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Analysis and Evaluation on Acupuncture Treatment of Cervical Pains in the UK - A Study of 74 Cases

by Dan Jiang and Ming Zhao Cheng

Introduction

Cervicodynia, or cervical pain or neck pain, is a common condition in modern societies. There are particularly higher occurrences in white collar workers who use a computer. Modern societiesí internal and external injuries, such as car accidents and stress, increase the morbidity of cervical pain. In the UK during the last 10 years, neck pain was the most prevalent condition treated and it accounted for 11% of the total number of patient cases.

The cervical vertebrae are close to the cranial cavity, particular the basilar artery and the vital centre. Therefore, some manipulation therapies, such as chiropractic, osteopathy, physiotherapy and massage, can be very difficult in giving appropriate levels of treatment. If the manipulation is too strong, it may make the condition worse, or even cause serious complications. If the manipulation is too light, the level of treatment may not be effective and the results will not be satisfactory. In contrast, acupuncture treatments may be more appropriate. Chinese acupuncture, which uses a variety of techniques, can achieve the best treatment level and the best possible results.

Methods

Questionnaire

From January 2002 to December 2004, questionnaires were sent to patients with cervical pain and 74 were returned and analysed.

General Information:

Gender: Age:

Your Neck Pain:

1 Do / did you have neck pain?

2 How long have you had neck pain ( )?
a) <1 week b) < 1 year c) < 3 years d) >3 years

3 Your neck pain is ( ).
a) First time seizure b) Recurrent seizure c) Persistent seizure

4 Have you had an X-Ray? ( )
No
If you have, indicate that there are negative findings
If you have, indicate that there are positive findings

Please give details of positive findings if possible:
____________________________________________

5 Have you been diagnosed by a medical doctor that your neck pain is caused by ( )
a) Whiplash b) Injury of cervical spinal c) Spondylitis on neck
d) Spondylosis on neck e) other:

6 Have you received treatment from a medical doctor?
a) Painkillers: How long do you take them? ( ) Do they work for you? Yes ( ) /No ( )
b) Anti-inflammations: How long do you take them? ( ) Do they work for you? Yes ( )/ No ( )
c) Epidural injection: How many times have you been done them? ( ) Do they work for you? Yes ( )/No ( )
d) Other2: ______________ How long do you take them? ( ) Do they work for you? Yes ( )/No ( )

7 Have you received any other complementary & alternative treatments in the past?
a) Physiotherapy: Yes ( ) / No ( )
If yes, how long? ( ) Work ( )/not work ( )
b) Chiropractic: Yes ( ) / No ( )
If yes, how long? ( ) Work ( )/not work ( )
c) Osteopathy: Yes ( )/No ( )
If yes, how long ( ) Work ( )/not work ( )
d) Western Acupuncture: Yes( )/No( )
If yes, how long?( ) Work( )/not work( )
e) Chinese Acupuncture Yes ( ) / No ( )
If yes, how long? ( ) Work ( ) / not work ( )
f) Others: ______________________________________
If yes, how long? ( ) Work ( ) / not work( )

8 Since you started to have acupuncture treatment,
a) How many sections have you had? ( )
b) How long have you been having acupuncture ( )
c) Had you had acupuncture before? ( )
d) Have you taken: Patent herbs ( ) Dry herbs ( ) External use herbs ( )

9 Please evaluate these treatments ( )
a) Your neck pain has disappeared b) Your neck pain has been remarkable better
c) Your neck pain has been better d) your neck pain has been no better at all
e) Your neck pain has been worse

10 Have your other conditions or symptoms, apart from chronic neck pain, been changed due to your acupuncture treatments?
Conditions or symptoms: ___________________________________
Better ( ) Worse ( )

Patients

Table 1. General Data pf Patients

Gender

Male

Female



33

41



Age

<30

30-50

>50


4 (5%)

33 (45%)

37 (50%)


Occupation

Office Worker

Homemaker

Manual Worker


45 (61%)

12 (16%)

17 (23%)


Causes of Pain

Whiplash Injuries (Muscular and Ligament Spasm)

Other injuries

Spondylitis and Spondylosis


14 (19%)

12 (16%)

48 (65%)


Since the onset, only 5 cases had used Chinese acupuncture as their first choice of treatment (6.7%). 69 cases had received routine orthodox treatments or other complementary treatment before using Chinese acupuncture. The following table shows the results of routine orthodox treatments and other complementary treatments.

Table 2. 68 cases who had received routine orthodox treatments

Anti-rheumatics

Anti-inflammatory tablets

Blocking injection

Tranquilisers

Anti-depressants

Effective for a short time

12

20

5

6

0

No effect

56

48

0

0

5


Table 3. 28 cases who had received complementary treatments other than Chinese acupuncture

Chiropractic

Physiotherapy

Osteopathy

Western acupuncture

Effective for a short time

4

0

0

0

No effect

5

12

5

2


Table 4. The relationship between the causes and the length of cervical pain

Whiplash

Other neck injuries

Spondylitis/spondylosis

<3 weeks

5 (35.7%)

4 (33%)

2 (4.2%)

< 1 year

5 (35.7%)

4 (33%)

20 (41.7%)

> 1 year

4 (28.6%)

4 (33%)

26 (54.1%)

Note: some patients had 2 or more of the above conditions.

Protocol

a. Acupuncture Main Acupoints

Neck Jiaji Pang Points: cervical vertebrae 1-7, 1 cun from the middle of the inter-vertebral gap. 2-3 pairs each time according to the location of the cervical pain. 1 cun needles directed 45ļ obliquely towards the vertebrae. No manipulation.

Bai Hui (DU20), Feng Chi (GB20), Wai Guan (SJ5) and Zhu Lin Qi (GB41)

b. Acupuncture Assisting Acupoints

Cervical vertebrae 2-3: Yu Zhen (BL9), Tian Zhu (BL10)
Cervical vertebrae 4-5: Tian Ding (LI 17), Fu Tu (LI 18)
Cervical vertebrae 6-7: Bi Nao (LI 14), Jian Yu (LI 15)

The following assisting points were chosen according to individual accompanying symptoms:

Dizziness: calm the liver to expel wind. Xuan Li (GB6), Shuai Gu (GB8) Yi Feng (SJ17)

Depression: activate qi to clear depression. Shen Ting (DU 24), Shang Xing (DU 23)

Migraine: sooth the liver and relieve depression. Tai Yang (EX-HN5), Yang Bai (GB14)

Nervousness: calm the liver and nourish the heart. Tai Chong (LR 3), Jian Shi (PC 5)

Fatigue: strengthen the spleen and nourish the kidney. San Yin Jiao (SP 6) Zhao Hai (KI 6)

Insomnia: clear away and relieve stagnated heat. Da Zhui (DU 14), He Gu (LI 4)

c. Strengthening Acupoints

San Yang Luo (SJ 8), Hui Zong (SJ 7), Zhi Gou (SJ 6), Wai Guan (SJ 5)

Points were selected according to which ones were sensitive.

d. Assisting Treatments

Frequency spectrum lamp
Chinese patent medicine: Jiu Wei Qiang Hui Wan, Jia Wei Xiao Yao Wan, Jiu Ding Guan Jie Wan, Chuan Xiong Cha Tiao Wan and Wang Bi Chong Ji.

Formulas were used according to the individualís condition.

Results

Table 5. Change in Clinical Symptoms

Results

Total Control

Much Better

Better

No Changes

Worse

Number of Cases

16

29

20

9

0

Total control: all clinical symptoms and signs cleared

Much better: all clinical symptoms and signs much improved. There is still slight discomfort, but they are still able to maintain normal life without further treatments

Better: all clinical symptoms and signs improved

No changes: clinical symptoms and signs not changed

Worse: clinical symptoms and signs worse

Table 6. The relationship between results and Chinese acupuncture treatment methods

Acupuncture

Acupuncture and patent herbs

Acupuncture and loose herbs

Acupuncture and external herbs

Total control

4

12

0

2

Much Better

5

22

3

3

Better

2

17

1

1

No changes

1

8

0

0

Worse

0

0

0

0

Total

12

59

4

6

Notes: 1. Loose Chinese herbs are used in severe cases only when patent herbs and acupuncture combination cannot control the condition. A patient could have used patent herbs earlier and later loose herbs. 2. External herbs usually are used in combination with patent herbs.

Discussion

Cervicodynia is one of the common conditions for patients seeking acupuncture treatment. Using a combination of traditional Chinese acupuncture techniques to reach an appropriate treatment level is a key element in achieving good results.

Local acupoints

Select Jiaji Pang points along the cervical spine according to the diseased vertebrae. Jiaji Pang points are 1 cun from the back midline. They are 0.5 cun outside of the normal Jiaji points, which are 0.5 cun away from the back midline. From experience, patients will feel very painful or severe reactions after treatments if Jiaji points are normally used, since the acupoints are close to the inflammation and the injured areas in cases of facet joint syndromes. The points that are 0.5 cun outside of the Jiaji points are exactly located in the tense neck muscles. From an anatomical perspective, this explains the reason that relaxing the local muscular strain will effectively relieve pain. Therefore, if the patient has pain between C2 and C3, with headache and dizziness, C2 and C3 Jiaji Pang points will be selected. If the patient has pain between C6 and C7, with pins and needles in the arms and formication in the hands, C6 and C7 Jiaji Pang points will be selected. These local points ensure that local diseased foci are treated properly to an appropriate level; muscles are relaxed, local circulation improved. All these are important factors for achieving good results in a short space of time.

Points selected according to syndrome differentiation (Bian Zheng points)

Points are selected after considering the whole bodyís diseases, the patientís constitution and special characteristic of the individual.

Main acupoints: all patients will have these points

Bai Hui (DU 20): the Du channel is the collection of the whole bodyís yang qi. Bai Hui is the yang of all yangs and the commander of all qi regulations. No matter whether it is qi stagnation, qi deficiency, yin deficiency, blood deficiency or a mixture of deficiency and excess, Bai Hui must be selected. Needling the point which commands all the qi will make it easier to relieve all other channel stagnation.

Wai Guan (SJ 5) and Zhu Lin Qi (GB41): these two are a pair of the eight confluence points. They regulate the bodyís qi disturbance. There is pain because of blockages. No matter whether this is yin, yang, qi and blood deficiency, or phlegm, dampness, stagnation or wind in excess, if there is pain, there must be blockages. Therefore, the first treatment is to regulate the disturbed qi.
Assisting acupoints: selected according to individual conditions

If it is an external injury to the neck, and the differentiation result is wind and dampness blocking the jingluo with qi and blood stasis, then Feng Chi (GB20), Qu Chi (LI 11), Fei Shu (BL13), Pi Shu (BL20) and San Yin Jiao (SP 6) will be selected. If it is cervical Spondylitis in the menopausal period, and the differentiation is liver and kidney yin deficiency, empty heat mixed with dampness blocking the channels, Gan Shu (BL18), Shen Shu (BL23), Zhao Hai (KI 6), Tai Xi (KI 3 and Tai Chong (Liv 3) were used. The assistant points form a regulatory mechanism for the whole body and regulate the unstable situation. This is an important step in achieving long term effects. Many other accompanying symptoms are also better. This is the key technical advantage of Chinese acupuncture.

Strengthening acupoints

After the treatment was finished and all the needles are removed, the patient was asked to relax and take a sitting or standing position. When standing, the patient would hold on to the couch to steady the body when receiving a strong stimulation. The patientís arm was held on the pain side. A 1.5 cun (40 mm) needle was inserted perpendicularly to one of the following acupoints: San Yan Luo (SJ 8), Hui Zong (SJ7), Zhi Gou (SJ 6) or Wai Guan (SJ 5). Before needling, these points were palpated between the ulna and the radius and slide the thumb up and down to find and select the most sensitive point. The depth of the insertion was 1 cun. When the needle was inserted, the patient would feel a marked achy feeling or even a pain. According to the patientís constitution and tolerance level, the needle was twisted, lifted and thrusted from slight manipulation to medium and strong manipulation.

If the local points and the Bian Zheng points were effective, and the affected area relaxed, the patientís reaction to this needling was not too strong, and the acupuncturist would also feel the needling sensation was quite loose. Therefore, it was only necessary to needle this point briefly.

If the local points and the Bian Zheng points were effective, but the affected area was not relaxed, or the local soft tissues and nerves were relaxed but the facet joints syndrome, the disc protrusion, the compressed and incarcerated nerves were not released due to chronic inflammation, adhesion and stagnation, the effect of needling was not very noticeable. Sometimes the pain relief was very short and the pain returned. In these situations, the points between Wai Guan (SJ5) to San Yang Luo (SJ8) were very sensitive. It would feel achy and possibly very painful. When needling, the acupuncturist would noticeable heaviness and tightness in the needle, or even feel the needle being ďsucked inĒ.

At this time, according to the patientís constitution and tolerance level, the needle was manipulated by twisting and lifting and thrusting from slight manipulation to medium and strong manipulation, and give the point an intermittent but strong stimulation. At the same time, the patient was asked to turn the neck from side to side and move the shoulders and the upper arms. The patient would feel the tight neck muscles relax, the neck, the occiput, the shoulders and the upper back also suddenly relax. Some patients felt the neck pain transfer to the forearm. After removing the needle in the forearm, the pain at this strengthening point would disappear and no after pain would remain. It was not suitable to apply the strengthening needling method if the patientís constitution was weak, or they were sensitive to needles. For chronic cases, who have received many other treatments, only using strengthening needling can one achieve better results than other treatments.

Assisting Treatments

All 74 cases received acupuncture treatment. However, acupuncture treatment alone, particularly for these western patients who can only have one treatment per week, can be just as effective from minor or short term cases. For the medium and long term cases with medium to severe symptoms, the treatment would not be effective as it is not potent enough. Therefore, assisting treatments were necessary.

Chinese herbal medicine (CHM)

Of the 74 cases,
Acupuncture only 12 cases (16%)
Assisted with CHM 62 cases (84%)
Assisted with patent herbs 59 cases (79%)
Assisted with loose CHM 4 cases (5%)
Assisted with external herbs (pastes, oils and lotions ) 6 cases (8%)

Note: Loose Chinese herbs are mostly used in severe cases only when patent herbs and acupuncture combination can not control the condition. External herbs usually are used in combination with acupuncture and patent herbs.

The significance of receiving CHM treatment were:

Maintain the effects of acupuncture in relieving spasms, local relaxation, stopping pain, calming and regulating the whole body

Clear away heat and dampness or remove wind and ease pain. They can induce an anti-inflammatory effect and make stasis dissipate. For inflammations in deeper tissues and joints, CHM is better at clearing inflammation than acupuncture alone

Treat the root and strengthen the vital qi, improve the unstable state of the body. This can be positive in helping enhance the responses to acupuncture

Frequency spectrum lamp treatment

Heat stimulation at the local area can improve local blood circulation and enhance the absorption of inflammation.

Relationship between treatments and results

Table 7. Relationship between causes of neck pain and treatment results


Whiplash

Other injuries

Spondylitis/spondylosis

Total Control

7 (50%)

6 (50%)

8 (16.7%)

Much Better

2 (14%)

4 (33.4%)

22 (45.8%)

Better

2 (14%)

1 (8.3%)

12 (25%)

No Change

3 (22%)

1 (8.3%)

6 (12.5%)

Table 8. Relationship between length of neck pain and treatment results

Acute (<3eeks)

Subacute (<3 years)

Chronic (>3years)

Total cases

Total Control

6 (75%)

5 (14.7%)

5 (15.6%)

16

Much Better

0 (0%)

15 (44.1%)

14 (43.8%)

29

Better

1 (12.5%)

9 (26.5%)

10 (31.3%)

20

No Change

1 (12.5%)

5 (14.7%)

3 (9.3%)

9


Table 9.
Relationship between number of treatments and treatment results

1-3 times

4-10 times

>10 times

Total

Total Control

5 (17.9%)

7 (25%)

4 (22.2%)

16

Much Better

5 (17.9%)

14 (50%)

10 (42.9%)

29

Better

10 (35.7%)

6 (21.4%)

4 (22.2%)

20

No Change

8 (28.5%)

1 (3.6)

0 (0%)

9


Table 10.
Relationship between onset and treatment results

First time

Recurrent

Total

Total Control

10 (31.2%)

6 (14.3%)

16

Much Better

11 (34.4%)

18 (42.9%)

29

Better

6 (18.8%)

14 (33.3%)

20

No Change

5 (15.6%)

4 (9.5%)

9


When analysing the relationship between Chinese acupuncture and the treatment results mentioned above, it is possible that:

In terms of the causes and the results, neck pain caused by whiplash and injuries was controlled in 50% of cases. Most neck pain caused by spondylitis and spondylosis are much better or better.

In terms of the length of the condition and the results, 75% short-term cases were controlled, whereas the control rate of the longer-term cases was much lower, although the much better and better cases were relatively higher.

In terms of the numbers of treatments and results, in cases that had less than 3 treatments, control, much better and better were evenly spread and the no change rate was high. This indicates that if Chinese acupuncture didnít give a quick result, the patients did not have confidence in continuing treatment. Therefore, the no changes rate is high. In cases that had more than 4 treatments, particularly those that had more than 10 sessions, the much better rate is increased, and the no changes rate is reduced to 0. Therefore, the most important factor is to continue with treatment.

Onset and results: first time onset have an obviously high control rate, whereas the recurrent cases have a high rate in much better and better cases.

Typical Cases

Case 1. Acute attack of chronic neck pain

Female, 59 years old, doctor

Neck pain on and off for 7 years. Acute attack for 1 week. Been to have massage a few times, but it makes the pain worse. Recently, she had been writing in front of her desk. A week ago, the pain suddenly became acute, which radiated to the left shoulder and the upper back. Movements of the neck, upper back and left shoulder were restricted. Because of the pain, it is very hard for her to lie flat on her back and she must lean on a chair. She is agitated and unable to sleep due to the pain. She had routinely taken anti-rheumatics for a week and the pain seemed to be slightly better, but it is still very painful and movements are restricted. The joints are stiff.

On examination, the neck muscles on both sides were tense. There was evident tenderness and swelling in the area of the 3rd, 6th and 7 cervical vertebrae. Neck movements were restricted, particularly the left side. Left shoulder movements were restricted. Pink tongue with thin, white coating, wiry pulse.

Treatments

Bai Hui (Du 20), Feng Chi (GB20), Neck Jiaji pang points 3, 6 and 7, Wai Guan (SJ 5), Zhu Lin Qi (GB41), Zhao Hai (KI 6, Jian Yu (LI 15), Bi Nao (LI 14).

After removing all the needles, a point on the left forearm was selected. It was found that the pressure pain point is on Hui Zong (SJ 7) between the ulna and the radius. Twisting, lifting and thrusting the needle from slight manipulation to strong manipulation, whilst the patient moved her neck. Alternating the needling manipulation and the neck movements for 5 minutes.

After removing the needle, the patient felt the pain in the neck and the left shoulder was much better and she could move autonomously. She was then told to move her neck by extension, bending and turning. One week later, the patient came back to report that all pain has disappeared and the neck and the shoulder moved freely.

Case 2. Chronic neck pain

Male, 53 years old, company manager

Neck pain on and off for more than 10 years, and constant neck pain for more than 2 years. X-ray diagnosed as C4-5 osteoarthritis. Works in front of a desk. The neck pain and ache was getting gradually worse. 2 years ago, his car was hit from behind by another car whilst he was driving. There was no pain at the time, but since then there have been more neck pain attacks and they come more frequently. Upper back is also achy and tired. Left arm is numb and there is formication. In recently years, neck pain is constant and sometimes it can be very severe and radiates to the top of the head and the occiput. He is on anti-rheumatics all year round, but pain killers make his stomach very uncomfortable and he has to stop taking them. He has received chiropractic, osteopathy and physiotherapy treatments, but there has been no substantial improvement. Recently, he had headaches and slept bad.

On examination, there was tenderness from C2 to C7, and swelling in C4 and C5. Pink tongue with thin, white coating, wiry pulse.

Treatments

Bai Hui (Du 20), Feng Chi (GB20), Neck Jiaji pang points 4, 5 and 6, Gan Shu (BL18), Wai Guan (SJ 5), Zhu Lin Qi (GB41), Tai Chong (LR3)

Qiu Wei Qiang Huo Wan 15 pills twice per day
Jia Wei Xiao Yao Wan 15 pills twice per day

After the first acupuncture session, San Yang Luo (SJ 8) was used to strengthen the effects. After this treatment, the patient felt the neck was much looser, but the movements were still restricted. After 5 treatments over 5 weeks, all pain disappeared, but there was still pain attacks when over extending or in an improper position. Following up for 5 more treatments once every fortnight interval, the neckís swelling and tenderness was completely cleared.

Conclusions

Chinese acupuncture treatment is an effective and safe treatment method for treating cervicodynia. In treatment, a combination of a number of Chinese acupuncture techniques should be used to achieve the best results, including the use of Chinese herbal medicine.

Chinese acupuncture treatments are suitable for acute, subacute and chronic neck pain, and it is particularly effective for inflammation cases.

Biographies

Dan Jiang MD MMedSci
Visiting Senior Lecturer, Middlesex University, UK

Ming Zhao Cheng MD MSc PhD
Postgraduate Program Leader, Principal Lecturer, Traditional Chinese Medicine, Middlesex University, UK. m.cheng@mdx.ac.uk

Bibliography

Hongchao Li et al 2004 Introduction to the points singly used for stiff neck. Journal of Chinese Medicine76:56
Jia Li 2004 A combined therapy for cervical spondylopathy. Journal of Chinese Medicine 76: 53
Liemin Huang 2004 Comparison of the effects of electro-acupuncture plus cupping with that the electrical pulse therapy for different types of cervical spondylopathy. Journal of Chinese Medicine 76: 56
Tianping Zhao et al 2001 Observation on therapeutic effect of 40 cases of cervical spondylosis of vertebroarterial type treated with Yangzi Time point-open method. Chinese Acupuncture & Moxibustion 21: 203
Xinlie Lin et al 2001Superficial view on acupoint therapy for treatment of cervical spondylosis of nerve root type. Chinese Acupuncture & Moxibustion 21: 371

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