ETPS Neuropathic Acupuncture 665

PAIN
MANAGEMENT
A Practical Guide for Clinicians

SIXTH EDITION

Editor Richard S. Weiner

AMERICAN ACADEMY OF PAIN MANAGEMENT

CRC PRESS
Boca Raton London New York Washington, D.C.
 666 Pain Management: A Practical Guide for Clinicians, Sixth Edition

The publishers, the authors, and the American Academy of Pain Management cannot assume responsibility for the
validity of all materials contained in this book or for the consequences of their use. Some of the content represents an
emerging area of study. As new information becomes available, changes in treatment and in the use of drugs may be
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Pain management : a practical guide for clinicians / executive editor, Richard S.

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Includes bibliographical references and index.
e ISBN 0-8493-0926-3 (alk. paper)
1. Pain–Treatment. 2. Analgesia. I. Weiner, Richard S., Ph.D.
[DNLM: 1. Pain–therapy. 2. Chronic Disease–therapy. 3. Disability Evaluation. 4.
Pain–diagnosis. 5. Patient Care Management. WL 704 P14656 2001]
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ETPS Neuropathic Acupuncture 667

54
ETPS Neuropathic Acupuncture

Bruce Hocking, [Link].

FOREWORD against chronic pain, long-term victory appears elusive

The social and human costs of chronic pain are stagger- when approaching a patient with a single modality or
ing. During the 20 th century, chronic pain has disabled treatment philosophy.
millions of people, costing hundreds of billions of dollars The development of Electro-Therapeutic Point Stim-
in rehabilitation costs and lost productivity in addition ulation (ETPS) therapy represents a turning point in the
to untold human suffering (Statistics Canada, 1992). fight against chronic pain. Where surgery and prescrip-
According to some statistics, 80% of these payments have tion drugs fall short, ETPS provides nonsurgical, non-
been made for patients with neuromyofascial pain. invasive treatment of chronic neuromyofascial pain.
For the future, there is little evidence to suggest that the ETPS does not replace, nor does it dispute the validity
rate of growth of chronic soft tissue pain conditions will of conventional medicinal approaches. Rather, ETPS rec-
decrease or even plateau. ognizes that all therapeutic approaches must be exam-
Today, doctors and patients can choose from a variety ined to determine the most efficacious treatment for the
of treatments, though surgery and prescription drugs are patient. ETPS also recognizes that different therapies
the most popular avenues in the United States. The major produce different responses and that the key to under-
disadvantage associated with drugs or surgery is that they standing the source of a patient’s chronic pain is to
do not always solve the root problems; rather, they mask perform an overall mechanical and neuropathic analysis
pain or surgically remove local pathology. Pharmaceuti- of the body. This analysis helps to identify problematic
cals occasionally are effective, but can result in unpleasant areas that contort the body resulting in asymmetrical
interactions and side effects to a degree that reduces the posture and motion; physical conditions that ETPS ther-
quality of life for those who ingest them on a long-term apy believes can lead to degenerative changes and
basis. Moreover, the risks associated with drugs and sur- chronic pain throughout the body.
gery are not always outweighed by the benefits, as many
patients actually feel worse.
A number of complementary and alternative modal-
INTRODUCTION
ities (CAMs) have been promoted as solutions to fill the ETPS neuropathic therapy is a hybrid modality used in
void left by allopathic medicine. However, their relative the treatment neuromyofascial pain. In its most basic
efficaciousness may be regarded as sporadic. Progress form, ETPS therapy applies brief, staged, concentrated
in identifying a broader range of therapeutic benefits of stimulation to points relating to different therapeutic sys-
CAMs has been hindered by considerable infighting tems. Patient assessments are performed at the end of each
among different disciplines, to a degree reminiscent of stage to determine therapeutic effectiveness. Through a
a quest to be the first to race up the hill, plant a flag, series of systematic and reproducible protocols, the
and claim victory in a winner-takes-all contest. While diagnosis and treatment of root causes of soft tissue pain
natural solutions do offer some relief in the battle can be completed with a high degree of accuracy.
_________________________
0-8493-0926-3/02/$0.00+$1.50
©2002 by CRC Press LLC
667
668 Pain Management: A Practical Guide for Clinicians, Sixth Edition

The theoretical underpinnings of ETPS therapy are hormone (ACTH) and hydrocortisols for
based on sound medicine, firmly grounded on the princi- acceleration of soft tissue repair.
ples of acupuncture, osteopathic trigger points, neuromus- 4. Myofascial release. Chronic pain is known to
cular and neural therapies. As such, the constituent ele- originate in neuropathy, or functional alterations
ments of ETPS therapy are not new. Its unique of the peripheral nervous system (PNS).
contribution to pain relief however comes from the syn- Neuropathy is always caused by muscle con-
thesis of different approaches, combining the therapeutic traction, while radiculopathy is neuropathy at
“pearls” of trigger, motor and acupuncture points with a the spinal root. Relaxing contracted muscles
mechanical analysis of the body. The result is a simple, relieves impingement of the nerves, reduces
easy-to-use series of protocols. heightened sensitivity of pathways and
By following the recommended protocols, physicians improves patient’s ROM.
are able to identify which stage(s) is/are most responsible
for contributing to a patient’s pain condition. Stages The balance of this chapter, divided into two main
deemed ineffective in producing positive therapeutic sections, provides an overview of ETPS therapy. Part A
responses are eliminated from future treatments. Those describes the six pillars of ETPS therapy, the core founda-
stages producing positive responses are examined diag- tion of knowledge upon which the synthesis of different
nostically to determine interrelationship(s) with the modalities is built. They are (1) acupuncture; (2) the rela-
patient’s condition and are integrated into future protocols. tionship between radiculopathy, neuropathy and
ETPS therapy does not isolate or treat a pain condi- chronic pain; (3) the relationship between dermatomes and
tion; rather, it is used to determine how the patient’s over- chronic pain; (4) the relationship between gait and chronic
all body mechanics and neuropathic/radiculopathic man- pain; (5) the relationship between scar therapy (neural) and
ifestations can be combined with acupuncture and trigger chronic pain; and (6) ETPS stimulation. Based on this body
points to produce unique protocols. These protocols bridge of knowledge, Part B describes five ETPS protocols, all of
many different treatment philosophies to provide thera- which use an approach to treatment which allows therapists
peutic responses where other modalities fail to achieve to diagnostically isolate and treat chronic pain concur-
successful results. Because it is effective in the diagnosis rently.
of root causes of pain, ETPS therapy can serve as an ETPS therapy has proven successful in the treatment
invaluable tool to all types of physicians in their efforts of various indications. These include back and neck pain,
to substantiate current treatment and as an integrative tool whiplash, TMJ, fibromyalgia, neuropathies, migraines,
for current protocols. headaches, sport injuries, carpal tunnel, failed backs, post-
The therapeutic benefits of ETPS are based on four operative radiculopathy, plantar fasciitis, frozen shoulder
different physiological principles. and shoulder pain, tennis elbow and most other neuro-
1. Circulation response. Increasing or decreasing myofascial pain syndromes. Due to the limitations of this
circulation (called “chi” in Eastern therapies) forum, the description of ETPS therapy and related treat-
can benefit the patient in a manner similar to ments will focus on back and neck pain, fibromyalgia
the application of heat (vasodilation) and ice and plantar fasciitis protocols.
(vasoconstriction) in Western medicine.
2. Autonomic / parasympathetic response. A PART A: THE SIX PILLARS
medium for chronic pain, the Autonomic Ner- OF ETPS THERAPY
vous System (ANS) covers over 90% of the body
and consists of the sympathetic and para- ACUPUNCTURE
sympathetic nervous systems. ETPS stimula-
tion of parasympathetic “gates” can have a In order to utilize ETPS protocols effectively, therapists
calming effect on the body, providing the must have a basic, practical understanding of acupuncture.
patient with immediate and long-lasting relief Long regarded as an effective modality for the treatment
from pain, anxiety and insomnia. of pain, acupuncture contributes four key dimensions to
3. Endorphin response. Endorphins are similar the development of ETPS protocols: the release of endor-
to morphine in their ability to reduce pain, but phins, key acupuncture points, a numbering system for
are thousands of times stronger and do not point location, and the movement of circulation and
produce harmful side effects. Endorphins may energy. Each dimension is discussed below.
be released through concentrated low fre-
quency ETPS stimulation of neural points The Release of Endorphins
causing the pituitary to secrete endorphins Acupuncture has been scientifically proven to release endog-
thereby releasing adrenal cortico-atrophic enous morphines from the anterior pituitary (Andersson,
ETPS Neuropathic Acupuncture 669

1999; Augustinsson, et. al., 1977; Cheng, McKibbon, Roy,

& Pomeranz, 1980; Fisher, 1992; Martelete & Fiori, 1985;
Pomeranz, 1981). Once released, internal morphines stimu-
late the release of ACTH and glucocorticoids, natural hor-
mones that accelerate soft tissue healing. These powerful
non-addictive opiates are circulated throughout the body to
relieve pain and remain elevated for a period of 12 to 72
hours. All acupuncture points can release endorphins as long B 40
as a proper therapeutic response is achieved with needles or
low-frequency stimulation. ETPS therapy activates endor-
phin response for overall pain relief through the application
of low-frequency endorphin-releasing parameters to ETPS
protocols (Christopher, Lorenzo, Zirbs, Chantraine, &
Visher, 1992; Lehmann, Russell, Spratt, Liu, Fairchild, &
Christensen, 1986; Pomeranz & Niziak, 1987)

Key Acupuncture Points FIGURE 54.1 B 40 is a distal acupuncture point that influences
proximal low-back pain
Key acupuncture points are utilized for their beneficial
therapeutic effects on the body. Distal points located
on the extremities are stimulated to produce proximal
pain relief and have been integrated into ETPS proto-
K3
cols to enhance pain relieving benefits. Four examples
of distal points related to the treatment of back pain
are described below.
• B 40 (Figure 54.1). An effective low back pain
point integrated into circuits with ETPS back
pain protocols to produce a highly effective
therapeutic stage. Located on the midline of the
transverse knee crease. FIGURE 54.2 K 3 is a distal acupuncture point for low-back
pain. Very effective for sciatica patients with pain aggravated in
• K 3 (Figure 54.2). Is circulated with L4-L5 seg- the morning
mental levels for back pain that is worse in the
morning. Located halfway between the apex of
the medial malleolus and the Achilles tendon.
• B 60 (Figure 54.3). A powerful sciatic point cir-
cuited with L 4-L 5 segmental levels for afternoon
back pain. Located halfway between the apex of B 60
the lateral malleolus and the Achilles tendon.
• Gb 34 (Figure 54.4). An influential point for
muscles, tendons and tissues that should
always be incorporated into the first stage of a
standard protocol because of its ability to
reduce muscular hypertonicity and spasticity
throughout the entire body. Applying ETPS FIGURE 54.3 B 60 is a distal acupuncture point for low back
therapy to this acupuncture point is an absolute pain. Effective for sciatica patients reporting aggravation in the
evening
must for therapists who perform manual or soft
tissue therapy on patients. Located inferior and
posterior to the head of the fibula.
brandt, 1976; Hartley, 1989; Low & Reed, 1994; Robin-
son, Mackler & Snyder, 1995; Travell & Simons, 1992).
Meridian Numbering System for Point Location
For this reason, ETPS therapy uses the acupuncture merid-
Soft tissue research suggests that there is a strong thera- ian numbering system to assist in point location. In addi-
peutic connection between trigger, motor and acupuncture tion, the meridian system facilitates greater anatomic spec-
points and a low level of skin resistance (Gunn & Mil- ificity when locating trigger points compared to palpation.
670 Pain Management: A Practical Guide for Clinicians, Sixth Edition

The circulatory setting is especially important with

some chronic pain categories, such as fibromyalgia and
reflex sympathetic dystrophy, where the traditional vaso-
constrictive approach to pain therapy is poorly tolerated
by patients. The therapeutic versatility necessary to treat
positive and negative polarity is accomplished with
Gb 34 ETPS’ neuro point stimulator, which has a current rever-
sal function.
The importance of polarity in the treatment of pain
should not be discounted. Based on our clinical experi-
ence there appears to be a 70:30 split in the chronic
pain population: approximately 70% of patients respond
better to vasoconstrictive therapy (sedation), while 30%
report respond better to vasodilative therapy (tonification).
With ETPS stimulation, therapists have the option of
FIGURE 54.4 GB 34 is the myofascial release point, also easily incorporating these ancient, but powerful healing
known as the “physical therapy point” in acupuncture. Applied in philosophies into treatment protocols increasing flexi-
circuits for myofascial release of receptor muscles bility and individualizing the therapy to better suit
patient needs.
To demonstrate the advantages of the meridian numbering
system, consider acupuncture point Gb 21 and the upper
THE RELATIONSHIP BETWEEN R ADICULOPATHY,
trapezius trigger point. Although physically the same
AND NEUROPATHY AND CHRONIC P AIN
point, locating Gb 21 through the acupuncture meridian
system is generally easier and will result in a more exact Neuropathic Therapy
positioning compared to efforts to identify the upper tra- ETPS therapy has achieved significant success in relieving
pezius trigger point through palpation alone. pain by integrating acupuncture philosophies into pain
protocols. However, a singular reliance on acupuncture
Circulation and Energy for treatment was found to be insufficient in addressing
Blood and circulation in ETPS therapy are assumed to a number of neuropathic and mechanical issues. For
be in line with the concept of chi in acupuncture. Chi is instance, acupuncture offers no clear direction for the
a difficult concept to translate into English, but can be treatment of impinged nerves, nor does it integrate der-
described as flowing energy, vitality or life force. In the matomes and neuropathic pain patterns into protocols.
Oriental concept of medicine and the human body, the Through years of experience, ETPS therapy has found
maintenance of health is achieved by releasing blocks, that neuropathy plays a role in chronic pain and that its
often caused by muscular tension, that restrict the flow treatment through ETPS therapy can, in some cases,
of positive (yang) and negative (yin) energy. Many ailments, reduce or eliminate the need for drugs and surgery.
including neuromyofascial pain, are thought to be symp- The introduction of neuropathic pain therapies into
tomatic of restricted or unbalanced chi. ETPS protocols greatly enhanced the understanding and
Much of the skepticism with chi in Western culture therapeutic outcomes of chronic pain syndromes. The
largely centers on the inability of modern science to quan- theories of radiculopathy and neuropathy suggest that noci-
tify this energy force. Rather than casting doubt on the ception and inflammation are not the catalyst for chronic
existence of chi, the lack of recognition reflects the inflex- pain syndromes. Instead, the root of many chronic pain
ibility and underlying hubris of modern Western para- syndromes appears to be neuropathy and the muscular
digms. Acceptance of chi is not a prerequisite for practic- contractions causing neuropathy.
ing ETPS therapy; however, an open mind to its potential The cause of neuropathy is thought to be severe mus-
healing power is necessary. cular contraction, that is, muscles that have contracted
ETPS adopts a simplified approach to chi. Positive and remain contracted in the absence of action potential.
or negative polarity (vasodilative or vasoconstrictive Radiculopathy, defined as neuropathy at the nerve root,
therapy) may be applied to trigger or acupuncture points seems to have the strongest influence on chronic pain
depending on the historical response of the condition to syndromes. Radiculopathy impinges nerves at the root
heat and ice. Excessive or hyperfunctioning conditions and causing abnormal functioning of the pathways as
usually respond better to vasoconstrictive therapy, while well as the muscle tissue they innervate. In this way,
deficient or hypofunctioning conditions respond better radiculopathy creates an increased susceptibility to
to vasodilative therapy. injuries along the dermatomes to the nerve endings.
ETPS Neuropathic Acupuncture 671

environment created by increasing susceptibility to

extremity neuropathy also increases susceptibility to distal
injuries. Based on this series of relationships, it should be
apparent that the treatment of most distal injuries must
include an examination of the spine. In other words, if the
spine significantly contributes to distal injuries, it should
be a focus in pain therapy.
If paraspinal muscular contractions (radiculopathy)
are a significant contributor to distal pain and/or disease, then
the release of paraspinal muscles through ETPS therapy
should provide relief to distal pain disorders. Therefore
stimulating the paraspinal “Back Shu” points, which
directly influence radiculopathic segments, can relax con-
tracted muscles to a degree sufficient to reduce nerve
FIGURE 54.5 Top muscle illustrates muscular homeostasis. impingement and allow the increase of motor impulses
Lower muscle indicates muscle shortening, stretching of the throughout the nerve pathways.
tendons and straining of the joints.

Manifestations of Radiculopathy
ETPS electrical stimulation produces a myofascial
and Neuropathy
release of contracted muscles. When muscles contract
and remain contracted, there is an electrical Back Shu points are located paraspinally at the level of
depolarization within the muscle (Fambrough, Hartzell, the spinous process interspace. Segmental levels with
Powell, Rash & Joseph, 1974; Becker & Gary Selden, radiculopathy should be selected according to the follow-
1987). ETPS direct current stimulus creates an electrical ing manifestations:
loop within the muscles, enabling electrical repolarization Bilateral signs of trophedema are usually located at
and thus, relaxation of the muscles (Figure 54.5). segmental levels L1 – S3. Trophedema is a col-
lagenic change in the skin that occurs when
Radiculopathy and Chronic Pain impinged nerves reduce the flow of motor
Poor postural lifestyle and repetitive strain motions, impulses through pathways. Trophedema may
usually occurring while playing sports or in the workplace, be located with the “skin rolling” test, which
contribute to a pooling of “micro” injuries in the paraspi- will clearly identify the location in relation to
nal muscles. If a sufficient number of micro injuries build non-trophic skin (Figure 54.6). Another mani-
up over time, a relatively minor movement by the patient festation, sudomotor, can be identified visually
can initiate paraspinal muscular contraction severe because it produces a general warmth and sweat-
enough to produce radiculopathy and chronic pain (Brad- ing in the vicinity of radiculopathy. Troph-
ley, 1974; Gunn, 1980; Gunn, et al., 1976; Gunn, et al., edema and sudomotor manifestations are com-
1978; Gunn & Milbrandt, 1976; Loh & Nathan, 1978; monly located in the lumbar sacral segmental
Sola, 1981; 1984, Thomas and Ochoa, 1993). levels of L1 - S3. Once the radiculopathic seg-
Radiculopathy caused by paraspinal muscular con- ments have been identified, they are correlated
traction is believed to affect the ANS by impinging nerves via dermatomes to distal injuries/pain conditi-
at the nerve root, usually proximal to the dorsal/ventral ons to determine root involvement in chronic
rami juncture. Nerve impingement reduces the flow of pain conditions.
motor impulses throughout the nerve pathway. According Motor bands may be palpated paraspinally through-
to Cannon’s Law of Denervation (Cannon & Rosenbluth, out contracted muscles, usually T2–T12. Cross-
1949), a reduction of motor impulses through a nerve fiber palpation will easily identify thick, ropy
pathway produces disuse sensitivity and abnormal behav- bands within paraspinal muscle bellies which often
ior within the receptor organ or tissue. run the entire length of the muscle.
Radiculopathy influences tissue throughout the entire Posterior and lateral neck creasing at segmental
dermatome by reducing the flow of motor impulses at levels, usually C2–T1 (Figure 54.7). Skin
the nerve root. Nerve impingement and radiculopathy also creasing suggests that some degenerative
influence distal pain by elevating acetylcholine (ACH) changes have occurred in the neck at the
and adrenaline levels throughout the pathways (Cannon related segmental level. Occasionally, major
& Rosenbluth, 1949), thereby increasing susceptibility creases will occur at every correlating segmen-
to extremity muscular contraction (i.e., neuropathy). The tal level on the neck.
672 Pain Management: A Practical Guide for Clinicians, Sixth Edition

FIGURE 54.6 Illustration of trophedema (physical manifestation of nerve impingement, called radiculopathy) as demonstrated using
the “skin rolling” test.

ley, 1974; Gunn, 1980; Gunn, et al., 1978; Gunn, et al.,

1976; Gunn & Milbrandt, 1976; Loh & Nathan, 1978;
Sola, 1981; 1984, Thomas and Ochoa, 1993).
Neuropathy, and radiculopathy in particular, increases
the upregulation of the sympathetic nervous system by
reducing the flow of motor impulses making treatment dif-
ficult due to the patient’s high sensitivity levels. Parasympa-
thetic points treated with vasoconstrictive therapy deregulate
the sympathetic nervous system, thereby permitting a more
aggressive and proactive approach to patient treatment.
Key parasympathetic points are as follows:

• Lu 9 (Figure 54.8). A powerful vascular/para-

sympathetic point. Located on the transverse wrist
FIGURE 54.7 Illustrates lateral creasing in the neck and the crease, in the a hollow on the ulnar side of the
suggested location of myofascial release points throughout tight radius bone
motor bands. DO NOT apply microcurrent stimulation anterior • P 6. A good nausea and parasympathetic point.
to the corner of the jaw (over the carotid sinus).
Located three fingers proximal from the most distal
wrist crease, deep between the palmaris longus and
Sympathetic Deregulation flexor carpi tendons.
with Parasympathetic Points • H 7. A good mind calming and parasympathetic
The ANS is comprised of the sympathetic and parasympathetic point. Located on the transverse wrist crease, in a
nervous systems. Both neuropathy and radiculopathy hollow on the radial side of the thick, flexor carpi
stress the ANS by producing nerve impingement. Nerve ulnaris tendon.
impingement blocks the flow of motor impulses and • Sp 6 (Figure 54.9). An immune, parasympa-
deprive an organ or tissue of excitatory input (e.g., neural thetic and distal pain point for perineum. Located
impulses) for a period of time causing disuse supersen- four fingers superior to the medial malleolus and
sitivity. Supersensitive nerve pathways and innervated posterior to the tibia bone. Press against the
structures react abnormally to stimuli, causing patients to posterior edge of the tibia bone to find this tender
perceive more pain than is actually being created (Brad- point properly.
ETPS Neuropathic Acupuncture 673

• K 3. A low back pain, congenital energy and

parasympathetic point. Located in the hollow
midway between the medial malleolus and the
Achilles tendon. Used for morning back pain,
circuited with B 25 (L4-L5 interspace).
• Cv 17 (Figure 54.10). A respiratory and para-
sympathetic point. Located on the midline of
the sternum, horizontal with the fourth inter-
costal space.
H 7 THE RELATIONSHIP BETWEEN D ERMATOMES
AND CHRONIC PAIN
Lu 9
The application of ETPS therapy requires an inspection
of dermatomes for their interrelationship with segmental lev-
P6 els. This important inspection will provide evidence in
determining if radiculopathy is contributing to a pain con-
FIGURE 54.8 Three upper limb parasympathetic points Lu 9,
P 6, and H 7, used to deregulate the Autonomic Nervous System
dition. Distal injuries are correlated first with their der-
(ANS), permitting continued therapy on supersensitive patients. matomes and second proximally to the segmental levels that
innervate the dermatomes. ETPS stimulation to paraspinal
points that influence the dermatomes and nerve pathways
will relax contracted muscles, allowing for increased motor
impulses throughout pathways, improved nerve regenera-
Sp 6 tion and reduced pain levels (Figure 54.11).
There are three ways to integrate the nerve root with
K3 pathways and dermatomes: segmental nerve root and
paraspinal stimulation, nerve pathway treatment, and inte-
grative circuits and nerve ending treatment using distal
dermatome and acupuncture points.

Paraspinal Point Location

FIGURE 54.9 Sp 6 and K 3 are lower limb parasympathetic
Radiculopathy and nerve impingements often occur
points, for deregulation of lower viscera. Again, permitting paraspinally at the segmental nerve root and innervate the
continued therapy on sensitive patients. injury or pain area. Locating and treating paraspinal points
corresponding to radiculopathic segmental levels is an
important step in the application of ETPS protocols.
These paraspinal points are located approximately 1 in.
bilateral to the midline on the medial border of the erector
spinal muscles ridge. When stimulated, they provide a
relaxing effect on the deep paraspinal muscles of semispi-
nalis, longissimus and iliocostalis, all of which influence
the entire spinal column and the extremities through the
Cv 17 dermatomes. One of the most successful applications of
this ETPS paraspinal therapy is at the L4-S2 segmental levels,
which innervate the lower limbs and feet. Paraspinal stim-
ulation of L4-S2 segmental levels can provide significant
pain relief to the vast majority of patients suffering from
lower extremity pain such as plantar fasciitis, peripheral
neuropathy, metatarsalgia and heel spurs.
The integration of paraspinal segmental points into
the clinical pain setting is an effective therapy. Pain
FIGURE 54.10 Acupuncture point for body calming. Also
called “sea of tranquility”, Cv 17 should ONLY be treated on
must travel through the pathways and all pathways are
severe pain patients, and only AFTER all the above points have connected to the spinal cord. Spinal Back Shu points
been treated. are selected according to neuropathic manifestations
674 Pain Management: A Practical Guide for Clinicians, Sixth Edition

region. In traditional acupuncture, this segmental level

relates to the kidneys, widely regarded as powerful organs
in pain therapy, which indirectly influence the spinal col-
umn. Paraspinal points at segmental level L2-L3 (B 23
radiculopathy in acupuncture) are circuited with B 40 (a distal acupunc-
ture point for the lower back) to produce a powerful anal-
gesic response for lower back pain.
Another circuit combines segmental levels L4–L5
(B 25 in acupuncture) with the important low back pain
point B 60 (lateral malleolus). B 60 strongly influences
the L5 dermatome, and produces a strong analgesic
response in sciatic patients when circuited with the L4-
L5 nerve roots. This circuit is ideal for patients whose
radiculopathy pain gets progressively worse throughout the day.
The circuit L4–L5 (B 25) and K 3 (medial malle-
pain
olus, opposite B 60) provides another opportunity to
individualize pain treatment to meet patients’ needs.
This circuit is ideal when sciatic/low back patients dis-
play morning pain and stiffness that may or may not
improve throughout the day. Recognizing that patients
with morning back pain and stiffness often display weak
kidneys, circuiting B 25 and K 3 treats the kidneys by
helping to relieve stiffness and stimulate nerve roots,
thereby addressing radiculopathic and energetic contri-
butions to injury. (See Figure 54.12.)
In ETPS therapy, there are numerous circuits that
produce outstanding responses. A therapist who pos-
sesses a working knowledge of dermatomal patterns and
extremity acupuncture points may use this understanding
to create integrative circuits. Circuits are created between
the dermatomal nerve root (spinal points) and any major
trigger/acupuncture points located distal to the injury.
These circuits permit therapists to release individual or
pain groups of muscles in one application, ultimately saving
manual therapists time and effort.
FIGURE 54.11 Illustrates nerve root impingement called
radiculopathy, influences distal pain throughout the extremities.
Integrating Dermatome Points
observed at the segmental levels that innervate the injury The final approach to integrating segmental/dermal ther-
or pain syndrome. Different manifestations will affect apy is the treatment of dermatome points located on the
different segmental levels. Brief stimulation of these lateral and medial side of the nail base at the tips of the
spinal points with ETPS therapy provides an easily fingers and toes. All dermatomes and meridians connect
integrated, diagnostic and effective approach to chronic the extremities with the midline. Therefore, if stimulation
pain management. is applied at the nerve root to alleviate distal pain, stimu-
lation may also be applied to the extremities to alleviate
Integrative Neural Circuits proximal pain. Stimulation is applied to dermal points on
Circuits have been used in acupuncture therapy for cen- the fingers and toes relating to pain along dermatomes and
turies. A circuit consists of a series of stimulated points meridians. In our experience dermatome point stimulation
integrated into a single treatment to produce enhanced has been found to be a successful treatment for a signifi-
therapeutic benefits. In ETPS therapy, selected acupunc- cant percentage of patients who are unresponsive to nerve
ture, trigger and motor points are circuited for their ability root and pathway treatments and an integrative adjunct
to isolate nerve pathways and relax specific muscles and to improve outcomes. (See Figure 54.13.)
groups of muscles. Segmental level L2-L3 has, for Successful applications of this circuit are often applied
instance, a strong analgesic relationship with the lumbar on the feet. Segmental levels L4-S2 innervate the feet
ETPS Neuropathic Acupuncture 675

B 23 FIGURE 54.12 Illustrates neural

circuits performed in ETPS therapy.
B 40 B 40 Circuits B 23-B 40 are treated
B 25
bilaterally to reduce upper leg pain
and calm nerve pathways resulting
from radiculopathy. Circuits B 25 –
K 3 are integrated bilaterally for back
patients with pain aggravation in the
morning. Circuits B 25 –B 60 are
B 60 integrated bilaterally for back
K3 patients with pain aggravation in the
afternoon or evening.

ETPS individually to produce an effective analgesic

response in the lower back. More importantly, these der-
mal points also represent the end of the two acupuncture
meridians, the gall bladder and the bladder, both of which
have a strong influence over hip and back pain. Gb 44 is
located on the fourth toe and B 67 is located on the fifth
“baby” toe. Proximally following the meridians, the gall-
bladder meridian influences the lateral leg and hip region,
while the bladder meridian influences the spine. There-
fore, these two points may be used to diagnostically deter-
mine root causes of low back or hip pain. If Gb 44 is more
sensitive than B 67, the piriformis-iliotibial fascial mus-
cles (and therefore the gait) are more likely to be respon-
sible for a patient’s back pain. If B 67 is more sensitive,
local spinal pathology, such as a bulging disc, is most
likely responsible. Through years of ETPS experience, the
sensitivity of these two points has proven to be an accurate
diagnostic indicator of pain, mechanical imbalances or
neuropathy along the meridian or the muscles that inter-
sect the meridian. (See Figure 54.14.)

Myofascial Release with Dermatome

Therapy Points
The cross integration of dermatomal points with acupunc-
ture meridians displays the flexibility of ETPS therapy.
Dermatome points correspond strongly with jing well
points, acupuncture points used to treat acute diseases in
related organs. Dermatome point stimulation is also an
effective treatment for myofascial release of muscles relat-
ing to, or intersecting with, correlating meridians. The
integration of dermatomal and jing well points has proven
successful in the treatment of hard to reach muscles, such
FIGURE 54.13 Illustration of the segmental dermatomes. as the psoas, and difficult injuries, such as adductor groin.
Far from experimental, this technique has been applied
for decades in many therapies, including Electro Acupunc-
with the fourth and fifth toes representing the L5 and S1
ture According to Voll (EAV) therapy, with much reported
dermatomes. These two points may be stimulated with
success. The example described below, focusing on the
676 Pain Management: A Practical Guide for Clinicians, Sixth Edition

psoas
muscle

B 67
(S 1)
Gb 44
(L 5) Sp 1
K1 (L 4)
(L 5) St 45
Liv 1
(L 5)
(L 5)
FIGURE 54.14 Distal acupuncture points which correspond to
the segmental dermatomes. Located at the base of the nail, on the
illustrated side.

stomach meridian and the psoas muscle, demonstrates

an effective application of this approach.
There is a strong myofascial/therapeutic relationship FIGURE 54.15 Illustrates the stomach meridian and the
between the psoas muscle, the stomach meridian and the anatomical location of the psoas muscle.
corresponding jing well point. If the stomach merid-
ian is followed proximally from the distal end at St 45
(located on the lateral base of the second toenail), the
meridian travels through the quadriceps and intersects
the psoas muscle (Figures 54.15 and 54.16). Stimulation
of St 45 provides effective myofascial release of the
corresponding ipsilateral psoas muscle. Widespread suc-
cess of this technique has been witnessed at ETPS work-
shops and reported through clinical feedback, with
approximately 80% myofascial release occurring within
minutes of treatment. This unique ETPS response can
save manual therapists a significant number of hours of
therapeutic work in addition to rescuing patients from
the agony of deep manual therapy.
Another therapeutic pearl is the stimulation of Sp 1
(L4 dermatome point located at the medial nail base
of the first toe) for groin pain. Traditionally used for
acute menstrual cramping, this technique has proven
successful in relieving pain associated with difficult to
treat adductor groin injuries in ETPS therapy. In many
cases, successful results have been achieved within St 45
(L 5) Sp 1
minutes of treatment.
psoas (L 4)
The integration of dermatome points provides one of
hip flexors
the simplest approaches to the treatment of pain. With a
working knowledge of dermatomal patterns and acupunc- FIGURE 54.16 Illustrates the integration of acupuncture “jing
ture meridians, a therapist can quickly treat any proximal well” points with meridians for myofascial release of psoas and
segment or muscle with the related dermal points. hip flexor muscles.
ETPS Neuropathic Acupuncture 677

THE RELATIONSHIP BETWEEN THE GAIT the nerves and an upregulation of the sympathetic nervous
AND CHRONIC P AIN system. Thus, radiculopathy not only contributes to and
perpetuates chronic pain, but can also serve as the major
For many years, different fields of science and meridian precipitator of chronic pain syndromes in many cases.
research have studied the mechanics of the human body After studying hip positioning and mechanical relation-
in order to identify potential relationships with chronic ships to the gait, there appears to be a neuropathic, and
pain. Based on our experience with ETPS therapy, there therefore, myofascial component to asymmetrical position-
appears to be a causal relationship between the gait and ing. If contracted, the piriformis muscle, and its specific
several chronic pain syndromes. In more precise terms, attachments, may be responsible for gait misalignments.
body asymmetry produces an irregular gait that stresses Viewed through the ETPS framework of analysis, the tro-
the ANS, which in turn causes pain (Figure 54.17). chanter will be pulled upward (superiorly) in the acetabulum
“Gait” refers to the postural positioning of the iliac if the piriformis contracts, thereby producing a positive,
crest and its subsequent relationship to the spine and or higher, hip on one side. This imbalance in turn pulls up
lower limbs. A positive right ‘gait’ will, for instance, the femur to create a LLD. Therefore, the first step in treating
produce a shortened right leg and a length discrepancy gait imbalances should be a manual correction of the gait
between the two legs. Leg length discrepancy (LLD) and LLD after a visual inspection has been completed.
leads to asymmetrical movement with a disproportional Current therapeutic solutions to LLD include lifts and
amount of body weight shifted to the longer and often orthotics. The problem with these solutions is that they
weaker leg (Figures 54.18 and 54.19). do not specifically address the root causes of LLD. The dom-
Positive gait irregularities also stress the spine to pro- inant one-sided nature of human body, combined with
duce misalignment of the segments, asymmetrical move- the prevalence of repetitive-action lifestyles, places stress
ment and paraspinal degenerative changes. These on the piriformis muscle resulting in contraction. If true,
mechanical imbalances precipitate muscular contractions leg length corrections that do not address the gait may
and radiculopathy (Friberg, 1983; Yochum & Berry, 1994). actually contribute to poor body mechanics and a
Radiculopathy leads to denervation supersensitivity of continued stressing of the ANS.

Mechanical
homeostasis

FIGURE 54.17 Mechanical homeostasis, as seen by level hip, shoulders and trochanters.
678 Pain Management: A Practical Guide for Clinicians, Sixth Edition

shoulder
imbalances

release left
trochanter

Positive left “gait”

(from rear view)
FIGURE 54.18 Illustrates superior movement of left trochanter
in the acetabulum. This is often due to contraction of the piriformis
muscle, which precipitates mechanical imbalances of the shoulders
and hips, and leg length discrepancy of the left leg. Called a
positive “left” gait.

release right
Positive right “gait” trochanter
(from rear view)

FIGURE 54.19 Illustrates superior movement of right trochanter

in the acetabulum. This is often due to contraction of the piriformis
muscle, which precipitates mechanical imbalances of the shoulders
and hips, and leg length discrepancy of the right leg. Called a
positive “right” gait.
ETPS Neuropathic Acupuncture 679

Manual Piriformis Stretch thereby misaligning the gait and creating the conditions
for the cycle to reappear.
In ETPS therapy, a specific manual therapy called a piri-
Two circuits will release the piriformis, hip and
formis stretch is performed in order to reposition properly
lateral thigh muscles (Figure 54.20). The first is the pir-
the trochanter in the acetabulum. In other words, realign
iformis-IT circuit. To start, palpate cross-fiber at the
the hip and pelvis. Stretching the piriformis until the tro-
superior angle of the piriformis muscle. Thick motor
chanter and acetabulum restore proper gait balance will
bands are often easily palpated where piriformis glute
produce symmetrical leg lengths and mechanical homeo-
min/medius meet. Apply one circuit to the most tender
stasis throughout the body. With the patient in the prone
trigger point found within the motor bands; the other
position, approach from the right (R) side, place your
circuit should be applied to the trigger point of the ili-
R hand on the superior angle of the trochanter at a 45o
otibial band (found at the end of main rae with hands at
angle. Lift the leg 6 in. above the knee with the left (L)
the side (Gb 31 in acupuncture). Simultaneous stimula-
hand and abduct the leg to a 30 o angle or until trochanter
tion of these two points often provides a strong myofas-
becomes prominent on the R hand.
cial response between the hip and lateral thigh muscles,
In one motion, rotate your R hand medially and use
creating immediate pain relief. It also allows the pirifor-
the L hand to gently lift the R leg on midline (beside the
mis muscle to relax and facilitates proper positioning of
L leg). If properly executed, this piriformis stretch places
the trochanter in the acetabulum.
the trochanter in the proper anatomical location creating
Piriformis-Gb 34 is the second circuit. For this treat-
hip, spine and mechanical symmetry throughout the
ment, keep one modality on the same tender piriformis
body. In some cases, the shortened leg is so badly dis-
trigger point as above. The other modality is placed on
placed in the trochanter that this realignment technique
Gb 34, the acupuncture point responsible for relaxing
will make the shorter leg longer than the other one. For
muscle tissue (inferior and posterior to the head of the
this reason, the piriformis stretch should always be per-
fibula). This circuit performs an overall myofascial
formed bilaterally to ensure symmetry of the hip and
release and often relaxes muscular tissue not released in
pelvis. The importance of symmetry throughout the hip
the first circuit.
and pelvis region in general, and the piriformis stretch
To perform a myofascial release, two circuits must be
in particular, cannot be understated in the fight against
created. The first is a circuit between the superior angle
chronic pain.
of the piriformis trigger point and the middle of the IT
band (acupuncture point Gb 31). The second circuit is
Myofascial Release of Piriformis using Circuits
performed between the superior angle of the piriformis
After achieving mechanical repositioning, a myofascial trigger point and the myofascial acupuncture point Gb 34
release on the piriformis must be completed to prevent the (inferior/posterior to head of fibula). These two circuits,
leg from recontracting and producing the same positive performed bilaterally, are effective in maintaining a myo-
gait and LLD. Without this release, a repetitive lifestyle fascial release of the piriformis and related gluteal and
would constantly pressure the piriformis to recontract, hip muscles responsible for gait misalignment.

Gb 31

Piriformis circuits

Gb 34

FIGURE 54.20 Piriformis circuits are performed to produce myofascial release of hip and leg muscles responsible for gait imbalances.
They are applied bilaterally after mechanical realignment for optimal, lasting results.
680 Pain Management: A Practical Guide for Clinicians, Sixth Edition

The integration of a piriformis stretch/release is an microcurrent stimulation may be applied with traditional
important part of ETPS protocols. Its introduction can pads or via point stimulation. Truly integrative therapies,
significantly improve soft tissue and mechanically-based such as ETPS, employ potent, versatile and patient-
therapeutic outcomes of any pain program. Once learned, friendly stimulation. Based on these criteria, an initial
the stretch can be applied in seconds and should be inte- treatment utilizing invasive needles is relatively less pro-
grated into any pain management protocol. ductive because it damages tissue and requires a recovery
and/or an incubation period of 20-30 minutes to deter-
THE RELATIONSHIP BETWEEN S CAR THERAPY mine therapeutic efficacy. In contrast, ETPS therapy can
AND CHRONIC P AIN often generate positive results in a matter of minutes.
Occasionally, patients may continue to suffer from pain after ETPS therapy is best applied with noninvasive direct
receiving treatment based on the above-mentioned therapeu- current (DC) stimulation. Alternating current (AC) is
tic steps addressing the mechanical and myofascial compo- ineffective because it does not produce the square wave
nents of chronic pain. Therefore, other sources of pain, such necessary for the stimulation of an endorphin response
as neural therapy, have been included into ETPS protocols (Christopher, et al., 1992; Lehman, et al., 1986; Pomer-
to treat scars throughout the dermatomes and meridians. anz et al., 1988; Pomeranz & Niziak, 1987). Further-
Neural therapy, the stimulation of scars for pain reduc- more, AC cannot by definition produce a monophasic
tion and homeostasis, has been an accepted and proven pulse, a form of stimulation that can be reversed in order
form of neuromyofascial pain therapy for years. Neural to produce the highly sought after vasodilative and vas-
therapy theory suggests that scarring restricts the flow oconstrictive responses (Bronzino, 1998). DC is also
of energy, disrupts the lymphatic and circulatory systems favored for its ability to repolarize contracted muscle
and interferes with muscle energy and mechanical tissue, a necessary physiological response for the release
stability of the body. All of these systems are adversely of myofascial tension. Finally, DC stimulation is pre-
affected when a scar influences the dermatome or ferred because it produces few, if any, adverse side
meridian to which it is connected. effects. With no significant iatrogenic responses, nonin-
For unresponsive pain conditions, inspection for distal vasive and concentrated DC stimulation can be used to
scarring along the dermatomes or distal/proximal scarring treat multiple systems at one sitting, thereby creating an
along the meridian can be helpful in determining where opportunity to outperform traditional needle therapies
to treat the pain condition next. If a scar is located in the that concentrate on one system in each treatment. The
corresponding dermatome or meridian, ETPS stimulation result is greater therapeutic versatility and productivity.
along the scar perimeter can provide immense relief to ETPS applies DC microstimulation in stages to deter-
suffering patients. This approach is especially effective mine the root cause of chronic pain syndromes. Concen-
if there is extremity joint scarring, especially around the trated DC microstimulation, applied by a point stimulator,
ankle and knees. is the only modality that can produce therapeutic
Based on current medical knowledge, it is not clear responses quick enough to eliminate or include
why scar stimulation is an effective form of treatment for therapeutic systems into future treatment protocols.
some patients. One leading theory suggests that neural Traditional TENS, applied by pads, is far too inefficient
therapy “breaks up” the collagenic tissue surrounding the a stimulation to produce beneficial therapeutic response
scar. Intermittent stimulation of the scar perimeter, some- in a short period of time (Cheng & Pomeranz, 1986;
times called “surrounding the dragon,” is thought to break Gadsby & Flowerdew, 2000). Therefore, pad stimulation
up scars, thereby permitting an increase in the functioning is not the desirable modality for ETPS therapy.
and homeostasis of the lymphatic, energetic, neural and
circulatory systems. Irrespective of the pathology, scar PART B: ETPS INTEGRATIVE PROTOCOLS
treatment has been found to reduce local pain. The stim- ETPS integrative protocols combine the therapeutic
ulation of scars relative to the injury via dermatomes and efficacy of acupuncture, intramuscular therapy and
meridians has produced impressive therapeutic responses neural therapies. As a rule, a mechanical neuropathic
with some hard-to-treat chronic local pain as well as dis- assessment is performed and stimulation is applied in
comfort along the dermatome and meridians stages in order to isolate fascial, neural or meridian
systems and to determine and treat the root cause(s) of
APPLICATION OF ETPS STIMULATION neuromyofascial pain. The application of these differ-
Traditional stimulation of trigger, motor and acupuncture ent integrative therapies, methodically and in stages, to
points includes invasive techniques such as acupuncture isolate different therapeutic systems provides a window
and hypodermic needles and non-invasive modalities such of opportunity for health care practitioners (HCP) to
as TENS and microcurrent stimulation. Both TENS and diagnose soft tissue pain.
ETPS Neuropathic Acupuncture 681

The first step in the treatment of any chronic pain 3. Treat radiculopathy at levels identified in Step 1
condition is to assess and apply the ETPS Standard with a paraspinal release using Back Shu points.
Protocol. The ETPS Standard Protocol is designed These points are located at each segmental level
to address body mechanics, radiculopathy and spine at the spinous process interspace (SPI), ap-
therapy as well as fascial contractions responsible for proximately 1 in. bilateral at the medial border
positive gait and body misalignment. ETPS therapy of erector spinal muscle ridge (two fingers
initially assumes that chronic pain syndromes have a bilateral from midline).
precipitory influence from the hip misalignment and The simultaneous application of two ETPS
lower back radiculopathy. Therefore, the Standard modalities to these bilateral spinal points
Protocol will identify or eliminate the nerve root, provides an exceptional myofascial release
gait and body mechanics as a major contributor to of the paraspinal muscles that precipitate
the chronic pain condition. radiculopathy and nerve impingement. If
Depending on the results of the initial assessment, ETPS therapy is applied to a series of spinal
one or more specific sets of protocols may be performed. points correlating to an area of radiculopathy
The Standard Protocol is described below as well as that innervate distal pain or injuries the entire
protocols for back pain, neck pain, fibromyalgia and pain condition may be treated. (Figure 54.21)
plantar fasciitis. 4. Release piriformis with fascial circuit Pirifor-
mis – IT band, Piriformis – Gb 34.
STANDARD PROTOCOL Release fascia responsible for gait misalignment
1. Assess patient for gait and radiculopathic irreg- by performing a fascial circuit between any
ularities. tender motor bands palpated throughout the
The first step in standard protocol is to assess piriformis muscle, the IT band point (Gb 31)
the patient in order to determine the degree and the myofascial point Gb 34 (Figure 54.22).
of discomfort, range of motion or injury, Ask the patient to sit up slowly and then
degree of disability and level of pain. Iden- slide off the table placing both feet on the
tify gait imbalances through iliac crest levels ground at the same time (to prolong treat-
and leg length discrepancies. Select vertebral ment outcome).
segments that display radiculopathic manifesta- The Standard Protocol effectively treats lower
tions of trophedema and sudomotor responses. back radiculopathy and fascial components
of gait and overall mechanical imbalances.
2. Manually release gait and stretch piriformis. Many pain conditions throughout the body
Manually release the gait using the piriformis may be effectively treated with the Standard
stretch (as described in Part A). Start with the Protocol, suggesting that radiculopathy and
side that has the positive (or higher) gait and gait imbalances are major contributors to the
the shorter leg. Perform stretch bilaterally. chronic pain cycle.

Treat spinal points at

segmental levels where
radiculopathy is found

FIGURE 54.21 Illustrates paraspinal points treated in areas of trophedema (nerve root impingement), identified during skin rolling
test. (See Figure 54.6)
682 Pain Management: A Practical Guide for Clinicians, Sixth Edition

Gb 31

Piriformis circuits

Gb 34

FIGURE 54.22 Piriformis circuits are performed to produce myofascial release of hip and leg muscles responsible for gait imbalances.
Applied bilaterally after mechanical realignment for optimal, lasting results.

Other Integrative Protocols Presented below are four additional protocols for the
ETPS Integrative protocols go beyond standard procedures diagnosis and treatment of back pain, neck pain, fibromy-
with the inclusion of segmental levels, fascial planes and algia and plantar fasciitis.
acupuncture-trigger points that work well for individual
pain conditions. Additional circuits, fascial groups and BACK PAIN PROTOCOL
modalities are included on a step-by-step basis with an Step 1 Apply Standard Protocol.
assessment performed at the end of each step or stage. Assess patient after each of the following stages.
ETPS protocols are designed to integrate different • Check gait–piriformis
philosophies and apply treatments in stages to determine • Inspect for signs of neuropathy and radicu-
the root cause of pain. Once the root causes have been lopathy, especially between L2–S2.
determined, continued treatment may be applied to areas • Manually release gait
known to produce therapeutic responses. If applied prop- • Perform paraspinal release at segments with
erly, ETPS therapy can diagnosis the root cause of pain trophedema (-ve)
with a significant degree of accuracy, thus assisting all • Circuit piriformis–IT Band (-ve) and piri-
HCP in the treatment of chronic soft tissue pain. formis–Gb 34
In ETPS therapy, the patient is assessed before and Step 2 Stimulate circuits designed to treat the nerve
after each therapeutic stage to determine the degree of pathway or meridian involved with injury.
success. With several therapeutic stages in back pain, it Perform these circuits bilaterally with patient
is possible to determine which segmental levels, muscle
lying in the prone position. Ask patient to sit
dermatomes and meridians are responsible for the
up and dismount with both feet landing on
patient’s pain in approximately 10 to 15 minutes. Gener-
the floor at the same time. (See Figure 54.23)
ally, one or more stages will produce pain relief for the
• Circuit L2–L3. Interspace with B 40 (low
majority of patients, thus indicating which dermatomes,
back pain distal point) and treat with nega-
segments, muscles and meridians should be investigated
further as the source of chronic pain. Stages that produce tive (vasoconstrictive) polarity.
minimal or negative responses (i.e., the patient and pain • Circuit L4–L5. Interspace with B 60 (ana-
are noticeably worse after treatment) should be elimi- tomic and acupuncture trigger point) for
nated in future treatment episodes. Using this therapeutic patients whose pain becomes more severe
process of elimination, therapists can investigate and treat throughout the day
patients at the same time, ultimately producing faster and • Circuit L4–L5 with K 3 (kidney source
more effective outcomes. After assessing the exact points point) for patients with back pain and stif-
and therapeutic systems using the ETPS elimination pro- fness that is most severe in the morning.
cess, concentrate only on those stages that produce Step 3 Stimulate Sacral Triangle and dermatomal points
positive therapeutic benefits. for lateral hip release and spinal pain.
ETPS Neuropathic Acupuncture 683

B 23
B 40 B 40
B 25

B 60 K3

FIGURE 54.23 Neural circuits performed between paraspinal nerve root points and key distal acupuncture points to reduce upper
leg pain and calm nerve pathways resulting from radiculopathy. Circuits B 23–B 40 are treated bilaterally. Circuits B 25–K 3 are
integrated bilaterally for back patients with pain aggravation in the morning. Circuits B 25 –B 60 are integrated bilaterally for back
patients with pain aggravation in the afternoon and evening. Apply vasoconstrictive ETPS Therapy.

• Sacral triangle includes B 67, Gb 44 and Gb 41.

B 67 (located at base of fifth toenail on lateral
side) and Gb 44 (located base fourth toenail
lateral side) and correlate to S1 and L5 derma-
tomes and nerve roots. Gb 41 is located at
proximal end of the fourth and fifth tendons.
The application of ETPS dermatome points can
produce useful information:
Gb 41
i. Are stimulated nerve endings most efficacious
in the treatment of proximal pain?
ii. Are the hip and gluteal muscles responsible
for back pain? If true, Gb 41 and Gb 44 will
be sensitive.
B 67 iii. Is spinal injury or disc bulge responsible for
back pain B 67? If true, the spine will be tender.
Gb 44
Step 4 Dermatomal points for anterior hip flexors.
FIGURE 54.24 Distal acupuncture points B 67 and Gb 44 are Located at the lateral side of the base of the second
combined with Gb 41 to produce “sacral triangle”. These points
toenail, St 45 isolates the treatment release of the
are treated to reduce proximal nerve root pain and for myofascial
release of hips in stage three (3) of back pain protocol. Apply psoas and hip flexor muscles. (Figure 54.25) With
vasoconstrictive ETPS Therapy. some pain patients, the psoas muscle may be con-
tracted alone or with the piriformis muscle. If pain
If success is limited in the first two steps, Step 3 can continues to persist after Steps 1 to 3, a quick
often provide immense relief to patients. Stimulation stimulation of St 45 (second toe base nail lateral
need only be applied for 20 to 30 seconds on the proper side) will reveal if the psoas muscle is contributing
dermatome point in order to provide relief. Based on to the pain condition. Patients should be assessed
our experience using ETPS therapy, a significant number between treatments of both the R and L points to
of patients with back pain will respond only to Step 3. determine which psoas muscle is most involved in
Treat the distal dermatome points involved with painful the injury. This step was integrated to include both
or radiculopathic vertebral segments and the posterior posterior and anterior hip stabilizing muscles in
lateral muscles believed to be involved with mechanical order to determine if they individually or collec-
gait imbalances. tively contribute to the patient’s chronic pain state.
684 Pain Management: A Practical Guide for Clinicians, Sixth Edition

St 45 Sp 1

FIGURE 54.25 Illustrates the acupuncture jing well points Sp 1 FIGURE 54.26 Tender points are treated at the end of ETPS
and St 45 used ipsilaterally for the myofascial release of the psoas protocols for additional pain relief. They are identified by the
and hip flexor muscles. Apply vasoconstrictive ETPS therapy. patient and treated in short intense bursts with ETPS stimulation.
Apply vasoconstrictive ETPS therapy.

Step 5 Neural therapy. NECK PAIN PROTOCOL

Application of ETPS stimulation to scars that intersect Step 1 Apply Standard Protocol.
with, or are located in, the dermatomes or on Pay special attention to radiculopathy at the L2-L3
meridians that relate to pain is an effective approach interspace levels, as they have a strong influence
to more complex pain conditions. Inspect for on neck pain.
scarring, either surgical or injury related, distal in Assess patient after each of the following stages.
the dermatomes to the injury and distal proximal • Check Gait – piriformis
to the injury/pain along the meridian. For back pain, • Look for signs of neuropathy and radiculopathy,
especially at the L2-L3 level.
inspect for scars along the lateral anterior knees
• Manually release gait
and paraspinal back. If scars exist, stimulate briefly
• Perform paraspinal release at segments with
(10 to 15 seconds) at 1/8-inch intervals surrounding
trophedema (-ve)
the scar. This process has produced effective
• Circuit piriformis - IT Band (-ve) and piriformis
responses with many patients.
- Gb 34
Step 6 Tender points. Step 2 Posterior Neck and Trapezius release.
• Paraspinally release cervical neck at level of
Tender trigger points are treated as a last step in the
crease identified in Step 1. This step is designed
therapy because ETPS assumes that all pain is
to diagnose and treat the posterior muscles of
referred from another anatomical area of the
the neck involved with injury.
body. Therefore, the treatment of local pathology • Stimulate Gb 21, Tw 15 and Si 13, designed to
is secondary to root sources of pain (i.e., body release the trapezius, rhomboid and supraspinatis
mechanics and radiculopathy). However, local muscles (Figure 54.27).
pathology can exist and the tender trigger Step 3 Lateral neck release
point(s) may be identified by the patient and • Laterally release neck, palpating for motor bands.
treated by the therapist after Steps 1 through 5. Stimulate the motor bands at the level of the
After identification, apply brief ETPS stimulation horizontal neck creases. All contributors to neck
of 15 to 20 seconds per point. This technique has and limb disorders, stimulation of these areas is
proven successful in alleviating the majority of any designed to release the scalenes, levator scapula
pain that remains. (See Figure 54.26) and splenius capitus muscles (Figure 54.28).
ETPS Neuropathic Acupuncture 685

Motor bands
Gb 21 in scalenes
Tw 15
Si 13
Lateral neck creases

FIGURE 54.28 Illustrates lateral neck muscles and suggested

location of myofascial release points throughout tight motor bands
points. Release these with ETPS stimulation for highly effective
relief of upper extremity pain. DO NOT apply microcurrent
stimulation anterior to the corner of the jaw (over the carotid
sinus). Apply vasoconstrictive ETPS Therapy.

FIGURE 54.27 Illustrates the posterior paraspinal neck points

and the trapezius myofascial release points. A positive therapeutic
response indicates involvement of these segments and muscles
with the injury. Apply vasoconstrictive ETPS Therapy.

Si 3
Step 4 Distal point for the neck.
• Si 3: posterior muscles of the neck. Located at
the medial end of the distal transverse palm crease.
Note: locate and treat this point with the fist
clenched. This is the first point to treat when there
is a wry neck or torticollis. Treat bi-laterally.
Step 5 Dermal points for the neck.
Treat these points first if patient’s neck is hyper-
FIGURE 54.29 Confluent acupuncture point Si 3, displays
sensitive (i.e., post accident/whiplash or post influence over the posterior neck and spine. Often highly sensitive
operative). If not hypersensitive, follow protocol on patients with posterior disc problems. Treat bilaterally, apply
order. vasoconstrictive ETPS Therapy.
• Li 1: Designed to release SCM ipsilaterally.
Located at the radial side of the base of the index
fingernail.
• Si 1: Designed to release ipsilateral scalenes. Li 1
Located at the lateral side of the base of the little (C 7) Si 1
fingernail (fifth metacarpal). (C 8)
Step 6 Neural therapy.
Inspect for scarring, either surgical or injury, distal
in the dermatomes from C5-T1 or along any upper
limb meridians. For neck pain, inspect for scars
around the elbow and wrist.
Step 7 Tender trigger points.
Ask the patient to identify any local tender points
remaining in the cervical region. Apply ETPS
therapy to these points, usually trigger points
(TP’s) or acupuncture points (AP’s) throughout
FIGURE 54.30 The hand illustrates the integration of
injured tissue. Brief stimulation of 15 to 20
acupuncture jing well points for myofascial release of Sterno
seconds per point has been successful in alleviating Cliedo Mastoid (SCM) using Li 1 and the scalene muscles using
the majority of any pain that remains. Si 1. Treat bilaterally, applying vasoconstrictive ETPS therapy.
686 Pain Management: A Practical Guide for Clinicians, Sixth Edition

FIBROMYALGIA P ROTOCOL
Step 1 Treat the parasympathetic points (-ve)
Treat the following parasympathetic points. Assess
the patient after each stage.
• Lu 9 (Figure 54.31): A powerful vascular and
parasympathetic point. Located on the transverse
wrist crease, in a hollow on the ulnar side of the
radial bone.
• P 6: A good nausea and parasympathetic point.
Located three fingers proximal from the most distal H 7
wrist crease, deep between the palmaris and flexor
Lu 9
carpi tendons.
• H 7: An excellent mind calming and para-
sympathetic point. Located on the transverse wrist P6
crease, in a hollow on the radial side of the thick FIGURE 54.31 Three upper limb parasympathetic points Lu 9,
flexor carpi ulnaris tendon. P 6 and H 7, used to deregulate the Autonomic Nervous System
(ANS), permitting continued therapy on supersensitive patients.
• Sp 6 (Figure 54.32): An immune, parasympathetic
Treat bilaterally, applying vasoconstrictive ETPS Therapy.
and distal pain point for perineum. Located four
fingers superior to the medial malleolus and
posterior to the tibia bone. Note: press directly
against the bone to find this point. Sp 6
• K 3: A low back pain, congenital energy and
parasympathetic point. Located in the hollow
K3
midway between the medial malleolus and Achilles
tendon. Also used for morning back pain and
circuited with B 25 (L4-L5 interspace).
• Cv 17: A respiratory and parasympathetic point.
Located on the midline of the sternum, horizontal
with the fourth intercostal space.
FIGURE 54.32 Sp 6 and K 3 are lower limb parasympathetic
Step 2 Apply Standard Protocol.
points, used for deregulation of lower viscera, permitting
Assess patient after each stage. continued therapy on sensitive patients. Treat bilaterally, applying
• Check Gait – piriformis vasoconstrictive ETPS Therapy.
• Look for signs of radiculopathy, (motor bands)
especially at T9-10 levels.
• Manually release gait
• Perform paraspinal release from T10–S2 (+ve)
encompassing segments with trophedema.
Note: Use positive polarity for paraspinal
Cv 17
stimulation.
• Circuit piriformis - IT Band (-ve) and piriformis -
Gb 34
Step 3 Homeostatic point Li 11 (-ve).
If success is limited in the first two steps, Step 3 can
often provide relief to the patient. Stimulation
needs only to be applied for 20-30 seconds on the
proper dermatome point in order to provide relief.
Located at the lateral end of the transverse elbow
crease, with the elbow semi-flexed. (Figure 54.35)
Step 4 Sacral triangle B 67, Gb 44, Gb 41 (-ve) FIGURE 54.33 Acupuncture point for body calming. Also known
(Figure 54.36) as “sea of tranquility”, Cv 17 should ONLY be treated on severe
patients, and only AFTER all the above points have been treated.
Isolate the treatment release of the psoas muscles.
ETPS Neuropathic Acupuncture 687

With some patients, the psoas muscle may be

contracted alone or with the piriformis muscle. If
pain still exists after Steps 1 through 3, a quick
stimulation of St 45 (second toe base nail lateral
side) will reveal if psoas muscle is contributing to
the pain condition.
Patients should be assessed between treatments of
both the R & L points to determine which psoas
muscle is most involved in the injury. This step
was integrated into this protocol to include both
posterior and anterior hip stabilizing muscles in
order to determine if they individually or
collectively contribute to the patient’s chronic pain
Inspect for trophedema state.
in T10 - L5 region
Step 5. Release tender trigger points.
As noted earlier, tender trigger areas are treated as a
last step in ETPS therapy because it is assumed
that all pain is referred from another anatomical
area of the body.
FIGURE 54.34 Palpate for paraspinal motor bands throughout (Figure 54.37)
the thoracic region. Release identified motor bands with paraspinal Ask the patient to identify tender points and apply
points. Apply vasodilative ETPS Therapy. ETPS therapy to these points (usually TP’s or AP’s
throughout injured tissue). Brief stimulation of 15
to 20 seconds per point has proven successful in
alleviating the majority of any pain that remains.
After each stage, stop and assess patient. Treat
all points bilaterally.

PLANTAR F ASCIITIS P ROTOCOL

Step 1 . Apply Standard Protocol.
Li 11 Assess patient after each stage.
• Check gait – Piriformis
• Look for signs of neuropathy and radiculopathy.
• Manually release gait.
FIGURE 54.35 Homeostatic acupuncture point Li 11. Apply • Perform paraspinal release from L4–S2
vasoconstrictive therapy to right arm and vasodilative therapy to (encompassing segments with trophedema)
left arm. (Figure 54.38)
• Circuit piriformis - IT Band and Piriformis - Gb
34
Step 2 Myofascial release of fascial overlay
FIGURE 54.36 Sacral triangle
may be treated with vasoconstrictive throughout calf muscles.
ETPS stimulation for additional • B 57 (Figure 54.39): Located at the Achilles
relief beyond steps 1 to 3. Note the tendonis muscular junction, this is an excellent
audible differences between B 67
Gb 41 and Gb 44. A high pitch with point for releasing the entire calf area.
Gb 44 denotes hip and fascial pain
root, and a high pitch with B 67 Step 3 Treat local points for pain relief.
denotes spinal radiculopathic
involvement in pain cycle.
• K 3 (Figure 54.40): The best point to treat for
B 67 patients who display a stiff back in the morning.
Located in the hollow between the medial
Gb 44 malleolus and the Achilles tendon.
688 Pain Management: A Practical Guide for Clinicians, Sixth Edition

• K 5: Located one thumbs width below K 3.

• K 6: Located in the hollow just below the medial
malleolus.
• B 60 (Figure 54.41): Located in the hollow
between the lateral malleolus and the Achilles
tendon. Very tender on sciatica patients.
• B 62: Located in the hollow just below the lateral
malleolus.
Step 4. Treat dermatome points.
• B 67 (Figure 54.42): At the base of the baby
toenail, on the lateral side. Innervation - S1
• Gb 44: At the base of the fourth toe nail, on the
lateral side. Innervation - L5
• St 45: At the base of the 2nd toenail, on the lateral
side. Innervation - L5
• Sp 1: At the base of the big toe nail, on the medial
side. Innervation - L4
Step 5. Tender trigger points.
Ask the patient to identify tender points and apply
ETPS therapy to these points, (usually TP’s or
FIGURE 54.37 Two to Three tender points may be identified by AP’s throughout injured tissue). Apply brief
patient and treated AFTER the previous steps are completed. stimulation of 15 to 20 seconds per point. (Figure
NOTE: do not apply stimulation to more than three tender points, 54.43)
as aggravation of symptoms is common with excessive stimulation.

FIGURE 54.38 Inspect for trophedema at segmental levels L 4–

S 2, as identified with skin rolling test. (see figure 6). Paraspinally
release with vasoconstrictive ETPS therapy.
ETPS Neuropathic Acupuncture 689

Gastroc
X X Tender
X X Points
X X
B 57
B 67
(S1)
Gb 44
(L 5) St 45 Sp 1
(L 5) (L 4)

FIGURE 54.39 Release acupuncture point B 57 and tender points FIGURE 54.42 Distal “Jing Well” acupuncture points Sp 1, St
located throughout motor bands (identified through palpation) 45, Gb 44, and B 67. Treat for additional relief of Plantar fasciitis
using vasoconstrictive ETPS therapy. pain using vasoconstrictive ETPS Therapy. NOTE audible
differences between points and correlate to dermatomes for clues
to root causes of pain.

K3
K5
K6
X X
X X
X
X X
X X Tender
X X points
FIGURE 54.40 Local medial acupuncture points K 3, K 5, and
K 6 which are treated for additional relief from plantar fasciitis X X
pain. Treat with vasoconstrictive ETPS Therapy.

FIGURE 54.43 Apply vasoconstrictive ETPS therapy to tender

points identified by patient on plantar region of foot.

B 60

B 62

FIGURE 54.41 Local lateral acupuncture points B 60, B 62

which are treated for additional relief from plantar fasciitis pain.
Treat with vasoconstrictive ETPS Therapy.
690 Pain Management: A Practical Guide for Clinicians, Sixth Edition

CLINICAL RESEARCH STUDY

In a pilot study on Carpal Tunnel Syndrome recently group treated themselves weekly for three months.
completed at the Canadian Centre for Integrative Assessments were performed at the beginning and end
Medicine, Markham, Ontario. Dr. Gordon Ko of each time frame.
(Physiatrist, American Association of Electrodiagnostic Mean scores improved in both groups without any
Medicine) recorded improvements in five consecutive adverse side effects. A significant improvement was
patients who completed ETPS (one time per week for 4 reported in the mean score with patients listed below:
– 6 weeks). Using the Neuromax 1004 (including skin
temperature measurements), the pre- and post- treatment Mean Values Pre-Treatment Post-Treatment
median nerve latencies and amplitudes improved (9 Average pain score: 7.48/10 (9.9 to 5.8) 2.99/10 (6.3 to 1.5)
hands). The means scores are listed below with range in Daily n = 293
brackets. Average pain score: 6.13/10 (8.5 to 4.2) 2.35/10 (6.8 to 0.5)
Weekly n = 52

Mean Values Pre-Treatment Post-Treatment

Distal Motor Latency 4.61 msec 4.22 msec Clinical improvement was reported in all patients
(3.8 to 6.0) (3.7 to 5.9) without any adverse side effects. Further research is
Sensory Onset Latency required to verify the efficacy of treatment and accu-
Palmar 1.98 msec 1.81 msec racy supporting data.
(1.5 to 3.0) (1.5 to 2.9)
2nd & 3rd Digits 3.13 msec 2.93 msec
CONCLUSION
(2.5 to 4.2) (2.5 to 3.6)
ETPS therapy incorporates acupuncture, osteopathic,
Sensory Amplitudes
trigger point, neuromuscular & neural therapies into
Palmar 37.0 uV 44.5 uV
simple, easy to use protocols. With this approach, it is
(19.3 to 99.0) (29.3 to 120.3)
possible to integrate different philosophies and access a
2nd & 3rd Digits 13.6 uV 16.7 uV
wide variety of soft tissue pains using one modality. With
(5.0 to 22.7) (5.3 to 26.0)
back pain, an exceptionally common condition, each
stage in an ETPS protocol treats a specific pathway, group
Clinical improvement was reported in all patients without of muscles, segmental levels, acupuncture meridian or
any significant adverse effects. scar. Through this step-by-step elimination process, it
One patient with severe CTS who completed the “Dash” is possible to identify and treat those levels, muscles or
(Disabilities of the arm, shoulder, hand) survey meridians at the root of a patient’s pain.
demonstrated marked improvement with a pre-score of Although ETPS therapy has been able to make modest
20/100 and a post-score of 1.7/ 100 (a higher score breakthroughs in the diagnosis and treatment of chronic
indicates increased functional limitations). Prior to pain through its synthesis of different modalities,
treatment, the patient’s right hand sensory responses were additional research is required to advance the body of
absent. After treatment, palmar and 3 rd digit responses knowledge. Perhaps an even greater challenge than pure
were measurable. research is the need for competing disciplines to work
Further research is required to verify the efficacy of cooperatively by reducing the barriers that
treatment and supporting data. A call for patients is now compartmentalize medicine. Drawing from the Oriental
underway to proceed with a larger controlled study with paradigm, the advancement of knowledge and the pursuit
Dr. Gordon Ko of truth begin with questions, rather than proclamations
at the University of Toronto. of answers. This paradigm is the foundation of ETPS
therapy, “How can the constituent elements of medicine
ETPS NEUROPATHIC THERAPY be combined to advance the treatment of chronic pain?”
CASE STUDY
A case study of the benefits of ETPS Neuropathic ACKNOWLEDGMENT
Therapy on 345 chronic pain patients was performed. The author wishes to thank Chris Stillinger for the artwork
Patients were all over the age of 65, and divided into in this chapter.
two groups: one group treated daily for three weeks, one
ETPS Neuropathic Acupuncture 691

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