Homeostatic Acu Reflex Point System

SYSTEMIC PATTERN OF ACU-REFLEX POINT SENSITIZATION

From a physiologic perspective, there are two types of acu-reflex points (ARPs): homeostatic and symptomatic. Paravertebral ARPs, as clinically important ARPs, can be either homeostatic or symptomatic. According to both clinical experience and research, the sensitization of homeostatic ARPs follows an anatomically predictable pattern and sequence. This pattern of sensitization is found equally in all human beings for at least two reasons, according to current knowledge: First, homeostatic ARPs are neuroanatomically and pathologically dependent; second, the sensitization of homeostatic ARPs is related to human behavior: how we use our body to walk, to work, and to sit. If a person engages in special behavior such as the overuse of particular muscles in sports, a new pattern of ARP sensitiza-tion occurs and eventually causes the transformation of homeostatic ARPs into symptomatic ARPs. This phenomenon is examined in more depth in this chapter.

The anatomic configuration of ARPs, either homeostatic or symptomatic, varies in different parts of human body. As described in previous chapters, the common components of all ARPs are peripheral nerve fibers, which may include the sensory or postganglionic nerve fibers, or both, and motor nerve fibers such as muscle or tendon spindles. Secondary components include other soft tissues such as blood vessels, lymphatic vessels, and tendons or fasciae. The nerves at which the points form can be very different, according to their location; some are made of nerve endings, some are associated with big nerve trunks, and some contain a variety of different nerve fibers. The anatomic depths at which the points are formed are also varied. Ten anatomic features of ARP formation were discussed in detail in Chapter 8. All these features affect the formation, development, and appearance of passive ARPs when homeostasis declines or central sensitization increases. As a whole, the sensitiza-tion of human homeostatic ARPs has a predictable pattern with regard to the locations and sequence of sensitization. This is very important in the pathophysiologic processes of the nervous system and has great clinical significance in both preventing and treating diseases and in slowing down the aging process.

SYMPTOMATIC PATTERN OF ACU-REFLEX POINT SENSITIZATION

When affected by particular pathologic factors, any sensory nerve fiber anywhere in the body may become sensitized. This is the random pattern of ARP formation. For example, diseased visceral organs above the diaphragm—such as the heart, lung, or esophagus—will sensitize ARPs on the upper part of the body and on the upper limbs, whereas the diseased visceral organs below the diaphragm will sensitize ARPs on the lower part of the body and on the lower limbs. Organs located on the level of the diaphragm—such as the stomach, liver, gall bladder, pancreas, and spleen—will sensitize ARPs on both upper and lower body and limbs. Liver disease may cause sensitization of liver ARPs on the right side of the body.

ARPs of both random and predictable pattern often coexist. For instance, the primary homeo-static H1 deep radial ARP is sensitized in all people, healthy and unhealthy alike. However, patients with neck, shoulder, elbow, wrist, and hand pain also exhibit sensitized random additional points around the H1 deep radial ARP. In such cases, the H1 point has become a symptomatic point.

ARPs have a dynamic physical and pathologic nature. They all have three phases: latent (nonsensitive), passive (sensitive), and active (oversensitive). The three phases reveal the quantitative and qualitative dynamics of an ARP: when affected by pathologic factors, the sensitivity and size of an ARP increase. With proper treatment, the sensitivity of an ARP is reduced, relieved, or even returned to normal. In the absence of proper treatment, or when the self-healing potential is impaired, an ARP grows in size and can become a permanent pathologic structure.

THE INTEGRATIVE NEUROMUSCULAR ACU-REFLEX POINT SYSTEM AS A CLINICAL GUIDANCE FOR TREATMENT

According to both clinical evidence and anatomic research, the most frequently used and therapeutically effective ARPs are associated with major peripheral nerves. The location of all ARPs can be clearly defined in terms of their neuroanatomic arrangement. With basic training in human anatomy, a clinician can easily locate each point.

ARPs become sensitive in association with certain anatomic structures and physiologic processes. For example, repetitive overuse or abuse injures particular muscles and soft tissues, which leads to the sensitization of specific ARPs. Thus these ARPs are specifically related to the abnormal condition. Direct needling of these symptomatic ARPs is more effective than indirect treatment of nonsymptomatic points in most cases, although sometimes indirect treatment also provide satisfactory results because of higher healing potential. Selecting specific symptomatic ARPs is therefore essential. The homeo-static ARP system, or the integrative neuromuscular acu-reflex point system (INMARPS), provides both physiologic and pathologic guidance for finding the most important symptomatic ARPs in every case. Thus it is important to understand the physiologic and pathologic implications of this system.

In the clinical setting, INMARPS provides important information: how healthy the person is or how the person will respond to any medical intervention. In addition, INMARPS provides reliable guidance for acupuncture treatment.

Needling is nonpharmaceutical and nonspecific therapy, and its efficacy depends partly on the health condition, or healing potential, in each case.

Health is defined in Dorland's Illustrated Medical Dictionary, 30th edition,1 as "a state of optimal physical, mental, and social well-being; the popular idea that it is merely an absence of disease and infirmity is not complete." Physiologic health is definitely the foundation of physical and mental health. INMARPS is a quantitative system that can be used to more objectively define or measure the health condition of each individual.

All peripheral pathophysiologic factors are currently understood to interact with the central nervous system. Peripheral pathologic conditions or peripheral sensitization will lead to the sensiti-zation of the neurons inside the central nervous system. These sensitized neurons then sensitize segmental peripheral nerves, and the sensitized ARPs are formed at the sensitized peripheral nerves. Thus the central sensitization represents peripheral physiologic health: The less healthy a person is, the more central sensitization exists, the more likely peripheral sensitization is to occur, and more sensitized ARPs will appear, in both quality (sensitivity) and quantity (the total numbers), on the entire body. Therefore the state of health can be measured by the number of sensitized or passive ARPs on the body. In this chapter, the concepts and method of measuring peripheral sensitization are introduced.

HISTORICAL REVIEW

The ancient Chinese practitioners noticed that pathologic insults created sensitized or painful spots on particular parts of the body surface. They traced these spots and formed the classic meridian charts, which included 361 meridian points and numerous nonmeridian points.

In the 1940s, Janet Travell independently discovered myofascial trigger points. It was noticed later that 80% of the trigger points matched the meridian acupuncture points.1a A. E. Sola, a military physician working in Lackland Air Force Base, San Antonio, Texas, in the 1950s, noticed that the young recruits developed sensitized spots in particular muscles after intensive training. He wrote, "These observations led to the question of the possible existence of latent trigger points in an asymptomatic individual, which upon being subjected to the physiological insult of strain, chronic fatigue, chilling, or other irritating stimuli, might serve as the source of clinical symptoms."2 His observation reveals the dynamic physiology of these trigger points.

H. C. Dung, professor of human anatomy at the University of Texas Health Science Center at San Antonio, has studied the anatomy of acupoints and discovered systematic physiologic dynamics of these ARPs since the1970s.3 Dung and the author collaborated in two books that introduced these concepts to Chinese acupuncture clinicians. Despite Dung's achievements, more research is needed to deepen the understanding of the systemic behavior of ARPs in the human body. The next section describes Dung's pioneer work in the 1970s to determine the distribution and sequence of sensitization of ARPs.

CHARTING THE ACU-REFLEX POINT SYSTEM

After careful research on classic acupuncture meridian points and modern trigger points, Dung selected 110 points from both systems according to neuro-muscular anatomy. The selected points represent the different anatomic configurations, anatomic distribution, and clinical frequency of using these points. A checklist with all 110 points was made for recording the sensitivity of each point.

After the points were selected and the chart designed, 221 people with various pain symptoms were recruited for study (Table 9-1). Of these subjects, 130 (58.8%) were female and 91 (41.2%) were male. Patients between 40 and 69 years of age made up 63.8%. Only two patients were younger than 19 years of age. Some subjects were healthy young medical students. No attempt was made to differentiate the types of health problems present. All 110 points were palpated in each subject, and their sensitivities were recorded. All the subjects were examined by H. C. Dung himself. According to their own accounts, most of them suffered from soft tissue pain such as lower back pain, arthritis of various forms, joint pain, and headache.

If a point was sensitive in all the subjects, the sensitizing frequency of that point was described as 100%. If a point was sensitive in 70% of the patients, the frequency of that point was 70%. The data were processed to yield the percentage frequency of all 110 points. Thus the physical or physiologic pain of each patient was quantified by the number of sensitive ARPs.

In the following 30 years, these data were repeatedly applied to every patient at clinics in the United States, including Dung's, the author's, and a few other medical doctors' clinics. The pain quantified in each patient was compared with the results of treatment, and it was discovered that the fewer the sensitive points a patient had, the less treatments the patient needed and the longer the pain relief would last. This makes it possible to quantify, for each patient, the pain, the number of treatment sessions, and the prognosis.

Gender and Age Distribution of Patients Examined for Passive Acu-Reflex Points

Age (Years)

FEMALE PATIENTS

MALE PATIENTS

TOTAL PATIENTS

No.

%

No.

%

No.

%

10-19

0

0

2

2.2

2

0.9

20-29

8

6.2

7

7.7

15

6.8

30-39

17

13.1

14

15.4

31

14.0

40-49

25

19.2

11

12.1

36

16.3

50-59

32

24.6

18

19.8

50

22.6

60-69

31

23.8

24

26.4

55

24.9

70-79

15

11.5

14

15.4

29

13.1

80-89

2

1.5

1

1.1

3

1.4

Total

130

100.0

91

100.0

221

100.0

Modified from Dung HC: Anatomical acupuncture, San Antonio, Tex, 1997, Antarctic Press, p 145.

Modified from Dung HC: Anatomical acupuncture, San Antonio, Tex, 1997, Antarctic Press, p 145.

From these empirical data—the number of sensitive ARPs they have—patients can be classified according to the level of their pain. As a clinical procedure, the quantification should be simple, quick, and reliable in its predictions.

There are two ways of classifying patients: the ABCD method or the 12-degree method. In the ABCD method, the 110 points are divided into four groups: A (points 0 to 24), B (points 25 to 50), C (points 51 to 80), and D (points 81 to 110). Patients of group A have fewer than 24 sensitive ARPs; those of group B, between 25 and 50; those of group C, between 51 and 80; and those of group D, more than 80. In the 12-degree method, each of the A, B, C, and D groups is divided into three subgroups; for example, of the patients in group A, those with fewer than 8 sensitive ARPs are classified as first degree, and those with 16 to 24 sensitive points are classified as third degree. Those with more than 100 sensitive ARPs have 12th-degree pain. In this book, the ABCD method is used (Tables 9-2 through 9-5 and Figs. 9-1 through 9-4).

The author and colleagues have developed a simple and reliable procedure to classify patients into ABCD groups. The procedure takes about 5 minutes and is introduced in this chapter.

A few words should be said about the research from which this method was derived. First, the pathophysiologic meaning of these empirical data needs to be explored further. Second, the developmental pattern of ARP sensitivity varies and is not exact point-like. When sensitivity starts to appear, it is restricted to a very specific location associated with a sensory nerve and can be regarded as a point. As the sensitivity develops, the sensitive area increases in size, becoming a big "point." If this "point" is located in the limbs, the continuous sen-sitization develops along the nerve trunk in a linear pattern; thus all the sensitive "points" on the same nerve trunk are connected, not discrete. If the sensitive "point" is located in the face or torso, it develops by increasing in area. Obviously, the difference in the patterns of development of sensitive points is related to the different innervation patterns of the peripheral nerve endings in the limbs and the face or torso (Figure 9-5).

ABCD GROUPING OR QUANTIFICATION OF PATIENTS: THE 16-POINT METHOD

The supply of energy is limited in every human body, and healing requires energy. The ABCD grouping is, in fact, a division into different energy levels, which provides the basis for predicting the response to and outcome of the treatment. Every pathologic condition, including peripheral sensi-tization and mental stress, consumes some energy. The more health problems a person has, the more slowly that any one of the problems will heal. For example, lower back pain heals much faster in a healthy person than in a person who has many health problems, with pain in several different parts of the body.

The nature of peripheral sensitization differs between chronic and acute cases. For example, a healthy person who suffers from acute lower back pain may have pain only in the lumbar area, whereas a patient with chronic lower back pain may also have pain in the upper back or legs, or both. With the same treatment, the first patient will recover in a few days, whereas the latter patient's recovery may take months. The healing of local pathologic conditions depends on the general health condition, or, in other words, the general level of healing energy in the body. The same lower back pain heals faster and better in a healthy and younger body. Thus it is important to know the general healing potential of the body in order to predict the outcome of each case.

The 110 acu-reflex point charts can be used to develop several methods of grouping patients because the homeostatic ARP system represents a regular pattern of sensitization. As a clinical principle, the grouping or quantification procedure should be simple, reliable, and reproducible. After more than a decade of clinical practice and teaching experience, the author and colleagues have used two points, H1 deep radial and H4 saphenous, for the purpose of quantification or grouping (Fig. 9-6). On each patient, H1 and its secondary, tertiary and nonspecific points are palpated on both upper limbs, and H4 and its secondary, tertiary, and nonspecific points are palpated on both lower limbs.

Supraorbital Infraorbital

Lateral pectoral

Supraorbital Infraorbital

Lateral pectoral

Greater occipital

Spinal accessory Dorsal scapular

Suprascapular (infraspinatus)

Lateral antebrachial cutaneous

Deep radial

Superficial radial

Saphenous

Common fibular (peroneal)

Deep fibular (peroneal)

Greater occipital

Lateral antebrachial cutaneous

Deep radial

Superficial radial

Saphenous

Common fibular (peroneal)

Deep fibular (peroneal)

Great auricular

Posterior cutaneous of T6 Spinous process of T7

Posterior cutaneous of L2 Posterior cutaneous of L5

Figure 9-1 The primary 24 acu-reflex points. A, Anterior view. B, Posterior view. C, Surface anatomy of the primary homeostatic points.

Great auricular

Posterior cutaneous of T6 Spinous process of T7

Posterior cutaneous of L2 Posterior cutaneous of L5

Figure 9-1 The primary 24 acu-reflex points. A, Anterior view. B, Posterior view. C, Surface anatomy of the primary homeostatic points.

TABLE 9-2 Primary Homeostatic Acu-Reflex Points

Sequence

Name of Point

Frequency

%

1

Deep radial-I*

220

99.5

2

Great auricular

219

99.1

3

Spinal accessory-I

217

98.2

4

Saphenous-I

216

97.7

5

Deep fibular (peroneal)

215

97.3

6

Tibial

214

96.8

7

Greater occipital

213

96.4

8

Suprascapular (infraspinatus)

212

95.9

9

Lateral antebrachial cutaneous

211

95.5

10

Sural-I

209

94.6

11

Lateral or medial popliteal

207

93.7

12

Superficial radial

203

91.9

13

Dorsal scapular

201

91.0

14

Superior cluneal

198

89.6

15

Posterior cutaneous of L2

196

88.7

16

Inferior gluteal

195

88.2

17

Lateral pectoral

192

86.9

18

Iliotibial-I

185

83.7

19

Infraorbital

184

83.3

20

Spinous process of T7

178

80.5

21

Posterior cutaneous of T6

172

77.8

22

Posterior cutaneous of L5

168

76.0

23

Supraorbital

167

75.6

24

Common fibular (peroneal)

165

74.7

*The suffix "I" denotes the primary homeostatic point at the particular site.

*The suffix "I" denotes the primary homeostatic point at the particular site.

The distance between two points is about the width of the thumbnail. A total of 16 ARPs are palpated. To estimate the general healing energy—that is, to classify a patient into A, B, C, or D groups—all the sensitive points must be added together (Table 9-6).

Because the sensitization develops linearly along the nerve trunk, what is measured is not isolated or discrete points but the extent of the development of sensitivity of the deep radial and saphenous nerves.

Temporomandibular Masseter Mental Cervical plexus

Medial pectoral Radial Xyphoid Medial antebrachial cutaneous Deep radial - II

Iliotibial - II Femoral Saphenous - II

Common fibular (peroneal) - II

Tibial - II

Superficial fibular (peroneal)

Figure 9-2 The secondary homeostatic acu-reflex points. A, Anterior view. B, Posterior view.

Sural - II

Lesser occipital Spinal accessory - II Supraspinatus Axillary

Posterior cutaneous of T4 Spinous process of T5 Posterior cutaneous of T8

Posterior cutaneous of L1

Posterior cutaneous of L3

Recurrent branch of median

Sural - II

Figure 9-2 The secondary homeostatic acu-reflex points. A, Anterior view. B, Posterior view.

TABLE 9-3 Secondary Homeostatic Acu-Reflex Points

Sequence

Name of Point

Frequency

%

25

Medial antebrachial cutaneous

164

74.6

26

Tibial-II*

164

74.6

27

Temporomandibular

164

74.6

28

Cervical plexus

163

74.2

29

Deep radial-II

163

74.2

30

Masseter

162

73.6

31

Femoral

161

72.9

32

Xyphoid

160

72.4

33

Saphenous-II

156

70.6

34

Lesser occipital

152

68.8

35

Posterior cutaneous of T5

148

67.0

36

Iliotibial-II

147

66.5

37

Medial pectoral

146

66.1

38

Radial

143

64.7

39

Spinous process of T5

142

64.3

40

Axillary

138

62.4

41

Posterior cutaneous of L1

138

62.4

42

Spinal accessory-II

135

61.1

43

Superficial fibular (peroneal)

134

60.6

44

Sural-II

132

59.7

45

Posterior cutaneous of L3

128

57.9

46

Recurrent branch of median

123

55.7

47

Posterior cutaneous of T8

122

55.2

48

Common fibular (peroneal)-II

114

51.6

49

Suprascapular-II (supraspinatus)

111

50.2

50

Mental

110

49.8

*The suffix "II" denotes the secondary homeostatic point at the particular site.

*The suffix "II" denotes the secondary homeostatic point at the particular site.

Coronal suture Temporalis Superior auricular Transverse cervical Intermediate supraclavicular Upper biceps brachii Medial brachii cutaneous Intercostobrachial Costal margin Lateral cutaneous of T8 Deep radial - III Ilioinguinal

Iliotibial - III

Saphenous - III Common fibular (peroneal) - III

Third metatarsal

Iliotibial - III

Saphenous - III Common fibular (peroneal) - III

Third metatarsal

Plantar

Greater trochanter

Achilles

Inferolater and ineromedial malleolus

Bregma Pterion

Superior auricular Spinal accessory - III

Acromioclavicular Deltoid

Spinous process of T3 Posterior brachial cutaneous

Spinous process of T6

Greater trochanter

Achilles

Inferolater and ineromedial malleolus

Figure 9-3 The tertiary homeostatic acu-reflex points. A, Anterior view. B, Posterior view.

TABLE 9-4

Tertiary Homeostatic Acu-Reflex Points

Sequence

Name of Point

Frequency

%

51

Superior auricular

108

48.8

52

Acromioclavicular

108

48.8

53

Transverse cervical

108

48.8

54

Achilles

107

48.4

55

Upper biceps brachii

105

47.5

56

Inferolateral malleolus

104

47.1

57

Inferomedial malleolus

104

47.1

58

Intercostobrachial

102

46.2

59

Temporalis

102

46.2

60

Lateral cutaneous of T8

100

45.2

61

Spinous process of T3

95

43.0

62

Iliotibial—III*

93

42.1

63

Obturator

91

41.2

64

Spinous process of T6

83

37.6

65

Plantar

81

36.7

66

Ilioinguinal

79

35.8

67

Costal margin

78

35.3

68

Saphenous-III

76

34.4

69

Third metatarsal

73

33.0

70

Spinal accessory-III

72

32.6

71

Coronal suture

71

32.1

72

Pterion

71

32.1

73

Greater trochanter

70

31.7

74

Medial brachial cutaneous

69

31.2

75

Bregma

67

30.3

76

Common fibular (peroneal)

65

29.4

77

Posterior brachial cutaneous

63

28.5

78

Deltoid

63

28.5

79

Deep radial-III

61

27.7

80

Intermediate supraclavicular

61

27.7

*The suffix "III" denotes the tertiary homeostatic point at the particular site.

*The suffix "III" denotes the tertiary homeostatic point at the particular site.

Frontalis

Nasion Lacrimal Zygomaticofacial Depressor septi Mentalis Lateral supraclavicular Medial supraclavicular Sternal angle

Anterior cutaneous of T8 Anterior cutaneous of T10

Median - N

Rectus femoris Vastus medialis

Saphenous - N

Common fibular (peroneal) - N

Fifth metatarsal Great toe

Saphenous - N

Common fibular (peroneal) - N

Fifth metatarsal Great toe

Posterior auricular Occipital protuberance

Spinous process of T10 Lateral cutaneous of T10 Olecranon

Posterior cutaneous of S3 Posterior interosseous

Third proximal interphalangeal

Third distal interphalangeal

Medial sural

Peroneus brevis Heel

Figure 9-4 The nonspecific homeostatic acu-reflex points. A, Anterior view. B, Posterior view.

TABLE 9-5

Nonspecific Acu-Reflex Points*

Sequence

Name of Point

Frequency

%

81

Fifth metatarsal

60

27.1

82

Medial sural

58

26.2

83

Zygomaticofacial

55

24.9

84

Saphenous-N

51

23.1

85

Medial supraclavicular

48

21.7

86

Lateral supraclavicular

44

19.9

87

Common fibular (peroneal)-N

41

18.6

88

Fibular (peroneal) brevis

39

17.6

89

Sternal angle

37

16.7

90

Posterior auricular

35

15.8

91

Median-N

34

15.4

92

Depressor septi

32

14.5

93

Vastus medialis

28

12.7

94

Lateral cutaneous of T10

26

11.8

95

Nasion

24

10.9

96

Occipital protuberance

21

9.5

97

Rectus femoris

20

9.0

98

Frontalis

18

8.1

99

Spinous process of T10

17

7.6

100

Lacrimal

16

7.2

101

Mentalis

15

6.8

102

Posterior cutaneous of S3

14

6.3

103

Anterior cutaneous of T10

13

5.9

104

Great toe

12

5.4

105

Posterior interosseus

11

5.0

106

Third proximal interphalangeal

9

4.0

107

Anterior cutaneous of T8

8

3.6

108

Heel

7

3.2

109

Third distal interphalangeal

6

2.7

110

Olecranon

3

1.4

*The suffix "N" denotes the nonspecific homeostatic point at the particular site.

*The suffix "N" denotes the nonspecific homeostatic point at the particular site.

98 Frontalis

95 Nasion 100 Lacrimal 83 Zygomaticofacial 92 Depressor septi 101 Mentalis 86 Lateral supraclavicular 85 Medial clavicular 89 Sternal angle

107 Ant. cutaneous of T8 103 Ant. cutaneous of T 10

91 Median

97 Rectus femoris 93 Vastus medialis

84 Saphenous -N 87 Common peroneal - N 81 Fifth metatarsal

104 Great toe

9C Posterior auricular 96 Occipital protuberance

99 Spinous process of T 10 94 Lateral cutaneous of T10 110 Olecranon

102 Posterior cutaneous of S3

105 Posterior interosseous

106 Third proximal interphalangeal

106 Third distal interphalangeal

82 Medial sural 88 Peroneus brevis

108 Heel

Figure 9-5 As the acu-reflex points become more sensitized, the sensitized or sensitizing area of each acu-reflex point increases, and finally all the neighboring points become sensitized in a huge area (on the torso and face) or in a linear zone on the limbs. A, Anterior view. B, Posterior view.

Acupuncture Point

H4-1 Saphenous H4-2

Figure 9-6 Acu-reflex points for evaluation on the arm (A) and the leg (B).

H4-1 Saphenous H4-2

Figure 9-6 Acu-reflex points for evaluation on the arm (A) and the leg (B).

TABLE 9-6

ABCD Grouping with i6-Point Method

Group Classification

Number of Sensitive

Acu-Reflex Points

A

0-4

B

5-8

C

9-12

D

>13

TABLE 9-7 Pain Quantification and Prognosis

TABLE 9-7 Pain Quantification and Prognosis

Characteristic

GROUP

Number of passive acu-reflex points <24 24-50 51-80 >80 found in a patient

Percentage of patient 28% 34% 30% 8% population

Number of treatments 4-8 8-16 16-32 >32 required for pain relief

Time lapse before recurrence Years Months to years Weeks to months Days to weeks of the same pain

Modified from Dung HC: Anatomical acupuncture, San Antonio, Tex, 1997, Antarctic Press, p 226.

PREDICTION OF TREATMENT OUTCOME

Even the healing of pain that is confined to a small local area involves many body systems and is a very complicated process; the result will be related to personal medical history, genetic makeup, and social behavior. Correct treatment may produce two results—cure or relief—or it may fail. The same treatment for the same pathologic condition produces different results in different patients because of different levels of healing energy (health) and different genetic, historical, and behavioral situations. To achieve a more reliable prediction of treatment outcome, the author and colleagues focus on soft tissue pain. Most soft tissue pain, as discussed previously, is related to soft tissue dysfunction. From the author's clinical experience, acquired since the 1970s, it is clear that each group needs a different number of treatment sessions and will experience different durations of relief (Table 9-7).

References

1. Anderson D, et al: Dorland's Illustrated Medical Dictionary, ed 30, Philadelphia, 2003, Saunders.

1a. Melzack R, Stillwell DM, Fox EJ: Trigger points and acupuncture points for pain: correlations and implications, Pain 3:3-23, 1977.

2. Sola AE, Rodenberger ML, Gettys BB: Incidence of hypersensitive areas in posterior shoulder muscles; a survey of two hundered young adults, Am JPhys Med 34:585, 1955.

3. Dung HC: Anatomical features contributing to the formation of acupuncture points, Am J Acupunct 12:139, 1984.

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