Treatment of Trigeminal Neuralgia With Sa-Am Acupuncture

Abstract

Trigeminal neuralgia (TGN) is a unilateral electric shock or knife-like pain occurring in one or more branches of the trigeminal nerve that affects four to five people in 100,000. Korean Taoist physician Sa-Am lived during the Choson dynasty and originated Sa-Am acupuncture therapy (also known as four-needle technique), which is based on Five-Element theory. This case study examines the effectiveness of Sa-Am acupuncture in treating a woman with TGN over a three-month period. Pain on a scale from 0 to 10 dropped from 9 at the start of treatment to 0 at the end, suggesting that Sa-Am acupuncture was an effective alternative for this condition.

Introduction

The International Association for the Study of Pain (IASP) and the International Headache Society (IHS) have similar diagnostic criteria to diagnose TGN¹ (Table 1). Trigeminal neuralgia can be associated with structural problems inside the skull, but usually no treatable cause is found. The trigeminal nerve is divided into three branches: V1, which innervates the forehead and eye; V2, the cheek; and V3, the jaw. The pain of trigeminal neuralgia can occur in one or all of these areas. It is often a sudden, sharp or electric shock-like pain of short duration (seconds to minutes). It can be bilateral, but in such cases it usually begins on one side of the face. Pain related to TGN can be triggered by opening the mouth to talk, laugh, chew, brush one's teeth, or by wind or a touch on the face.

A wide range of treatments for TGN was in use by the beginning of the 20th century. Modern neurosurgical treatment for TGN began in 1925 with the introduction of the concept of vascular compression.² Eventually, microvascular decompression (MVD) came into favor. Currently, radiosurgery has begun to be used.³ Pharmacotherapy originally had little success in treating this condition. After Bergouignan discovered that phenytoin was effective in preventing pain paroxysms in 1942, however, carbamazepine was introduced for the treatment of epilepsy and TGN. Since then, a nticonvulsants have been recognized as an important pharmacological treatment for TGN.

Surgery may cause side effects such as nerve injury or cerebrospinal fluid leak.⁴ Pharmacotherapy remains the mainstay of treatment of TGN even though few randomized controlled trials have been conducted.⁵ Table 2 lists the drugs most commonly used and their side effects. Regarding microvascular decrompression, cerebellar injury was reported in 0.45%, eighth-nerve injury in 0.8% and CSF leak in 1.85% in a recent retrospective study.⁴ Percutaneous rhizotomy procedures yield initial pain relief in more than 80% of patients, but 12-month recurrence rates vary from 10% to 50%.⁶³ Within three years, one-third of patients may have recurrent neuralgia. Long-term, annoying paresthesias are experienced by 5% to 10% of patients treated.⁶ Six percent to 15% of patients report troublesome dysesthesia (i.e., odd, unfamiliar feelings, including burning sensations) after the procedure. Recurrence is reported in 6% to 14% of patients in the first year.

Oriental medicine has seen a dramatic increase in popularity in Western society because acupuncture therapy has fewer side-effects than many pharmaceutical drugs and surgery. If its effectiveness is demonstrated through research, we may feel more confident recommending acupuncture before investigating higher-risk Western medical treatments. This paper presents an example of how Sa-Am acupuncture guided by traditional Korean medical theory can effectively treat TGN. Because few references have been published in English related to Sa-Am acupuncture, this system is also explained briefly.

Traditional Chinese Medicine (TCM)

TCM classifies TGN differently than does Western medicine. TCM categorizes disease into different patterns. Patterns based on the standard theory of TCM explain TGN as follows:^13,14,15

• Wind heat mixed with phlegm obstructs the network vessels: Due to wind heat, evils invade the body from outside. They may lodge with phlegm in the channels and vessels on one side of the face, where they impede and inhibit the free flow of qi and blood and thus result in pain.
• Wind cold mixed with phlegm and stasis: Due to wind cold, evils invade the body from outside. They may lodge with phlegm in the channels and vessels on one side of the face, where they impede and inhibit the free flow of qi and blood and thus result in pain.
• Liver depression transforming fire: The most common cause of this pattern is a long-standing emotional state of anger, resentment, repressed anger, or frustration. The emotional repression makes qiqi and blood to the face. stagnate and implode, giving rise to heat. Liver fire has a natural tendency to flare upwards; this inhibits the free flow of
• Phlegm stasis impediment and obstruction: Due to overtaxation, over-thinking, worry, and consumption of cold, raw and greasy foods, the spleen cannot perform the job of transporting and transforming qi, leading to damp accumulation. Eventually the dampness will turn into phlegm, and because the qi is deficient, the phlegm will lodge in the channels, causing obstruction and leading to pain.
• Phlegm fire harassing above: Due to severe emotional problems and depression leading to stagnation of qi which, over a long period time, turns into fire and Liver fire has a natural tendency to flare upwards. Also, excessive consumption of hot/greasy foods creates heat and phlegm. These conditions inhibit the free flow of qi and blood to the face area, leading to pain.
• Blood stasis: This generalized impairment to the flow of blood and localized stagnation of blood in the blood vessels leads to pain.
• Yin vacuity-yang hyperactivity and blood stasis: By 40 years of age, yin is half consumed. Through aging, if yin blood fails to nourish and moisten the liver, the liver may not be able to perform its function of coursing and discharge. Hence, depression becomes more prevalent with age. If yin fails to control yang, liver yang may become hyperactive and ascend. Further, either qi vacuity, qi stagnation, yin vacuity, or yang vacuity may result in blood stasis.

Traditional Korean Medicine

To practice traditional Chinese acupuncture, one must know meridian theory and the locations of many points throughout the body. Each point has specific curative effects. For example, UB 40 (weizhong) is the empirical point for acute lumbar sprain. Sa-Am acupuncture, however, does not have specific acupuncture points for certain diseases. This suggests that Sa-Am acupuncture has a different mechanism than Chinese acupuncture. The theoretical system of Sa-Am acupuncture is based on Five Element theory and uses only five shu points - jing or well, ying or spring, shu or stream, jing or river, and he or sea.^{7,8,9,10,11,12} Sa-Am acupuncture is safer than TCM because all five shu points are located distal to elbows and knees.

The monk Sa-Am, creator of Sa-Am acupuncture, defined the meridians as mind paths. According to Sa-Am theory, 12 meridians carry six different qualities of qi produced by the mind.^{7,8,9,10,11,12} The 12 meridians - taiyin, yangming, shaoyin, taiyang, jueyin, shaoyang - can be paired with the six energies, which are dampness, dryness, fire (warmth), coolness, wind, and fire (lightning), respectively (Table 3). To understand the function of the meridians and the six qualities of qi, Sa-Am resorted to the yi ching, the Book of Changes. Each of the eight hexagrams has two sets of names. One set reflects the material world: heaven, earth, lake, mountain, fire, water, thunder, and wind. The other set reflects the spiritual world: gun, tai, li, jin, son, gam, gan, and gon (Table 4). To explain the relationship between the mind and meridians, Sa-Am theorist and proponent Hongkyung Kim added the prefix mind to the hexagram tae and gan in his book.¹¹ In the hexagrams, tae and gan are opposite to one another. Also, tae belongs to yang and gan belongs to yin (Table 4). The meaning of tae is "joyous" and gan is "to go astray." With the prefix mind tae changes to yol, which means "to be delighted," and ganhan, which means "to be anguished." Thus, yol refers to a positive mind, whereas han refers to a negative mind.^{7,8,9,10,11,12} Hexagrams reflect the state of the cosmos in relation to the mind at any given moment. Sa Am changes to realized that the 12 meridians serve as the path by which the mind moves in its "yea" and "nay" with regard to the three aspects of the phenomenal world, which are three types of "biorhythms" (rhythmically alternating life energies).

The three types of Sa-Am "biorhythms" are as follows: hunger and satiation; grief and affection; and diffidence and confidence.^{7,8,9,10,11,12} According to Sa-Am theory, the feeling of satisfaction and dissatisfaction with regard to meeting these basic needs is carried by the taiyin and yangming meridians. Man's secondary desire is for sexual and aesthetic gratification. Satisfaction and dissatisfaction with regard to this desire are carried by the shaoyin and taiyang meridians. Tertiary desire is the desire for honors, fame, power, and knowledge. Jueyin and shaoyang meridians carry the degree of satisfaction here (Table 5).

Relationship Between Five Elements in Sa-Am Acupuncture

The original Sa-Am acupuncture therapy is based on the mutual generation, mutual control, over-control, and insult relationships of the Five Elements (Wood, Fire, Earth, Metal, and Water), which can also be thought of as phases. Mutual generation means promotion, while mutual control means restriction. The order of mutual generation among the five phases is as follows: Wood generates Fire, Fire generates Earth, Earth generates Metal, Metal generates Water, and Water generates Wood.¹³ In this way, generation is circular and endless. In the mutual generating relation of the Five Elements, each of the phases has the property of being generated and generating. What generates is the "mother"; what is generated is the "son." This is known as the "mother and son" relationship. Regarding control, however, Wood controls Earth, Metal controls Wood, etc. "Being controlled" means that one element is inferior to another, while "controlling" means one is superior to another. Therefore, the mutual controlling relationship among the Five Elements is also known as the relationship of "being superior to" and "being inferior to" another element. Mutual generation and mutual control are two aspects that cannot be separated. Without generation, birth and growth will not exist. Without control, no way to develop and maintain harmonious relationships exists.

Over-control and counter insult are pathological conditions. Over-control means that the control of one of the Five Elements over another surpasses the normal level. For example, a hyperactive Wood element will subjugate the Earth element. The latter element will become weak and insufficient. An insult relationship means that one of the Five Elements insults the other opposite to the normal mutual control order. For example, when Metal is weak and insufficient, it leads to the hyperactivity of Wood. The latter will then insult the former. The text Huang Di Nei Jing¹⁴ says, "When the qi of one of the five phases is excessive, it will dominate its controlled element and counter control the insulting element." Moreover, Five-Element theory recognizes a relationship between those things related to a particular element. As Huang Di Nei Jing¹⁴ points out, "The East generates wind, wind generates wood, wood generates sour, sour generates liver, liver generates tendons... . " According to Five-Element theory, each element has its own repertoire of relationships among the objects that compose the physical world. The Five-Element theory is therefore the theoretical basis of the unique bond between man and nature.

Sa-Am Acupuncture Technique

Sa-Am acupuncture, or four-needle technique, is especially valuable in treating chronic diseases in which the root or origin must be addressed for the illness to be cured. The procedure corrects imbalances in the functioning of the internal organs where the elements perpetuate the problem and affect one another after an imbalance has occurred in the root element.^{7,8,9,10,11,12} Sa-Am acupuncture corrects the root element, the mother element, the son element and the controlling element at the same time.

Deficiency conditions are treated using the following methods (Table 6):

• Tonify the horary point on the mother organ's channel. Horary means that the point's element and the channel's element are the same, i.e., the wood point on the wood channel.
• Tonify the mother organ's element point on the affected channel.
• Sedate the horary point on the "controlling" organ's channel.
• Sedate the controlling organ's element point on the affected organ.

Excess conditions are treated using the following methods (Table 7):

• Tonify the horary point on the controlling organ's channel.
• Tonify the controlling organ's element point on the affected organ's channel.
• Sedate the horary point on the "son" organ's channel.
• Sedate the son organ's element point on the affected organ.

According to the ancient textbook Huang Di Nei Jing,¹⁴ two of the most significant techniques in acupuncture stimulation are known as tonification (bu) and sedation (xie). Tonification strengthens a physiological function. Sedation harmonizes hyperactive physiologic functions.¹⁵ The book known as Sa-Am's Clinical Records of Acupuncture and Moxibustion¹⁶ states three different tonification and sedation methods: youngshu bo sa, shu gi bo sa and gu liu bo sa. These three techniques are used at the same time. The method of young shu bo sa places the needle at a 45° angle, either along the meridian flow for tonification or against the meridian flow for sedation.^17,18,19 In shu gi bo sa (Table 8), rotation of the needle to the right or left side produces a tonification or sedation effect, respectively. The direction may reverse according to time and location of meridians.¹⁸ Gu liu bo sa simply means rotation of the needle 9 times for tonification and 6 times for sedation.^17,18,19 For example, in the morning, the tonification method for left-hand yang, left-foot yin, right-hand yin, and right-foot yang meridians is to place the needle at a 45° angle with the meridian flow, with rotation clockwise or to the right side 9 times, whereas rotation to the left or counter-clockwise 6 times is sedation. In the afternoon, only shu gi bo sa technique is opposite to the morning methods.

Previous Research

A number of published articles support the benefits of using oriental medicine or acupuncture to treat TGN. Two articles are considered here as representative of this literature: "Observation on the Effect of Acupuncture Treatment in 300 Cases of Primary Trigeminal Neuralgia" by Xu and Ge²⁰ and "Practical Application of Meridian Acupuncture Treatment for Trigeminal Neuralgia" by Satoshi, Yasumichi, Yoshihiro and Ichirou.²¹ Xu and Ge evaluated the effects of local points to treat trigeminal neuralgia. Treatment was given every other day, with 10 sessions constituting a course. The point protocol used was as follows: branch I was involved in 10 cases (meizhong, an extra point), branch II was in 51 cases (St 2), branch III in 28 cases (St 7), branches I and II in 36 cases (meizhong and St 2), branches II and III in 146 cases (St 2 and St 7), branches I, II and III in 29 cases (meizhong, St 2 and St 7) were treated with acupuncture only. One hundred thirty-eight of 300 people showed immediate and complete relief of symptoms. This study did not report the patients' TCM patterns. Xu and Ge directly stimulated the acupuncture points overlying the trigeminal nerves. The reader is left to assume that all TGN is caused by the same pathological mechanism and therefore should be treated by the same group of points on the affected side.

Satoshi et al. evaluated the effect of meridian acupuncture treatment on TGN. The 10 subjects chosen for the study were between 26 and 67 years old. Five patients suffered from idiopathic TGN, and five from symptomatic TGN. A pain score chart was used to evaluate the effect of the meridian acupuncture treatment, which in this study ranged from only one session to up to 5 years of treatment. Patients were asked to rate the rate the degree of pain on a scale 0 to 10, with 10 being the greatest level of pain. Of the five patients with idiopathic TGN, treatment was most effective in three patients, who became pain-free (0 rating). A decrease of pain (1 to 3) was obtained in the other two patients. Of the five patients with symptomatic trigeminal neuralgia, the treatment was most effective (0) in two patients and rather effective (1 to 3) in two patients. The fifth patient was switched to another mode of treatment because the pain had not been adequately relieved.⁷ The meridian acupuncture points generally used were Lu 5, Lu 6, LI 3, LI 4, LI 8, Sp 4, Sp 5, St 1, St 2, St 3, St 4, St 5, St 6, St 7, St 39, GB 5, GB 6, GB 14, Kid 3, Kid 7, and Kid 10. Four TCM diagnostic methods were used in the treatment: inspecting diagnosing (physical examination), hearing diagnosis, questioning diagnosis (patient history and report), and palpitating diagnosis. The article did not inform the reader of how the four methods were used or what the underlying TCM patterns of the 10 patients were.

No journal articles about Sa-Am acupuncture have been published in America, even though it is commonly used and considered effective in Korea. The goal of this paper is to present a typical, complex case of TGN in-depth to help clarify our understanding of Oriental medicine treatment options and rationales and their relation to the patient's overall health issues. This paper thus introduces Sa-Am acupuncture treatment and presents one case study to illustrate its efficacy for TGN.

Case Report

Over three months, an outpatient with TGN was treated in the acupuncture clinic of Sound Shore Medical Center in New Rochelle, NY (SSMC) using Sa-Am acupuncture. This 58-year old woman had been diagnosed with TGN 3 years prior by a biomedical physician, just before stomach cancer was found. Sixty percent of her stomach was removed about 2 years before the treatment reported here.

The pain related to TGN affected the left side of the face. It was severe and sharp and included electrical sensations near UB 2 and LI 20, especially when she opened her mouth to speak. Her neurologist prescribed carbamazepine for pain management; she did not take it, however, because the pain remained unchanged with medication, which bothered her digestion.

Her bowels moved once per day, with loose stools. She urinated normally four to five times per day without waking up during the night. The volume of urination was reported to be moderate and its color was light yellow. The patient's pulse was slippery in both front positions, wiry in the left-middle, slippery in the right-middle, and deep, weak and thin in both rear positions. Her pulse rate was 68 bpm. Her tongue was wet, bright red, and tooth-marked, with small cracks all over and a yellow coating on the rear. The patient did not smoke or drink alcohol. Her diet consisted of vegetables, rice, fish, and meat.

The patient strongly believed that both TGN and her stomach cancer came from family stressors, which continued to result in bouts of anger and depression.

OM Diagnosis: TCM

Liver qi stagnation can be caused by emotional stress, anger, and frustration.¹³ The main function of the liver in TCM is free flow of qi in the body. Stress, anger and frustration, however, can cause the liver to lose control over the smooth flow of qi and eventually result in qi stagnation. Qi stagnation leads to a stagnation of blood. This generalized impairment to the flow of blood and localized stagnation of blood leads to facial pain. The wiry pulse in the left front position indicates liver diseases and pain patterns.

The liver depression eventually counter-flows and over-controls the stomach and spleen. When it invades the stomach, the stomach qi rebels upward and may cause stomach cancer in severe cases. When it invades the spleen, the spleen becomes weak and fails in its primary function of transformation and transportation. This leads to fatigue, loose stools or diarrhea, and dampness accumulation.

Liver depression transforming fire can be caused by a longstanding emotional state of anger, resentment, repressed anger or frustration. The emotional repression makes qi stagnate and implode, giving rise to heat. Liver fire has a natural tendency to flare upward, and this inhibits the free flow of qi and blood to the face, causing facial pain.

The signs and symptoms presented show multiple patterns of pathology. The most predominant pattern is liver depression heat and dampness accumulation caused by liver qi stagnation, which eventually over-acted on the stomach and spleen.

OM Diagnosis: Sa-Am

Using Sa-Am theory, the diagnosis of this case is excess gallbladder and large intestine deficiency. First, the gallbladder meridian belongs to foot-shaoyang, which carries fire (shanghua, lightning) energy. Shanghua is one of the Fire energies, but does not have heat.^{7,8,9,10,11,12} Moonlight, for example, differs from sunlight because moonlight does not have heat. Another fire energy, guanhua (warmth), has heat like sunlight. In pathology, shanghua demonstrates anger and sexual desire, whereas guanhua displays fever and inflammation.^{7,8,9,10,11,12} In this case, the patient had long-term emotional stress, a main cause of liver depression; emotional stress is excess shanghua energy. The foot-shaoyang Gallbladder meridian is different from the hand-shaoyang San Jiao meridian even though these two meridians pair with shanghua energy, because the gallbladder is under the Wood element and is related to anger, which easily generates internal wind and fire. For these reasons, the Gallbladder meridian is a more reasonable choice than the San Jiao meridian.

Second, the large intestine is under the Metal element and belongs to hand-yangming, which carries dryness energy. The hand-yangming Large Intestine meridian is a better choice in treating damp conditions than the foot-yangming Stomach meridian since Metal is drier than the other elements. The slippery pulse in the right middle position, loose stools, and swollen and tooth-marked tongue indicates spleen qi deficiency and dampness accumulation. Dryness energy should be used for damp conditions. Furthermore, the primary channel of the large intestine also runs through the face, and the LI 20 area was one of the most tender points. Thus, the Large Intestine meridian was a better choice than the Stomach meridian.

Treatment focused on the yangming meridian, which paired with dryness energy, and the shaoyang meridian, which paired with shanghua fire. A protocol of four-needle points (Tables 6 and 7) was used based on this Sa-Am pattern. Stainless steel 30- to 36-gauge disposable needles were inserted. After needle insertion, three different types of sedating and tonifying techniques were utilized. Needles were retained for 15 minutes.

Treatments Week by Week

The treatment principle used initially was to clear excessive shanghua fire and to dry dampness. According to Huang Di Nei Jing, "Diseases of the left side are treated with right-side points, and diseases of the right side are treated with left-side points. The patient's right side of the body was needled because she had left TGN pain.

Young shu bo sa, shu gi bo sa and gu liu bo sa needle techniques were utilized. For shu gi bo sa, a morning technique was used for the first session because it occurred before noon. The point protocol and needle techniques used for treatments 1 to 4 are reported in Table 9.

Since the patient's TGN pain could be triggered by talking, laughing, chewing, teeth brushing, and touching the face, the patient was asked to close and open her mouth after each needling and report how it felt. During the first treatment, the pain progressively decreased from an initial value of 9 to a final value of 5 (Fig. 1). At treatment 4 (week 2), the patient no longer felt any pain or pulling sensations from the most tender area, left UB 2.

At treatment 5 (week 3), the patient reported her TGN pain was "fine" for the first time. Because she came to the clinic after noon, the shu gi bo sa afternoon technique was used. The needle techniques used for treatment 5 and subsequent treatments were changed as follows: LI 1 was rotated clockwise 9 times; GB 44 counter-clockwise 9 times; SI 5 counter-clockwise 6 times; ST 36 counter-clockwise 9 times; LI 11 clockwise 9 times; and LI 5 counter-clockwise 6 times. Otherwise, the treatment remained the same.

For treatment 6 (week 4), the patient came to the clinic before noon, so the shu gi bo sa morning technique was used. At treatment 7 (week 4), the patient reported she did not feel any sharp pain when she opened her mouth to speak. At treatment 8 (week 5), the patient reported that she had not felt any pain since the last treatment. At treatment 9 (week 5), the patient reported some pulling sensation on the left side of the LI 20 area, but no pain. The shu gi bo sa afternoon technique was used. For treatment 10 (week 6), the morning shu gi bo sa technique was used. At treatment 12 (week 8), the patient reported that she had experienced a little pain the previous Friday, but it was gone. Treatment 13 (week 10) was the last treatment. The patient reported she had not felt any pain since her previous treatment (a rating of 0 on the pain scale before and after treatment, Fig. 1).

Discussion

This case was presented to illustrate the basic principles and potential value of Sa-Am acupuncture in treating TGN. During a 10-week course of treatment, the patient's pain level decreased from a 9 to 0 on a pain scale of 0 to 10 where 10 was the most severe pain. The results suggest that the symptoms of TGN may improve through each session of treatment. Western medicine brings good results through pharmacotherapy and surgery in treating TGN,^3,6,22,23 but is associated with many potential side effects.^3,4,6,22 The results of Sa-Am acupuncture were similar to the best reports of Western medicine in terms of treating TGN, and the patient here had no side-effects.

Xu and Ge²⁰ and Satoshi et al.²¹both showed that acupuncture could be beneficial in treating TGN but lacked information on the TCM patterns that were being treated and the rationale for specific point protocols. The present case study shows not only TCM patterns but also Sa-Am patterns the theory behind the Sa-Am protocol.

In pain treatment, TCM usually emphasizes symptoms as did the two studies above. Sa-Am acupuncture, however, emphasizes the harmony of six different qualities of qi. In this case study, TGN pain diminished to 5 from 9 on the pain scale after the first treatment, suggesting that this approach was effective in TGN. Thirteen treatment sessions were required to complete recovery. Compared with results in Sa-Am's Clinical Records of Acupuncture and Moxibustion, the length of treatment was unexpectedly long: diseases including those associated with severe pain treatment were cured in a few sessions.¹⁶ This could be related to treatment occurring an average of once a week. Perhaps improvement of pain syndromes would be more rapid with at least two to three treatments a week.

This case report evaluated only one patient. The treatment protocol may change in other TGN patients who have different patterns, since Sa-Am acupuncture protocols vary based upon pattern identifications even though the same biomedical disease is being treated. Future studies could investigate the efficacy of other Sa-Am protocols in treating TGN. Another important factor in treating TGN is the amount of time the patient had this condition. The present study involves one case of relatively long duration. Future researchers might consider the efficacy of Sa-Am acupuncture with short- as well as long-term TGN.

This report has shown that Sa-Am acupuncture was effective in reducing pain associated with TGN. Because the patient's condition was chronic and the improvement occurred in the absence of any other treatment, this suggests Sa-Am acupuncture was an effective alternative for this condition.

References

Table 1. Definition of TCH provided by the International Association for the Study of Pain (IASP, 1994) and the International Headache Society (IHS).

ISAP Definition	IHS Definition
Sudden, usually unilateral, severe brief stabbing recurrent pains in the distribution of one or more branches of the fifth cranial nerve	Painful unilateral affliction of the face, characterized by brief electric-shock like pain limited to the distribution of one or more divisions of the trigeminal nerve. Pain is commonly evoked by trivial stimuli including washing, shaving, smoking, talking, and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination, and may remit for varying periods.

Table 2. Summary of drugs commonly used i