Acupuncture Trigger Points

7/29/2019 Acupuncture Trigger Points

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Pain, 3 ( 1 97 7 ) 3 - - 2 3 E l sev i e r /Nor th -Ho l l and B iomed ica l P re ss

R e v i e w A rt ic le

T R I G G E R P O I N T S A N D A C U P U N C T U R E P O I N T S F O R PA I N :C O R R E L A T I O N S A N D I M P L I C A T I O N S

R O N A L D M E L Z A C K *, D O R O T H Y M . S T I L LW E L L a nd E L I S A B E T H J . F O X

Dep ar tme nt o f Psychology, McG il l Univers ity, andDe pa rtm ent of Medicine, Ro yal Victoria Hospital, Montreal , Que. (Canada)

(Accep t ed Ju ly 21s t , 1976 )

S U M M A R Y

Trigger points associated with myofascial and visceral pains often tie with-in the areas of referred pain but many are located at a distance from them.Furthermore, brief, intense stimulation of trigger points frequently producesprolonged relief of pain. These properties of trigger p o i n t s - their wide-spread distribution and the pain relief produced by stimulating them-resemble those of acupuncture points for the relief of pain. The purpose ofthis study was to dete rmine the correlation between trfLgger poin ts ar.d acu-puncture points for pain on the basis of two criteria: spatial distribution andthe associated pain pattern. A remarkably high degree (71%) of correspon-dence was found. This close con'elation suggests tha t trigger points a~ad acu-puncture pointsfor pain, though discovered independently and labeled dif-ferently, represent the same phenomenon and can be explained in terms ofthe same underlying neural mechanisms. The mechanisms that play a role inthe genesis of trigger points and possible underlying neural processes are dis-cussed.

I N T R O D U C T I O N

It is well known that short-acting, local anesthetic blocks of trigger pointsoften produce prolonged, sometimes permanent relief of some forms ofmyofascial or visceral pain [5,16,35]. Astonishingly, brief, intense stimula-tion of trigger points by dry needling [35], intense cold [35], injection of

Repr in t r eques t s t o P ro f . R . M e lzaek , Depa r tm en t o f Psycho logy, S t e , aa r t B io logyBui ld ing , McG i l l Ur.ivers ity, M ontrea l , Q ue . , Canada .


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n o r m a l s al in e [ 3 3 , 3 4 ] , o r t r a n s c u t a n e o u s e l e c tr i c al s t i m u l a t i o n [ 2 4 ] m a ya l s o ~ i m i n i s h o r a b o l i s h t h e s e p a i n s f o r d a y s , w e e k s , a n d s o m e t i m e s p e r m a -n e n t l y. T h e s e e f f e ct s o f i n t e n s e s t i m u l a t i o n , w h i c h h a v e b e e n l a b e le d a shyp,;rstimulation a~algesia[22], r e s e m b l e t h e e f f e c ts o f a c u p u n t u r e - - i nwhi,~h b r i e f , i n t ense pa in i s p ro du ced by rot a~ :ing the need le s man ua l ly o r

pas~ ing e lec tr i~ -d ~ i z e n t s t h r ou gh t h e m - on a~:'~hr itic , neu ra lg i c , and o th e rform0 o f chron ic pa in [5 ,12~.20] . Well -contro!]c~d s tu 'd ies [3 , 10 ,1 2 , 2 4] showtha t t hese p roce dures p ro du ce s ign i f i can t ly gr~ -~ater pa in r e l i e f t han p l aceb oc o n t r i b u t i o n s . I t i s a p p a re n L , t h e r e f o r e , t h a t ~ n te ns e s t i m u l a t i o n o f e i t h e rt r ig g e r p o i n t s o r a c u p u n c t u r e p o i n t s c a n p r o d u c e p r o l o n g e d r el i e f o f p a in .I n d e e d , F o x a n d M e l za c k [ 9 ] h a v e f o u n d t h a t a cu p un a- ~u re a n d t r a n s c u t a n e -ous e l ec t r i ca l s t imu la t ion a re equ a l ly e ff ec t ive ~n r e li ev ing ch ron ic low-b ackpa in .

The re i s ye t ano th e r s imila~Aty be tw een t r i gge r po in t s and acu pu nc tu rep o i n t s f o r p a i n : t h e y o f t e n l ie w i th i n t h e a r e as o f r e fe l r e d p a in , b u t m a n y a r e

l o c a t e d a t a d i s t a n ce f r o m t h e m . F u r t h e r m o r e , s o m e ~;rig ger p o i n t s a p p e a r t oc o i n c id e s p a t ia l l y w i t h a c u p u n c t u r e ~ p o i n t s , a n d b o t h k i n d s m a y b e a s so -c i a te d w i t h t h e s a m e p a i n p a t t e r n s . 1 h e p u r p o s e o f t h is s t u d y , th e r e f o r e , w a st o d e t e r m i n e t h e c o r r e l a t i o n b e t w e e n t r ig g e r p o i n t s d e s c ri b e d b y Tr a v el l a n dR i n z l e r [ 3 5 ] , K e n n a r d a n d H a u g e n [ 1 3 ] , S o l a a n d K u i t e r t [ 3 3 ] , S o la a n dWi l li am s [ 3 4 ] m ad a c u p u n c t u r e p o i n t s f o r p a i n [ 11 , 1 8 , 1 9 ] .

DISTRIBUTION OF TRIGGER POINTS

Tr i gg e r p o i n t s h a v e l o n g b e e n u s e d i n W e s t e r n m e d i c a l p r a c t ic e f o r t h ed i ag n o s is a n d t r e a t m e n t o f p a t h o l o g i c a l p a in [ 1 5 , 3 5 ] . A p p l i c a t i o n o f p r es -su re a t a t r i gge r po in t evoke s pa in a t t he po in t a s we l l a s r e f e r r ed p a in in

m yofa sc i a l o r v i sce ral s t ruc t l r e s . Trave ll and R inz le r [35 ] , i n a c l as si c s tud yo f m y o f a s c i a l p a i n , d e s c r i b t d a la rge n u m b e r o f s p a ti a l p a t t e r n s o f p a i nas soc ia t ed w i th t r igge r po in t~ (F igs . 1 - -4 ) . O the r po in t s have been fou nd byS o l a a n d K u i t e r t [ 3 3 ] a n n ~ o l a a n d Wi l li am s [ 3 4 ] ( F ig . 5 A ) , w h o e x a m i n e dm yofa sc i a l pa in a s soc ia t ed ,~ i~h the sho~ider, a rm and n eck . Ad d i t iona lpo in t s have been desc r ; ibed by Bon ica [5 ] , L iv ings ton [16 ] , Kraus [15 ] ando t h e r s .

Tr igge r po in t s a r e ~dso a s soc ia t ed wi th v i sce ra l s t ruc tu re s . M cB um ey ' spo in t i s a we l l known s i t e o f t ende rness i n acu te append ic i t i s , and gen t l ep res su re a t t h e p o in t t r i gger s l oca l pa in a s we l l as d i s t an t d i f fuse abdom ina l

~?::in | 1 ] . S imi l a r ly, p a t i en t s w i th ca rd i ac d isease f r eque n t ly deve lop r e fe r r edp a i n in t h a s h o u l d e r, c h e s t , a n d a r m [ 1 3 , 3 5 ] . E x a m i n a t i o n o f c a r d ia c p a -t i e n ts b y K e n n a r d a n d H a u g e n [ 1 3 ] r e v e al e d a c o m m o n p a t t e r n o f ~ rig ge rpo in t s (F ig . 5B) in t he sho u lde r and ches t . F re s su re on the t r i gge r po in t sgene ra l ly p roduces in t ense pa in wh ich somet imes pe r s i s t s fo r s eve ra l hour s . I tis i m p o r t a n t t o n o t e t ha ~ s u b j ec t s w h o d o n o t h a v e h e a r t d is e a se h a v e a n~ I m o s t i d e n t ic a l d i s t r i b u t i o n o f t ri g g er p o i n t s [ 1 3 ] . T h e a p p l i c a t i o n o fp res su re a t t he t r igge r po in t s i n t hese sub jec t s ~ ' ok es pa in wh ich l a s ts fo rsevera l m inu tes and m ay even increase in in :Lens'; ,ty for a few seco nds a f te rr em ova l o f ~he p re s su re .


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DISTRIBUTION OF ACU PUNCTURE POINTS

P e r h a p s t h e m o s t b a ff l in g f e a t u r e o f a c u p u n c t u r e m a p s , o n f ir s t e n c o u n t e r ,i s t h e p r o f u s i o n o f p o i n t s . S o m e d e g r ee of c la r i f ica t io n i s achiew.~d i f a par-t ic u l ar b o o k o n a c u p u n c t u r e is e x a m i n e donly f o r p o i n t s r e l e v a n t t o p a i n .We h a v e d o n e t h i s f o r K a o a n d K a o ' s [ 11 ] b o o k ,Acupuncture Therapeutics.W h e n t h e a c u p u n c t u r e p o i n t s a r e o rg a n i z ed o n t h e b a s is o f p a i n s y n d r o m e so r d i s c r e te s p a t i al l o c a t i o n s o f p a in , t h e n u m b e r o f r e l e v a n t a c u p u n c t u r ep o i n t s is r e l a t iv e l y s m a l l . A n e x a m i n a t i o n o f F i gs . 6 a n d 7 , d e ri v e d f r o m K a oa n d K a o ' s [ 11 ] b o o k , r e v e al s t h a t e a c h m a j o r p a i n s y n d r o m e o r p a i n f u lr e g io n is a s s o c i a t e d w i t h (a} a c u p u n c t u r e p o i n t s t h a t a r e a t o r n e a r t h e a c t u a ls i te o f pa in , a s we l l a s (b} mo re d i s t an t po in t s t ha t a r e s eeming ly un re l a t e d .

A s im i l a r a n a l y si s h a s b e e n c a r r i e d o u t w i t h t h e m a p s a n d b o o k p r e p a r e db y M a n n [ 1 8 , 1 9 ] . A l t h o u g h a m u l t i t u d e o f p o i n t s a r e d e s i g n a t ed s p e ci f ic a l lyf o r t h e r e l i e f o f p a r t i c u l a r p a i n s y n d r o m e s , o n l y a r e l at i ve l y s m a l l n u m b e r

o f p o i n t s i s g e n e r a l l y u s e d i n t h e a c t u a l d a y - t o - d a y p r a c t i c e o f a c u p u n c t u r efo r t he r e l i e f o f pa in (F igs . 8 and 9 ) . As in F igs . 6 and 7 , i t is ev id en t t h a tthe re a r e po in t s wh ich l ie w i th in o r nea r t he pa in fu l a r ea (F ig. 8~ , and o the r stha t l i e a t a d i s t ance f rom i t (F ig . 9 ) .

C O R R E S P O N D E N C E B E T W E E N A C U P U N C T U R E P O I N T S A N D T R I G G E R P O I N T S

I n o r d e r t o d e t e r m i n e t h e d e g r e e o f c o r r e s p o n d e n c e b e t w e e n t r ig g e r p o i n t sa n d a c u p u n c t u r e p o i n t s , e a c h t r ig g e r p o i n t o n t h c m a p s o f Tr a v e ll a n d R i n z-l e r [ 3 5 ] , S o l a a n d K u i t e r t [ 3 3 ] , S o l a a n d Wi l li am s [ 3 4 ] a n d K e n n a r d a n dH a u g e n [ 1 3 ] ( F ig s . 1 - - 5 ) w a s n u m b e r e d a n d a c u p u n c t u r e m ~ p s w e r e e x -a m i n e d t o s e e w h e t h e r t h e r e w a s a n e a r b y a c u p u n c t u r e p o i n t . B e c a u s e K a oa n d K a o [ 11 ] u s e d o n l y s e l e c t e d p o i n ts f o r t h e i r e x p o s i t i o n o f a c u p u n c t u r e ,t h e m o r e c o m p l e t e m a p s p r e p a r e d b y M a n n [ 1 8 ] w e r e u se d. D ~ e to o b v i ou sd i f f e re n c e s i n d r a w i n g s , o r e v e n a n a t o m i c a l v a r i a t i o n f ro m p e r s o n t o p e r s o n ,t h e p r o x i m i t y o f t h e p o i n t s t o p a r t ic u l a r m u s c l e g r o up s o r o t h e r a n a t o m i c a ll a n d m a r k s w a s s o u g h t . A d i f f e r e n c e o f 3 c m b e t w e e n t h e t w o s i te s s e e m e d t ob e a r e a s o n a b l e a l l o w a n c e f o r v a r i a t io n b a s e d o n d r a w i n g s o r a ( t u a l a n a t o m i -ca l va r i ab i l i t y. I f t he p o in t s sho we d go od co r r e sp ond enc e (w il~hin t he 3 cmc r it e ri o n } , t h e s i te w a s la b e l e d " p l u s " ( + ). A c u p u n c t u r e p o i n t s o u t s i d e t h e3 c m c r i t e r i o n w e r e l ab e l e d " m i n u s " ( - - ) . T h e n e x t s t e p w as t o f i n d t h e c li ni -

c al s y n d r o m e s , l i st e d in M a n n ' s [ 1 9 ] a n d K a o a n d K a o ' s [ l l J b o o k s , a ss o-c i a te d w i t h t h e a c u p u n c t u r e p o i n t s . I f t h e c l in i c al s y n d r o m e c o r r e s p o n d e dreasonab ly t o t ha t a s soc i a t ed w i th t he t r i gge r po in t , a "p lu . , , " (+ ) was r e -c o r d e d . L a c k o f c o r r e s p o n d e n c e w a s l a b el e d " m i n u s " ( -- ).

The r e su l t s o f t h i s ana lys i s (Tab le I ) , u s ing Trave l l and R inz l e r ' s po in t s ,i n d i c a te t h a t e v e r y t ri g g e r p o i n t h a s a c o r r e s p o n d i n g a c u p u n c t u r e p o i n t .Fu r th e rm or e , t he re is a c lo se co r r e sp Gn dence (64%} be twee r~ the pa in syn -d r o m e s a s s o c i a t e d w i t h t h e t w o k i n d s o f p o i n t s . A s i m i la r p r o c e d u r e w a sca r r i ed o u t u s ing th e t r i gge r po in t s d esc r ibed b y So la and h i s ,~o ll eagues , andb y K e n n a r d a n d H a u g e n ( Ta b l e I I ). T h e d e g r e e o f c o r r e s p o n d e n c e , in t e r m s


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H E A D A N D N E C K

S T E R N O M A S T O I D

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T E M P O R A L I S

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P O S T E R I O R C E RV I C A L

P #. ~N PA T T E R N ~ l TPIGGIER AR EA X

F i g. 1 . Tr i g g e r p oin t~ ; a s s o c i a t e d w i t h m y o f a s c i a l p a i n s y n d r o m e s o f t h e h e a d a n d n e c k .R e p r i n t e d : t o rn Tr a v el l a n d R i ~ zle r [ 3 5 ] . E a c h t r ig g e r p o i n t i s n u m b e r e d a n d t h e m a j o rnerve inne r ca t ion is, desc r ibed i~. Ta b le I .


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S H O U L D E R A N D ~:A RMI NFRASPINATUS

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FIRST INTEROSSEO'~JS

1 7

SUPRASPINATUS

D E L T O , D

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MIDDLE EXTENSORFINGER CARPI

EXTENSOR RADIALIS

1 4 , 1 5 , 1 6

SUPINATORS

| 8

ADDUGTOF POLLICUS

, ~ ; . . : . . : . .PAIN PATTERN E~ TRGGER AREA X

F i g . 2 . Tr i g g e r p o i n t s t ~ ss o c ia t ed w i t h m y o f a s c i a l p a i r s y n d r o m e s v f t h e s h o u l d e r a n d a r ~ .R e p r i n t e d f r o m Tr a v e ll an d R i n z l e r [ 3 5 ] . E a c h t r ig g e r p o i n t is I m m b e r e d a n d t h e m a j o rn e r v e i n n e r v a t i o n i s d e s c r i b e d i n Ta b l e I .


6/21

C H E S T A N D B A C K

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IL I O C O S TA L IS

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PA i N PAT T E R N i ._ _ ~ J T R IG G E R A R E A XF it.:. 3 . Tr i g g er p o i n t s a s s o c i a t e d v i t h m y o f a s c i a l p a i n s y n d r o m e s o f t h e c h e s t a n d b a c k .~ [ e p r in t e d f r o m Tr a v e ll a n d R i n z e r [ 3 5 ] . E a c h t r i gg e r p o i n t i s n u m b e r e d a n d t h e m a j o rn e r v e i n n e r v a t i o n i s d e s c r i b e d i n 2 a b l e I .


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TRIGGER AREA X

F i g . 4 . Tr i g g e r p o i n t s e ,~ s o c ia t ed w i t h m y o f a s c i a I p a i n s y n d r o : n e s o f t h e l o w e r e x t re m i: Ly.Re pr in t ed ~ ' r0m Trave l ] and R in z te r [3 5 ] . Each t r igge r po in t h n um ber ed an d L '.,~emaio~:n e r v e i n n e r v a t i o n i s d e s c r i b e d i n Ta b l e I .


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1 0

Tr igger Zones fo r :

Shou lder Pa in Shou lder and N ec k Pa inArm Pa in

A

Tr igger Zones in Card iac Pa t i en t s

B

'1 1

Fig. 5. Trigger points associated with (A) myofascial pain syndromes and (B) cardiac painsyndromes. The ~oints in A are de'ived from Sola and Kuitert [33] and Sola and Williams[34]. The points ~a B are reprintefl from Kennard and Haugen [13]. Each trigger point isnumbered and the major nerve and muscle innervation is described in Table II.

TABLE I

Left: the number of the trigger points described by Travell and Rinzler in Fig. 1, thenerve innervation of the points, and the associated clinical syndrome(s}. Right: the acu-puncture point that coincides wittl the trigger point and the associated clinical pain syn-drome(s) designated for the acupuncture point by Mann [19] andKao andKao [11]. Theplus signs (++) indicating correspondence are shown under the Clinical Syndrome columnat the right. Tke first plus sign indicates coincident or adjacent trigger and acupuncturepoints; the second indicates correspondence of clinical syndromes. A minus (--) signdenotes lack of correspondence. Abbreviations of the acupuncture points: see Fig. 6.

Point Trigger pointsr i o .

Nerve innervationof trigger point

Clinical syndrome

Acupuncture points

Nearest Clinical syndromeacup. pnt.

1. Accessory N. (XI)

2. Dorsal Brs. C2--8

~, L ::~'3!1i~; myalgia Li 18of neck muscles;head and facial pains.Cervical disc disease; T] 6degenerative arthriti sof cervical spine;

kaeadaches.

Orbital neuralgia;hip pain. (++)

Headache; eye pain;shoulder, back andarm pain; stiff neck.

(++)


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TA B L E I . ( c o n t i n u e d . )

11

P o i n t Tr i g g e r p o i n t sr i o .

N e r v e i n n e r v a t i o no f t r i g g e r p o i n t

C l i n i c a l s y n d r o m e

A ~ u p u n c t u r e p o i n t s

N e a r e s t C l i n ic a l s y n d r o m eacup . ~ '~ t .

3 . T r i g e m i n a l N .

(V, Br. 3 )

4 . Tr i g e m i n a l N .( V, B r . 3 )

.

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1 1 .

1 2 .

1 3 .

1 4 .

1 5 .

1 6 ,

A c c e s s o r y N . ( X I )a n d b r a n c h e s o fC 3 - - 4

A c c e s s o r y N . ( X I )a n d b r a n c h e s o fC 3 - - 4C 3 - - 5

C I - - T I

S u p r a s c a p u l a r N .

S u p r a s c a p u l a r N .

C 4 - - 8 ( v i a c e r v ic a lp l e x u s )C 5 " 6 : ( v i a b r a c h i a lp l e x u s ) ; A x i l l a r y N .S u b s e a p u l a r N .

( C 5 - - 6 v i a b r a c h i a lp l e x u s )R a d i a l N .

R a d i a l N .

R a d i a l N .

M i g r a i n e ; m y a l g i a . X H 3

F a c i a l m y a l g i a ; S 7t o o t h a c h e ; h e a d a c h e ;t e m p o r o - m a n d i b u l a rj o i n t p a i n .S h o u l d e r , a r m a n d G 2 1n e c k p a i n ; h e a d a c h e ;s t i f f n e c k .

S h o u l d e r , a r m a n d n e c k B 3 7p a i n ; h e a d a c h e ; i n t r a -s c a p u l a r p a i n .M y a l g i a i n s h o u l d e r ~ l i l4r e g i o n .

D e g e n e r a t i v ed i seases o f ce rv ica ls p i n e .

M u s c u l o s k e l e t a l d i s ea s e s

o f t h e s h o u l d e r.

M u s c u l o s k e l e t a l d i s ea s e so f s h o u l d e r.

P a i n i n n e c k a n d s h o u l -d e r.S h o u l d e r p a in .

M u s c u l o s k e l e t a l d i s e a s es

o f s h o u l d e r.

E x t e n s o r t e n d o n i t i s o ff o r e a r m ; t e n n i s e l b o wp a i n .E x t e n s o r t e n d o n i t i s o ff o r e a r m ; t e n n i s e l b o wp a i n .E x t e n s o r t e n d o n i t i s o ff o r e a r m ; t e n n i s e l b o wp a i n .

3 1 0

i~i13

r15

L i l 7

L 2

H 1

T 9

T 9

L i 11

H e a d a c h e ; t r i g e m -ina! [ neura lg ia ; too th -a c h e ; e y e p a i n ( + + )F a c i a l n e u r a l g i a o rs p a s m ; h e a d a c h e ;o r b i t a l n e u r a l g ia ;e y e p a i n . ( + + )S t i f f n e c k ; s h o u l d e ra n d b a c k p a i n ;r h e u m a t i s m ; a r mp a i n . ( + + )

A c u t e p a i n o fs h o u l d e r s . ( + + )

M u s c u l a r p a i n ;n e u r a l g i a a n d s p a s mo f s h o u l d e r a n d a r m ;s p a s m o f n e c km u s c l e s . ( + + )Brach ia l neura lg~a ;n e c k s p a s m ; t o r t i -c o l l i s ; w r i t e r ' sc r a m p . ( + + )N e u r a l g i a a n d

n u m b v, es s o f t h es h o u l d e r a n d a rm .(++)P a i n o f s h o u l d e r ;b a c k , a r m , e l b G w,n e c k , c l a v i c i e ;s t i f f n e c k . ( + + )T h r o a t p a i n . ( + - - )

N e u r a l g i a o t s h e a l -d e r ; c h e s t p a i P. ( + + )Pain ia che.~t and

r i b s ; c a r d i a c p a i n .(+-)P a i n i l l f o r e a r ma ~ t d e l b o w j o i n t ;t c o t h a c h e . ( + +)[~ in in fo rea r ma u d e l b o w j o i n t;t o o t h a c h e . ( + + )B r a c h i a l o r i n t e r -c o s t a l n e u r a l g i a ;t o r t i c o l ! i s ; e l b o wp a i n s ; p a i n i n f r o n to f e a r. ( + + )


10/21

12

TA B L E I ( c o n t i n u e d )

Po in t Tr ig ge r po in t sn o .

N e r v e i n n e r v a t i o no f t r i gge r po in t

C l in i c a l synd rome

A c u p u n c t u r e p o i n ts

N e a r e s t C l i n ic a l s y n d r o m ea c u p . p n t .

17 . U lna r N . (C8 , v i~ Te nd in ous s t r a i n i nb r a c h i a l p l e x u s ) h a n d .

18 . U lna r N . (C8 , v i a Sp r a i n o f t hu mb .b rac h i a l p l exus )

19 . An te r i o r t ho rac i c N . S t e rn oc l av i cu l a r

(C5- -T 1 , v i a b r a ch i a l a r t h r i t i s .p l e x u s )

20 . An te r i o r t ho rac i c N . S t r a in o f pec to r a l i s( C5- -6 , v i a b r ach i a l ma j o r.p l e x u s )

21 . Long t ho rac i c N . Co s t a l ve r t eb r a l(C5- -7 , v i a b r ach i a l sp r a i n ; s capu l a rp l exus ) f r a c t u r e s .

22 . C 3 - -4 ( ? ) Ch es t pa in ; shou lde ra n d a r m p a i n .

23 . L1 Low ba ck pa in ;mya lg i a o f t he l onge x t e n s o r s o f t h e b a c k .

24 . Su p e r io r g lu t ea l N .(L~--Sl)

2r~. L1

26.

27 .

),8.

29.

T8 - -T9 (do r sa l b r s . )

TS- -T9 (do r sa l b r s . )

C3 - -5 (do r sa l k r s . )

C3 - -5 (do r sa l h r s . )

L u m b o s a c r a l s t r a in .

L o w b a c k p a i n ;m y a l g i a o f l o n g e x t e n -

so r s o f b ack .L o w b a c k y a i n ;m y a l g i a o f l o n g e x t e n -so r s o f back .D o r s o - l u m b a r p a i n .

Myalgia of long e:~. ten-s o r s o f b a c k ; p a r a u m b i l -ica i pa in .

Mya lg i a o f l ong ex -t enso r s c ,f b ack ; p a r a -umb i l i c a l pa in .

L i 4 H e a d a c h e ; m i g r a i n e ;n e u r a l g i a o f s c a p u l a,b a c k a n d r e n a la r e a s; t o o t h a c h e ;s o r e t h r o a t ( + - - )

L i 4 H e a d a c h e ; m i g r a i n e ;n e u r a l g i a o f s c a p u l a,b a c k a n d r e n a la r e a s; t o o t h a c h e ;s o r e t h r o a t . ( + - - )

$15 Ches t , r i b s and

l im b s " h e a v y " ;i n t e r cos t a l neu ra lg i a .(++)

Sp19 Ches t , r i b s andl im b s " h e a v y " ;d i f f i cu l t y i n l y ingd o w n o r tu r n in g .(++)

S p l 7 C h e s t , r ib s a n dl i m b s " h e a v y " ;d i a p h r a g m a t i cpa in . (++)

C~ 19 Ches t and b r ea s tpa in ; c a rd i ac pa in .(++)

B 4 4 R h e u m a t i s m ; i n te r -cos t a l neu ra lg i a ;a b d o m i n a l d i s c o m -fo r t . (+ - - )

B48 Pa in and s t i f fne s si n b a c k a n d r e n a la rea; , pa in in lowe ra b d o m e n . ( + + )

B47 Pa in and s t i f fne s so f b a c k . ( + + )

B 19

B 18

B25

B 22

Pa in i n l ow er r i b s ;eye pa in . (+ - - )

I n t e r c o s t a l n e u r a lg i a ;eye pa in . (+ - - )I. u m b a r m u s c l es p a s m ; p a i n a r o u n dumbi l i cu s ; i n t e s t i na lpa in . (++)S t i f f v e r t e b r a lc o l u m n ; t i g h t e n i n gi n b a c k a n d s h o u l d e r ;pa in in lo ins . (++)


11/21

13

TABLE I (continued)

Pointn o .

Trigger points

Nerve innervationof trigger point

Clinical syndrome

Ac apuncture points

Nearest Clinical syndromeacvp. pnt.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

Superior gluteal N.(L4--S1 via lumbo-sacral plexus).

Superior gluteal N.(L4--S1 via lumbo-sacral plexus).

Obdurator N.(L 2, 3, via lumbo-sacral plexus).Obdurator N.(L2--3, via lumbo-

sacralplexUs)::Femoral N, (L2--4via lUmbosacralplexus) :Tibial N. (L5--$2 vialumbosacral plexus)

Tibial N. (L5--$2 vialumbosacral plexus)

Tibial N. (81--2, vialumbosacral plexus)

Tibial N. ($1--2, vialumbosacral plexus)

Anterior tibial N.(L4~ 5: via !umbo-sacral plexus )

Common peroneal N.(L4--S1, via lumbo-sacral plexus )Common peroneal N.(L4--$1, via lumbo-sacral plexus)

Diseases of the hipjoint; degenerativeconditions of lumbarspine.Diseases of the hipjoint; degenerativeconditions of lumbarspine.

B49 Lum bar and sacralpain; sciatica. (++)

G3O

Strain of adduc tor Li~ 11muscles; degenerativc,diseases of the hip.Strain of adductor Livl 0muscles; degenera-tive diseases of the hi p.Diseases of the knee Sp 10joint; injury to qua-driceps.Diseases of the knee B51joint; myalgia of theposterior thigh.Tendon and muscle K5strains of the lower leg;periostitis of the calca-neus.Tendon and muscle K: 0strains of the lower leg;periostitis of calcaneus.

Disease of metatarso- K'2phalangeal joint of thebig toe.Strain of dorsiflexors S~;6of foot; ankle sprain.

Strain of toe extensors. S37

Foot strain. G40

Pain in buttocks ;sciatica; pain inloins, spine andthighs; rheumatism;pain in knee, painin hip joint. (++)No pain syndromes.(+-)

N o painsyndromes. (+--)

Pain along thigh.(++)

Pain in back andloin; sciatica. (+--)

Pain in loins andback. (+--)

Knee and thighpain; genital painduring micturition;abdominal pain. (+--)Chest pain; sharpstomach pain; legand foot pain. (++)Weak limbs; ab-dominal pain. (+--)

Arthritis of knee;pain on dorsifiexionof foot. (+--)Pain in heels; painin lower limbs;pain in chest andribs; pain in buttocks.pain in lower abdo-men; sciatica; mus-cular spasms. (++)

42. Common peroneal N.(L4--S1, via lumbo-sacral plexus )

Strain of foo t evertors; C34ankle sprain.

Knee pain; pain inribs; lumbago;sciatica. (+--)


12/21

14.

TABLE II

Left: the number of the trigger point s described by Sola, Kuiter t and Williams (A) and byKennard and Haugen (B) in Fig. 2, the muscle (M) and nerve (N) innervation of thepoints, and the associated clinical syndrome(s). Ri~ht: the acupuncture point that coin,cides with the trigger point and the associat ed clit~ical pain syndrome(s) designated for

the ~cupuncture point by Mann [19] and Kao and Kao [11]. The plus signs (++) indi-ca~;in.~ corr espondenc e are shown unde r the Clinical Synd rome column at the right. Thefirst ~lus sign indicates coincident or adjacent trigger and acupuncture points; the secondini, ;~tes corr espondence of clinical syndromes. A m~.nus ( -- ) sign deno tes la ck of corre-spondence. Abbreviations of the a cupunc ture points: see Fig. 6.

Point Trigger pointsn o .

Acupuncture points

Muscle and nerve Clinical Nearestinnervation of trigger syn dro ~e acup.point point

Clinical syndrome

A1

A2

A3

A4

A5

A6

B1

B2

B3

B4

B5

M: Uppe r trapez':.us Shoulder pain G21N: Spinal accessory

(XI) and hrs. fromC3--4

M: Levator scapula Neck pain Si l4N: C3--4 and dorsal shoulder pa:n

scapu!arM: Supra.~pinatus Shoulder pain Si l0N: Suprascapular

M: Rhomboi d major Shoulder pain B40N: Dorsal scapul ar

M: Infraspinatus Shoulder pain S il lN: Suprascapul ar shoulde r andarm pain

M: Teres minor Shoulde r pain Si9N: Axillary

M: Pector~li~ ~. ajor Card iac S13(clavicular b. ead) synd rom es

N: Lateral pectoral(C5-- 7 ~,

M: Pectorali~ major Cardiac K24(sternal head) syndromes

N: Medial pectoral, C 8 - - T I )

M: Pectoralis major Cardiac K23(sterna l head) ~yndromes

N: Medial pectoral(C8--T1)

M: Pectoralis major Cardiac G22(both heads) syndromes

N: Pectoral nerves(C5--T1)

M: Trapeziu s Cardiac T15N: Accessory syndromes (G 2I)

(cranial XI)

Shoulder, back, andarm pain; rheumatism;stiff neck. (++)

Spasm and muscle painof neck; neuralgia ofshoulder and arm. (++)Muscle pain; arthritisor swelling of shoulderand scapular area. (++)Brachial and intercostalneuralgia; spasm of bac k(+)

Neuralgia in scapulaor forearm. (++)

Arthritis and pain ofupper limb and scapula.(++)Chest, ribs, limbs"heavy"; spasm of dia-phragm. (++)

Pain in chest and dia-phragm; effort anginasyndrome; neuralgia offorearm. (++)Angina pectoris. (++)

Intercostal neuralgia.(+-)

Shoulder, back and armpain; rheuma tism; stiffneck. (++)


13/21

(Table I c o n t i n u e d )

15

Poin t Tr igger poin tsr i o .

A c u p u n c t u r e p o i n ts

Muscle and nerve Cl in ica l Neare s ti n n e r v a ti o n o f t r i g g e r s y n d r o m e a cU p.po in t po in t

C l in i ca l synd rom e

B 6 Card i ac S i l 0s y n d r o m e s ( S i l 1 )

Muscular pa in in shoulderand scap ula ; neura lg ia inscapu la and fo rea rm. (++)

Deeper t i s sues :M: Leva to r s capulaeN: C3- -4 and do r sa l

s capu la r C5M: Trapez iu sN: Acces so ry (XI )Deeper t i s sues :M: In f r a sp ina tu sN: Sup ra scapu la r

(C5- -6 )M: Trapez iu sN: Acces so ry (XI )Deeper t i s sues :M : R h o m b o i d m a j o rN: Dorsa l scapular

(C5)M: Trapez iu sN: Acces so ry (XI )Deeper t i s sues :M : R h o m b o i d m a j o rN: Dorsa l scapular

(C5)

B7 Cardiac B15 Cardiac pa in . (++)s y n d r o m e s

] ]8 Card iac B16 Cardiac pa in . (++)s y n d r o m e s

of myo fasc i a l pa in o r pa in in t he r e fe r r ed a rea o r d i seased vi scus was 100%a n d 8 8 % r e s p e c t i v e l y fo r S o l a a n d K e n n a r d a n d H a u g e n . T h e o v e r a ll co r r e-spondence fo r a l l 3 sou rces i s 71%.

I M P L I CA T I O N S O F T H E C O R R E L A T I O N

T h e c l o s e c o r r e l a t io n b e t w e e n t ri g g e r p o i n t s a n d a c u p u n c t u r e p o i n t s f o rpa in i s r em arka b le s ince the d i s t r i bu t ions o f bo th typ es o f po in t ,s a r e h i s to r i -

c a l ly d e r iv e d f r o m s u c h d i f f e r e n t c o n c e p t s o f m e d i c i n e . Tr ig g e r p o i n t s a r ef i r m l y a n c h o r e d i n t h e m l a t o m y o f t h e n e u r a l a n d m u s c u l a r s y s t e m s , w h i lea c u p u n c t u r e p o i n t s a r e a s s o c i a t e d w i t h a n a n c i e n t c o n c e p t u a l b u t a n a t o m i -c a l ly n o n - e x i s t e n t s y s t e m o f m e r i d i a n s w h i c h c a r r y Yi n ( sp ir it;s ) a n d Y a ~(b lood) . Desp i t e t he d i f f e ren t o r ig ins , however, i t i s r ea sonabJe to a s sumet h a t a c u p u n c t u r e p o i n t s f o r p a i n r e l ie f , li k e tr i g g er p o i n t s , a : : e d e r i v ed f r o mt h e s a m e k i n d o f e m p i ri c a l o b s e r v a t i o n : t h a t p r e s s u r e a t c e r t a in p o i n t s i sa s s o c ia t e d w i t h p a r t i c u l a r p a i n p a t t e r n s , a n d b r i e f, in t e n s e s t i m u l a t i o n o f t h ep o i n t s b y n e e d l i n g s o m e t i m e s p r o d u c e s p r o l o n g e d r e l i e f o f p a i n . T he ~;ec o n s i d e r a t i o n s s u g g e s t a h y p o t h e s i s : t h a t t r i g g e r p o i n t s a n d a c u p u n c t u r e


14/21

16

p o i n t s f o r p a i n , t h o u g h d i s c o v e r e d i n d e p e n d e n t l y a n d l a b e l e d d i f f e r e n t l y,r e p re s e n t th e s a m e p h e n o m e n o n .

P r e s s u re o r n e e d l i n g a t e i t h e r t ri g g er o r a c u p u n c t u r e p o i n t s f o r p a i np r o d u c e s a d e e p a c h i n g f e e l i n g , w h i c h i s a s s u m e d i n We s t e r n m e d i c i n e t ob e t h e r e s u l t o f s t i m u l a t i o n o f a n u n d e r l y i n g f o c al i ze d p a t h o l o g i c a l p ro -c es s [ 1 3 , 1 5 ] w h i l e i n a c u p u n c t u r e i t is n a m e dtech'i a n d i s a s s u m e d t or e p r e s e n t a p r o p e r t y o f t h e m e r i d ia n s y s t e m [ 1 9 ] . R e c e n t e v i d en c e [2 ]sugges*~ that tech'i m a y b e d u e , a t le a s t i n p a r t , t o a lo c a l m u s c l e r e fl e x t h a tg r ip s t h e a c u p u n c t u r e n e e d l e w h e n i t p e n e t r a t e s t h e m u s c l e b e l o w a n a c u -p u n c t u r e p o i n t . W h y t h is d e e p a c h in g fe e l in g is f e l t a t s o m e m u s c l e s it es a n dn o t o t h e r s is , h o w e v e r, n o t e n t i r e l y e x p l a i n e d . I t is m o r e l ik e l y t h a t , in a dd i -t i o n t o l o c a l m u s c l e r e fl e x e s , th e r e i s a n u n d e r l y i n g p a t h o l o g i c a l p r o c e ss t h a tis t h e b a s i s o f t h e u n p l e a s a n t f e el in g p r o d u c e d b y p r e s s u r e o r n e e d li n g .

T h e n a t u r e o f t h i s f o c a l i z e d s u b c u t a n e o u s p a t h o l o g i c a l p r o c e s s is s ti ll n o tf l f l l y u n d e r s t o o d . T h e m y o f a s c i a l t r i g g e r p o i n t s , p a r t i c u l a r l y t h o s e f o u n d i n

t h e l o w e r r eg i o n s o f t h e b a c k , a r e s o m e t i m e s a s s o c i a te d w i t h d e f i n i t e n o d u l e so f f i b r o u s t is s u e. K e n n a r d a n d H a u g e n [ 1 3 ] h a v e r e v i e w e d e v i d e n c e t h a tt h e s e n o d u l e s m a y d e v e l o p a f t e r v i ru s i n f e c t i o n s a n d o t h e r f e v e r - p r o d u c i n gd i se a se s . C o p e m a n a n d A c k e r m a n [ 7 ] b e l ie v e t h a t t r i gg e r p o i n t s r e s u l t f r o mf e b r i l e d i s e a s e p r o c e s s e s w h i c h p r o d u c e a b n o r m a l f i b r o u s n o d u l e s t h a t r e -m a i n f o r y e a r s . K o r r e t a h [ 1 4 ] p r o p o s e a n a l t e rn a t i v e h y p o t h e s i s : t h e ys u g g es t t h a t t ri g ge r p o i n t s d e v e l o p d u r i n g t h e c o u r s e o f g r o w t h a s a r e s u l t o fmuscu lo - ske l e t a l s t r e s se s and s t r a in s , pa r t i cu l a r ly a s soc i a t ed w i th t he musc l e so f t h e b a c k . T h e s e t r ig g e r a r e a s, t h e y o b s e r v e d , ar e c h a r a c t e r i z e d b y a b -n o r m a l v a s o m o t o r a n d s t , d o m o t o r a c ti v it y. I t is a p p a r e n t f r o m K e n n a r d a n dH a u g e n ' s s t u d y t h a t t r i g g e r z o n e s a t t h e c h e s t a n d b a c k a r e r a r e i n i n f a n t sa n d c o m m o n i n a d u l ts , ~^ hic h m a y b e a t t r i b u t a b l e t o i n f l a m m a t i o n o f t is s ue sas a r e su l t o f d i s ease o r 1;o s t r a in s on the mu scu lo - s ke l e t a l sy s t em . The wide -s p r e a d d i s t r i b u t i o n o f t r i g ge r p o i n t s a s s o c i a t ed w i t h r e f e r r e d p a i n p a t t e r n ssuggest:~ t ha t bo th mecha :a i sms m ay p l ay a ro l e .

I t i s a l so poss ib l e , a s Kenna rd and Haugen have sugges t ed , t ha t t he a r ea s a twh ich b lood vesse ls and ne rves l ie c lo se t o t he su r f ace , r a th e r t ha n h idde nu n d e r m u s c l e s a n d o t h e r t is s u es , ar e p a r t i c u l a r l y s u s c e p t i b le s it e s f o r t h efom~a t ion o f t r i gge r po in t s . F ina l ly, t he re i s ev idence tha t s i t e s o f ea r l i e rin ju ry o r d i s ease ma y b ec om e t r i gge r po in ts " i n ju red t i s sues , l ong a f t e r t o t a lhea l ing and pa in r e l i e f, m ay neve r the l e s s b eco m e ac tive t r i gge r po in t s i n

o t h e r p a i n p a t t e r n s l o n g a f t e rw a r d s [ 5 , 6 , 1 6 , 2 8 , 3 5 ] . T h e g e n es i s o f t ri g g erpo in t s , t hen , is s ti ll l a rge ly unexp la ined , bu t i t is c l ea r t ha t t he y a r e com-m on ly foun d . I t is f u rther " ev id en t t ha t m os t t r i gge r po in t s { such a s t hose d ueto mu scu lo - sk e l e t a l s t re s se s and s t ra in s} w ou ld be re l a t i ve ly i nva r i an t f romp e r s o n t o p e r s o n , w h i l e ~ s m i l e r n u m b e r ( s u c h a s l~ ho se d u e t o e a r li e r i n ju -r ie s) w o u l d v a ~ c o u s i d e r a b ly.

i t i s r ea son ab le t o a s.~ume tha t t r igge r po in t s , wh e the r t h ey a r e f i b rousn o d u l e s o r s i m p l y a r ea s o f a b n o r m a l p h y s i o l o g i c a l a c t i v it y, p r o d u c e a c o n -t inuou- , l~w- leve l input ; in to i ;he cent ra l nervous sys tem. Diseased v iscera ,th en ~ m a y p r o d u c e a n i .l p u t w h i c h s u m m a t e s w i t h t h e i n p u t f r o m tr ig g e r


15/21

1 7

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!

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F i g . 13. A c u p u n c t u r e p o i n t s a s s o c i a t e d w i t h h e a d a n d n e c k p a i n , u p p e r l i m b p a i n , a n dl o w e r l i m b p a in . R e p r i n te d , w i t h m o d i f i c a t i o n s , f r o m K a o a n d K a o [ 1 1 ] . T h e a c u p u n c -t u r e p o i n t s f o r e a c h s y n d r o m e a r e : H ead and neck pain: f r o n t a l h e a d a c h e , 1 - G v 2 3 , 2 - $ 8 ,3 - L i 4 ; v e r t e x h e a d a c h e , 1 - G v 2 0 , 2 - B 6 0 ; o c c i p i t a l h e a d a c h e , ! - G 2 0 , 2 - S i 3 ; m i g r a i n e , 1 -t 'a iy a n g , 2 - T 5 ; t o o t h a c h e , 1 -$ 7 0 2 - $ 6 , 3 - L i 4 , 4 - $ 4 4 ; t r i g e m i n a l n e u r a l gi a , 1 - $ 4 , 2 - $ 6 ; n e c k

p a i n , 1 - $ 6 . Upper limb pain: e l b o w, l - L 5 , 2 - B 3 , 3 -L i l l, 4 - T 4 , 5 - L i 4 , 6 - T 1 0 ; lo w e r a r m ,l - H 5 ; w r i st , 1 - L i 5 , 2 - L i 4 .L ower ,!imb pain: t h i g h p a i n , 1 - S p l 0 ; k n e e j o i n t , 1 - G 3 4 , 2 - $ 3 4 ,3 - $ 3 5 , 4 - S p 9 ; a n k l e , 1 - S p 6 ; 2 - B 6 0 . A b b r e v i a t i o n s o f t h e a c u p u n c t u r e p o i n t s : B = b l a d d e r;C v = c o n c e p t i o n v e s s e l ; G = g a ll b l a d d e r ; G v = g o v e r n i n g v e s s e l ; H = h e a r t ; K = k i d n e y ;L = l u n g ; L i = l a rge i n t e s t i n e ; L i v = l iv e r ; P = p e r i c a r d i u m ; S = s t o m a c h ; S i = s m a l l i n t e s -t i n e ; S p = s p l e e n ; T = t ri p le w a r m e r ; X H = n o n - m e r i d i a l p o i n t .

poin ts to produce pa in re fer red to the la rger sk in a reas which sur round thet r igger po in ts . Con verse ly, s t imu la t ion of the t r igger poin ts may ev okevo l l eys o f impu l se s t ha t summate w i th l ow- l eve l i npu t s f rom the d i seased

viscera l s t ruc ture , w hich wo uld prod uce pa in tha t i s fe l t in bo th a reas. S imi-la r m echan i sms m ay ac cou n t fo r myofasc i a l pa in a s soc ia t ed w i th t ri gge rp o i n ts . A b n o r m a l i n p u t f r o m m u s c l e s, t e n d o n s o r j o i n t s - d u e t o s p ra in ,s tr a in , e x c e s s i v e s t r e t c h i nj u ry, o r o t h e r u n u s u a l a c t i v i t y - m a y s u m m a t ewi th ac t iv i ty f ro m t r igger poin ts and produ ce the pa in pa t te rns show n inFigs . 1 - -5 . The pa in prevents normal muscular and propr iocept ive ac t iv i ty sotha t t he abnorma l sumIaa t ion o f t he two inpu t s i s ma in t a ined . When thepa in i s b locked , even b r i e f ly, no rma l p rop r iocep t ive i npu t s may p reven tsum ma t ion and d i s rup t t he ab norma l pa in cyc l e b e tween inpu t s f rom thet r igger poin t and those f rom muscles , fasc ia , and propr iocept ive processes .


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T h e s e p h e n o m e n a o f r e fe r r ed p a in , th e n , p o i n t t o s u m m a t i o n m e c h a n i s m sw h i c h c a n b e u n d e r s ~ oo d i n te r m s o f th e g a te c o n t r o l t h e o r y [ 2 5 ] .

Tw o t y p e s ,~ f ~ e c h a n i s m m a y p l a y a r o l e . T h e f ir s t i n v o l v e s ~ h e s p r e a d o f

SHO ULDE R, BA CI < ~,',,' CHFSGFPA I N

Shoulder Jo i r l t Lumbar

S h o u l d e r - B a c k

L 2 : '- o l I

LumbarIA c c e s s o r ~ , P o i n t s )

( I - . C h e s t o r . , bHip-joint

J / 4 " .. , .,~ /

/ ' . " "~

A B D O M IN A L PA I N

C h e s tor Rib

?(

U p p e rA b d o m e n

T12: ,~ 1

L o w e r A b d o m e n

(

Fig. 7 . Acu pun cture points associa ted with shou lder, back and chest pain , and abdominalpain . Reprinted, wi th modiJ 'ica tions , f rom Kao and Kao [ t l ] . The acupu ncture points foreach syndrome are:Shou l de r, ba c k an d ch es t p a in :shoulder jo int pain , 1-Li15, 2-T14;should er bac k pain, 1-G21, 2-B12, 3-B43 ;hip joint ~ain, 1-G30; lum bar pain, 1-B23, 2-Gv3,3-B54, (accessory points) 4-Gv9, 5-Gv4, 6-Gv25, 7-B57, 8-K3; chest or rib pain, 1-YAvl4,2-T5, 3-G34, 4-B17, 5.B18, 6-Sp6, 7-Liv3.A b d o m i n a l p a i n : upper abdomen, 1-B21,2-$36, 3-Li4, 4-Sp4; pain arou nd navel, 1-$25; IGwer abd om en, 1-Cv4, 2-Sp6. Abbrevia-tions: see Fig. 6.

2

/ / 3

\


17/21

Pain Dis t r ibu

19

L~4

N e c k pain

- S h o u l d e r pa

E l b o w pair

L o w b a c k p c

pain

Knee pain

" Leg poin

S~l II ; I IT B 6 2

Fig. 8. Basic acupuncture points for pain syndromes which lie on or adjacent to the siteof pain. Based on Mann [18,19]. Abbreviations: see Fig. 6.

2

in Dis t r ibu t ion ~ \

minal neuralgia

,dominal painc

iysmenotrhea

Hq

.Toothache 1

B62

) w b a c k p a i n ~ - - ' - ' - ' - ' - - ~ _

Fig. 9. Basic acu punc ture points for pain syndr omes which are distant fro m the site ofpain. Based on Mann [18,19]. Abbreviations: see Fig. 6.


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pa in t o ad j acen t bod y a reas . Transm is s ion ce l ls i n t he do r sa l ho r ns hav e r e -s t r i c t e d r e c e p t i v e f i e l d s w h i c h d o m i n a t e t h e i r n o r m a l a c t i v i t i e s ; i n a d d i t i o n ,h o w e v e r, e a c h c e ll is a ls o a f f e c t e d b y e l e ct r ic a l s t i m u l a t i o n o f a f f e r e n t h e x e st h a t c o v e r a m u c h l a rg e r b o d y s u r f a c e [ 2 6 ] . M e l z a c k a n d Wa ll [ 2 5 ] s u g g e stt h a t t h is d i f f u s e i n p u t i s n o r m a l l y i n h i b i t e d , b u t m a y t r i g g er f i ri n g i n t h et r ansmis s ion ce ll s i f t he i n pu t i s su ff i c i en t ly i n t ense . A nes the s i a o f t he a r eat o w h i c h t h e p a i n h a s s p r e a d , w h i c h b l o c k s t h e ~ p o n t a n e o u s i m p u l s e s f r o mt h e a r e a , is s u f f i c i e n t t o r e d u c e t h e b o m b a r d m e n t o f t h e ce ll b e l o w t h et h r e s h o l d l ev e l f o r p a i n . T h e r e c e n t d i s c o v er y [ 2 9 , 3 1 ] t h a t s m a l l v i sc e ra la f f e r e n ts p r o j e c t d i r e c t ly o r i n d i r e c t l y o n t o l a m i n a 5 c el ls p r o v i d e s f u r t h e ri m p o r t a n t e v i d e n c e t o e x p l a i n r e f e r r e d p a i n . B e c a u s e la m i n a 5 c el ls r e ce i v e ac o n v e rg e n c e o f s o m a t i c a n d v i s ce r a l a f f e r en t s [ 2 9 , 3 1 ] , t h e y a r e g o o d c an d i -da t e s fo r exp la in ing som e k ind s o f r e f e r r ed pa in a s we ll a s pa in o f d i r ec tc u t a n e o u s o r i g i n [ 2 5 ] .

T h e s e c o n d m e c h a n i s m t o e x p l a i n r e f e r r e d p a in i n v o lv e s t h e s p r e a d o f p a in

and t r i gge r zones t o r eg ions a t a cons ide rab l e d i s t ance , and m ay inc ludev i sce ra l s t ruc tu re s a s we l l a s cu t ane ou s a nd m yof asc i a l a rea s . The se r e f e r r edpa ins sugges t t ha t t r ansmis s ion a t a g iven syn ap t i c s i te can be f ac i l i t a t ed byac t iv i t ie s i n d i s t an t b3 dy a reas . Th i s pos s ib i l i t y i s cons i s t en t w i th t he ga t econ t ro l t h eo ry [2~] s ince t he subs t an t i a ge l a t i nosa a t any l eve l r ece ivesi n p u t s f r o m b o t h s id e s o f th e b o d y a n d ( b y w a y o f L i s s au e r 's t r a c t ) f r o m t h es u b s t a n t i a g e la t in o s ~ i n n e i g h b o r i n g b o d y s e g m e n t s . I n a d d i t io n , t h e s u b s t a n -t i a g e l a t i n o s a o f t h e s p i n a l c o r d i s f u n c t i o n a l l y c o n t i n u o u s w i t h t h a t o f t h et r ig e m i n a l s y s t e m [ 3 6 ] . M e c h a n i s t , s s u c h as t h e s e m a y e x p l a i n t h e ob s e rv a -t io n s t h a t a n g in a l p a in [ 6 ] o r p r e s s u r e o n o t h e r b o d y a r ea s s u c h as t h e h e a d[ 8 ] m a y t r ig g e r p a i r i n a p h a n t o m l i m b .

The re l ie f of pa l .~, by br ie f , i n ten se s t im ula t ion of d is t an t t r igger poi r~ ts is alna jo r ~ )uzz le . The m os t p l aus ib l e exp lana t io n [23 ] s eems to be t ha t t heb r a i n s t e m a r e a s w h i c h a r e k n o w n t o e x e r t a p o w e r f u l i n h i b i t o r y c o n t r o love r t ransm is s ion in t he pa in s igna ling sys t em m ay be invo lved . The se ar ea s ,w h i c h m a y b e c o n s i d e r e d t o b e a " c e n t r a l b i a s in g m e c h a n i s m " [ 2 2 ] , re c e iv ei n p u t s f r o m w i d e s p r e a d p a r t s o f t h e b o d y a r d i n t u r n p r o j e c t t o w i d e s p r e a dpa r t s o f t he sp ina l co rd and b ra in . I t is t hus con ce ivab le t ha t t he r e l i e f o fp a in b y s t i m u l a t i o n o f a c u p u n c t u r e p o i n t s a n d t r ig g e r p o i n t s m a y b e a s p e ci a lc a se o f h y p e r s t i m u l a t i o n a n a lg e s i a [ 2 3 ] . T h e s t i m u l a t i o n o f p a r t i c u l a r n e r v eso r t is s ue s b y n e e d l e s c o u l d b r i n g a b o u t a n i n c r e a s e d i n p u t t o t h e c e n t r a l b ia s-

i ng m e c h a n i s m , w h i c h w o u l d c l o se t h e g a t e s t o i n p u t s f r o m s e le c t e d b o d ya re a s. T h e c e ll s o f t h e m i d b r a i n r e t i c u l a r f o r m a t i o n a r e k n o w n t o h a v e la rger e c e p ti v e f ie ld s [ 3 0 ] a n d t h e e l e c t r ic a l s t i m u l a t i o n o f p o i n t s w i t h i n t h er e t i c u la r f o r m a t i o n c a n p r o d u c e a n a lg e s ia i n d i s c r e te a r ea s o f t h e b o d y [ 4 ,21 ] . I L is pos s ib i e , t hen , t h a t pa r t i cu !a r b od y a reas ma y p ro j ec t e spec i a l l ys t r o n g l y t o s o m e r e t i c u l a r a r e as , a n d t h e s e , in t u r n , c o u l d b r i n g a b o u t a c o m -p l e t e b l o c k o f i n p u t s f r o m p a r t i c u l a r p a r t s o f t h e b o d y .

Th e pr ol on ge d rel ief of pa in af te r on ly brie:? ~;i:~at~_lation req uir es t he addi-t i ona l p os tu l a t i on o f p ro long ed , r eve rbex ' a to ry ac t iv i t y wh ich ma y be f ac il i-t a t e d b y l o w l e v el i n p u t s , s u c h a s t h o s e f r o m t h e p a t h o l o g i c a l s t r u c t u r e s o r


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21

proces se s t ha t subse rve t r i gge r po in t~ ; (o r acupunc tu re po in t s ) , and i s d i s -r u p t e d f o r l o n g p e r io d s o f t im e s ( p e r h a p s p e r m a n e n t l y ) b y a m as s iv e i n p u tp r o d u c e d b y n e e d l i n g , o r b y a t o t a l b l o c k o f i n p u t b y i n j e c t i o n o f l o c al a n es -the t i c s i n to t r i gge r po in t s .

T h i s s p e c u l a t i o n s u g ge s ts t h a t t h e o b s e r v e d r e l a t i o n s b i p b e t w e e n t r i g g e r o ra c u p u n c t u r e p o i n t s a n d p a i n f u l a r e a s a t d i s t a n t s i t e s r e p r e s e n t s i m p o r t a n ti n f o r m a t i o n o f t h e o rg a n i z a t i o n o f t h e c e n t r a l n e r v o u s s y s t e m . S t u d i e s o na n i m a l s r e v e al s o m e d e g r e e o f a n a t o m i c a l o rg a n i z a t i o n o f t h e " c e n t r a l b i a s in gm e c h a n i s m " s i n c e s t i m u l a t i o n a t a g iw ~ n s it v m a y p r o d u c e g r a d i e n ts o f a na l-ges ia in w h ich the m ax im um ana lges ic e f fec~ i s obse rved in a r e l a t i ve ly sma l lp a r t o f t h e b o d y, s u c h a s a f o o t o r p o r t i o n o f a l eg [ 4 ] . S t u d i es o f t ri g g e r ar ida c u p u n c t u r e p o i n t s i n m a n m a y p r o v i d e f u r t h e r v a l u a b l e c lu e s o n t h e o rg a n -i z a t io n o f t hi s m e c h a n i s m . T h e s e d a t a , m o r e o v e r, a r e c o n s i s t e n t w i t h e a r li e ro b s e r v a t io n s w h i c h r e v e a l u n u s u a l i n t e r a c t i o n s b e t w e e n d i s t a n t b o d y a r e a s[ 2 7 ] . P a t ie n t s w h o h a v e u n d e r g o n e a n t e r o l a te r a l sp i n al c o r d o t o m y, u s u a ll y

f o r r e l ie f o f p a i n d u e t o m a l i g n a n c y, r e p o r t p a i n a t s o m e d i s t a n t a r e a ( ~ u ch a st h e c h e s t o r a b d o m e n ) w h e n p r i c k e d b y a p i n o n a n a n a l ge s ic a r e a (s u c h a st h e l eg ) . T h e s e p a i n s c a n b e e v o k e d o n t h e s a m e o r t h e o p p o s i t e s : / - ,~f t h ebo dy . In som e cases , t he pa in i s evo ked a t t he s i t e o f an ea r l ie r i n ju ry [ 28 ] .A r e c e n t s t u d y [ 3 2 ] i n n o r m a l s u b j e c t s f u r t h e r d e m o n s t r a t e s c o m p l e :: ~ p at ia ls o m a t i c i n t e r a c t i o n s w h i c h d e f y e x p l a n a t i o n i n t e r m s o f t h e t r a d i t i o n a lsegm en ta l o rgan iza t ion o f t he pe r ip he ra l n e rvous s ys t em . T he ev iden ce , take~-~t o g e t h e r, s u g g es t s t h e e x i s t e n c e o f i n t e g r a ti n g m e c h a n i s m s in t h e c e n t r a ln e r v o u s s y s t e m w h i c h p e r m i t i n t e r a c t i o n s o f in p u t~ f r o m w i d e s p r e a d p a - t s o ft h e b o d y.

ACKNOWLEDGEMENTS

S u p p o r t e d b y G r a n t A - 7 8 9 1 f r o m t h e N a t i o n a l R e s e a r c h C o u n c il o f C a n a d a .We a re g r a t e f u l t o P a u l Ta e n z e r a n d J a c q u e s P e r r a s f o r t h e i r i n v a l u a b l e

sugges t ions and a s s i s t ance , and to Dr. F e l ix Man n fo r p rov id ing one o f u s( E . J . F. ) w i t h t h e i n f o r m a t i o n o n t h e b a s i c a c u p u n c t u r e p o i n t s s h o w n i n F, g s .8 and 9 . We a re a l so g ra t e fu l t o Dr. J an e t Trave l l, Dr. F rede : i ck Kao , Dr.M a rg a r e t K e n n a r d , D r. F r e d e r i c k H a u g e n , a n d D r. A n d e r s S ol a f o r p e r m i s -s ion to r ep r in t d i r ec t l y o r i n r ev i sed fo rm the ma te r i a l i n F igs . 1 - -7 .

D r. E .J . F o x w a s s u p p o r t e d b y t h e J o h n s o n a n d J o h n s o n C o m p a n y d u ~ n g

h e r s a b b a t i c a l l e a v e f r o m t h e D e p a r t m e n t o f A n e s t h e s i o l o g y, D o w n s t a t eM e d i c al C e n t e r , B r o o k l y n , N . Y. , U . S .A .

REFERENCES

1 Aach, R.D., Abdominal pain. In: C.M. MacBryde and R.S. Black|ow (Eds.), Signs ancSymptoms, Lippincott, Philadelphia, Pa., 1970, pp. 181--192.

2 Acupuncture Anesthesia Group, Shanghai Institute of Physiology, Electromyographicactivity produced locally by acupuncture manipulation, Chin. reed. J., 9 (1973) 532--535.


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Anderson, D.G., Jamieson, J .L. ant i Man, S .C. , Analges ic e ffec ts of acu pu nctu re onthe pa in o f i c e -wa te r : a doub le -b l i nd s tudy, Canad . J . P sycho l. , 28 (1974) 239 ~24 4 .

4 Balagura , S . and R alph , T. , The ana lges ic e ffec t o f e lec t r ica l s t im ula t io n of the d ien-cepha lon and m esencepha lon , B ra in Res ., 60 (1973) 369 - -379 .

5 Bonica , J. J,~ The M anag em ent of Pa in , Lea and Febiger, Phi lade lphia , Pa , , 1953,6 Cohen , H . , The m echan i sm o f v i s ce rai pa in , Trans . Med . Soc . (Lond : ) , 64 (1 94 4) 65 - -

99.7 Cop ema n , W.S .G . and A cke rm an , W.L . , Edem a o r he rn i a t i ons o f f a t l obu l e s a s a cause

o f l um bar and g lu tea l fi b rosi t is , Arch . i n t e rn . Med . , 79 (1947) 22 - -35 .8 Cronh o lm, B . , Pha n tom L imbs i n ampu tee s , A c t a p sych i a t , neu ro l , s cand . , 72 , Supp l .

(1951) 1 - -310 .9 Fox , E . J . and M e lzaek , R . , Transcu t aneous e l ec t r i ca l s timu la t i on and acupu nc tu re :

com par i son o f t r ea tm en t fo r l ow-back pa in , Pa in , 2 (1976) 357 - -373 .10 J eans , M.E . , E ff ec t s o f B r ie f , I n t ense Transcu t aneo us E l ec tr i c a l S t imu la t i on on Chron ic

Pain , Doctora l Disser ta t ion , McG i l l Univers i ty, 1976.11 Kao , F.F. and Kao , J . J ., A cupu nc tu re The rapeu t i c s , Eas t e rn P re s s, New Haven , Conn . ,

1973 .12 Katz , R .L. , Kao, C.Y. , Spiege l , H. and Katz , G.J . , Pa in , acupuncture , hypnos is . In :

J . J . Bonica (Ed. ) , Advances in NeuJology, Vol . 4 , ~nt . Syrup . on Pa in , Raven Press ,New Y..~rk , 1974, pp . 7 49--7 54.

13 Ken nard , M .A. and Ha ugen, F.P. , T he re lat i .n of su bcu taneo us foca l sens i t iv i ty tor e f e r r ed pa in o f ca rd iac o r ig in , Anes thes io logy, 16 (195 5) 297 - -311 .

14 Kor r, I .M. , Thom as , P.E . and Wr igh t , H .M., Sym pos iu m on the func t i ona l imp l i ca t ionof segm enta l fac i li ta t i,~n , J . Am er. os teo path . Ass . , 54 (195 5) 1" 18

15 Kraus , H . , C l in i ca l Trea tme n t o f Back and Neck Pa in , McGraw-Hi ll , New York , 1970 .16 Liv ings ton , W.K. , Pa in M echanism s, Macm il lan , Ne w York , 1943.17 Man , C .S . and Ba rage r, F .D , P re l imina ry c l in i ca l s t udy o f acup unc tu re i n rheum a to id

ar thr i t ics wi th pa infu l knees , J . Rheumat01 . , 1 (1974) 1- -8 .18 Mann , F. , A t l a s o f Acupu nc tu re , He inem ann Med ica l Books , London , 1966 .19 Mann , F. , The Trea tmen t o f D i sea se b~ ' Acupunc tu re , He inemann Med ica l Books ,

L o n d o n , 1 9 6 7 .

20 Mann, F. , Bow sher, D. , M um ford , J . , L ip ton , S . and Mi les , J . , Trea~l;ment of in t rac t -ab le pa in by acupunc tu re , Lance t , i ( 1973 ) 57 - -60 .

1 Ma yer, D .J . a nd Lie besk ind, J .C. . Pain reduc tion b y focal electr ical s ';~.mulat ion of theP~rain" an a na tom ica l and behaviora l ana lys is , Bra in Res . , 68 {1974) 73- -9 3 .

22 Me lzack , R . , Phan to m l imb pa ' n : imp l i ca t i ons fo r t r ea tm en t o f pa tho iog i c pa in ,Anes thes io logy, 35 (197J . ) 409--419.

23 Melzack , R. , The Puzz le of ]?a in , Bas ic Books , New Yo rk , 1973.24 Melzack , R. , Pro longed re lie~" of pa in by br ie f , in tense t ransc utane ous so ma t ic s t imula-

t i on , Pa in , 1 (1975) 357 - -373 .25 I~ielzack, R. and W all, ]? .D. , Ps ych oph ysio logy of p ain, Int . An esthe siol . Clin. , 8

(1970) 3 - -34 .26 Mendel i , L .M. and Wal l, P.D. , Presy napt ic hyp erpo lar iz a t ion : a ro le for f ine a ffe ren t

f i ber s , J . Phys io l . (Lond . ) , 172 (1965) 274 - -294 .27 Nath an: P. , Refere nce o f sensa t ion a t the sp ina l leve l, J . Neurol . Neurosurg . Psychia t . ,

19 (1956) 88 - -100 .28 Na than , P.W. , Pa in t races le f t in the cent ra l nervous sys tem . In : C.A. Keele and R.

Smi th CEds . ) , The Assessment of Pa in in Man and Animals , L iv ings tone , Edinburgh ,1962 , pp . 129 - -134 .

29 Pomeranz , B. , Wal l , P.D. and Weber, W.V. , Cord ce l l s responding to f ine myel ina ted~:'~:: ~ts f rom viscera , musc le aad sk in , J . Phys io l . (Lond. ) , 199 (1968) 511--532.

30 Ross i , G.F. and Zan chet t i , A. , The bra ins tem re t icu lar formatic~n, Arch . it a l . Bio l. , 95(19571 199--435.

31 Se|zer M. and Spenc~ W.A., Cony a gence of visceral and cutaneous afferent path-ways },I the lumbar spinal cord, i ra~n P~es., 14 (1969) 331--348,


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32 S t e rl ing , P. , Re fe r r ed cu t aneous s ensa t i on , Exp . Neuro l . , 41 (1973) 4 51 - -45 6 .33 So la , A .E . and K u i t e r t , J .H . , Myofasc i a l t ri gger po in t p a in i n the neck and sh ou lde r

g i rd l e, No r thw. Med . (Sea t t le ) , 54 (195 5) 980 - -984 .34 So la, A .E . and Wi l li ams , R .L . , Myofasc i a l pa in synd rom es , Neuro logy (Minneap . ) , 6

(1956) 91 - -95 .35 Travel l , J . and R inz ler, S .H., Th e myofa sc ia l genes is of pa in , Pos tgrad . Med. , 11 (195 2)

4 2 5 - - 4 3 4 .36 Wal l, P.D . and Tau b , A . , Fou r a spec t s o f t r i gemina l nuc l eus and a pa radox , J . Neu ro -

phys io l . , 25 (1962.) 1 10--12 6.

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