Case Report

Collateral 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%,13 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: w82556@ndmctsgh.edu.tw Accepted May 1, 2009. Copyright 2009 by The Southern Medical Association 0038-4348/0 2000/10200-1179

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.

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nique.15 Here, we report five cases of persistent postneuraxial anesthesia backache resolved with CMAT.

Case Reports
Case 1
A 32-year-old pregnant woman (weight 75 kg, height 162 cm) with a gestation period of 40 weeks was scheduled for labor analgesia. It was the patients second pregnancy. An 18-guage Tuohy needle was inserted via the L3 4 interspace after 1% lidocaine skin infiltration, and the catheter was advanced 4 cm in the epidural space via loss-of-resistance (LOR) technique. After four hours of labor, a healthy newborn was delivered uneventfully, and the patient was pleased with the labor analgesia. However, on postpartum day 2, the patient complained of right-sided low back pain with a visual analog pain score (VAS) of 5/10. The backache persisted for one week despite bed rest, cold/warm compresses, physical therapy, and use of oral ketoprofen (200 mg daily). No lower extremity weakness was found. The discomfort was significant enough to influence her sleep and daily nursing routine for 7 days. We were consulted for her pain management. Physical examination revealed local tenderness over the right L3 4 region without a radicular component, and the pain intensity was 5/10. After obtaining written informed consent, we performed CMAT by applying constant static pressure at a well-defined C-point, while applying dynamic pressure in a cephalic direction at a corresponding F-point (Fig. 1). The performance was manipulated at a frequency of 60/min for one minute using a constant force of 4 dynes/kg. The pressure applied at the both C and F-points was enough to cause mild to moderate achy pain. Following the procedure, the patient reported immediate relief of her right-sided backache with a VAS of 1/10. However, the pain returned to a VAS of 4/10 approximately 4 hours later. The CMAT was repeated twice per day for three days with complete resolution of pain.

quality of life. Due to the persistent pain, the patient was referred to our pain clinic. Physical examination revealed local tenderness over the right L34 region without radicular pain and a pain score of 6/10. After obtaining consent, the same CMAT was performed as in case 1. The pain intensity was reduced to 1/10 immediately, but the pain level returned to 4/10 approximately 3 hours later. The treatment was repeated twice a day for three days with complete resolution of pain.

Case 3
A 21-year-old male (weight 65 kg, height 178 cm) with funnel chest was scheduled for a Nuss procedure. The patient was given combined general and thoracic epidural anesthesia. An epidural catheter was placed at the T8-T9 interspace and was placed 4 cm into the space after three attempts. The operation lasted three hours, there were no complications, and the patient reported good postoperative pain control. Five days after removal of the epidural catheter, the patient complained of a thoracic backache with a VAS of 7/10. The patient received another week of conservative treatment (bed rest, warm compresses, oral ketorolac tromethamine 10 mg every 6 hours, and tramadol 50 mg every 6 hours), but the backache persisted. The backache severely affected ambulation, and the patient was referred to our pain clinic for further management. Physical examination revealed local tenderness over the T8 10 region without radicular pain, and the pain intensity was 7/10. The CMAT was performed for 30 seconds using the same Cpoint as the previous cases and a different F-point (Figs. 1 and 2). After receiving treatment, the pain intensity dropped to 1/10. Three hours later, the pain level returned to 3/10. The same treatment modality was repeated on a daily basis for three days, and the backache resolved completely.

Case 4
A 30-year-old male (weight 55 kg, height 170 cm) was scheduled for herniorrhaphy for recurrent inguinal hernia. Spinal anesthesia (SA) was accomplished after three attempts at the L45 intervertebral space with a 25-gauge Quincke needle. Hyperbaric bupivacaine (12.5 mg) was injected intrathecally with a sensory blockade to the T8 level. The surgery lasted 75 minutes. Twenty hours after the SA, the patient began to experience backache at the SA site. The pain was partially relieved by lying in a supine position and by taking once daily ketoprofen 200 mg. After 5 days of conservative treatment, the back pain persisted with significant impact on daily activities. The patient was referred to us for further management. Physical examination revealed local tenderness over the bilateral L45 region with a pain intensity of 6/10. After obtaining consent from the patient, we performed CMAT using a Cpoint located at the lung meridian. The F-point was located at
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Case 2
A 28-year-old pregnant woman (weight 65 kg, height 158 cm) with a gestation period of 39 weeks was scheduled for normal vaginal delivery under epidural analgesia. An epidural catheter was placed with an 18-gauge Tuohy needle via a midline approach with LOR at the L34 interspace after two attempts. The catheter was advanced 4 cm into the epidural space. Five hours later, a newborn was delivered without any complication, and the patient was satisfied with the labor analgesia. The next morning, the patient experienced right-sided low back pain with a pain score of 6/10. Bed rest and oral ketorolac tromethamine 10 mg every 6 hours were prescribed. Ten days later, she still complained of pain and diminished

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the depression of the radial side of the bicep muscle tendon, and the point was manipulated for approximately one minute (Figs. 1 and 2). Similar to the previous cases, a constant static pressure was applied to the C-point, while the F-point was manipulated with a dynamic rhythmic force in a cephalic direction. The left side was addressed first, followed by the right side (Figs. 1 and 2). The pain intensity was reduced immediately to 0, but the pain returned to 3/10 five hours later. The same treatment modality as the previous cases was repeated, and the pain was completely resolved after the second treatment.

Case 5
A 75-year-old female (weight 60 kg, height 155 cm) with osteoarthritis of the left knee was scheduled for arthroscopy. SA was accomplished after two attempts at

the L4 5 intervertebral space with a 25-gauge Quincke needle. Isobaric bupivacaine (12.5 mg) was injected intrathecally with a sensory blockade to the T10 level. The operation took 60 minutes, and there were no complications. One day after SA, the patient complained of severe backache that was partially relieved by bed rest, cold compresses, and oral medication (ketoprofen 200 mg once daily and tramadol 50 mg every 6 hours). Eight days later, we were consulted for her persistent severe backache. Physical examination revealed local tenderness over the left L4 5 region with a pain intensity of 8/10. After obtaining patient consent, the same CMAT protocol as in case 4 was performed on the right forearm. After the treatment, the pain intensity was reduced immediately to 2/10 and returned to 5/10 about 3 hours later. The pain was completely resolved after two additional treatments.

Fig. 1 Schematic diagram shows CMAT acupoints used for rightsided backache in cases 14. C-point of TxI meridianlocated on the junction of metaphysis and diaphysis over the distal radius. F-point 4 of TxI meridianlocated at the medial fossa of brachioradialis at the junction of metaphysis and diaphysis over proximal radius. F-point 5 of TxI meridianlocated at the fossa between biceps brachii and brachialis at the junction of metaphysis and diaphysis over distal humerus. F-point 6 of TxI meridianlocated on the groove between the medial aspect of the deltoid and the lateral side of the biceps brachii, approximately two-thirds above the elbow crease toward the axilla.

Fig. 2 Schematic diagram shows CMAT acupoints used for

left-sided backache treatment in cases 35.

Discussion
The backache associated with neuraxial blockade localizes with varying degrees of tissue trauma which can lead to ligament, tendon, or periosteum inflammation with or without muscle spasm.5 Postepidural backache is usually characterized by marked tenderness of the needle insertion site. Risk factors for the development of the backache include position during the neuraxial block, type of surgery, duration of surgery, and degree of postoperative immobilization.1, 3,16 Conventional analgesics such as NSAIDs and opioids have been used widely to treat postlumbar puncture backache. However, side effects and lack of efficacy have largely discouraged their prolonged use.8,9

Kleinman17 suggested that conventional treatment modalities such as bed rest, cold/warm packing, physical therapy, and medications with acetaminophen or NSAIDs should be sufficient for treating postneuraxial backache. However, our patients found conventional treatment to be ineffectual, prompting the CMAT therapy. The patients improved remarkably after CMAT (Table); therefore, CMAT may act as effectively as analgesics for patients with postneuraxial block backache who are unresponsive to conventional treatments. According to traditional Chinese medicine, the obstruction of energy (Qi) flow within the meridian can be manifested as pain.18 The traditional acupressure technique utilizes a single acupoint for pain management.14 However, the CMAT method recruits noncontiguous meridians to connect with the diseased meridian to restore Qi flow, resulting in significant improvement in pain relief. The point that connects the 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). All five patients presented here suf-

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Table. 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

L34, Rt/AyIII 5 L34, Rt/AyIII 5 T810, Bil/AyIII 6 L45, Bil/AyIII 4 L45, Lt/AyIII 4

CMAT, collateral meridian acupressure therapy; AyIII, lesion over bladder meridian; AyIII4, level 4; AyIII5, level 5; AyIII6, level 6; TxI, lung meridian in TCA; TxI:1/4, the C-point is over level 1 and corresponding F-point is over level 4; TxI: 1/5 & TxI:1/6, the C-point is over level 1(the same as TxI:1/4), corresponding F-point is over level 5 and level 6, respectively; Lt, left side; Rt, right side; Bil, bilateral; TCA, traditional Chinese acupuncture. 4. Bromage PR. Epidural Analgesia. Philadelphia, PA, WB Saunders, 1978, pp 36 39. 5. Usubiaga JE. Neurological complications following epidural anesthesia. Int Anesthesiol Clin 1975;13:45 46. 6. Schultz AM, Ulbing S, Kaider A, et al. Postdural puncture headache and back pain after spinal anesthesia with 27-gauge Quincke and 26-gauge Atraucan needles. Reg Anesth 1996;21:461 464. 7. Sharma SK, Gambling DR, Joshi GP. Comparison of 26-gauge Atraucan and 25-gauge Whitacre needles: insertion characteristics and complications. Can J Anaesth 1995;42:706 710. 8. Stephens JM, Pashos CL, Haider S, et al. Making progress in the management of postoperative pain: a review of the cyclooxygenase 2-specific inhibitors. Pharmacotherapy 2004;24:1714 1731. 9. Shapiro A, Zohar E, Zaslansky R, et al. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. J Clin Anesth 2005;17:537542. 10. Chernyak GV, Sessler DI. Perioperative acupuncture and related techniques. Anesthesiology 2005;102:10311049. 11. Usichenko TI, Dinse M, Hermsen M, et al. Auricular acupuncture for pain relief after total hip arthroplastya randomized controlled study. Pain 2005;114:320 327. 12. Lin JG, Lo MW, Wen YR, et al. The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. Pain 2002; 99:509 514. 13. Niggemann B, Gruber C. Side-effects of complementary and alternative medicine. Allergy 2003;58:707716. 14. Yeh CC, Ko SC, Huh BK, et al. Shoulder tip pain after laparoscopic surgery analgesia by collateral meridian acupressure (shiatsu) therapy: a report of 2 cases. J Manipulative Physiol Ther 2008;31:484 488. 15. Wong CS, Kuo CP, Fan YM, et al. Collateral meridian therapy dramatically attenuates pain and improves functional activity of a patient with complex regional pain syndrome. Anesth Analg 2007;104:452. 16. Bratteb G, Wisborg T, Rodt SA, et al. Intrathecal anaesthesia in patients under 45 years: incidence of postdural puncture symptoms after spinal anaesthesia with 27G needles. Acta Anaesthesiol Scand 1993;37: 545548. 17. Kleinman W. Spinal, Epidural, & Caudal Blocks, in Morgan GE, Mikhail MS, Murray MJ, et al (eds): Clinical Anesthesiology, New York, McGraw-Hill, 2002, pp 253282. 18. Lee YH, Lee MS, Shin BC, et al. Effects of acupuncture on potential along meridians of healthy subjects and patients with gastric disease. Am J Chin Med 2005;33:879 885.

fered from obstruction of the bladder meridian (AyIII). The lung meridian (TxI) was chosen as a collateral meridian for the treatment. The C-point and F-point for the lung meridian are shown in Figures 1 and 2, respectively. When these two points are manipulated as described in these cases, pain reduction is usually immediate, and complete resolution is achieved with a few additional sessions without adverse effects. Moreover, the CMAT technique usually avoids direct stimulation of the painful meridian, hence minimizing further exacerbation of the painful region. In CMAT protocol, if the disease meridian is on the left side, the treatment meridian is usually on the right side and vice versa. In cases 1 and 2, the affected meridian was on the left side; hence, the treatment was performed on the right side. Similarly, in case 5, the diseased meridian was on the right side; therefore, the treatment meridian was on the left side. A static pressure applied on the C-point links the diseased meridian to the treatment meridian, while pressure on the F-point facilitates movement of Qi. If there is tenderness over the L4 5 level, the corresponding F-point is 4 (cases 4 and 5). For tenderness over the L3 4 level, the corresponding F-point is 5 (cases 1 and 2). If the tenderness is over the thoracic spine, the corresponding F-point is 6 (case 3). This report demonstrates that CMAT is a viable alternative modality for treating postneuraxial block backache for patients whose conventional treatments fail. The CMAT indeed provided notable pain relief with no side effects. However, larger, controlled studies are needed to prove the efficacy of this new treatment modality.

References
1. Pan PH, Fragneto R, Moore C, et al. Incidence of postdural puncture headache and backache, and success rate of dural puncture: comparison of two spinal needle designs. South Med J 2004;97:359 363. 2. Kely D, Hewitt SR. Lumbar epidural block in labor: a clinical analysis. Br J Anaesth 1972;44:414 415. 3. Miro M, Guasch E, Gilsanz F. Comparison of epidural analgesia with combined spinal-epidural analgesia for labor: a retrospective study of 6497 cases. Int J Obstet Anesth 2008;17:1519.

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