Case Report

Collateral Meridian Acupressure TherapyEffectively Relieves Postregional Anesthesia/Analgesia BackacheChun-Chang Yeh, MD, FIPP, Ching-Tang Wu, MD, Billy K. Huh, MD, PhD,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% andthe incidence of back pain on the third postoperative day ranges from5.91% to 22% after spinal anesthesia. Five patients suffering frompostneuraxial block backache after regional anesthesia or analgesia arereported. Despite administering conventional treatment modalities in-cluding bed rest, cold/warm packing, physical therapy, and medicationswith nonsteroidal anti-inflammatory drugs (NSAIDs), strong analge-sics, and opioids, the backache persisted and disturbed the patients’daily life. Surprisingly, utilization of a new acupressure technique, col-lateral meridian acupressure therapy (CMAT), relieved the backachedramatically.

Key Words: acupressure, backache, collateral meridian therapy,regional anesthesia

Backache is a common postoperative complaint after epi-dural and spinal anesthesia. The incidence of post-

neuraxial block backache after obstetric delivery is between9% and 50%,1–3 and the incidence of immediate postopera-tive backache after nonobstetric surgery is 2%–31%.4,5 Theincidence of back pain has been reported as ranging from5.91% to 22% after spinal anesthesia on the third postoper-ative day.6,7 Nonsteroidal anti-inflammatory drugs (NSAIDs)have been frequently used to treat backache with well-knowngastrointestinal, cardiovascular, coagulation, and renal-func-tion side effects.8 In addition, all opioids will cause some sideeffects, such as increased tolerance, addiction, increased in-tracranial pressure, and respiratory depression.9

Traditional acupuncture has shown efficacy in perioperativepain management10–12; however, it is also associated with sideeffects such as needle-related infection, pneumothorax, bleed-ing, or tissue injuries.13 One of the primary benefits of collateralmeridian 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 consid-ered, such as open wounds at the acupoints, psychiatric diseasewith the presence of overt clinical symptoms, infections, metas-tases, osteoporosis, fractures, spine deformity, and surgical con-ditions. CMAT treatment involves manipulation of distant col-lateral meridians to facilitate the dissipation of pain whileavoiding the stimulation of the affected meridian to enhancepatient tolerability.14 The point that connects a diseased merid-ian to a distant collateral meridian is called the “control point”(C-point), while the acupressure point corresponding to the pain-ful region is called the “functional point” (F-point). Previously,we reported two postoperative shoulder-tip pain cases whichwere successfully treated by CMAT following inadequate relieffrom conventional analgesics and traditional needle acupunc-ture.14 Moreover, we have also successfully treated a case ofcomplex regional pain syndrome (CRPS) with the CMAT tech-

From the Department of Anesthesiology, Tri-Service General Hospital andNational Defense Medical Center, Taipei, Taiwan, Republic of China;and Department of Anesthesiology and Duke Primary Medicine, DukeUniversity Medical Center, Durham, NC.

Reprint requests to Chih-Shung Wong, MD, PhD, Department of Anesthe-siology, Tri-Service General Hospital and National Defense Medical Cen-ter, #325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, Re-public of China. Email: w82556@ndmctsgh.edu.tw

Accepted May 1, 2009.

Copyright © 2009 by The Southern Medical Association

0038-4348/0�2000/10200-1179

Key Points• Backache is a common postoperative complaint after

epidural and spinal anesthesia. Nonsteroidal anti-in-flammatory drugs (NSAIDs) or opioids have beenused widely to treat backache, but they can produceadverse effects that patients are unable to tolerate.

• The traditional acupressure technique utilizes acupointslocated in or near dermatomes related to painful areas.In contrast, collateral meridian acupressure therapy(CMAT) involves the manipulation of distant collat-eral meridians to facilitate dissipation of pain whileavoiding the stimulation of the affected meridian.

• CMAT is a viable alternative modality for treatingpost neuraxial block backache for patients who failconventional treatments.

Southern Medical Journal • Volume 102, Number 11, November 2009 1179

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

Case Reports

Case 1

A 32-year-old pregnant woman (weight 75 kg, height162 cm) with a gestation period of 40 weeks was scheduledfor labor analgesia. It was the patient’s second pregnancy.An 18-guage Tuohy needle was inserted via the L3–4 in-terspace after 1% lidocaine skin infiltration, and the catheterwas advanced 4 cm in the epidural space via loss-of-resis-tance (LOR) technique. After four hours of labor, a healthynewborn was delivered uneventfully, and the patient waspleased with the labor analgesia. However, on postpartumday 2, the patient complained of right-sided low back painwith a visual analog pain score (VAS) of 5/10. The back-ache persisted for one week despite bed rest, cold/warmcompresses, physical therapy, and use of oral ketoprofen(200 mg daily). No lower extremity weakness was found.The discomfort was significant enough to influence her sleepand daily nursing routine for 7 days. We were consulted forher pain management. Physical examination revealed localtenderness over the right L3–4 region without a radicularcomponent, and the pain intensity was 5/10. After obtainingwritten informed consent, we performed CMAT by apply-ing constant static pressure at a well-defined C-point, whileapplying dynamic pressure in a cephalic direction at a cor-responding F-point (Fig. 1). The performance was manip-ulated at a frequency of 60/min for one minute using aconstant force of 4 dynes/kg. The pressure applied at theboth C and F-points was enough to cause mild to moderateachy pain. Following the procedure, the patient reportedimmediate relief of her right-sided backache with a VAS of1/10. However, the pain returned to a VAS of 4/10 approx-imately 4 hours later. The CMAT was repeated twice perday for three days with complete resolution of pain.

Case 2

A 28-year-old pregnant woman (weight 65 kg, height 158cm) with a gestation period of 39 weeks was scheduled fornormal vaginal delivery under epidural analgesia. An epiduralcatheter was placed with an 18-gauge Tuohy needle via amidline approach with LOR at the L3–4 interspace after twoattempts. The catheter was advanced 4 cm into the epiduralspace. Five hours later, a newborn was delivered without anycomplication, and the patient was satisfied with the labor an-algesia. The next morning, the patient experienced right-sidedlow back pain with a pain score of 6/10. Bed rest and oralketorolac tromethamine 10 mg every 6 hours were prescribed.Ten days later, she still complained of pain and diminished

quality of life. Due to the persistent pain, the patient wasreferred to our pain clinic. Physical examination revealed localtenderness over the right L3–4 region without radicular painand a pain score of 6/10. After obtaining consent, the sameCMAT was performed as in case 1. The pain intensity wasreduced to 1/10 immediately, but the pain level returned to4/10 approximately 3 hours later. The treatment was repeatedtwice a day for three days with complete resolution of pain.

Case 3

A 21-year-old male (weight 65 kg, height 178 cm) withfunnel chest was scheduled for a Nuss procedure. The pa-tient was given combined general and thoracic epidural an-esthesia. An epidural catheter was placed at the T8-T9 in-terspace and was placed 4 cm into the space after threeattempts. The operation lasted three hours, there were nocomplications, and the patient reported good postoperativepain control. Five days after removal of the epidural cath-eter, the patient complained of a thoracic backache with aVAS of 7/10. The patient received another week of conser-vative treatment (bed rest, warm compresses, oral ketorolactromethamine 10 mg every 6 hours, and tramadol 50 mgevery 6 hours), but the backache persisted. The backacheseverely affected ambulation, and the patient was referredto our pain clinic for further management. Physical exam-ination revealed local tenderness over the T8–10 regionwithout radicular pain, and the pain intensity was 7/10. TheCMAT was performed for 30 seconds using the same C-point as the previous cases and a different F-point (Figs. 1and 2). After receiving treatment, the pain intensity droppedto 1/10. Three hours later, the pain level returned to 3/10.The same treatment modality was repeated on a daily basisfor three days, and the backache resolved completely.

Case 4

A 30-year-old male (weight 55 kg, height 170 cm) wasscheduled for herniorrhaphy for recurrent inguinal hernia. Spi-nal anesthesia (SA) was accomplished after three attempts atthe L4–5 intervertebral space with a 25-gauge Quincke needle.Hyperbaric bupivacaine (12.5 mg) was injected intrathecallywith a sensory blockade to the T8 level. The surgery lasted 75minutes. Twenty hours after the SA, the patient began to ex-perience backache at the SA site. The pain was partially re-lieved by lying in a supine position and by taking once dailyketoprofen 200 mg. After 5 days of conservative treatment, theback pain persisted with significant impact on daily activities.The patient was referred to us for further management. Phys-ical examination revealed local tenderness over the bilateralL4–5 region with a pain intensity of 6/10. After obtainingconsent from the patient, we performed CMAT using a C-point located at the lung meridian. The F-point was located at

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Yeh et al • Collateral Meridian Therapy for Postneuraxial Blocks Backache

1180 © 2009 Southern Medical Association

(Case Report continued from previous page)

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 staticpressure was applied to the C-point, while the F-point wasmanipulated with a dynamic rhythmic force in a cephalicdirection. The left side was addressed first, followed bythe right side (Figs. 1 and 2). The pain intensity wasreduced immediately to 0, but the pain returned to 3/10five hours later. The same treatment modality as theprevious cases was repeated, and the pain was com-pletely 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 forarthroscopy. SA was accomplished after two attempts at

the L4–5 intervertebral space with a 25-gauge Quinckeneedle. Isobaric bupivacaine (12.5 mg) was injected in-trathecally with a sensory blockade to the T10 level. Theoperation took 60 minutes, and there were no complica-tions. One day after SA, the patient complained of severebackache that was partially relieved by bed rest, cold com-presses, and oral medication (ketoprofen 200 mg once dailyand tramadol 50 mg every 6 hours). Eight days later, wewere consulted for her persistent severe backache. Physicalexamination revealed local tenderness over the left L4–5region with a pain intensity of 8/10. After obtaining patientconsent, the same CMAT protocol as in case 4 was per-formed on the right forearm. After the treatment, the painintensity was reduced immediately to 2/10 and returned to5/10 about 3 hours later. The pain was completely resolvedafter two additional treatments.

DiscussionThe backache associated with neuraxial blockade local-

izes with varying degrees of tissue trauma which can lead toligament, tendon, or periosteum inflammation with or withoutmuscle spasm.5 Postepidural backache is usually character-ized by marked tenderness of the needle insertion site. Riskfactors for the development of the backache include positionduring the neuraxial block, type of surgery, duration of sur-gery, and degree of postoperative immobilization.1, 3,16 Con-ventional analgesics such as NSAIDs and opioids have beenused widely to treat postlumbar puncture backache. However,side effects and lack of efficacy have largely discouragedtheir prolonged use.8,9

Kleinman17 suggested that conventional treatment mo-dalities such as bed rest, cold/warm packing, physical ther-apy, and medications with acetaminophen or NSAIDs shouldbe sufficient for treating postneuraxial backache. However, ourpatients found conventional treatment to be ineffectual, prompt-ing the CMAT therapy. The patients improved remarkably af-ter CMAT (Table); therefore, CMAT may act as effec-tively as analgesics for patients with postneuraxial blockbackache who are unresponsive to conventional treatments.

According to traditional Chinese medicine, the obstruc-tion of energy (Qi) flow within the meridian can be mani-fested as pain.18 The traditional acupressure technique uti-lizes a single acupoint for pain management.14 However, theCMAT method recruits noncontiguous meridians to connectwith the diseased meridian to restore Qi flow, resulting insignificant improvement in pain relief. The point that con-nects the diseased meridian to a distant collateral meridian iscalled the “control point” (C-point), while the acupressurepoint corresponding to the painful region is called the “func-tional point” (F-point). All five patients presented here suf-

Fig. 1 Schematic diagram shows CMAT acupoints used for right-sided backache in cases 1–4. C-point of TxI meridian—located on thejunction of metaphysis and diaphysis over the distal radius. F-point 4of TxI meridian—located at the medial fossa of brachioradialis at thejunction of metaphysis and diaphysis over proximal radius. F-point 5of TxI meridian—located at the fossa between biceps brachii and bra-chialis at the junction of metaphysis and diaphysis over distal hu-merus. F-point 6 of TxI meridian–located on the groove between themedial 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 forleft-sided backache treatment in cases 3–5.

Case Report

Southern Medical Journal • Volume 102, Number 11, November 2009 1181

fered from obstruction of the bladder meridian (AyIII). Thelung meridian (TxI) was chosen as a collateral meridian forthe treatment. The C-point and F-point for the lung meridianare shown in Figures 1 and 2, respectively. When these twopoints are manipulated as described in these cases, pain re-duction is usually immediate, and complete resolution isachieved with a few additional sessions without adverse ef-fects. Moreover, the CMAT technique usually avoids directstimulation of the painful meridian, hence minimizing furtherexacerbation of the painful region. In CMAT protocol, if thedisease meridian is on the left side, the treatment meridian isusually on the right side and vice versa. In cases 1 and 2, theaffected meridian was on the left side; hence, the treatmentwas performed on the right side. Similarly, in case 5, thediseased meridian was on the right side; therefore, the treat-ment meridian was on the left side. A static pressure appliedon the C-point links the diseased meridian to the treatmentmeridian, while pressure on the F-point facilitates movementof Qi. If there is tenderness over the L4–5 level, the corre-sponding F-point is 4 (cases 4 and 5). For tenderness over theL3–4 level, the corresponding F-point is 5 (cases 1 and 2). Ifthe tenderness is over the thoracic spine, the correspondingF-point is 6 (case 3).

This report demonstrates that CMAT is a viable alterna-tive modality for treating postneuraxial block backache forpatients whose conventional treatments fail. The CMAT in-deed provided notable pain relief with no side effects. How-ever, larger, controlled studies are needed to prove the effi-cacy of this new treatment modality.

References1. Pan PH, Fragneto R, Moore C, et al. Incidence of postdural puncture

headache and backache, and success rate of dural puncture: comparisonof 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 withcombined spinal-epidural analgesia for labor: a retrospective study of6497 cases. Int J Obstet Anesth 2008;17:15–19.

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 andback pain after spinal anesthesia with 27-gauge Quincke and 26-gaugeAtraucan needles. Reg Anesth 1996;21:461–464.

7. Sharma SK, Gambling DR, Joshi GP. Comparison of 26-gauge Atraucanand 25-gauge Whitacre needles: insertion characteristics and complica-tions. Can J Anaesth 1995;42:706–710.

8. Stephens JM, Pashos CL, Haider S, et al. Making progress in the man-agement of postoperative pain: a review of the cyclooxygenase 2-spe-cific inhibitors. Pharmacotherapy 2004;24:1714–1731.

9. Shapiro A, Zohar E, Zaslansky R, et al. The frequency and timing ofrespiratory depression in 1524 postoperative patients treated with sys-temic or neuraxial morphine. J Clin Anesth 2005;17:537–542.

10. Chernyak GV, Sessler DI. Perioperative acupuncture and related tech-niques. Anesthesiology 2005;102:1031–1049.

11. Usichenko TI, Dinse M, Hermsen M, et al. Auricular acupuncture forpain relief after total hip arthroplasty—a randomized controlled study.Pain 2005;114:320–327.

12. Lin JG, Lo MW, Wen YR, et al. The effect of high and low frequencyelectroacupuncture in pain after lower abdominal surgery. Pain 2002;99:509–514.

13. Niggemann B, Gruber C. Side-effects of complementary and alternativemedicine. Allergy 2003;58:707–716.

14. Yeh CC, Ko SC, Huh BK, et al. Shoulder tip pain after laparoscopicsurgery analgesia by collateral meridian acupressure (shiatsu) therapy: areport of 2 cases. J Manipulative Physiol Ther 2008;31:484–488.

15. Wong CS, Kuo CP, Fan YM, et al. Collateral meridian therapy dramat-ically attenuates pain and improves functional activity of a patient withcomplex regional pain syndrome. Anesth Analg 2007;104:452.

16. Brattebø G, Wisborg T, Rodt SA, et al. Intrathecal anaesthesia in pa-tients under 45 years: incidence of postdural puncture symptoms afterspinal anaesthesia with 27G needles. Acta Anaesthesiol Scand 1993;37:545–548.

17. Kleinman W. Spinal, Epidural, & Caudal Blocks, in Morgan GE, MikhailMS, Murray MJ, et al (eds): Clinical Anesthesiology, New York,McGraw-Hill, 2002, pp 253–282.

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Table. Case summary regarding CMAT therapya

Lesion/diseasedmeridian

Initialpain

intensity

CMATtreatmentmeridian

(acupoints)

Immediate painintensity after

CMATtreatment

Maximal painintensity afterfirst CMAT

treatment in 3 d

Total numbers CMATadministration to

obtain complete painrelief in 3 d

Case 1 L3–4, Rt/AyIII 5 5 Lt TxI:1/5 1 4 6

Case 2 L3–4, Rt/AyIII 5 6 Lt TxI:1/5 1 4 6

Case 3 T8–10, Bil/AyIII 6 7 Bil TxI:1/6 1 3 6

Case 4 L4–5, Bil/AyIII 4 6 Bil TxI:1/4 0 3 2

Case 5 L4–5, Lt/AyIII 4 8 Rt TxI:1/4 2 5 3

aCMAT, collateral meridian acupressure therapy; AyIII, lesion over bladder meridian; AyIII4, level 4; AyIII5, level 5; AyIII6, level 6; TxI, lung meridian inTCA; 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.

Yeh et al • Collateral Meridian Therapy for Postneuraxial Blocks Backache

1182 © 2009 Southern Medical Association