Volume 10, Number 3 | Fall 2015

Clinical Report 1 (Acupuncture)
A Case of Intractable Pain of Around the Right Shoulder
Effectively Treated by Acupuncture and Moxibustion at
the Lumber Jiaji Point (Ex-B2)

resonance imaging (MRI) of the cervical spine andShiho Kohama, Go Ito, Hiroshi Odaguchi and
Toshihiko Hanawa

right-sided C5 nerve root disturbance also did not

Oriental Medicine Research Center, Kitasato University

Introduction
Chronic pain may be caused by many factors andhave a major impact on the patient’s quality of life.
There are a variety of treatment forms from such as
pharmacotherapy, psychotherapy, nerve blocks,
laser therapy, non-invasive and brain stimulation1).
However there is few standard method of treatment.
A substantial number of patients with refractorychronic pain have symptoms that are not alleviatedby those treatments. They suffer from pain for many
years. Often some of them visit acupuncture andmoxibustion clinics. We report a case of pain in theright shoulder that was unknown origin andcontinued for more than 2 years with successfultreatment by acupuncture and moxibustion.
Case Presentation
An 18-year-old male high school student had been
suffered from continuous pain of the proximal region
of

the

right

shoulder.

He

hadsustainedacompression fracture of a lumbar vertebra (L5)during soccer practice 8 years ago. About 2 years ago,
numbness and pain developed radiating upon flexionof the neck from the right scapular region towards
the

right

upper

arm.

When

the

condition

exacerbated he consulted an orthopedist. Loxoprofen
Sodium and Pregabalin were administered, but were
not effective. Following the recommendation of theorthopedist

heunderwent

severaltreatment

sessions at a different acupuncture and moxibustion
clinic, but this had no effect either. In June, he washospitalized for detailed examinations. The resultsof nerve root stimulation tests during extension andlateral flexion were negative. There were neither
obvious motor and sensory disturbances nor deep
tendon12

reflexanomalies.

Neithermagnetic

the brachial nerve plexus nor a myelo-CT duringflexionshowedanyorganic

disease.

Anelectromyogram performed because of suspicion of ashow any abnormality. To prevent exacerbation hewore a Polyneck. When he went to bed, he could not
maintain the same posture over 30 minutes, evenwhen using a pillow. For this reason, he was referredin August for consultation to our acupuncture andmoxibustion outpatient.
During the first examination pain associated witha tingling numbness from the right side of the necktowards the right scapula and into the right upperarm was observed. The pain was particularly strong
along the medial edge of the right scapula andexacerbated by anteflexion of the neck and continued
even after returning to the original position.
Present state had no problem (height: 177.7cm,
weight: 78.6 kg, BMI: 24.9, blood pressure: 116/70
mmHg, pulse rate: 65 bpm). Subjective symptoms
were lack of motivation, depressive mood, and easy
sweating. In physical findings, Jacksoncompression test, Spurling's test, and Allen test
were all negative, and there was no restriction ofneck and shoulder ROM and no sensory anomalies.
In oriental medical findings, tongue was observed
pale red color with moistwhitecoat by tongue
diagnosis.

Abdominal

wall

strengthwasintermediate and both sides of rectus abdominal
muscles were strain by abdominal diagnosis. The
Pulses were decreased at the left middle and the left
proximal pulse which concluded as liver meridian
deficiency by six-position pulse diagnosis.
Treatment
Based on the six-positon pulse diagnosis theessential treatment was administered by using
acupuncture needle according to the Kitasato style
meridians therapy and the symptoms were treatedlocally and symptomatically by using acupunctureneedle and moxibustion. The needles were retainedin both supine and abdominal position for about 15

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

Volume 10, Number 3 | Fall 2015

minutes. Disposable stainless steel needles of 0.2×40

Results

mm (No. 3) and 0.23×50 mm (No. 4) were used with

From the 1st to the 20th treatment visit no major

insertion tube. Insertion depth was in generalchanges were observed and the pain subsided only

approximately 2-3 mm on essential treatment, but

temporarily after the treatment. The patient’s VAS

depending on site occasionally also 5-10 mm. The

score of 100 obtained before the first treatment

treatment was started in intervals of basically one

decreased at best to a level of around 80. The

week, but switched during the course to 2-3 times

treatment effect did not last and the VAS score

per week. Also, the intensity of the pain was

would return to 100 by the next visit. However, theassessed before and after treatment using a Visualpatient

Analogue Scale (VAS).

motivation, depressive mood and easy sweating. Also

Most of pulse findings in this case over the entire
course indicated either kidney or liver deficiency.

stoppedcomplaining

about

lack

of

the patient reported that "except for the pain I am
now in good physical condition".

The main acupoints used for the essential treatment

Figure 1 shows the clinical course from the 21stwere LU5, LI10, KI10, KI7 and KI3 for the kidney

treatment. At the 21st treatment the VAS score of

deficiency. For the liver deficiency PC4, KI10, LR8,

the pain before the treatment was 100. At that time

LR4 and LR3 were used. Also, GV20, CV12, ST25,

he also complained about low back pain that had

CV6, CV4, BL10, GB20, BL11, BL13, BL17, BL23,

not been present at the time of the first visit. Since

BL40 and BL57 were chosen as the supplemental

the patient’s cold feet was found, we applied moxa

points of essential treatment.

needle at BL26 for symptomatic treatment. Afterthe treatment the VAS score had dropped to 70.

Sudden exacerbations ceased to occur.
There is pain, but could lie down on a pillow
Can turn neck down ward.

VAS (mm)

The pain became intermittent.

Number of treatment

Before treatment
After treatment

Jiaji point, lateral of the 5th lumbar vertebra for the symptomatic treatment
Once/every 2 weeks

Once/every 3 weeks

Figure 1 Clinical course

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

13

Volume 10, Number 3 | Fall 2015

During the 22nd visit, the VAS score was 63 before

from onset of a compression fracture of his lumbar

treatment, indicating that the effect of the previous

vertebra. This injury is hard to explain anatomicallytreatment continued. We administered the samethe causes of his right shoulder pain, where hetreatment until the 26th visit. By the 27th visit the VAS

complained. Yet, we found severe pressure pain onscore before treatment was 66. The low back pain had

the right side next to the 5th lumbar vertebra at the

become localized at the lumber Jiaji point (Ex-B2) tostandard location of the lumber Jiaji point.

the right of L5. We changed the acupoint to that

Symptomatic treatment on the acupoint almost

location instead of using BL26 for symptomatic
treatment (Figure

2).

When

we

continued

toadminister the moxa needle because the patient’s coldfeet persisted the VAS score dropped to 44. The patientreported during the 29th visit "I do have pain, but canlie down on a pillow". By the 36th visit he said he wasable to anteflex the neck without exacerbating the pain.
By the 49th visit the pain became intermittent andfollowing the 50th visit treatment intervals wereextended to once every 2 weeks. By the 65th visit the
VAS score had markedly improved to 27 before and 8
after the treatment. At the time of this writing the painis almost gone.

side of the 5th lumbar vertebra has a correlation to
the medial edge of the right scapula.
Usually, a compression fracture of the lumbar
vertebrae is a disease, causing injury to the ventral
column of the lumbar vertebrae, but throughvertebral body deformation it may also induce
chronic pain originating from the paravertebral
erectorspinaemuscles.

Accordingtoreports

indicating muscles as the responsible region ofchronic pain indicates the continuous contraction ofmuscles results in indurations of the muscles andlocal circulation

as

well

as

continuous

stimulation of polymodal receptors inside theNociceptive pain disappears when the injured
tissue heals. However, even though lesions have been
repaired and no anomalies can be observed, subjective
pain may develop into chronic pain generally caused byneurogenic or psychogenic factors.
In this case, the patient was worried at the timeof the first visit about chronic pain of unknown originthat had lasted for more than 2 years. The pain was
located at the proximal right shoulder and intensity
was highest along the medial edge of the rightEven

thoughcervical

anteflexion

exacerbated the symptoms, detailed examinations
did not reveal any causes for neurogenic pain. Since
the patient was a high school student just before
taking entrance examinations of university, hiscomplaints about "lack of motivation and depressivemood" suggested involvement of mental symptoms
and stress. However until the 20th visit, weconsidered few possibilities of psychogenic factors.
His past history showed a long interval of 8 years
14

observation induced our conclusion that the rightpoor

Discussion

scapula.

completely alleviated the right shoulder pain. This

muscles develops myalgia. Also, muscle tension
induced excessive stress on the tendon attachment
sites may possibly result in the development ofinflammation at these sites and therefore contributeto the myogenic pain2).
There are a few reports describing prolonged pain
when tissues surrounding the bone are injured incase of fractures, leading to prolonged pain or edemain the vicinity of the injured region. However, we
could not find any cases in which these symptoms
continued over prolonged periods of time after
healing of the fracture. Also, regarding the site of thepain there have been reports describing low backpain after compression fractures of thoracic or
lumbar vertebrae, but any reports about the onset ofpain in a region as remote from the fracture site as
in this case could not be found.
The longissimus thoracis muscle attaches to both
the region of the most intense pain along the medial
border of the right scapula and the right side of the

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

Volume 10, Number 3 | Fall 2015

5th vertebra. This longissimus thoracis muscle arises

In this case we used Jiaji point for thefrom the sacrum, iliac crest, spinous processes of thesymptomatic treatment. Jiaji point is a group of

lumbar vertebrae, the transverse processes of thealtogether 34 extraordinary points located 5 bu

lower thoracic vertebrae, attaches medially to the(about 0.5inch) lateral from the 1st thoracic to the 5th

costal processes of the lumbar vertebrae to support

lumbar spinous processes. In this case we used only

the lumbar region and laterally to the 2nd throughthe point located below and to the right of the 5th

12th ribs and thoracic transverse processes tolumbar vertebra as shown in Figure 2.

support the chest. Innervating nerves are theindividual posterior and external branches from the
1st cervical to the 5th lumbar vertebrae3).
painful regions

In this case the lumbar vertebral fracture may
have injured the longissimus thoracis muscle andcausedchronic

elevated

muscletensionthat

generated pain at a distant location. We considered
the lumbar vertebral compression fracture to be thecause for the pain in the proximal region of the rightshoulder.
The meridian therapy consists of both essential
treatment that treat the primary aspect of a disease
andsymptomaticaltreatment

that

treat

the

secondary aspect of a disease. The essential

Jiaji point for the symptomatic treatment

treatment of meridian therapy itself is based onclassical theories of reinforcement and reduction,
which are describe in chapter 69 in the classic text

Nanjing. In the classical theories, diseases areinterpreted as imbalances of the zang (solid) and fu

Figure 2(hollow) organs. Those imbalances appear deficiency

treatment and painful regions in this caseor excess along the course of the meridian. Following
the rule in chapter 69 therapeutic acupoints are
determined. Pulse diagnosis and other techniques
were used to identify deficiency or excess inmeridians to find the imbalance of zang and fu.
Treatment consists tonifying deficiency meridians
and reducing excess meridians and thus returning
the body to its normal state.
Sodo Okabe, the first head of our acupuncture andmoxibustion department, developed the Kitasato
style

meridiantherapybyimprovingonfundamental meridian therapy with feedback fromhis clinical experience. It is a style of treatment thatconcentrates on reinforcement of deficiencies which
we currently employ at our research institute.

Jiaji point for the symptomatic

We found Jiaji point seems to be classified into 2
types. One type is named as Hua Tuo’s paravertebral
acupoint, used for treating a patient with distortionof the body, as described in the classic text

Sanguozhi ( 三 国 志 )4). The other type is named
paravertebral point used for treating patients withsevere diarrhea such as that caused by cholera, anddescribed in the classic text Zhouhoubeijifang (肘後備急方), Qianjinyifang (千金翼方), Waitaimiyaofang(外台秘要方) and Ishimpo (医心方). All five classicaltexts only described treatment by moxibustion.
However, in the classic text Shinkyusetsuyaku (鍼灸説 約 ), the book of acupuncture and moxibustion
written by Sotetsu Ishizaka, and published during
the latter Edo period in 1812 (Figure 3), a section

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

15

Volume 10, Number 3 | Fall 2015

with an anatomical description of the individual

neuralgia7) Since treatment using Jaiji point hasvertebral bodies is followed by the passage: "these

spread in Japan, both the way they are used andpoints are found next to the spine all the way down

their applications have changed. Sorei Yanagiya andat the distance of 5 bu (about 0.5inch) each, they

Sodo Okabe had a major influence on acupuncture

should all be needled, they should all be treated withand moxibustion in Japan during the Showa periodmoxa. In other words, these are the point describedboth reprinted the works of Sotetsu Ishizaka. It is

by Kada [Hua Tuo] of the latter Han dynasty",

conceivable that Ishizaka’s efforts

showing that by the late Edo period that they had

still influence the way they used andalso been adapted for use with needles. According totheir applications of Jiaji point.

the Shinkyusetsuyaku Jiaji point could be used totreat "steaming bone taxation fever, various forms ofdepression, all kinds of diseases of the chest,
abdomen, head and neck, syncope and epilepsy,
chronic abdominal masses, disease of the uterus in
women, irritability and convulsion in children,
twisting of back and shoulders as well as bending of
the backbone". Their use had also become more
frequent; the text states, "They [Jiaji point] haveoften been tried and often found to be effective".
Figure 3 shows a piece of the Shinkyusetsuyaku
manuscript wherein Jiaji point is described.
In 1957 Sorei Yanagiya, who had restored theJapanese traditional acupuncture and moxibustion,
reprinted

thesurviving

text

of

the

Shinkyusetsuyaku along with his commentary
under the name of

Figure 3

Shinkyusetsuyaku (鍼灸説約)Shinkyumeiwa (鍼灸 茗 話 ). In Shinkyumeiwa he wrote "theparavertebral point is generally known as Hua Tuo’s
paravertebral acupoint or as paravertebral point,
and also as the first line of the bladder meridian"(Figure 4). In the same year Yanagiya also wrote thebook Hihouipponshindensho ( 秘 法 一 本 鍼 伝 書 ), in
which he describes acupuncture for five viscera andsix bowels and the needling techniques for internalorgan

diseases

by

using

Jiaji

point5).

The

Shinkyusetsuyaku was reprinted as well in 1970 by

Figure 4 Shinkyumeiwa(鍼灸茗話)

that had persisted for more than 2 years. It seemed
possible that a previously sustained compression
fracture had induced the pain in the right shoulder.
A part of this manuscript has been published at
the 66th annual conference of The Japan Society for
Oriental Medicine8).

reportedly been shown to be effective for the16

radicular

pain6)

orandtreating pain in the right shoulder of unknown origin

point to achieve nerve root stimulation hasofAcupuncture

moxibustion treatment of Jiaji point was effective for

Sodo Okabe. In recent years, deep needling at Jiaji

treatment

Conclusion

postherpetic

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

Volume 10, Number 3 | Fall 2015

Reference
1) Editing Committee for drafting of the
Neurological Therapeutics Guidelines by theJapanese Society of Neurological Therapeutics.
Standard Neurological Therapeutics: Chronic
Pain. Neurological Therapeutics; 2010; 27: 591622
2) Atsuhiro Ushida. Mechanisms of locomotor organ
pain and tasks. The Journal of Japanese Physical
Therapy Association; 2010; 37: 319-322
3) Translation by Yasuo Sakai et al. Prometheus Lernatlas der Anatomie: Allgemeine Anatomie
und Bewegungssystem. Igaku Shoin; Tokyo 2007;
pp 120-121
4) Ippei Suho et al. Use of paravertebral acupoints
as seen in Kada's (Hua Tuo) therapy. Journal of
the Japanese Society for the History of Medicine;2013; 59: 299

Hihouipponshindensho.
5) Sorei
Yanagiya.
Idononihon, Tokyo; 1995; pp 39-40
6) Nariake Tanabe et al.: Effects of acupuncture
treatment on radicular sciatica. The Japan
Society of Acupuncture and Moxibustion: 1984;
34: 242-245
7) Nariake Tanabe et al.: Effects of acupuncture
treatment on postherpetic neuralgia. The Japan
Society of Acupuncture and Moxibustion: 1984;
33: 383-387
8) Shiho Kohama et al.: One case in which
acupuncture and moxibustion treatment atlumbar Jiaji point was effective for pain in theproximal region of the right shoulder. Journal of
The Japan Society for Oriental Medicine: 2015;
66:286* Only in Japanese

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

17