Acupuncture in fight with acute pain of lower cervical and higher thoracic segment of spine, case study.


Student Name :       Witold Nowak

Address:              Swadlincote


Date of course : Start 06 September - end 02 November

Word Count  : 2612



This case study documents the use of acupuncture with support of massage and physiotherapy techniques for the treatment of an acute pain between 6-7 cervical and 1-2 thoracic vertebra area. I like to explain how the acupuncture fits in to the physiotherapy basing treatment on underlying physiological mechanisms. An 31 years old women with last few years history suffering of casual pain in different segments of spine. In this case I did treat her with acupuncture hand massage, vibro-massage, exercises and manipulation techniques to eliminate pain and potential inflammation in the area of pain.

Patient with acute pain after four session of supply treatment has reduced pain for 97% and after another three days  without any treatment another 3% improvement occur, so she has been free of any previous symptoms at all.

To recognise intensity of the pain I used Numerical Rating Scale (NRS) where '0' mean no pain at all and '10'  corresponds with maximum pain the patient could imagine. 


Introduction to condition

The not comfortable position during the driving  caused unbalance within neck muscles tension and then disc moved towards nerve roots irritating it and  creating pain and  inflammatory. It seems to be an typical example of neck pain problem. As the lady is a half professional volleyball player her joints within the spine, especially in cervical section, could overstrain and could have repetitive strain injury symptoms conduct to spondylosis. Many researches show spondylosis occur within professional sport players. However pathology is noted in both athletic and non athletic populations.[ Lisa A Ferrara. 2012 ]

Cervical spondylosis is the manifestation of retrogression of the cervical intervertebral disk, cervical hyperosteogeny and degeneration of connecting ligaments with the pathological changes pressed nerve roots, spinal cord and vertebral artery.[ China Beijing 2011

The acupuncture mobilising natural body's immune system to fight with infections or inflammatory such as increase of antibodies ,increase engorge attribute of phagocyte, increase bactericidal attribute of plasma, decrease level of albumin which is responsible  for buffering Ph level etc.[ Prof. dr Zbigniew  Garnuszewski 1998].

There are many researches and pragmatic randomized controlled trials showing the acupuncture is able to reduce pain and inflammatory level. The trials show as well acupuncture is helpful mainly for chronic pain disorders and there is no relapse. However some researches shows improvement in acute pain disorder but with less effectiveness compared to chronic pain disorder.[, White AR Ernst E. 1999;  Am J Chin Med 2002 ; Steven R Garfin Christopher M Bono 2013;Longbottom 2010;  NYU Langone Medical Centre " Acupuncture for Neck Pain Irnich D Behrens N, Molzen H,2001; Dziedzic K, Hill J, Lewis M 2005]

A 2012 analysis of data on participants in acupuncture studies looked at back and neck pain together and found actual acupuncture was more helpful than either no acupuncture or simulated acupuncture. [NCCAM]

A 2009 analysis found that actual acupuncture was more helpful for neck pain than simulated acupuncture but the analysis was on based on small amount of evidence.[ NCCAM]

A large study with more than 14000 participants evaluated adding acupuncture to usual care for neck pain. The research showed that participants reported greater pain relief than those who didn't receive it; the researches didn't test actual acupuncture against simulated acupuncture.[ ( NCCAM]

From other research we know it is important to increase amount of needling points and increase time of appliance in consecutive acupuncture sessions to achieve better therapeutic results.



               Patient details

Patient name:  J.L.

Age:                 31 years old      




Case Report

The subject was a 31 years old women playing half professionally volleyball so she is relatively fit but with repetitive strain movement concentrated in neck joints and top part of thoracic area.

Follow the interview with the patient, she said she have been driving with car about 4hours to London and after 3 hours break another 4 hours drive back on 27.09.2014 having head not supported on head rest. Afterwards she feel her neck very weak and tired. On the day after(28.09.2014) she woke up and then she shake her head and very sharp pain (she described it as 09 in NRS)  occured in her neck, reducing almost completely range of movement within the neck section. She used cold gel compress for 20 min three time in that day and at evening the pain reduced to 07 in NRS and the range of movement improved slightly. She said she did feel she needed immediate contact with physiotherapist as she had similar pain in past months and years in other parts of spine and she knew the treatments delivered by physiotherapists can reduce the pain within few days.

She has been under pressure as on next week she has very important volleyball match and she needs to support the team as she is the main and important player.

The lady said she has her trainings 3 times per week and she has volleyball match once per month.


Subjective findings:

- 6 months ago pain in the middle part of thoracic spine. The pain

    occur in the morning and after few physio treatment  and comply with manipulations techniques the pain reduced completely.

- there was no specific trauma

- she reported constant on and  of bladder and

   urinary tract infection problem

- about 15 months ago similar pain occur in lower back and it has been treat by physiotherapist in very similar way and after one week the pain has gone. Again there was no specific trauma

Unfortunately the lady never had any X-ray or MRI scan for her spine to find out if there is any spondylosis symptoms or other possible problems which could lead to neck or other spinal section pain.


Objective examination:

Observation:  the lady has hold her head straight up right and she has been worry to flex her head forward. She present some movement to the left and right but with limitation. Her posture was petit like for half professional volleyball player. Within the conversation she said in the past years her weight was only 48  kg and her height is 170cm.


Examination:  there was no abnormal postural build within any part of her shoulders, arms head and trunk. All spine seems to be correct without  any curvatures scoliosis abnormal kyphosis  or lordosis.

 None visual bruises or red marks within observation area. 

Temperature in the painful area was  no different than in other parts within patient's trunk and head, which can suggest no acute and widespread inflammatory was present.


Head flections reduced to 30% of full range of movement.

Head extension  reduced to 70% of full range of movement.

Head rotation to the right reduced to 85% of full range of movement.

Head rotation to the left reduced to 85% of full range of movement.

Sharp pain restrict movement possibility over the reduced limit.



Soft Tissue Tenderness Grading Scheme  

Grade                      Definition

0                              No tenderness

I                               Tenderness to palpation without grimace or flinch

II                              Tenderness with grimace and/or flinch to palpation

III                             Tenderness with withdrawal (+"jump sign")

IV                             Withdrawal (+"jump sign") to non-noxious stimuli (ie.superficial palpation, pin

                                 prick, gentle percussion)



Some tenderness  Grade 1 perceptible on right and left side of spine on level between 4 cervical and 4 thoracic vertebra with higher tension between 6 cervical and 1 thoracic vertebra.

Pressure around the tenderness area did not increas nociception.


Patient perception:   problems with the neck after driving so many hour

Goals: To decrease pain  and increase range of movement to be able

               come back for daily routine with her trainings and volleyball

               matches within a week. 

Severity: moderate   Irritability: moderate    Nature: primary hyperalgesia


Clinical impression:

Possibility of slightly disk movement follow not comfortable position during the driving on 27.09.2014. The position caused unbalance tension within neck muscles and then disc could havemoved creating pain and not acute inflammatory(whiplash).


Clinical reasoning and underlying mechanism:

 Pain in cervical especially in between cervical 6-7 and thoracic 1 area is very common problem seen in physiotherapy departments and clinics. In this section it is as well more difficult to achieve quick pain reduction compare to other spinal areas.

The palpation test did show tenderness around painful area as well as there was no bruises, red marks and high temperature it means there was not acute inflammatory and possibly no major damage was occur. Probably it was only whiplash that created the acute pain and restricted movement. However due to patient's intensive many years volleyball trainings and previous history of similar pain in different spine sections can't  exclude possibility of early stage of spondylosis.

The pain follow the western medicine can have different reasons to occur. One of the reason could be cervical spondylosis.

Cervical spondylosis is define as age related chronic disc degeneration. It is also defined as vertebral osteophytosis secondary to degenerative disc disease, which in the cervical spine may be asymptomatic or can present as pure axial neck pain, cervical radiculopathy, cervical myelopathy or cervical myeloradiculopathy. Neck pain caused by cervical spondylosis is associated with slight degenerative changes within the intervertebral disc in early cervical spondylosis. Cervical spondylosis is usually asymptomatic, but may present with symptoms of neck pain, neck stiffness or even shoulder pain and stiffness. Its etiological factors are multifactorial and involve poor posture, anxiety, depression, neck strain and sporting or occupational activities. With acceleration of the modern life, computers, air conditions, fans and cars food exhaustion  have become widely used and cervical neck pain has become  a common health problem worldwide.[ Lisa A Ferrara. 2012]

Non surgical treatment is usually the most appropriate course of initial management. The current clinical treatments mainly include administration of non-steroidal anti-inflammatory drugs, muscle relaxations, physiotherapy, analgesics, massage and so on.

Acupuncture is one of the most popular method in Chinese medicine to manage neck pain syndromes and number of clinical studies showing high effectiveness in immediate and short-term post- treatment period.[China Beijing 2011]

 Other reason for neck pain it can be mechanical micro damage within soft tissue such as pulled muscle which consequently creates inflammation, pain etc. or micro damage of vertebra bone or disc moved in to wrong position and then touching or pressing on nerve structure.

Follow Chinese medicine the reason of pain occur is disruption in the harmony energy flow through the five phrases (Fire, Earth, Metal, Water and Wood) and the restoration of this cycle will resolve the condition.[John Hobbs 2014]

Within Qi concept there is Qi energy flowing through human body via an meridians which are related to specific organs, organs system or functions. The disruption of energy in particular meridian or group of them creating pain and illness.[ John Hobbs 2014]

 In the case of the 31 years old lady, following the collected information  on first visit  29.09.2014 have used   4 needling points for 20 min. , vibro-massage, hand  massage and gently manipulation around tension area. Some exercises has been show to do 3 times per day till the problem is solved.

Apart of the main problem,  she reported co-morbidities -ongoing bladder and  urinary tract infection- and for that reason has been choose to needling bladder meridian points including :

BL11- Da Zhu, Bl10- Tian Zhu

The two points was chosen to achieve segmental effect of analgesia due to research show modulation of pain via the pain gate mechanism which involves stimulation of A- beta nerves that communicate with dorsal horn of spinal cord, brain stem and PAG, triggering descending inhibitory pathways in the shape of endogenous opioid mechanisms.

To achieve activation of midbrain and pituitary hypothalamic complex has been chosen:

Bl62- Shen Mai and Li4- He Gu [John Hobbs 2014]




Number and date of treatment

Needling point

Point location


Number of needles


Needle size





First day treatment


BL 11-DA Zhu



located on the upper back, 1,5 cun lateral to the lower border of the spinous process of the first thoracic vertebra

One needle on R side of the spine














Bl10- Tian Zhu




located in the nuchal region, on the lateral border of the trapezius muscle, 1,3 cun lateral to GV 15 at the level between cervical vertebrae C1 and C2.[

One needle on the R side of the spine















Bl62- Shen Mai



located on the lateral foot, in the depression directly inferior to the lateral malleolus, at dorsal dorsal -plantar skin junction.

One needle on the R foot



Needle: 25mm/0,30mm                        







Second day treatment



BL11- Da Zhu


Needles apply to both side of the spine

Needle: 25mm/0,30mm                        


Patient happy from the first day treatment, the pain reduced to 4 in NRS; much bigger range of movement achieved,  however still 30% reduction in head flexion.

 More needling points chosen and continue with hand massage, vibro-massage and manipulations.


BL10  Tian Zhu


Needles apply to both side of the spine

Needle: 25mm/0,30mm                        




Bl62- Shen Mai


One needle in L foot

Needle: 25mm/0,30mm       



Li4- He Gu


One needle in L hand

    Needle: 25mm/0,30mm       



Third day treatment



BL10 Tian Zu


Needles apply to both side of the spine

          Needle: 25mm/0,30mm       

Pain reduced again to 2 in NRS occuring only with maximum head flexion. Non reduction in range of movement.

Acupuncture continuation with some needling points changes as the patient didn't  like to needle  Li4- He Gu and B62 Shen Mai due to oversensitivity of this points. Instead of that choosen B57 in both legs and two more needles apply to GV14 and GV13. To support the acupuncture decided to do last massage and vibro-massage with manipulations.



BL11- Da Zhu


Needles apply to both side of the spine

Needle: 25mm/0,30mm       


BL57- Cheng Shan    

On the posterior leg, 8 cun inferior to BL 40, along the line conecting BL 40 at the popliteral crease and BL 60 posterior to the lateral malleolus.

Needle apply in both legs

Needle: 25mm/0,30mm       


GV 13-  Tao Dao

Below the spinal process of T1 

One needle

Needle: 25mm/0,30mm       


GV14-  Daz Hui  

Below the spinal process of C7

One needle

Needle: 25mm/0,30mm       


Forth day treatment


     BL10 Tian Zu                   


Needles apply to both side of the spine

Needle: 25mm/0,30mm       

Patient very happy only very slightly pain occurring with maximum head flexion.

 I decided to use the same needling points as in the session before without massage and other supportive treatment. 



BL11- Da Zhu


Needles apply to both side of the spine

Needle: 25mm/0,30mm       


BL57- Cheng Shan    


Needle apply to both legs

Needle: 25mm/0,30mm       


GV 13-  Tao Dao         


One needle

Needle: 25mm/0,30mm       


GV14-  Daz Hui           


One needle

Needle: 25mm/0,30mm       


I contacted the patient three days after we finished treatments and she said all her problems with the neck are gone and she is able to go back to her previous weekly routine with her trainings and matches.






The case study showing high effectiveness of acupuncture treatment supported by other physiotherapeutical techniques in the fight with acute pain and not acute cervical inflammation.

Application of acupuncture treatment with these kind of problems is one of the best forms of treatments due to possibility of relatively quick pain and inflammatory relief  without side effects that can occur using pharmaceutical support (Diclofenac, Ketanol, pain relieve medications etc.). For example acupuncture can release small amounts hydrocortisone to achieve therapeutic effect avoiding the side- effect of hydrocortisone chemotherapy. [ Trinh K, Graham N Gross A 2007]

Though it was only on the base of one patient and it is not possible to compare with other treatments with similar conditions it still has an impressive effect. However the effectiveness of acupuncture practice depends greatly on the proficiency of acupuncturists - their ability and skill in selecting and locating the acupuncture points and manipulating the needles. Some study showing difficulty of the ruling out placebo effect and comparative study with no treatment as the control may not be convincing in the evaluation of acupuncture practice.[ Trinh K, Graham N Gross A 2007]

It is very important is to chose right methods appropriate to symptoms show by patients. We always have to remember to choose right dose of acupuncture or other physiotherapeutic methods as it will reflect on the effectiveness and healing process. For example traditional Chinese medicine suggested to start treatment sessions with 8-10 needles maximum and in case where the patient is tolerating the treatment well it is possible to increase amount of the needles gradually and eventually shouldn't be over  amount of 17 needles.

The time of acupuncture treatment is dependent on what we want to achieve. Short time acupuncture up to 10 min. strengthen and stimulating patient`s body but treatment 20-30 min have placatory effect.

The intensity of acupuncture is dependent on illness persisting and escalation. In case of acute pain and inflammatory acupuncture suposed to be apply more often than in not acute condition. [Prof. dr Zbigniew  Garnuszewski 1998]

On the base of Master degree case study made by Witold Nowak in in 2001 "Comparison of effectiveness in fight of spinal pain by electroacupuncture and chosen physiotherapeutic methods" we know when we apply more than one treatment methods the result is improving gradually. Every single therapeutic method used by physiotherapist may have about 50%- 70% improvement but when  3-4 methods are involved at one time, then it is possible to achieve 95-98% improvement. Every physiotherapeutic method such as galvanic therapy[Jonophoresis(electrotherapy method with local medication)], ultrasounds, massage, exercises, manipulations, acupuncture, electroacupuncture etc. have similar effectiveness in the relief of spinal pain and inflammation.  

   Acupuncture could play a significant role in treating pain, not only spine related pain but pain from different back grounds as well [Trinh K, Graham N Gross A 2007]

The case study is proof that the acupuncture in physiotherapy daily treatments is a fantastic none invasive, welcome tool tolerated well by patients and has no side effects.






 China Beijing (2011);Chief Editors: Zhu Bing and Wang Hongcai;   Advisor: Cheng Xinnong

"Case Studies from the Medical Record of Leading Chinese Acupuncture Experts" (2011)

China Beijing International Acupuncture Training Centre, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences.

 Prof. dr Zbigniew  Garnuszewski 1998 "Renaissance Acupuncture" -; Editor: Sport i turystyka 1998.

White AR Ernst E. 1999 A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatology (Oxford); 38: 143-147

 Lisa A Ferrara. 2012 "The biomechanics of Cevical Spondylosis" - Volume  Article ID493605

 Am J Chin Med 2002 Zhu XM Polus B.A controlled trial on acupuncture for chronic neck pain; 30:13-28

 John Hobbs 2014 Acupuncture in Physiothrapy - training lead by tutor John Hobbs

Steven R Garfin Christopher M Bono 2013,  Degenerative Cervical Spine Disorder".Article from spineuniverse " What Work to Reliefe Neck Pain?" ; "

 Longbottom 2010 Kaptchuck 2002;

 NYU Langone Medical Centre " Acupuncture for Neck Pain".

Besson J.M(1999). "The neurology of pain" ; Lancet 353(9164), 1610-1615

 Irnich D Behrens N, Molzen H,2001 et al. Rondomized trial of acupuncture compared with conventional massage and "sham" laser acupuncture for treatment of chronic neck pain. BMJ. 2001; 322: 1-6

 Neurosurgery 2007"Cervical deformity correction" vol.60 no.1, supplement 1, pp.90-97,

Dziedzic K, Hill J, Lewis M 2005; et al. Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorder: A pragmatic randomized controlled trial in physical therapy clinic. Arthritis Rheum. 2005 Apr 7 [ Epub ahead of print].

 National Centre for Complementary and Alternative Medicine ( NCCAM)

Trinh K, Graham N Gross A 2007, et al. Acupuncture for neck disorder. Spine 2007;32:236-243

 Franca DL, Senna-Fernandes V 2008,   Cortez CM, et al. Tension neck syndrome treated by acupuncture combined with physiotherapy: A comparative clinical trial (pilot study). Complement Ther Med. 2008;16:268-277.

Sun MY, Hsieh CL, Cheng YY 2010 et al. The therapeutic effects of acupuncture on patients with chronic neck myofacial pain syndrome: a single - blind randomized controlled trial. Am J Chin Med. 2010;38(5):849-859.

Cameron ID,  Wang E, Sindhusake D.A 2011 Randomized trial comparing acupuncture and simulated acupuncture, for sub acute and chronic whiplash. Spine. 2011 Apr 7.

; Pubmed May 2011, Acupuncture Research Resource Centre

 Hubbard, D.R, & Berkoff, GM. "Myofacial triger points show spontaneus needle EMG activity" Spine 1993;18:1803-1807

Witold Nowak`s Master Degree  research "Comparison of effectiveness in fight of spinal pain by electroacupuncture and chosen physiotherapeutic methods" 2001.




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