Case ReportCollateral Meridian Acupressure Therapy Effectively Relieves Postregional Anesthesia/ Analgesia Backache Chun-Chang Yeh, MD, FIPP, Ching-Tang Wu, MD, Billy K. Huh, Sabina M. Lee, MD, and Chih-Shung Wong, MD, PhD Abstract: Epidural and spinal aesthesia may cause backache. In fact, the overall incidence of postneuraxial block backache is 9% to 50% and the incidence of back pain on the third postoperative day ranges from 5.91% to 22% after spinal anesthesia. Five patients suffering from postneuraxial block backache after regional anesthesia or analgesia are reported. Despite administering conventional treatment modalities including bed rest, cold/warm packing, physical therapy, and medications with nonsteroidal anti-inflammatory drugs (NSAIDs), strong analgesics, and opioids, the backache persisted and disturbed the patients’ daily life. Surprisingly, utilization of a new acupressure technique, collateral meridian acupressure therapy (CMAT), relieved the backache dramatically. Key Words: acupressure, backache, collateral meridian therapy, regional anesthesia MD, PhD, ackache is a common postoperative complaint after epidural and spinal anesthesia. The incidence of postneuraxial block backache after obstetric delivery is between 9% and 50%,1–3 and the incidence of immediate postoperative backache after nonobstetric surgery is 2%–31%.4,5 The incidence of back pain has been reported as ranging from 5.91% to 22% after spinal anesthesia on the third postoperative day.6,7 Nonsteroidal anti-inflammatory drugs (NSAIDs) have been frequently used to treat backache with well-known gastrointestinal, cardiovascular, coagulation, and renal-function side effects.8 In addition, all opioids will cause some side effects, such as increased tolerance, addiction, increased intracranial pressure, and respiratory depression.9 From the Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China; and Department of Anesthesiology and Duke Primary Medicine, Duke University Medical Center, Durham, NC. Reprint requests to Chih-Shung Wong, MD, PhD, Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, Republic of China. Email:
[email protected] Accepted May 1, 2009. Copyright © 2009 by The Southern Medical Association 0038-4348/0 2000/10200-1179 B Traditional acupuncture has shown efficacy in perioperative pain management10 –12; however, it is also associated with side effects such as needle-related infection, pneumothorax, bleeding, or tissue injuries.13 One of the primary benefits of collateral meridian acupressure therapy (CMAT) is that the painful region/ meridian is rarely stimulated. Before CMAT is administered, there are some contraindications and issues that must be considered, such as open wounds at the acupoints, psychiatric disease with the presence of overt clinical symptoms, infections, metastases, osteoporosis, fractures, spine deformity, and surgical conditions. CMAT treatment involves manipulation of distant collateral meridians to facilitate the dissipation of pain while avoiding the stimulation of the affected meridian to enhance patient tolerability.14 The point that connects a diseased meridian to a distant collateral meridian is called the “control point” (C-point), while the acupressure point corresponding to the painful region is called the “functional point” (F-point). Previously, we reported two postoperative shoulder-tip pain cases which were successfully treated by CMAT following inadequate relief from conventional analgesics and traditional needle acupuncture.14 Moreover, we have also successfully treated a case of complex regional pain syndrome (CRPS) with the CMAT tech- Key Points • Backache is a common postoperative complaint after epidural and spinal anesthesia. Nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids have been used widely to treat backache, but they can produce adverse effects that patients are unable to tolerate. • The traditional acupressure technique utilizes acupoints located in or near dermatomes related to painful areas. In contrast, collateral meridian acupressure therapy (CMAT) involves the manipulation of distant collateral meridians to facilitate dissipation of pain while avoiding the stimulation of the affected meridian. • CMAT is a viable alternative modality for treating post neuraxial block backache for patients who fail conventional treatments. Southern Medical Journal • Volume 102, Number 11, November 2009 1179 The pressure applied at the both C and F-points was enough to cause mild to moderate achy pain. Five days after removal of the epidural catheter. The CMAT was performed for 30 seconds using the same Cpoint as the previous cases and a different F-point (Figs. the pain level returned to 3/10. The patient received another week of conservative treatment (bed rest. Ten days later. The treatment was repeated twice a day for three days with complete resolution of pain. An epidural catheter was placed at the T8-T9 interspace and was placed 4 cm into the space after three attempts. the patient was referred to our pain clinic. quality of life. The surgery lasted 75 minutes. An 18-guage Tuohy needle was inserted via the L3– 4 interspace after 1% lidocaine skin infiltration. the pain returned to a VAS of 4/10 approximately 4 hours later. we performed CMAT using a Cpoint located at the lung meridian. After obtaining consent from the patient. After receiving treatment.Yeh et al • Collateral Meridian Therapy for Postneuraxial Blocks Backache nique. Case Reports Case 1 A 32-year-old pregnant woman (weight 75 kg. the back pain persisted with significant impact on daily activities. height 162 cm) with a gestation period of 40 weeks was scheduled for labor analgesia. the patient experienced right-sided low back pain with a pain score of 6/10. the patient complained of right-sided low back pain with a visual analog pain score (VAS) of 5/10. the patient began to experience backache at the SA site. Case 3 A 21-year-old male (weight 65 kg. height 170 cm) was scheduled for herniorrhaphy for recurrent inguinal hernia. the patient reported immediate relief of her right-sided backache with a VAS of 1/10. After 5 days of conservative treatment. The pain was partially relieved by lying in a supine position and by taking once daily ketoprofen 200 mg. Physical examination revealed local tenderness over the bilateral L4–5 region with a pain intensity of 6/10. However. the patient complained of a thoracic backache with a VAS of 7/10. Twenty hours after the SA. there were no complications. The performance was manipulated at a frequency of 60/min for one minute using a constant force of 4 dynes/kg. while applying dynamic pressure in a cephalic direction at a corresponding F-point (Fig. The operation lasted three hours. The catheter was advanced 4 cm into the epidural space. and the backache resolved completely. The patient was given combined general and thoracic epidural anesthesia. and the pain intensity was 7/10. and the patient was satisfied with the labor analgesia. No lower extremity weakness was found. After obtaining consent. and the catheter was advanced 4 cm in the epidural space via loss-of-resistance (LOR) technique.5 mg) was injected intrathecally with a sensory blockade to the T8 level. cold/warm compresses. Physical examination revealed local tenderness over the right L3–4 region without radicular pain and a pain score of 6/10. Physical examination revealed local tenderness over the T8 –10 region without radicular pain. The backache severely affected ambulation. we report five cases of persistent postneuraxial anesthesia backache resolved with CMAT. we performed CMAT by applying constant static pressure at a well-defined C-point. Spinal anesthesia (SA) was accomplished after three attempts at the L4–5 intervertebral space with a 25-gauge Quincke needle. and use of oral ketoprofen (200 mg daily). The same treatment modality was repeated on a daily basis for three days. warm compresses. However. After obtaining written informed consent. a newborn was delivered without any complication. After four hours of labor. The CMAT was repeated twice per day for three days with complete resolution of pain. height 158 cm) with a gestation period of 39 weeks was scheduled for normal vaginal delivery under epidural analgesia. Physical examination revealed local tenderness over the right L3– 4 region without a radicular component. the same CMAT was performed as in case 1. The patient was referred to us for further management. Bed rest and oral ketorolac tromethamine 10 mg every 6 hours were prescribed. and the patient was referred to our pain clinic for further management. The backache persisted for one week despite bed rest. Following the procedure. The pain intensity was reduced to 1/10 immediately. she still complained of pain and diminished 1180 © 2009 Southern Medical Association . We were consulted for her pain management. a healthy newborn was delivered uneventfully.15 Here. and tramadol 50 mg every 6 hours). 1 and 2). The discomfort was significant enough to influence her sleep and daily nursing routine for 7 days. Three hours later. on postpartum day 2. the pain intensity dropped to 1/10. height 178 cm) with funnel chest was scheduled for a Nuss procedure. Five hours later. and the patient reported good postoperative pain control. and the pain intensity was 5/10. Hyperbaric bupivacaine (12. The F-point was located at (continued next page) Case 2 A 28-year-old pregnant woman (weight 65 kg. and the patient was pleased with the labor analgesia. An epidural catheter was placed with an 18-gauge Tuohy needle via a midline approach with LOR at the L3–4 interspace after two attempts. Due to the persistent pain. The next morning. but the backache persisted. Case 4 A 30-year-old male (weight 55 kg. 1). oral ketorolac tromethamine 10 mg every 6 hours. but the pain level returned to 4/10 approximately 3 hours later. It was the patient’s second pregnancy. physical therapy. Isobaric bupivacaine (12.9 Kleinman17 suggested that conventional treatment modalities such as bed rest. The same treatment modality as the previous cases was repeated.8. or periosteum inflammation with or without muscle spasm. the patient complained of severe backache that was partially relieved by bed rest. a constant static pressure was applied to the C-point. Fig. and the pain was completely resolved after the second treatment. and there were no complications. Number 11. November 2009 1181 . 2 Schematic diagram shows CMAT acupoints used for left-sided backache treatment in cases 3–5. we were consulted for her persistent severe backache. Eight days later.5 mg) was injected intrathecally with a sensory blockade to the T10 level. our patients found conventional treatment to be ineffectual. The pain was completely resolved after two additional treatments.16 Conventional analgesics such as NSAIDs and opioids have been used widely to treat postlumbar puncture backache. followed by the right side (Figs. the CMAT method recruits noncontiguous meridians to connect with the diseased meridian to restore Qi flow. CMAT may act as effectively as analgesics for patients with postneuraxial block backache who are unresponsive to conventional treatments. Discussion The backache associated with neuraxial blockade localizes with varying degrees of tissue trauma which can lead to ligament. prompting the CMAT therapy. physical therapy. All five patients presented here suf- Southern Medical Journal • Volume 102. and medications with acetaminophen or NSAIDs should be sufficient for treating postneuraxial backache. duration of surgery. The point that connects the diseased meridian to a distant collateral meridian is called the “control point” (C-point).5 Postepidural backache is usually characterized by marked tenderness of the needle insertion site. type of surgery. Risk factors for the development of the backache include position during the neuraxial block. approximately two-thirds above the elbow crease toward the axilla. the same CMAT protocol as in case 4 was performed on the right forearm. The pain intensity was reduced immediately to 0. 3. F-point 5 of TxI meridian—located at the fossa between biceps brachii and brachialis at the junction of metaphysis and diaphysis over distal humerus. After the treatment. The patients improved remarkably after CMAT (Table). and the point was manipulated for approximately one minute (Figs. the pain intensity was reduced immediately to 2/10 and returned to 5/10 about 3 hours later. resulting in significant improvement in pain relief.18 The traditional acupressure technique utilizes a single acupoint for pain management. tendon. and oral medication (ketoprofen 200 mg once daily and tramadol 50 mg every 6 hours).1. cold compresses. According to traditional Chinese medicine. C-point of TxI meridian—located on the junction of metaphysis and diaphysis over the distal radius. F-point 4 of TxI meridian—located at the medial fossa of brachioradialis at the junction of metaphysis and diaphysis over proximal radius. However. 1 Schematic diagram shows CMAT acupoints used for rightsided backache in cases 1–4. Fig. F-point 6 of TxI meridian–located on the groove between the medial aspect of the deltoid and the lateral side of the biceps brachii. and degree of postoperative immobilization. therefore. The operation took 60 minutes.14 However. SA was accomplished after two attempts at the L4 –5 intervertebral space with a 25-gauge Quincke needle. but the pain returned to 3/10 five hours later.Case Report (Case Report continued from previous page) the depression of the radial side of the bicep muscle tendon. Case 5 A 75-year-old female (weight 60 kg. while the acupressure point corresponding to the painful region is called the “functional point” (F-point). 1 and 2). After obtaining patient consent. 1 and 2). One day after SA. the obstruction of energy (Qi) flow within the meridian can be manifested as pain. height 155 cm) with osteoarthritis of the left knee was scheduled for arthroscopy. Similar to the previous cases. side effects and lack of efficacy have largely discouraged their prolonged use. However. The left side was addressed first. cold/warm packing. Physical examination revealed local tenderness over the left L4 –5 region with a pain intensity of 8/10. while the F-point was manipulated with a dynamic rhythmic force in a cephalic direction. Gilsanz F. Hewitt SR.104:452. Am J Chin Med 2005. 1978. fered from obstruction of the bladder meridian (AyIII). the treatment meridian is usually on the right side and vice versa. Zohar E. Guasch E.37: 545–548. 6. Murray MJ. Side-effects of complementary and alternative ¨ medicine. Effects of acupuncture on potential along meridians of healthy subjects and patients with gastric disease. TxI:1/4. Lt/AyIII 4 CMAT. the corresponding F-point is 6 (case 3). the C-point is over level 1 and corresponding F-point is over level 4. Ulbing S. Haider S.33:879 – 885. bilateral. respectively. corresponding F-point is over level 5 and level 6. the diseased meridian was on the right side. Bromage PR. level 4. Incidence of postdural puncture headache and backache. Comparison of 26-gauge Atraucan and 25-gauge Whitacre needles: insertion characteristics and complications. Anesthesiology 2005. Pashos CL. Lee MS. while pressure on the F-point facilitates movement of Qi. Chernyak GV. Similarly. Joshi GP. the corresponding F-point is 5 (cases 1 and 2). New York. Collateral meridian therapy dramatically attenuates pain and improves functional activity of a patient with complex regional pain syndrome. Kaider A. Wen YR.42:706 –710. Acta Anaesthesiol Scand 1993. 7. If the tenderness is over the thoracic spine. The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. 5. the CMAT technique usually avoids direct stimulation of the painful meridian. the C-point is over level 1(the same as TxI:1/4). Perioperative acupuncture and related techniques.97:359 –363. 3. traditional Chinese acupuncture. respectively. For tenderness over the L3– 4 level. 18. In cases 1 and 2. level 6. Neurological complications following epidural anesthesia. Kuo CP. Postdural puncture headache and back pain after spinal anesthesia with 27-gauge Quincke and 26-gauge Atraucan needles. Reg Anesth 1996. level 5. pp 36 –39. et al. collateral meridian acupressure therapy. Stephens JM. the corresponding F-point is 4 (cases 4 and 5). 9. and complete resolution is achieved with a few additional sessions without adverse effects. et al. hence. pain reduction is usually immediate. Lee YH.17:15–19. Moreover. Int J Obstet Anesth 2008. In CMAT protocol. The CMAT indeed provided notable pain relief with no side effects. 12. Shin BC. et al. in case 5. 13. TxI. AyIII. et al.31:484 – 488. J Manipulative Physiol Ther 2008. Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: a retrospective study of 6497 cases. 10. et al. The lung meridian (TxI) was chosen as a collateral meridian for the treatment. Sharma SK. The C-point and F-point for the lung meridian are shown in Figures 1 and 2. the treatment meridian was on the left side. Lumbar epidural block in labor: a clinical analysis.Yeh et al • Collateral Meridian Therapy for Postneuraxial Blocks Backache Table. Epidural Analgesia. South Med J 2004. et al. 4. Schultz AM. 16. Lin JG. Pharmacotherapy 2004. Pain 2002. Ko SC. et al. Epidural.21:461– 464.44:414 – 415.17:537–542. Can J Anaesth 1995. 14. Spinal. Yeh CC. When these two points are manipulated as described in these cases. Auricular acupuncture for pain relief after total hip arthroplasty—a randomized controlled study. 2002.58:707–716.114:320 –327. Int Anesthesiol Clin 1975. et al. Gruber C. McGraw-Hill. Fragneto R. therefore. 15. in Morgan GE. 17. the affected meridian was on the left side. Bil/AyIII 6 L4–5. Usubiaga JE.13:45– 46. Case summary regarding CMAT therapya Initial pain intensity 5 6 7 6 8 Lesion/diseased meridian Case Case Case Case Case a CMAT treatment meridian (acupoints) Lt TxI:1/5 Lt TxI:1/5 Bil TxI:1/6 Bil TxI:1/4 Rt TxI:1/4 Immediate pain intensity after CMAT treatment 1 1 1 0 2 Maximal pain intensity after first CMAT treatment in 3 d 4 4 3 3 5 Total numbers CMAT administration to obtain complete pain relief in 3 d 6 6 6 2 3 1 2 3 4 5 L3–4. et al (eds): Clinical Anesthesiology. Mikhail MS. PA. Niggemann B. Br J Anaesth 1972. Anesth Analg 2007. Moore C. Rt/AyIII 5 L3–4. lung meridian in TCA. AyIII4. Shapiro A. if the disease meridian is on the left side. et al. If there is tenderness over the L4 –5 level. TCA. Kely D. and success rate of dural puncture: comparison of two spinal needle designs. Gambling DR. 1182 © 2009 Southern Medical Association . Rt. & Caudal Blocks. J Clin Anesth 2005.102:1031–1049. Huh BK. Allergy 2003. Pan PH. Rodt SA. lesion over bladder meridian. Usichenko TI. 11. Bil/AyIII 4 L4–5. 2. AyIII5. Hermsen M. Rt/AyIII 5 T8–10. Dinse M.24:1714 –1731. et al. Fan YM. References 1. right side. Pain 2005. controlled studies are needed to prove the efficacy of this new treatment modality. TxI: 1/5 & TxI:1/6. 99:509 –514. Making progress in the management of postoperative pain: a review of the cyclooxygenase 2-specific inhibitors. Lo MW. Sessler DI. Wisborg T. AyIII6. the treatment was performed on the right side. This report demonstrates that CMAT is a viable alternative modality for treating postneuraxial block backache for patients whose conventional treatments fail. However. Kleinman W. left side. Brattebø G. Lt. Wong CS. larger. hence minimizing further exacerbation of the painful region. A static pressure applied on the C-point links the diseased meridian to the treatment meridian. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. WB Saunders. pp 253–282. Philadelphia. 8. Bil. Miro M. Shoulder tip pain after laparoscopic surgery analgesia by collateral meridian acupressure (shiatsu) therapy: a report of 2 cases. Intrathecal anaesthesia in patients under 45 years: incidence of postdural puncture symptoms after spinal anaesthesia with 27G needles. Zaslansky R.