INTRODUCTION: QUANTITATIVE EVALUATION PREDICTS THE EFFICACY OF ACUPUNCTURE THERAPY

To be a good clinical procedure, an acupuncture evaluation of patients should be simple, precise, reliable, and reproducible by any practitioner. In traditional Chinese medicine (TCM) the goal of qualitative evaluation (pulse, tongue, and tongue coating) is to determine the nature and the cause of the symptoms according to ancient pathologic concepts: (1) the diseased organ or organs (Zang fu) and related channels (meridians) and (2) the nature of the imbalance (yin or yang, hot or cold, excessive or deficient).

The coating of the tongue and the character of the pulse reflect qualitative features of the body’s pathophysiology but do not always provide stable, reliable information. For example, the tongue coating may change after food intake and the pulse is altered after drinking, walking, or emotional disturbance.

In addition, the art of qualitative diagnosis is subtle and complex. Years of training are required for a practitioner to learn the 28 different pulses and their combinations and the numerous types of coatings. Thus qualitative diagnosis is a time-consuming, highly empirical procedure that is difficult to master and unnecessary in acupuncture pain management.

The goal of the quantitative method presented in this book is to evaluate the self-healing capacity of each patient and to predict the effectiveness of acupuncture therapy for each individual case. Two pathophysiologic factors affect the efficacy of acupuncture: the individual self-healing potential of each patient and the severity and “healability” (the healable nature of the disease[s]) of the afflicting symptom(s) or disease(s) itself. These two factors affect the efficacy of treatment and the time required for each patient to heal. Therefore, when making an evaluation, acupuncture practitioners must take these factors into account to understand whether and to what degree a patient can recover from his or her specific pathologic symptoms or diseases.

The following clinical example can help us to understand the nature of acupuncture therapy.

Four patients (not necessarily in the same age group) were afflicted with essentially the same pain symptom. After receiving four acupuncture treatments using the same treatment protocol, patient A and patient B experienced total pain relief, patient C experienced a reduction of pain up to about 50%, and patient D did not feel any improvement from the treatments.

Five months later patient A was still experiencing no pain; patient B experienced some pain, which was totally relieved after two additional acupuncture treatments; patient C experienced a return of most of the pain symptoms and needed four additional acupuncture treatments to maintain control of the pain; and patient D experienced little or no benefit from acupuncture therapy despite having continued the treatments for 5 months.

Statistically, patient A represents 28% of the patient population who can completely self-heal; patient B, 34%; patient C, 30% (B and C can partially self-heal); and patient D, 8% (can slowly, or not all, self-heal) (Table 6-1).

Table 6-1 Patient Classification

This example clearly illustrates that the efficacy of acupuncture treatment depends primarily on (1) the degree of the patient’s self-healing potential and (2) the healability of the afflicting symptoms or diseases.

A good acupuncture evaluation should provide information concerning treatment efficacy and give an answer to the following questions for a specific patient:

Our method of quantitative acupuncture evaluation (QAE) determines the healing potential of each patient and provides answers to these questions. QAE is an easy method to learn, as well as being time-saving, reliable, and reproducible by any practitioner.

QUANTITATIVE ACUPUNCTURE EVALUATION

The results of QAE allow practitioners to predict the efficacy, duration, and prognosis of the treatment. Any pathologic insult or disease tends to reduce the patient’s self-healing potential and impairs homeostasis. The impaired or declining homeostasis transforms latent (nonsensitive) acupoints into passive (tender) acupoints. The homeostasis of each patient reflects his or her body’s ability to repair the damage evidenced by pathologic symptoms.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The following simple guidelines facilitate the evaluation procedure:

CLINICAL TECHNIQUES

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

Collecting Information to Evaluate a Patient’s Healing Potential

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

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

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

Current Pain Symptoms

What current pathologic symptoms is the patient experiencing? Where are the symptoms located on the body? How have the pain symptoms developed over time?

Medical Examinations

Blood pressure should always be recorded. Patients with blood pressure lower than 120/70 may have a needle reaction during the first few sessions (see later discussion). A practitioner needs to pay attention to the patient’s previous medical history, laboratory tests, and diagnoses.

Medical Interventions Used to Treat Pain Symptoms

By medical interventions we mean all conventional and alternative procedures and modalities. Acupuncture therapy by its nature does not conflict with any other medical modalities, but some medical procedures might reduce the effectiveness of acupuncture therapy. For example, addictive medications such as morphine will reduce acupuncture efficacy for pain relief. Blood-thinning medications may cause excessive bleeding or produce bruising during acupuncture treatments. Mild or moderate bruising produces no harmful consequences, but the practitioner should prevent any bleeding from occurring in the joint capsule.

Medical History

Medical history includes all medical problems, beginning from childhood, such as accidents, severe diseases, surgeries, hormonal problems in women, and any family history related to the symptoms experienced by the patient. Sometimes patients unintentionally ignore important information. For instance, a patient might forget having had whiplash from a low-speed car accident 20 years ago because he or she felt good a week afterwards. This ignored minor event could be the cause of current symptoms.

It is important to collect precise information about any surgical procedures the patient has undergone. Pain symptoms can be more difficult and time consuming to treat when they persist after surgery. This is because surgery alters some of the neuroanatomic structure, whereas acupuncture works best when applied to intact body anatomy.

Even if there are medical problems that are not directly related to the pain symptoms they can play an important role because they can diminish the efficacy of the acupuncture treatments. The more health problems that are found in a patient, the less self-healing potential can be expected; also more treatments will be needed, the pain relief will have a shorter duration, and the likelihood will be higher that the current symptoms will return.

Lifestyle and Profession

Special attention should be given to the patient’s lifestyle, personal habits, and occupational hazards. The practitioner’s ability to accurately project the efficacy of acupuncture treatments will be directly affected by the reliability of this information.

Contraindications and Complications During or After Acupuncture Needling

Correct acupuncture treatment produces no clinical side effects. Some adverse physiologic reactions occur because of human error or the unpredictable reaction of a patient. In acupuncture such adverse reactions are few and can be prevented and avoided when acupuncture treatments are given by a cautious and well-trained professional.

In the following section we describe possible negative reactions to acupuncture needling and the skills required for handling and preventing accidents.

Syncope or “Needle Fainting”

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

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

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1. 2: Dynamic Pathophysiology of Acupoints
2. 17: Case Studies
3. 13: Acupuncture Therapy for Non-pain Symptoms
4. 10: Upper Limb Pain: Shoulder, Elbow, Wrist, and Hand

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