Treatment Of Reflex Sympathetic
Dystrophy In 3 Pediatric Patients Using
7 External Dragons And Devils Acupuncture
Anna Kelly, MD
Background Reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS-I) is a syndrome of sustained, diffuse, burning pain following an initiating noxious event. The syndrome is believed to be both instigated and maintained by the sympathetic nervous system. Conventional medical treatment is aimed at interrupting sympathetic nervous system activity with medication, nerve blocks, or sympathectomy.
Objective To determine if 7 External Dragons and Devils Acupuncture can relieve pain associated with RSD in the pediatric patient.
Design, Setting, and Patients A case series of 3 pediatric patients with RSD and lower extremity pain treated in a private practice in Atlanta, Georgia, from May 2000 to February 2003.
Intervention Treatment with 7 External Dragons and Devils Acupuncture.
Main Outcome Measure Reported reduction in pain.
Results After acupuncture treatment, pain was completely resolved in 2 out of 3 patients. In the 3rd patient, pain was significantly reduced by 80% after acupuncture.
Conclusions 7 External Dragons and Devils Acupuncture is useful in the pediatric patient with RSD. The 7-needle treatment may "release the dragons, or protective forces, in order to chase away the devils" that manifest as the patient's chief complaint. All 3 patients reported an initiating traumatic event followed by severe foot pain, which had been only partially responsive to conventional medical treatment. All 3 patients experienced significant or complete pain relief with an acupuncture treatment that addressed the initiating noxious event.
Acupuncture, Reflex Sympathetic Dystrophy, Complex Regional Pain Syndrome, 7 External and Internal Dragons and Devils Acupuncture
Reflex sympathetic dystrophy (RSD), or complex regional pain syndrome (CRPS-I), is a syndrome of sustained, diffuse, burning pain following an initiating, noxious event that is traumatic, medical, infectious, or vascular. The syndrome is believed to be both instigated and maintained by the sympathetic nervous system and usually affects the limb, most often the distal portion. Peculiar to sympathetically maintained pain (SMP) is the lack of correlation of SMP to severity of the initiating noxious event. Clinical signs and symptoms are pain, hyperesthesia, vasomotor and sudomotor disturbances, and increased motor tone, followed by weakness, muscle atrophy, skin and hair changes, and trophic changes involving the bones and joints. Initially, pain is localized to the site of injury but can spread beyond the affected area over time. Pain and physical signs do not conform to known patterns of segmental dermatomes, myotomes, or sclerotomes, or to peripheral nerve distribution. Typically, the disease is progressive unless interrupted by treatment; prognosis is better with early recognition and treatment.1
Traditional pain management focuses on interrupting sympathetic nervous system activity with pharmacologic agents, nerve blocks, and surgical or chemical sympathectomy. Physical therapy and psychological counseling are useful adjuncts.
Acupuncture has been utilized successfully in the adult patient with RSD.2,3 Electroacupuncture is frequently the method used. Acupuncture has also been used successfully in the pediatric pain patient.4,5
A 16-year-old male presented with a 5-week history of severe, burning left foot pain following avulsion fracture and dislocation of the left hip due to a 4-wheeler crash. Following the injury, his left hip and leg had been immobilized and was successfully healing. Two weeks after the injury, the patient noted the onset of severe, constant, burning pain of the left foot, dorsal and plantar surfaces at the lateral border of the foot. He was unable to wear a sock or shoe and slept with his foot uncovered. He had been diagnosed with RSD, although he had not had any diagnostic sympathetic block. Electromyography had been attempted but aborted due to severe pain.
At his initial visit in May 2000, medications included 20 mg of amitriptyline nightly, and acetaminophen/hydrocodone, 7.5 mg 3 times daily. The patient and his father were concerned about the continuance of narcotics. The patient also expressed a fear of needles. Visual analog scale (VAS) score was reported 8/10 at the time of initial interview.
After obtaining written parental consent, 3 body needles and 2 ear needles were placed, after the patient gave permission for each needle placement (this technique honored his fear of needles, introduced him to acupuncture, and empowered him to decide when the treatment should stop). Bilateral GB 34, right LR 3, and left ear sympathetic and foot (Phase 3) were left in place 25 to 40 minutes. At follow-up 1 week later, the patient reported minimal to no improvement in his pain. In all cases, Seirin needles #5 were used, 30 mm, to a depth of 0.5 to 1 cm, and manipulated until De Qi was achieved.
During his 2nd visit, 7 External Dragons and Devils Acupuncture treatment was administered (GV 20, bilateral BL 11, 23, 61) for 30 minutes. In follow-up 10 days later by phone, the patient's father reported his son's complete pain relief by day 7, and by day 9, the patient discontinued medications. Follow-up 1 year later confirmed that the patient was pain- and narcotic-free. VAS score was 0/10.
A 10-year-old female presented with a 5-month history of left lower extremity pain following a soccer injury. Initial x-rays were negative for fracture but because of continued pain, her left foot and ankle were casted for 10 days. The patient experienced severe, constant pain in her left ankle and lateral foot while the cast was in place. After cast removal, pain spread proximally and the patient was diagnosed with RSD. She was evaluated at 3 prominent pain centers across the nation and treated with a series of diagnostic and therapeutic sympathetic blocks, which provided temporary relief. Medications had included tramadol, gabapentin, and amitriptyline, and were discontinued due to ineffectiveness and adverse effects. Physical therapy provided minimal relief. The patient was ambulatory with crutches. VAS was reported 7/10 at the time of initial interview.
7 External Dragons and Devils Acupuncture was administered (GV 20, bilateral BL 11, 23, 62) for 30 minutes. At follow-up 1 week later, the patient and her parent reported 95% resolution of symptoms, including pain. The patient ambulated without crutches. VAS was reported 1/10. Her 2nd treatment consisted of bilateral LR 3 and LI 4 with Yin Tang for 30 minutes. Follow-up by phone 1 week later revealed 100% resolution of all complaints. Ten months later, the patient was pain-free (VAS 0/10).
Case Report 3
A 13-year-old female presented with a 31/2-month history of right medial foot and ankle pain following an insect bite to the foot. Pain was described as constant, severe, burning, and had spread proximally within 2 weeks after the initiating event. The patient's diagnosis was RSD; she received 5 lumbar sympathetic blocks at another pain clinic, providing temporary relief. She also received physical therapy, water therapy, and neuromuscular stimulation. The patient's pharmacological regimen included gabapentin, 800 mg 3 times daily, at the time of her initial visit. Physical therapy was ongoing throughout her course of acupuncture. She ambulated with the use of crutches and a wheelchair before starting acupuncture. VAS was 9/10.
Initially, the patient was treated with 7 External Dragons and Devils for 30 minutes. In follow-up 1 week later, she reported significant pain reduction (VAS 5/10) and was able to wear a shoe. Three more acupuncture treatments were administered on a weekly basis.
During visits 2 and 3, the patient's chief complaints were consistent with a viral upper respiratory tract infection with fever, nausea, and body aches; points were chosen to clear heat, move Qi and blood, and an extraction to Tai Yang was performed. After resolution of these symptoms at week 4, the right foot pain was again addressed with 7 Internal Dragons and Devils. After this 2nd treatment to address the right foot and ankle pain, the patient reported an 80% reduction in pain.
After treatment 4, 1 week later, VAS was 3/10. She continued to receive acupuncture for pain (N –> N+1) with consistent relief.
There is a paucity of information in the English acupuncture literature about the acupuncture depossession treatments known as "7 Internal Dragons and Devils, and 7 External Dragons and Devils."
The treatments are useful clinically when patients have experienced life-changing events, frequently traumatic in nature, followed by complaints of pain or suffering.6 Either internal emotional factors resulting from the initiating event, or exogenous factors, have "invaded" the patient's energetic makeup to such an extent that they exert an overriding control.7
7 Internal or External Dragons and Devils Acupuncture may release the "dragons," which are felt to be benign, protective forces, in order to "chase away the devils" that manifest as the patient's chief complaint.
In these cases of pediatric RSD, all 3 patients reported severe pain following a traumatic initiating event, with minimal or temporary relief after conventional medical techniques. None of the 3 had internalized emotional factors related to the traumatic event, so that the 7 External Dragons and Devils treatment was administered. Patient 3 also had 7 Internal Dragons and Devils Acupuncture because of incomplete relief after the External treatment, and probable internalization of the initial traumatic event.
The 7-needle Dragons and Devils treatment promotes the reintegration of the patient's energy into a unified, harmonious system after a life-changing inciting event. Particularly with the Internal Dragons and Devils treatment, there may be signs of "upheaval" as the conflict is confronted and adjustment takes place.7 Proof that blockage to healing has been opened will be evident to the practitioner in that treatments previously ineffective now provide relief. In this case, 2 patients needed no further acupuncture, and 1 patient who experienced significant (80%) relief continued to undergo N>N+ l meridian acupuncture with good results.
- Hendler N, Raja S. Reflex Sympathetic Dystrophy and Causalgia. In: Handbook of Pain Management. Baltimore, Md: Williams & Wilkins; 1994:484-496.
- Kho KH. The impact of acupuncture on pain in patients with reflex sympathetic dystrophy. Pain Clinic. 1995;8(1):59-61.
- Gellman H. Reflex Sympathetic Dystrophy: Alternative Modalities for Pain Management. AAOS Instructional Course Lectures. 2000;49:549-557.
- Kemper KJ, Sarah R, Silver-Highfield E, Kiarhos E, Barnes L, Berde C. On pins and needles? pediatric pain patients' experience with acupuncture. Pediatrics. 2000;105:941-947.
- Lin YC, Bioteau AB, Lee AC. Acupuncture for the management of pediatric pain: a pilot study. Medical Acupuncture. 2002;14(1):45-46.
- Helms J. Class notes, UCLA Course Medical Acupuncture for Physicians; 1999.
- Worsley JR. Traditional Acupuncture. Vol. II. 1990; 170-174.
Dr Anna Kelly is a Board-certified Anesthesiologist, and is Medical Director of Metro Acupuncture in Atlanta, Georgia. Dr Kelly is President of the Georgia Association of Medical Acupuncturists.
Anna C. Kelly, MD, DABMA*
6255 Barfield Rd #175
Atlanta, GA 30328
Phone: 404-255-8388 • Fax: 404-255-1831
*Correspondence and reprint requests