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Arkady Kotlyar, PhD, DiplAc, Rina Brener, MD, and Michael Lis, MD
ABSTRACT
Introduction: Neck–shoulder pain is a common musculoskeletal problem that is often chronic or recurrent.
The mechanism of the neck–shoulder pain musculoskeletal disorder is complicated, multifactorial, and
sometimes unclear.
Cases: Seven patients presented at an outpatient pain clinic, each with a chief complaint of chronic neck–
shoulder pain that these patients had had for various time periods.
Intervention: The patients were treated with 45-minute sessions of Chinese Balance Acupuncture per the
protocol of Richard Teh-Fu Tan, OMD, LAc.
Main Outcome Measures: Pain intensity, pain duration, and quality of life (QoL) were measured during the
treatment period, and the QoL was measured during the 3-month follow-up after three acupuncture sessions.
Results: After the third session (1.5 weeks after the beginning of treatment), the patients reported complete
dissipation of pain or significant reductions in pain intensity. There was also substantial improvement in QoL
during the treatment period and during the 3-month follow-up.
Conclusions: To date, this is the first case report on the effectiveness of Dr. Tan’s Chinese Balance Acu-
puncture for treatment of chronic neck–shoulder pain. Studies to confirm the results of the present report are
warranted.
Key Words: Pain, Complementary and Alternative Medicine (CAM), Dr. Tan’s Chinese Balance Acupuncture
87
88 KOTLYAR ET AL.
Patient 4
A 41-year-old Caucasian male was referred to an outpa-
tient pain clinic with the chief complaint of chronic left
shoulder–neck pain that he had had for *15 years.
About 15 years before, this patient underwent surgery to
immobilize recurrent shoulder dislocation by screw fixation.
Postsurgery, pain in the left shoulder appeared and later
became exacerbated to neck–shoulder pain. About 6 years
FIG. 1. The neck–shoulder area of pain shown by the patient (in later, the patient was operated on again twice to excise the
gray). immobilizing screw. Based on a CT examination,
CHINESE BALANCE ACUPUNCTURE FOR NECK–SHOULDER PAIN 89
Patient 7
A 55-year-old Caucasian female was referred to the pain
clinic with the chief complaint of chronic left and right
shoulder pain that she had had for *7 months. Based on her
CT examination, she was diagnosed with rotator-cuff syn-
drome of the right shoulder and allied disorders, and adhe-
sive capsulitis of the left shoulder. The patient was
prescribed 600 mg of daily oral etodolac. During the treat-
ment period of 20 days, the NSAID treatment did not affect
her pain. Thereafter, the patient was prescribed acupuncture
treatment.
METHODS
Outcome Measures
The outcome measures included pain intensity, pain du-
ration, and quality of life (QoL). Pain intensity was rated
using a numeric scale from 0 to 10, in which 0 was defined
FIG. 3. The computed tomography scan depicting severe de- as ‘‘no pain at all,’’ 1–3 as ‘‘mild pain,’’ 4–6 as ‘‘moderate
generative changes in the left shoulder joint of Patient 4.
pain,’’ 7–9 as ‘‘severe pain,’’ and 10 as ‘‘the worst imag-
inable pain.’’7 At baseline, the patients rated their pain in-
tensity as 10.
performed after the third surgery, he was diagnosed with
The outcome measures were documented from the be-
adhesive capsulitis, also known as ‘‘frozen shoulder,’’
ginning of acupuncture treatment throughout the treatment
caused by severe degenerative changes in the shoulder joint
period. Prior to each session, all the details related to the
(Fig. 3). This patient was prescribed acupuncture treatment.
effect of the previous session were recorded carefully in the
patients’ files. After the pain had completely dissipated or its
Patient 5
intensity had significantly decreased, the patients were fol-
A 69-year-old Caucasian male was referred to an outpa- lowed up for 3 months.
tient pain clinic with the chief complaint of chronic pain in
both shoulders that he had had for *30 years. Based on his Diagnostics and Treatment
ultrasound examination, he was diagnosed with rotator-cuff
As the first step, Dr. Tan’s Balance Acupuncture 1–2–3
syndrome of the right shoulder and allied disorders, tendi-
diagnostics was used to determine the affected meridians.6
nitis and bursitis of the right shoulder, and a bilateral su-
The pain was determined as being a local problem involving
praspinatus tear. In his medical history, it was noted that he
an imbalance of the Shao Yang (Gall Bladder [GB] and
had pharmacologically balanced diabetes mellitus and hy-
Triple Energizer [TE; San Jao) and hand Yang Ming (Large
pertension, aspirin-treated coagulation defects, ischemic
Intestine [LI]) meridians (Table 1). Chinese pulse diag-
heart disease, congestive heart failure, and a pacemaker
nostics was used to confirm the involvement of the
defibrillator implanted *4 years before. The patient was
diagnosed meridians. An oral informed consent for the
prescribed acupuncture treatment.
publication of the present case report was obtained from
each patient.
Patient 6
After the ‘‘sick’’ meridians were diagnosed, the second
A 49-year-old Caucasian male was referred to an outpa- step was to select two out of the five most popular and
tient pain clinic, with the chief complaint of chronic left effective Dr. Tan’s systems of meridian interrelations as the
shoulder–neck pain that he had had for *6 months. About most appropriate treatment. Namely, System 2, the Bie-Jing
1.5 years before, the patient underwent surgery to immo- (Branching meridian) was chosen to balance the LI and TE;
bilize recurrent shoulder dislocation. Postsurgery, left neck– and System 3, the Biao-Li (Interior–Exterior pairs) was
shoulder pain appeared and increased, especially during selected to balance the GB (Table 1).
shoulder movements. Based on his MRI, he was diagnosed In System 2, the interrelation of the meridians is based on
with rotator-cuff syndrome of the left shoulder and allied their Chinese names. System 2 demonstrates the mutual at-
disorders. An ultrasound examination revealed a partial left traction and balance of the Yin–Yang meridians. Foot me-
supraspinatus tear. The patient was prescribed acupuncture ridians balance hand meridians and vice versa. Specifically,
treatment. foot Jue Yin (Liver meridian [LR]) balances hand Yang Ming
90 KOTLYAR ET AL.
(LI), formerly called hand Jue Yang, and foot Shao Yin (KI other words, an image of the painful neck–shoulder area on
meridian) balances hand TE. the foot–ankle area was expected to contain Ashi points
System 3 represents the Zang Fu interior and exterior along the LR and KI meridians. The Ashi points were found
counterparts. Namely, foot Jue Yin (LR) treats foot Shao above the medial malleolus, approximately up to SP 6. They
Yang (GB) and vice versa. The meridians defined by even were punctured using oblique insertion of 0.25 · 50–mm
systems (2 and 4) are punctured either ipsi- or con- silicone-covered, sterile acupuncture needles (Best Needles,
tralaterally, while those defined by uneven systems (1, 3, HaMillenium Chinese Medicine, Israel; Fig. 5). Acupuncture
and 5) are punctured contralaterally only. Considering that sessions lasted at least 45 minutes, and three such sessions
both an even and an uneven system were selected for were performed in the course of 1.5 weeks.
treatment, contralateral acupuncture was applied. The data were analyzed using an analysis of variance:
Finally, the third step was to determine the treating points two-factor without replication analysis. The value of
along the LR and KI meridians (Table 1). The Reverse p £ 0.05 was considered significant.
Mirroring Format, in which the foot–ankle mirrors the
neck–shoulder area and vise versa, was used (Fig. 4). In
RESULTS
Pain Intensity
A gradual dissipation of pain or a significant decrease of
its intensity in the neck–shoulder area was reported by the
patients following three acupuncture sessions (1.5 weeks
after the beginning of treatment; Fig. 6). According to the
patients’ reports, the improvement started during the first
FIG. 4. Illustration of the neck–shoulder pain area projection to FIG. 5. Representation of oblique acupuncture of the Ashi
the contralateral foot–ankle. points covering the LR and KI meridians.
CHINESE BALANCE ACUPUNCTURE FOR NECK–SHOULDER PAIN 91
FIG. 6. The intensity of pain throughout the 1.5-week acupuncture treatment period, assessed by using a numeric pain-rating scale,
expressed as mean – standard error. *Indicates statistical significance of the result.
session. Following the first session, the patients reported a To keep the duration of pain as short as possible for the
significant decrease in pain intensity from 10 to 5.5 – 0.5 other 6 patients, they continued treatment after the third
(mean – standard error [SE]; p = 0.00002). After the second session.
session, an additional significant decrease of pain intensity
to 3.07 – 0.3 (mean – SE; p = 3.04E-10) was reported. Post Quality of Life
the third session, 1 patient reported a complete dissipation of
Throughout the treatment period, starting post 1st session,
pain, and the rest of the patients reported significant de-
the patients reported a dramatic improvement in their
creases in its intensity to 0.88 – 0.09 (mean – SE;
quality of night sleep as well as gradual, improved ability to
p = 8.5E-15). No statistical difference among the results re-
move their upper extremities and considerable improvement
ported by the patients post each session was found ( p > 0.1).
in their QoL. During the follow-up period of *3 months
In patient 1, no severe irreversible damage was diag-
after the third session, no pain or a significantly decreased
nosed. Hence, the effect of the treatment was sustained and
intensity of pain was reported.
long-lasting. During the follow-up period of *3 months
after the third session, patient 1 did not report any pain.
In the other patients, the pain was associated with severe
DISCUSSION
irreversible damage to anatomical integrity. A cervical root
lesion and sensory axonal polyneuropathy diffuse idiopathic
Chronic pain is a widespread problem that is a significant
skeletal hyperostosis and stenosis in the cervical region, and
burden on society.8 The response of the healthcare system to
severe degenerative changes in the shoulder joint were di-
the issue of chronic pain can be generally divided into
agnosed in patients 2, 3, and 4, respectively. Rotator-cuff
several approaches. Among these approaches, the following
syndrome of the right shoulder was diagnosed in patients 5,
can be taken into consideration and discussed.
6, and 7. To keep the intensity of pain as low as possible,
these 6 patients continued treatment after the third session.
Invasive Treatment
Intravenous (IV) sedation analgesia is often used in pa-
Pain Duration
tients with chronic spinal pain undergoing diagnostic spinal
Following the first two sessions, patient 1 (without severe injection procedures.8 The drugs used for IV sedation an-
irreversible damage) reported a recurrence of pain with a algesia produce varying degrees of sedation, amnesia, an-
decreasing intensity, but the pain was not constant. Pain xiolysis, muscle relaxation, and analgesia.9 However, there
duration decreased from constant before the beginning of is no consensus with regard to the use of sedation analgesic
treatment to 7 – 1 hour (420 – 60 minutes) after the first measures prior to controlled diagnostic blocks and the in-
session, 30 – 15 minutes after the second session, and no fluence of these measures on the accuracy and validity of a
pain after the third session (Fig. 7). diagnosis.9 The immediate pain relief caused by cervical
92 KOTLYAR ET AL.
FIG. 7. The duration of pain throughout the 1.5-week acupuncture treatment period, expressed in minutes as mean – standard error
(SE). e, constant.
and lumbar-facet controlled nerve blocks is not enhanced by limited.8 Furthermore, chronic exposure to opioids can re-
IV sedation with midazolam or fentanyl.9 This is especially sult in opioid misuse, addiction, and risk of overdose.8
true if stringent outcome criteria are used, such as at least Therefore, nonopioid treatment options are warranted.8
75% pain relief combined with an increase in range of Novel pharmacologic nonopioid agents may eventually
motion for pain-limited movements.9 prove to be the most effective method of ameliorating the
Wu et al. investigated pulse radiofrequency stimulation symptoms and adverse consequences of chronic pain.8 The
applied to the suprascapular nerve for adhesive capsulitis pain-management approach of the future may use multi-
lesioning.10 The combination of pulse radiofrequency modal interventions that combine cognitive training regi-
stimulation with physical therapy provided better and faster mens with somatic therapies (e.g., physical therapy,
relief from pain, reduced disability, and improved passive massage, and/or acupuncture).8
range of motion, an effect that persisted for at least 12 In a study by Andersen et al., patients with chronic
weeks.10 nonspecific pain in the neck–shoulder region were ran-
Smith et al. investigated the use of cervical radio- domized to 10 weeks of 3 · 20 minutes of scapular function
frequency neurotomy for symptoms associated with chronic training.14 According to the results of the study, scapular-
whiplash disorder.11 The results of this study showed an function training is effective in reducing pain in adults with
attenuation of the psychophysical measures of augmented chronic nonspecific pain in the neck–shoulder region.14
central pain processing and improved cervical movement.11 Lidegaard et al. investigated the acute and longitudinal
Work by Fernandes et al. suggested that suprascapular effects of resistance training on occupational muscle ac-
nerve block is reproducible, reliable, widely used in clinical tivity in office workers with chronic neck–shoulder pain.15
practice, and an extremely effective treatment method for Acute response to a single session of resistance training
addressing chronic diseases that affect the shoulder.12 appeared to generate an unfavorable muscle activity pat-
Findings of a study performed by He et al. suggested that tern.15 Only the changes following 10 weeks of resistance
coblation is an effective, safe, minimally invasive, and less- training were beneficial in terms of longer and more fre-
uncomfortable procedure for treating discogenic upper-back quent periods of complete muscular relaxation and reduced
pain.13 pain.15
effects.16 However, there is no accepted mechanism by hand Yang and the foot Yin meridians balance each other and
which it could have persisting effects on chronic pain.16 vice versa. In this system, the acupoints are punctured on
Although TCM acupuncture is widely used for chronic either side of the body. Thus, balance is created by opposite
pain, considerable controversy regarding TCM’s value for Yang–Yin polarity and opposite extremities.
addressing chronic pain still remains.16 Vickers et al.
conducted a systematic review to identify randomized 3. Biao Li/Interior–Exterior pairs. In the third
trials using TCM acupuncture to treat chronic pain, in- system, the meridians are paired according to their Zang Fu
cluding nonspecific neck and shoulder pain.16 The indi- relationship (i.e., the foot Jue Yin (LR) and Shao Yang (GB)
vidual patient data meta-analyses in this review were balance each other. This is the only system in which the
conducted using data from 29 of 31 eligible trials, with a hand Yin and Yang meridians balance each other, and the
total of 17,922 patients analyzed.16 TCM acupuncture was foot Yin and Yang meridians balance each other. In this
found to be effective for treating chronic pain and, there- system, the acupoints are punctured on the contralateral side
fore, is a reasonable referral option.16 Significant differ- of the body. Thus, balance is created by the opposite side
ences between true and sham acupuncture indicated that and opposite Yang–Yin polarity.
acupuncture is more than a placebo.16
To summarize, TCM acupuncture continues to gain ad- 4. The opposite of the Chinese clock. In the fourth
ditional data confirming its effectiveness for treating various system, the meridians that are opposite on the Chinese clock
disorders. (Fig. 8) balance each other (i.e., the foot Tai Yin [SP] bal-
ances the hand Shao Yang [SJ] and vice versa). In this
system, the acupoints are punctured on either side of the
Dr. Teh-Fu Tan’s Chinese Balance Acupuncture
body. Thus, balance is created by the opposite Yang–Yin
Method
polarity.
As opposed to TCM, Chinese Balance Acupuncture is
fully based on the Meridian Theory, which has been his- 5. The neighbors of the Chinese clock. In the fifth
torically used as a diagnostic tool for effective acupuncture system, the hand meridians that are adjacent on the Chinese
treatment.6 In TCM acupuncture, the Zang Fu diagnosis of clock (Fig. 8) balance the foot meridians and vice versa (i.e.,
Chinese Herbal Medicine is used.6 This diagnosis includes the hand Tai Yin (LU) and the foot Jue Yin (LR) balance
such notions as Liver Qi Stagnation, Spleen Qi Deficiency, each other). Several meridian pairs of the fifth system
Blood Vacuity, and more.6 overlap those of the first system. In the fifth system, the
Certainly, the method of treatment detailed in the present acupoints are punctured on the contralateral side of the
case report is not the first and only instance in which Dr. Tan’s body.
Chinese Balance Acupuncture has been used successfully.
Actually, it is fully based on the I Ching (Yi Jing or Book of
Changes) Balance Acupuncture. This ancient method relies
on the interrelations of the acupuncture meridians, an idea
first introduced by Dr. Chao Chen, LAc, Taiwan.17 The
interbalancing relations of the acupuncture meridians are
summarized in the following five most efficient systems 6,17:
with lower back or neck–shoulder pain: A 5-year prospective 12. Fernandes MR, Barbosa MA, Sousa AL, Ramos GC. Su-
study. Scand J Public Health. 2015;43(3):315–323. prascapular nerve block: Important procedure in clinical
3. Hallman DM, Ekman AH, Lyskov E. Changes in physical practice. Part II [in English & Portugese]. Rev Bras Reumatol.
activity and heart rate variability in chronic neck–shoulder 2012;52(4):616–622.
pain: Monitoring during work and leisure time. Int Arch 13. He L, Tang Y, Li X, Li N, Ni J, He L. Efficacy of coblation
Occup Environ Health. 2014;87(7):735–744. technology in treating cervical discogenic upper back pain.
4. Moon MS, Kim SS, Yoon MG, Seo YH, Lee BJ, Moon H, Medicine (Baltimore). 2015;94(20):e858.
Kim SS. Radiographic assessment of effect of congenital 14. Andersen CH, Andersen LL, Zebis MK, Sjøgaard G. Effect of
monosegment synostosis of lower cervical spine between C2– scapular function training on chronic pain in the neck/shoul-
C6 [sic] on adjacent mobile segments. Asian Spine J. der region: A randomized controlled trial. J Occup Rehabil.
2014;8(5):615–623. 2014;24(2):316–324.
5. Sembrano JN, Yson SC, Kanu OC, Braman JP, Santos ER, 15. Lidegaard M, Jensen RB, Andersen CH, et al. Effect of brief
Harrison AK, Polly DW Jr. Neck–shoulder crossover: How daily resistance training on occupational neck/shoulder mus-
often do neck and shoulder pathology masquerade as each cle activity in office workers with chronic pain: Randomized
other? Am J Orthop (Belle Mead NJ). 2013;42(9):E76–E80. controlled trial. Biomed Res Int. 2013;2013:262386.
6. Tan RT-F. Acupuncture 1, 2, 3. San Diego: Richard Tan; 16. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for
2007. chronic pain: Individual patient data meta-analysis. Arch In-
7. McCaffery M. Using the 0-to-10 pain rating scale. Am J Nurs. tern Med. 2012;172(19):1444–1453.
2001;101(10):81–82. 17. Twicken D. I Ching Acupuncture—The Balance Method:
8. Garland EL. Treating chronic pain: The need for non-opioid Clinical Applications of the Ba Gua and I Ching. London,
options. Expert Rev Clin Pharmacol. 2014;7(5):545–550. UK, and Philadelphia: Singing Dragon, an imprint of Jessica
9. Smith HS, Colson J, Sehgal N. An update of evaluation of Kingsley Publishers; 2012.
intravenous sedation on diagnostic spinal injection proce-
dures. Pain Physician. 2013;16(2suppl):SE217–SE228. Address correspondence to:
10. Wu YT, Ho CW, Chen YL, Li TY, Lee KC, Chen LC. Arkady Kotlyar, PhD, DiplAc
Ultrasound-guided pulsed radiofrequency stimulation of the Outpatient Pain Clinic
suprascapular nerve for adhesive capsulitis: A prospective, ran- Kaplan Medical Center
domized, controlled trial. Anesth Analg. 2014;119(3):686–692. Post Office Box 1
11. Smith AD, Jull G, Schneider G, Frizzell B, Hooper RA, Ster- Rehovot 76100
ling M. Cervical radiofrequency neurotomy reduces central Israel
hyperexcitability and improves neck movement in individuals
with chronic whiplash. Pain Med. 2014;15(1):128–141. E-mail: dr.kotlyar@chi-point.com