Volume 5, Number 1 | Spring 2010

Clinical Report 1 (Japan)
A Case Report on Acupuncture Treatment for “Complex
Regional Pain Syndrome (CRPS)”
Shigeru Nakajima
Midori no Kaze Acupuncture Clinic,Morinomiya College of Medical Arts and Sciences

Introduction
Chronic pain, edema, skin temperature
anomalies, sweating and other symptoms areassociated with the refractory and chronic pain ofcomplex regional pain syndrome (CRPS) that may
be triggered with surgeries or injuries. CRPS wasonce called reflex sympathetic dystrophy (RSD) or
causalgia. Its morbidity is approximately 5 in
100,000 people and is therefore a disease ofcomparatively low incidence. We report a case ofacupuncture treatment for a patient who had
been diagnosed of RSD.
[Case Report]
Patient:
Age 52 years, female.
First visit:
March 10, 2008
Chief complaints:#1 dull pain of the left hand
#2 edema of the left hand, stiffness#3 irregular symptoms of feeling of sensations ofheat in the left hand, cold and sweating#4 feeling of weakness of the left upper extremity
Present illness:
The patient underwent surgery for left thumbtendosynovitis in June 2007. Following thesurgery a tingling sensation of the surgical scar
and a feeling of traction gradually developed.
Moreover, symptoms of dull pain, a sensation ofheat in the left hand, edema, stiffness, asensation of cold, irregular sweating and a senseof weakness of the left upper extremity developed.
Based on the results of a detailed examination
performed in a different clinic the physician
diagnosed as RSD. From July 2007 to February
2008 left stellate ganglion blocks (SGBs) were
performed and resulted in a mild improvement of12

the symptoms, but now the injection site on theleft side of the neck became painful. Concerns
about continuous nerve block treatment finallybrought the patient to our clinic.
Past history:
In 2004 temporomandibular arthrosis (treatedwith acupuncture in this acupuncture clinic)
Life style:
Alcohol: moderate amount of beer; tobacco: does
not smoke
Family history: nothing particularly noteworthy.
General symptoms: appetite: normal, bowel
movements: once a day; sleep: normal; stiffness ofthe back of the neck; shoulder stiffness, wearinessofthemuscles
aroundtheleft
temporomandibular joint.
General physical findings: Height: 155 cm;
weight: 51 kg; blood pressure: 128/80 mmHg;
pulse rate: 56 bpm (regular pulse)
Local physical findings: Jackson and Spurling
test (-), TOS tests (-); deep tendon reflexes (+: noleft-right differences), pathologic reflexes (-)
Left hand: edema (+), feeling of heat (+), redness(+), muscle atrophy (-), sensation (normal: noleft-right differences), nociception (little finger,digital pad: slightly hypersensitive), tenderness(-).
Right hand: Nothing particularly noteworthy.
Subjective symptoms during the night: nonocturnal pain of the left hand. However, there
is a sensation of edema.
Subjective symptoms in the morning: stiffness ofthe left hand.
Comprehension of the pathologic condition:(1) Following
surgeryfor
left
thumb
tendovaginitis gradual development of dull pain,
edema, stiffness, a sensation of heat and cold,
irregular sweating and a sense of weakness of theleft upper extremity. (2) Findings during the firstexamination. Based on the above described (1)and (2)the clinical characteristics were considered
to match those of a CRPS.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 1 | Spring 2010

Patient impression obtained during the medical
interview: speaks impatiently. Appeared slightly tired.
Informed consent: CRPS is a refractory condition.
The therapist had performed acupuncture andmoxibustion treatment only once about 4 years
ago for a patient with CRPS, but this patient
dropped out when the symptoms had improved toabout 1/2 of their original intensity. The above
described situation was explained to the patient
and the acupuncture and moxibustion treatment
started after obtaining the patient's consent.

 NRS for the acupuncture and moxibustion
treatment after the first examination(1) Edema: NRS 6(2) Pain: NRS 6(3) Redness: NRS 6(4) Irregular symptoms of sensations of heat, coldand sweating: NRS 5(5) Stiffness of the hand: NRS 7(6) Sense of weakness of the upper extremity:
NRS 7(7) Numbness: NRS 0

Acupuncture and moxibustion treatment plan:
Initially the approach was to gradually apply
local stimulation while observing the course.
Moreover,weappliedacupunctureandmoxibustion treatment also for the stiffness fromthe back of the neck to the shoulders and aroundthe left temporomandibular joint.

Acupuncture and moxibustion treatment andcourse (disposable needles, 40 mm, No.1 wereused)

Observation plan (evaluation):
Prior to the performance of the SGB treatment
the severity of the symptoms of the CRPS was
rated on a 10-step Numerical Rating Scale (belowcalled NRS).
 The NRS10 for the symptoms (1) - (7) prior to
the performance of the SGB treatment:(1) Edema: the edema is so severe that the patientcannot wear M size rubber gloves(2) Pain: dull pain (heaviness + pain)(3) Redness: the entire hand is red(4) Irregular symptoms of sensations of heat in
the left hand, cold and sweating: Depending on
the time the patient experienced hot and cold
sensations and sweating on an irregular basis.
(5) Stiffness of the left hand. Hand and fingers
could not be flexed.
(6) Sense of weakness of the upper extremity:
This sensation covered an area from the upperarm to the tip of the fingers.
(7) Numbness: pulling sensation at the site of thesurgical incision + numbness

 First treatment (March 10, 2008):
Supine position: GV20 (Hyakue, Baihui), left ST6(Kyosha, Jiache), left ST7 (Gekan, Xiaguan), left
GB3 (Jokan, Shangguan), bilateral LI11 (Kyokuchi,Quchi), bilateral GB34 (Yoryosen, Yanglingquan) retaining the needles for 10 minutes.
Single insertion at interdigital points (distal).
Single needling of interdigital points (proximal) indirect moxibustion, 5 cones.
Prone position: bilateral GB20 (Fuchi, Fengchi),bilateral GB21 (Kensei, Jianjing), bilateral BL43(Koko, Gaohuang), bilateralSI10 (Jue, Naoshu) retaining the needles for 10 minutes. At the sametime warming moxibustion on the shoulders (boxmoxibustion)
 Second treatment (March 21, 2008):
On the morning following the treatment thestiffness of the left hand and fingers haddecreased. Alleviation of the sense of weakness of
the left upper extremity. In addition to the firsttreatment pressure applied to the left auricle
resulted in some alleviation of the ipsilateral arm,so that the posterior part of the auricular wasneedled. GV20 (Hyakue, Baihui), bilateral LR3(Taisho, Taichong) retaining the needles for 10minutes. Left carpal tunnel, Tinel sign (-)

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13Volume 5, Number 1 | Spring 2010

 Third treatment (March 31, 2008):
Alleviation of the sense of weakness of the left
upper extremity. However, mild pain had
developed around the temporomandibular joint.
Development of stiffness of the MPs of the left
first and fifth fingers. Additional treatment ofright ST6 (Kyosha, Jiache), right ST7 (Gekan,Xiaguan), right GB3 (Jokan, Shangguan),retaining the needles for 10 minutes.
 Fourth treatment (April 4, 2008):
Following the treatment of pain and stiffness of
the MP of the left first and fifth fingers thealleviation of the symptoms continued for 1 week,
but after that returned to the original state.
Sensation of heat and swelling in the left thenarand hypothenar. Single insertion without
retaining the needle into in the left thenar andhypothenar (40 mm, #01). The NRS scores were:(1) edema 6, (2) pain 6, (3) redness 2, (4) irregularsymptoms of a sensation of heat, cold and sweating
4, (5) stiffness of hands and fingers 7, (6) weaknessof the upper extremity 7, (7) numbness 0.
 Sixth treatment (April 25, 2008):
Developmentofpainnear
theleftsternoclavicular joint, right blepharospasms.
 Seventh treatment (May 2, 2008):
No change of the pain near the left
sternoclavicular joint. Disappearance of the right
blepharospasms.
 Ninth treatment (May 16, 2008):
Sneezing has become impossible because of thepain near the left sternoclavicular joint;development of left blepharospasms. Needle
retaining at bilateral KI26 (Ikuchu, Yuzhong),
CV14(Koketsu,Juque).
Later
indirectmoxibustion (use of moxibustion paper); 5 conesof half rice grain size.
 Tenth treatment (May 26, 2008):
Disappearance of the left blepharospasms. Relief
14of the pain near the left sternoclavicular joint.
Appearance of sneezing and hiccupping.
 Twelfth treatment (June 11, 2008):
Irritation by weakness of the left upper extremityand stiffness of hands and fingers.
The NRS scores were: (1) edema 5, (2) pain 5, (3)redness 1, (4) irregular symptoms of a sensationof heat, cold and sweating 2, (5) stiffness of hands
and fingers 4, (6) weakness of the upper extremity
5, (7) numbness 0.
 Fourteenth treatment (June 27, 2008):
Relief of left chest pain and stiffness.
 Fifteenth treatment (July 11, 2008):
General relief of the symptoms.
The NRS scores were: (1) edema 2, (2) pain 2, (3)redness 0, (4) irregular symptoms of a sensationof heat, cold and sweating 1, (5) stiffness of hands
and fingers 2, (6) weakness of the upper extremity
5, (7) numbness 0.
 Seventeenth treatment (August 8, 2008):
Due to the general relief of the symptoms I planned
to extend the treatment intervals to 1 month. For
the stiffness of the hands and fingers carpal tunnel
needling (single insertion) was added.
The NRS scores were: (1) edema 0, (2) pain 0, (3)redness 0, (4) irregular symptoms of a sensationof heat, cold and sweating 0, (5) stiffness of hands
and fingers 1, (6) weakness of the upper extremity
2, (7) numbness 0.
 Eighteenth treatment (September 5, 2008):
The previously applied needling of the carpal
tunnel seemed to have been effective, since there
is almost no stiffness of hands and fingers. TheNRS scores were: (1) edema 0, (2) pain 0, (3)redness 0, (4) irregular symptoms of a sensationof heat, cold and sweating 0, (5) stiffness of hands
and fingers 0, (6) weakness of the upper extremity
2, (7) numbness 0.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 1 | Spring 2010

 Twentieth treatment (October 31, 2008):
General improvement of all symptoms.
The NRS scores were: (1) edema 0, (2) pain 0, (3)redness 0, (4) irregular symptoms of a sensationof heat, cold and sweating 0, (5) stiffness of hands
and fingers 0, (6) weakness of the upper extremity
2, (7) numbness 0.

period of approximately 7 months led to thefollowing improvement of the NRS scores: edema
6→0, pain 6→0, redness 6→0, irregularsymptoms of a sensation of heat, cold andsweating 5→0, stiffness of hands and fingers 7→0,
weakness of the upper extremity 7→2.
The improvement was maintained by subsequent
regular treatments.

Numberof treatments and NRS scores
治療回数とNRS
10987

NRS scores

NRS値①②6①浮腫

5(1)
edema
②痛み(2)
pain③発赤4(3)
redness④熱感・冷感・発汗の不安定症状③(4)irregular symptoms⑤手指のこわばり

3④(5)stiffness of hands and fingers⑥上肢の脱力感⑥2(6)weakness of upper extremity⑦しびれ(7) numbness⑤1⑦
20th: 10/31/2008

19th: 10/3/2008

18th: 9/5/2008

17th: 8/8/2008

15th: 7/11/2008

12th: 6/11/2008

8th: 5/8/2008

4th: 4/11/2008

1st: 3/10/2008

Pre-SBG: 7/2007

0

治療回数（治療日）
Number oftreatments (treatment date)

Figure 1: Number of treatments and NRS scores

Number of treatments and NRS scores (Figure 1:
Number of treatments and NRS scores)
Shows the improvement of the NRS scores withincreasing number of treatments.
A total of 20 treatments administered over a

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Volume 5, Number 1 | Spring 2010

Discussion
Yoshiki Hamada wrote in his summary of theCRPS seminar held in February 2007 titled"Early Diagnosis of CRPS and Points toConsider":"The Lankford classification is clinically of
extreme importance and an early initiation oftreatment of the minor type of the condition mayoften lead to favorably functional recovery
without
thedevelopmentofrefractory
symptoms".
Table 1shows the Lankford classification. Thisshows that it classifies the condition into a major
and a minor type.
 Moreover, in Yoshiki Hamada's summary"Early Diagnosis of CRPS and Points to Consider"
it also says:

16"Twenty out of 25 patients (80%) for whom thetreatment was initiated within 6 months of theonset recovered functions so far, that they wereable to return to ordinary daily life within one
year, but in 70% of these cases the condition had
been classified as minor type." The Lankford classification includes theitems "palpation impossible" for the major typeand "palpation possible" for the minor type. Thequestion whether palpation is possible or not is
considered to be closely related to the possibilityof administering acupuncture treatment.
 In this patient the condition was palpableand it is therefore reasonable to think, that astate of hyperaesthesia was present in the area
treatable by acupuncture.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 1 | Spring 2010

Conclusion(I) In this case the clinical condition of theCRPS based on NRS evaluations showedalready signs of improvement when thepatient first visited this acupuncture clinic.
The characteristics of the clinical symptomsof CRPS may vary significantly dependingon the disease progression in individualpatients. In this case the acupuncture
treatment for the various symptoms of thispatient with CRPS appeared to have beeneffective.
(II) CRPS is associated with severe physical andmental stress. Acupuncture treatment
seems also to be helpful for secondary
symptoms caused by irritation andconcerns.
(III) Although this was only one case, this one
case gave me the impression, that theconcepts pertaining to indications andcontraindications of acupuncture treatment
for CRPS should be reconsidered.

References1)
Shibata M., Yoshiya U., Masamo T.: "PainTreatment"; pp 131-135, Kokuseido Co. Ltd.,
2000
2)
Morimoto M.: "Pain Clinic and OrientalMedicine"; pp 505-512, Shinko Trading Co.
Ltd, Publishing Department of MedicalBooks, 2004
3)
Hamada Y.: "Early Diagnosis of CRPS andPoints to Consider"; Summary of the CRPS
Seminar, 2007
4)
Masamo T., Shibata M. editors: "Complex
Regional Pain Syndrome (CRPS)"; Shinko
Trading Co. Ltd, Publishing Department ofMedical Books, 2009

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Volume 5, Number 1 | Spring 2010

< Shigeru Nakajima >****-*-Graduated in 1986 fromthe Osaka Vocational
School of Acupunctureand Moxibustion(today: Morinomiya
College of Medical Artsand Science)
June 2001: employment in the department ofacupuncture and moxibustion of the clinic
affiliated with the Morinomiya College ofMedical Arts and Science (today: Midori no Kaze
Acupuncture Clinic affiliated with theMorinomiya College of Medical Arts and Science)
Member of the Japan Society of Acupunctureand Moxibustion, member of the JapanConference of Clinical Acupuncture andMoxibustion
Concurrent lecturer in the Department ofAcupunctureandMoxibustion oftheMorinomiya College of Medical Arts and ScienceIn charge of: clinical practice (1st – 3rd gradestudents),
practicalacupunctureandmoxibustion skills I (3rd grade students)
Concurrent lecturer in the department ofhealth services of the Department ofAcupuncture and Moxibustion of theMorinomiya College of Medical Arts andScience
In charge of: acupuncture and moxibustion
diagnostics and therapy I

Midori no Kaze Acupuncture Clinic affiliated withthe Morinomiya College of Medical Arts andScience / Midori no Kaze Acupuncture Clinic
The clinic affiliated with
the Morinomiya College ofMedical Arts and Science andthe affiliated acupuncture andmoxibustion clinic establishedin 1982 were reopened in
January 2010 after moving to
the third floor of a newbuilding under the name
"Midori no Kaze Acupuncture Clinic / Midori noKaze Clinic".
The clinic section has the following
departments: orthopedics, rehabilitation, internal
medicine, Kampo medicine and acupuncture andmoxibustion. This facility also focuses on thetraining of the next generation of medical
personnel and has the function of providingopportunities for clinical practice for the studentsof the Morinomiya College of Medical Arts andScience.

< Midori no Kaze Acupuncture Clinic (3rd Floor) >Clinic reception

18Acupuncture and moxibustion treatment room

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 1 | Spring 2010

Clinic staff

Clinical practice in the department of acupuncture and moxibustion< Midori no Kaze Clinic (1st Floor) >Orthopedics

Internal medicine, Kampo medicine

Physician: Yoshio Miyazaki; physician:Takahiro Shintani
Director of the Midori no Kaze Clinic

Professor of the department of healthservices of the Morinomiya College ofMedical Arts and Science

MRI< Midori no Kaze Clinic (2nd Floor) >Rehabilitation

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