because all the peripheral nerves are irritated or inflamed because of the injured SI joints. Desensitizing these nerve points reduces pain, relaxes the affected muscles, and improves regional blood supply, thus helping the recovery of the soft tissues of the SI joints.

Subluxation and Dislocation

Extended joint strain can cause a mild change in the position of the bones. Subluxation is a condition occurring when the articular surfaces of the bones inside a joint are not in perfect spatial relationship with each other. This slight misalignment of one or both bones produces pain in the joint and related soft tissues. Subluxation turns into dislocation when the bone surfaces are so far out of alignment that severe pain results.

Acupuncture needling relaxes the muscles that move the joint. The stimulation activates both the local blood circulation through the vasodilation mechanism of the autonomic nervous system and the neuroendocrine function of the central nervous system. The improved blood circulation eliminates swelling, reduces inflammation, desensitizes the irritated nerves, and alleviates the pain. Orthopedists or neurosurgeons can take care of severe dislocation, and modalities such as chiropractic, osteopathy, or physical therapy will address realignment of the subluxated bones.

Osteoarthritis

Osteoarthritis is a degenerative joint disease that can be caused by both normal and abnormal wear and tear on the joints. Consequently, there more patients who complain of pain from osteoarthritis than of pain caused by herniated disks.

Cartilage smoothly lines the surfaces of all joints and is constantly being worn away and replaced by fresh secretions. When the cartilage-producing cells of the joints are injured by normal wear and tear, their secretions form a slightly irregular surface on the joints. The progressive accumulation of such secretions results in more friction between joint surfaces and consequent damage. In more serious cases, the structural changes invade the bone and are sufficient to narrow the spinal canal (spinal stenosis) or intervertebral foramen (radiculopathy).

Patients with osteoarthritis suffer from painful and reduced motion of the arms, legs, and spine. Such sufferers experience a constant ache, which is usually worse in the morning and in the evening. As the osteoarthritis develops, the affected bones may deform, which changes the normal alignment of the joint, creating pain and tightness in the muscles that move the joint. This condition can compress the nerve roots, and the resulting pain often has a shooting or stabbing character. The neck is more prone to osteoarthritis than the rest of the back because the neck joints have greater mobility combined with weaker structural support.

Osteoarthritic pain irritates muscles and other soft tissues, resulting in tight muscles and swollen soft tissues. This process applies physical pressure on the joints and induces chemicals that irritate other joint tissues, including bone and blood vessels. Joint degeneration progresses with the resulting low blood supply, which causes an energy crisis: low nutrition and low oxygen supply, both of which are detrimental to healing. If the energy crisis persists, the affected tissues undergo constant and finally irreversible degeneration. Acupuncture relaxes tight muscles and restores blood circulation, thus ending the energy crisis. The relaxed muscles reduce the physical pressure applied on the joints and the restored blood circulation brings more nutrition and oxygen, which slows down the process of joint degeneration.

Please note that after the needles are removed, the needle-induced lesions in the muscles remain and continue to prevent the muscles from tightening, thus providing longlasting therapeutic effects. Acupuncture therapy effectively reduces muscle and joint pain as well as reducing tissue inflammation in patients with mild osteoarthritis or in the early stages of the disease.

Rheumatoid Arthritis

Current medical theory describes rheumatoid arthritis as an autoimmune disease that occurs when the body attacks the collagen in its own joint linings. This pain is accompanied by joint stiffness as well as a sporadic sensation of heat. The effectiveness of acupuncture in treating it depends on the degree and duration of the pathological condition in each patient, much as it does with osteoarthritic cases. Please note that the INMAS protocol can be successfully used for pain management regardless of the underlying cause of the pain in many cases. The success of acupuncture treatment will depend on the physiological repairability of the particular symptoms in each case combined with the ability of the body to support the self-healing process.

Acupuncture needling is helpful in treating early stages of rheumatoid arthritis by reducing swelling, inflammation, and pain, and it does so by desensitizing the peripheral nerves and improving the regional blood circulation. As the rheumatoid arthritis progresses, the efficacy of acupuncture becomes less.

Neuropathy

Neuropathy means that the peripheral nerve fibers and their myelinated sheaths are damaged and the nerves do not conduct any signals. Thus, patients with neuropathy lose their skin sensation and muscle strength. Neuropathy can be caused by toxic substances, diabetes, an ischemic condition, renal or thyroid diseases, or traumatic injuries. According to research conducted in China and also in our clinical experience, acupuncture can slow down the progress of neuropathy in early and mild cases but is not effective in more advanced cases, especially when the numbness has already invaded the regions above the wrist and ankle.

Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)

Amyotrophic lateral sclerosis (ALS) is a progressive neurologic disease characterized by degeneration of the cell bodies of the lower motor neurons in the gray matter of the anterior horns of the spinal cord and of the brainstem motor neurons. This condition kills motor neurons but does not affect sensation or mental capacity. Once the motor neurons die, the muscles supplied by those neurons become weak and atrophy. Lower back pain results from weakness of the muscles of the lower extremities, abdomen, and back. Although there may be periods of remission, the disease usually progresses rapidly. Acupuncture can provide different degrees of pain relief by relaxing the painful muscles and improving the blood circulation, but the efficacy is only short-term. After the muscles are deprived of their innervation of motor neurons, they gradually atrophy and the sensory nerves within the muscles become supersensitive.

Multiple Sclerosis

Multiple sclerosis (MS) is a chronic neurological disease in which sclerotic patches form in the myelin sheath of the nerves in the central nervous system (the spine and brain). The course of the disease is usually prolonged, with remissions and relapses over many years. The prevailing medical opinion is that an inherited immune response is probably responsible for the production of autoantibodies that attack the myelin sheath of the central nervous system. Patients with MS often show symptoms in two or three limbs; for example, tingling in one leg and numbness in one arm, trouble controlling bowel and bladder, dimming vision in one eye, and weakness in one leg. Acupuncture is helpful in providing temporary pain relief by relaxing muscles, improving blood circulation, and desensitizing the peripheral nerves but does not have long-term therapeutic results due to the irreversible process of the disease.

Onset of Neck Pain

Neck pain can be triggered by whiplash from a car accident; by a sports injury such as a fall from a bicycle or being struck on the head by a football; by hitting the head on an overhang; or by a fall, and so on. The impact from these accidents applies force to the neck and injures disks or joints, which generates muscle spasms. These types of impacts may also cause traumatic close brain injury and bring changes in memory, mental processes, and mood. Mild acute neck pain may come from bad posture during work-related activities or improper sleeping position. Most of the neck pain seen in our clinic is due to cumulative trauma from frequent repetitions of the same activity or from sports or car accidents.

Degenerative diseases such as arthritis or osteoarthritis are some of the major causes of chronic neck pain in people over 40 years old.

Whiplash from car accidents is a common neck injury. Most often neck pain begins hours or days after the accident, with most pain symptoms diminishing within several weeks afterwards. However, the pain may last as long as 4 to 6 months and research studies show that about 10% to 20% of those who experience whiplash are left with some degree of chronic neck pain. Some people who have neck pain soon after an accident recover initially but develop pain symptoms 5 to 10 years later. In these cases, the accident may have caused a minor injury to a disk that appeared to have healed. The injury may cause the affected disk or joint to degenerate much faster than normal and so eventually cause pain many years later.

Some neck pain is usually not a serious medical condition by itself, but it could be a signal of a more significant problem. Since shoulder injuries can refer pain to the neck, neck pain can be indicative of shoulder injuries. Neck pain with fever can indicate an infection. Neck pain that occurs during eating may indicate problems with the esophagus. Neck pain can be caused by problems with the thyroid gland or the lymphatic nodes. A heart problem can cause referred neck pain with or without chest pressure. Neck pain accompanied by weight loss may indicate a tumor. A practitioner should be aware of these possibilities when treating neck pain.

Other symptoms associated with neck problems, especially related to untreated whiplash, include headache, nausea, vomiting, dizziness, blurry vision, pain between the shoulder blades, and numbness in the upper limbs or fingers.

In general, acupuncture needling relaxes the muscles of the neck, shoulder, and lower back. This muscle relaxation also loosens the joints of the spine, increases the blood circulation to the soft tissue and joints, reduces inflammation and swelling, and desensitizes the irritated nerves. All these processes promote self-healing of the needled regions.

Patterns of Neck Pain

The pattern of the pain may serve as a clue to the nature of the pain and helps to predict the result of the treatment. Here we list a few pain patterns from our clinical experience.

Tenderness usually comes from muscles, joints, or both. A disk tear or herniation may compress the nerve root and cause severe neck and/or arm pain. If pain is worse after prolonged periods of reading, writing, or computer work, it is possible that a disk is damaged. Pain that is made worse by looking upward may be originating from an inflamed facet joint. It is common for pain from disks or facet joints to be referred (i.e., experienced in a different region, such as the shoulder blades, the upper arm, the base of the skull, or the head).

The pain pattern and/or level of pain may reveal the location of the injured joints and may help in determining the location of the SAs to be used in addition to the HAs. Pain in the upper neck and the occipital area is usually related to C2-C3. Pain in the upper neck and the levator scapulae muscle may originate from C3-C4. Pain in the lower neck and upper part of the shoulder may radiate from the joints of C4-C5. Pain to the lower neck and the supraspinatus area may originate from the joints of C5-C6. Pain in the sizeable area over the blade of the scapula may be caused by the joints of C6-C7.

In general, pain in the back of the neck is caused by injured disks, joints, muscles, or other soft tissues. Pain in the front of the neck may be due to a medical problem such as an infection in the lymph nodes, thyroid gland, or salivary gland. Persistent pain in the front of the neck, especially if associated with fever, difficulty swallowing, or weight loss, requires consultation with a physician.

A detailed evaluation is required in cases where pain has persisted for more than 3 or 4 months.

Whiplash

The leading source of trauma in developed countries is automotive accidents. Most of these create some degree of whiplash, so it is not surprising that whiplash has become a common cause of neck and lower back pain. The mechanics of whiplash are clearly understood but the extent and type of injuries vary greatly. All whiplash victims should seek early treatment regardless of whether or not they experience pain immediately following the accident because, as discussed above, a whiplash injury that is not painful after the accident may cause pain as much as 5 to 10 years later. If early treatment is provided, acupuncture can effectively reduce most whiplash pain, and it will also activate the recovery of most soft tissue injuries, as well as improving other related symptoms such as arm or lower back pain or numbness, dizziness, and nausea. The efficacy of acupuncture decreases proportionally as the treatment is delayed because in time the tissue damage invades deeper tissues and structures.

Whiplash injuries to the neck, especially after a rear-end collision, are caused by a combination of factors such as the sudden forced neck extension (backward), compression (upward), shearing (forward), recoiling, and possibly some lateral forces. During a rear-end collision, the force of impact pushes the torso forward and upward while throwing the head and neck backward (extension), all within one-tenth of a second. The upward movement of the torso compresses the cervical region from below and the backward movement of the head narrows the space between the cervical vertebrae and compresses the facet joints. Approximately six-hundredths of a second later, the neck begins to move forward, which produces a shearing action and reduces the front intervertebral space, thereby pressing the front edge of the disks. After the initial backward-forward motion, the head recoils backward. These combined movements apply great pressure on the facet joints and disks, resulting in immediate or potential injuries. For example, if the weight of the whiplash victim’s head is 10 pounds, the impact force on the neck can be as high as 170 pounds even in a low-speed rear-end collision. Due to the shape of the neck, the region from C5 to C7 suffers most from the strongest impact force and the region from C1 to C3 absorbs the remainder of the impact force.

During a rear-end collision some lateral neck flexion may occur with a slight rotation. This lateral force causes compression of the ipsilateral facet joints and distraction of the contralateral facet joints. Thus, the ipsilateral joints and disk can be damaged, while the joint capsules of contralateral joints sustain strain or enormous stress. In severe cases, possible fracture of the odontoid process and fractures of the laminar and superior process can occur and CT scanning is needed to confirm these injuries.

Most people with whiplash begin to have pain within 24 hours of the accident but often the pain begins later. Immediately following the accident, the body activates the hormonal mechanism that releases endorphins and adrenaline to help the body manage stress. This physiologic process suppresses the sensation of pain from the injury. A few days later, the hormone level drops, the injured structures become gradually inflamed, and the suppressed pain is liberated and increases over time. Acupuncture treatments immediately following the accident effectively reduce pain and inflammation. After the accident, it may take hours or days to develop the symptoms, but if acupuncture treatments are applied before the symptoms become severe or uncontrollable, the recovery will be easier, faster, and more complete. The needling provides better blood circulation to the injured tissues and introduces an antiinflammatory reaction, which prevent more severe or chronic consequence from the injuries.

All whiplash injures involve damage to some or all tissues in the neck and back area such as muscles, nerves, ligaments (soft tissues), facet joints, and disks. Acupuncture is effective in treating most whiplash symptoms. The INMAS protocol provides adequate treatment to both the neck and other parts of the body like the shoulder and lower back. Soft tissue injuries should heal within at most 1 to 4 months. If there is still pain after acupuncture therapy, it is usually due to injuries to facet joints or disks, or both. In these cases, additional evaluation is required.

If whiplash results in injury to cervical soft tissue, the direct consequence is sustained, continuous neck pain. Other complaints that may result from whiplash include headache, neck stiffness, and restriction of movement. The headache is typically at the occipital or temporal region, which is innervated by nerve roots from C1 to C3. A headache also can result from a concussion or from an injury to the lateral atlantoaxial joint. If there are injuries to the upper cervical facet joints of disks, the headache is usually located at the base or the top of the skull, the forehead, or the face and jaw.

Pain caused by whiplash-related injuries may radiate to the shoulders, arms, and the area between the shoulder blades. Pain in the shoulder, between the shoulder blades, or in the arms can be referred from the neck nerves or facet joints. Numbness, tingling, or heaviness in the arm and/or hand, especially in the ring and little fingers, are common symptoms. Lower back pain is also among the common complaints.

Some whiplash patients experience sleep disturbances, fatigue, dizziness, vomiting, ringing in the ears, or visual disturbances. Dizziness may be caused by inner ear disequilibrium or damage to the cervical musculature. About one-third of whiplash patients have shown deficits in concentration or problems with memory. Changes in personality are also observed in some patients who become irritable, depressed, or short-tempered because of neck pain.

If a whiplash patient has a history of neck pain, arthritis in the neck, or headaches prior to the accident, the whiplash may have caused more severe injuries to the neck structure, creating a higher risk that the patient will develop chronic neck pain months or years later.

Acupuncture therapy can effectively improve the majority of the physical symptoms associated with whiplash. In our clinic we have achieved very good results in whiplash patients with severe chronic neck pain, even where some of the patients were involved in several whiplash accidents. With the INMAS protocol, the neck and the whole muscular system receive appropriate treatment and the healing is optimal. However, mental or psychological symptoms associated with whiplash, such as personality changes, require longer treatments and multidisciplinary approaches because one modality will not solve all the complex problems involved.

Bicycling

Bicyclists may suffer neck and lower back pain; wrist pain; hamstring muscle pain from road vibrations; strain and fatigue of the muscles in the back of the neck, shoulders, and between the shoulder blades; and strain and fatigue of the lumbar muscles and leg muscles. They also may suffer from the consequences of poor body and/or head position, such as excessive extension or flexion of the neck and flattening of the lower back lordosis. All of the above may also result if the bicycle is not properly adjusted to the height of the user.

Running

The majority of runners have a flexible and relaxed neck but get lower back and leg problems. Their necks are in good condition possibly because they maintain a good neck posture and make little neck motion while running. The leg muscles, however, are subject to repetitive overuse injuries. If some muscles, like hamstring muscles, become tight or are injured, they are able to restrict or change the movement of the pelvis, which creates stress on the lower back muscles. Frequent acupuncture treatment will relax the tight lower back and lower limb muscles and increase blood supply to them. If the muscles are kept healthy, flexible and not tight, well-supplied with nutrition, and strong, there will be fewer problems during and after exercise.

Tennis

Tennis players are prone to several injuries. The forearm flexor muscles of tennis players are frequently stressed, which causes tennis elbow. Also, the need to look up and rotate the head rapidly can cause problems in the facets of the neck spine. A practitioner should carefully check the neck of a tennis player and needle the tender muscles and joints.

Swimming

When in the water, a swimmer’s neck does not bear the weight of the head but the head needs to be frequently rotated so the neck is routinely extended or flexed, which may cause neck strain or sprain. A practitioner should regularly check the neck of a swimmer and needle the sore neck muscles.

Golf

Golfers face many physiomechanical problems. A survey published in the June 2003 issue of the American Journal of Sports Medicine provides useful data regarding golf-related injuries.

Researchers surveyed 703 golfers (643 amateurs and 60 professionals) from 24 golf courses in Germany during two golfing seasons. They found that more than 80% of reported golf injuries were due to overuse. Golfer’s elbow was the most common overuse injury among amateur golfers, followed by back and shoulder pain. Professional golfers had more injuries in the back, wrist, and shoulder. There were also occasional reports of sprained ankles. The research showed that professional golfers suffer an average three injuries a year compared with an average of two injuries per year among amateurs.

The research further showed that players who warmed up for 10 minutes or less had an average of about one injury per player compared with an average of only about 0.4 injuries per player for those who warmed up for more than 10 minutes.

Overall, the golfers surveyed lost about 4 weeks of golfing time per injury, although a significant number had injuries that kept them from playing for up to 6 months. Our clinical experience shows that regular acupuncture treatments can reduce the likelihood of golf-related injuries and that acupuncture treatments that are received immediately after the injury can allow golfers to return back to the green much earlier.

When examining the ball and determining their swing, golfers often adopt a posture where the waist is bent and the neck is flexed, which can strain the neck muscles. The backswing, which requires rotating the shoulders and flexing the neck, also strains the neck and lower back spine.

When treating a golfer, a practitioner should always carefully examine the neck, shoulders, elbows, upper back, and lower back, and identify and needle all the tender points.

The Neck

The neck spine has seven vertebrae. Palpation of this part of the spine is very important for finding needling locations. In adults there is often a light hollow posterior to the C1 vertebra (atlas) that does not have a spinous process. When needling this area, a practitioner should stop inserting the needle when resistance is felt.

However, the tip of the transverse process of C1 (atlas) can be felt 1 cm anteroinferior to the tip of the mastoid process (Figure 9-11). A practitioner should first find this point and then ask the patient to rotate the head slowly from side to side, which movement allows the practitioner to feel the transverse process of C1. If a neck injury patient feels a tender sensation during palpation of this region, the transverse process of C1 should be needled all the way to touch the bone.

Figure 9-11 Lateral aspect of the neck: bones. 1, Angle of mandible. 2, Body of mandible. 3, Ramus of mandible. 4, Temporomandibular joint. 5, External acoustic meatus. 6, Mastoid process. 7, Tip of transverse process of atlas. 8, Clavicle. 9, Acromion. 10, Acromioclavicular joint.

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

C2 has a longer spinous process than C3, C4, and C5 and can be palpated with little pressure. The spinous processes of C3-C5 are short, lie deep to the surface, and are difficult to feel. The spinous process of C7 is more prominent than that of C6 (Figure 9-12) but both spinous processes are easily palpable when a patient’s neck is flexed as far as possible.

Figure 9-12 Lateral view of the cervical spine. 1, Angle of mandible. 2, Occipital bone. 3, Posterior arch of atlas. 4, Spine of seventh cervical vertebra. 5, Hyoid bone. 6, Tracheal gas shadow. 7, Clavicle.

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

It is important for acupuncture practitioners to understand that the transverse processes of the neck vertebrae divide the neck into anterior and posterior parts. The anterior part of the neck contains many important organs and neurovascular structures, and therefore deep needling should be avoided. If needling is necessary when treating skin problems such as neurodermatitis, fine needles of 1.5 cm in length can be used in this area.

The posterior part of the neck is responsible mostly for extension and side rotation. The back muscles must be sufficiently strong to perform such motions. The back muscles (extensors) sustain more stress than the front muscles when the cervical curve is not properly maintained, such as when working on computers, or overextended, as when looking upward. As the stress accumulates, the back muscles are subject to tightness, spasm, inflammation, strain, or sprain, and these may lead to reduced blood circulation and hypoxia in the muscles.

The needles are inserted from the back, tilting to the midline or toward the lamina or the transverse process, all the way to the bones. In treating joint problems, needles have to touch the joint coverings. Depending on the patient’s body size, the needling depth is from 2.5 cm to 5 cm. As noted above, the needles can be inserted all the way from the skin surface to the bone surface.

The sternocleidomastoid muscle should be mentioned. This broad straplike muscle divides the neck into anterior and posterior triangles and is one of the most used and stressed muscles in the neck. Contrary to expectation, however, this muscle does not often contribute to pain or stiffness in the neck. Superficial to the sternocleidomastoid muscle, the external jugular vein descends obliquely across about half way along the anterior border of this muscle. Deep and close to the anterior border of the muscle there are neurovascular structures, including the vagus nerve, the common carotid artery (which is divided into the internal and external carotid artery), and the internal jugular vein and its tributaries.

If the sternocleidomustoid muscle needs needling, the upper third can be needled with needles of 2.5 cm in length, whereas fine needles of 1.5 cm in length are suitable for the lower two thirds of the muscle. Be mindful that the apex of the lung is just behind the lowest part of these muscles (see below). Avoid needling the external jugular vein and the apex of the lung. Injury to the external jugular vein, especially in the lower part of the muscle, may cause air to be sucked into the vein during inspiration and leads to venous air embolism, which may result in dyspnea (shortness of breath).

The Back

The importance of understanding the anatomy of the back cannot be overemphasized. All acupuncture practitioners should have a solid working knowledge of the anatomy of the back. The back is the most important part of the body in acupuncture medicine. The spinal cord sends its peripheral nerves to all organs through structures related to the back. Sensory nerve roots and autonomic ganglions are located close to the back. Acupoints in the back are used to treat almost all the symptoms that are treated by acupuncture.

Avoiding Puncturing the Lungs (Pneumothorax)

Most accidents occurring from acupuncture needling are related to pneumothorax. If a needle punctures the pleural cavity when needling the anterior, lateral, or posterior surfaces of the thorax, air may be sucked into and accumulate in the pleural cavity after the needle is removed. Special attention should be paid to patients who are long-time smokers, who are extremely thin, or who have scoliosis. These patients have weaker and thinner back muscles or weaker lungs and are more prone to pneumothorax.

Figure 9-13 shows the outline of the pleura and lungs, as viewed from the back during gentle respiration. Viewed from the back, the apices of the lung are close to the transverse processes of T1. However, if observed from the front, the apices of the lung project superiorly through the thoracic inlet into the neck posterior to the sternocleidomastoid muscle. Practitioners should be very careful when working in the area just above the medial part of the clavicle bone and should use fine needles of 1.5 cm in length. Deep needling also should be avoided when needling acupoint H3 spinal accessory on the top of the shoulder because the apices of the lung are close to the base of the neck; a needle of 2.5 cm in length suffices in most cases. When deeper needling is needed such as when a nodule is detected in deep tissue, a practitioner can grasp and lift the trapezius muscle so as not to puncture the apex of the lung below (see Figure 9-10).

Figure 9-13 Surface markings of the lungs and the pleura: posterior view. 1, Spine of first thoracic vertebra. 2, Floating ribs. 3, Pleural markings. 4, Lung markings. 5, Oblique fissure. 6, Vertebra prominens.

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

Three parameters are critical when using paravertebral acupoints (PAs) in the thoracic area (T1-T12) shown in Figure 9-13: (1) the direction of the needle; (2) a safe distance from the needling point to the midline of the spine; and (3) the depth of needling.

Figure 9-14 shows the transverse section of the lung at the T3 level. To avoid puncturing the pleural cavity, it is safer to tilt the tip of needle toward the body of the vertebra (toward the midline). T3 and the base of the spine of the scapula (medial angle) are at the same level. The safe distance at the T3 level can be determined by first palpating the medial angle of the scapula and then locating the tip of the spinal process of T3. The medial one third of the distance between the medial angle and the spinal process of T3 is the safe distance for needling. Needling at a distance farther from the midline runs the risk of puncturing the pleural cavity. The depth of needling depends on the physical size of a patient’s body. For the sake of safety, it is best to needle at a depth of 2.5 to 3.0 cm for an average-sized person. If a patient is suffering from neuralgia or herpes simplex/zoster, fine needles of 1.5 cm in length should be used.

Figure 9-14 Axial CT image at the level of the 3rd thoracic vertebra showing the topography and thickness of the back wall for avoiding needling into the lungs.

(From Weir J, Abrahams P: Imaging atlas of human anatomy, ed 3, Edinburgh, 2003, Mosby.)

Avoiding Puncturing the Kidneys

Another pair of organs that acupuncture practitioners must take care not to puncture when needling the lower back area are the kidneys. Clear knowledge of surface anatomic markings on the back is necessary to avoid such an accident. The same three parameters are critical when needling in this region: (1) the direction of the needle; (2) a safe distance from the acupoint to the midline of the spine; and (3) the depth of needling.

The kidneys are two bean-shaped organs lying on each side of the vertebral column. The position of the kidneys varies somewhat with posture, body build, and respiration. Each kidney may move vertically about 3 cm when the diaphragm moves during deep breathing. In the prone position, the superior poles of the kidneys are protected by the 11th and 12th ribs (Figure 9-15), while the inferior poles extend to the level of L3 for the right kidney and a little lower than that for the left kidney due to bulky liver lobes. With respect to the midline, the superior poles are in the epigastrium, each 2.5 cm from the midline, while the inferior poles are 7.5 cm from the midline, slightly above the supracristal plane. The right kidney is about a fingerbreadth superior to the crest of the ilium. Based on the above anatomic description and on our clinical experience, the safe needling distance at the L1 level is about 2.5 cm (about 1 inch) from the midline.

Figure 9-15 Surface anatomical positions of the kidneys.

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

The important acupoint H15 is located on the lateral border of the erector spinae at the L2 level. The cross section at this level (Figure 9-16) shows that the distance between the body surface and the posterior surfaces of the kidneys is about one fifth to one sixth of the posterior-anterior body axis at the L2-umbilicus level. It is possible that the usual prone position for needling the low back may shorten this posterior-anterior body axis.

Figure 9-16 Transverse CT image at the level of L2 shows the topography of the kidneys.

(From Gosling J, Harris P, Whitmore I, Willan P: Human anatomy: color atlas and text, ed 4, Edinburgh, 2002, Mosby.)

Based on the above information about the topography of the kidneys, it is best to use needles of 4 cm in length for acupoints at L1 levels and to use needles of 5 cm in length for acupoints from the L2 to L5 levels. If the selected acupoints are situated on the ridge of the erector spinae muscles, the needle should be positioned perpendicular to the muscle surface. If the selected acupoints are located on the lateral border of the erector spinae muscle, the needle is tilted toward the midline.

Neck Pain and Upper Back Pain

3. Prescription

a. HAs

H2, H7, H3, H13, H8, H20, H21, H15, H22, H14, H16

b. SAs

SAs can be selected on the neck area (Figure 9-17), and around H3.

c. PAs (paravertebral points)

Figure 9-17 Needling the symptomatic acupoints (SAs) on the sides of the neck (posterior to the transverse processes of the cervical vertebrae) for neck pain. Note the right needle is the location of H7 greater occipital. The length of the needles is 4 cm to 5 cm (½ to 2 inches).

Along the cervical spine (C1-C7) and thoracic spine (T1-T7) (Figure 9-18). Some neck pain is caused by upper back pain, so the upper back area should be carefully palpated.

Figure 9-18 Paravertebral acupoints (PAs) from T1 to T4 and shoulder acupoint H8 infraspinatus (at the center of the infrascapular fossa). The other two needles are symptomatic acupoints (SAs) for shoulder pain.

Upper Back Pain

Lower Back Pain

Figure 9-19 Use low back homeostatic acupoints (HAs) H15, H22, H14, and H16 (from lumbar region to buttock).