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Case Report

J Acupunct Meridian Stud 2022; 15(4): 264-272

Published online August 31, 2022 https://doi.org/10.51507/j.jams.2022.15.4.264

Copyright © Medical Association of Pharmacopuncture Institute.

Treatment of Lumbosacral Radiculopathy with Acupuncture and Medical Herbs: Four Case Reports

Han Chae1 , Yoona Oh2 , Ji Won Choi2 , Soo Kwang An1 , Yeon Hak Kim2 , Jun Hwan Lee4,5 , Eunseok Kim2,3 , Byung Ryul Lee2,3 , Gi Young Yang2,3,*

1School of Korean Medicine, Pusan National University, Yangsan, Korea
2Department of Acupuncture & Moxibustion Medicine, Pusan National University Korean Medicine Hospital, Yangsan, Korea
3Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, Korea
4Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, Korea
5Korean Medicine Life Science, University of Science & Technology (UST), Campus of Korea Institute of Oriental Medicine, Daejeon, Korea

Correspondence to:Gi Young Yang
Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, Korea
E-mail ygy@pnu.edu

Received: October 21, 2021; Revised: January 20, 2022; Accepted: May 18, 2022

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Lumbosacral radiculopathy (LR) is a musculoskeletal disorder or pain syndrome that is generally linked to the compression or irritation of the nerve root. There is a growing interest in the development of efficient acupuncture-based treatments for LR comparable to western medicine. Structured traditional Korean medical treatments including intensified acupuncture stimulus on the EX-B2 point using the G-shaped posture modified from the sitting posture were applied to four LR patients, and the outcomes were evaluated based on objective clinical endpoints including a numeric rating scale (NRS), the Oswestry disability index (ODI), the manual muscle test (MMT), neurological symptoms, and plantar photography. Patients showed improvements in NRS, ODI, MMT, and neurological symptoms without adverse effects during hospitalization and follow-up visits. Moreover, we observed substantial dissolvement of hyperkeratinization and parchedness of the soles of the feet, which was not reported previously. These four cases demonstrate the clinical usefulness of traditional medicine and the diagnostic applicability of plantar photography. However, further randomized controlled trials are required to confirm our findings.

Keywords: Case report, EX-B2, Lumbosacral radiculopathy, Acupuncture, Plantar photography

INTRODUCTION

Lumbosacral radiculopathy (LR) is a common musculoskeletal disorder or pain syndrome caused by compression or irritation of nerve roots, adhesion around the nerve root, and blood circulation disorders in the lower back [1]. However, the pathogenesis of this disorder remains unexplored [2]. LR is often accompanied by L-spine herniated intervertebral disc (HIVD), stenosis, spondylolisthesis, and ankylosing spondylitis in extraordinary cases [3].

The major symptoms of LR are lancinating or shooting pain along the nerve pathway, sensory abnormalities, and muscle weakness, which might increase the risk of falling while walking and cause pain during daily activities. As of 2019, there were an estimated 9 million LR patients in Korea. This disease particularly affects the elderly, and medical expenses are increasing at a rate of approximately 2.2 billion won per year [4].

Commonly used interventions include nerve decompression and spondylodesis, which remove pressure on the nerve root and consist of the insertion of a supporting structure as a first therapeutic option. However, there is still a need for a sustainable and safe treatment, as commonly used approaches pose a severe risk of nerve damage during the surgical process with general anesthesia.

Moreover, physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for pain management in LR patients. Nerve blocking and percutaneous epidural neuroplasty (PEN) might be applied when these measures are not effective for pain control. However, although the aforementioned treatments can alleviate pain, there are still some concerns regarding nerve damage and their long-term clinical effects [5,6].

Acupuncture treament is a traditional East-Asian therapy that has long been used for relieving pain in lumbar spine disorders and has shown promising clinical effects on pain relief and recovery of physical function compared with NSAIDs or physical therapy [6]. Acupuncture is currently recommended as an effective alternative for chronic lower back pain (LBP) and radiculopathy patients [7], and has been linked to a decrease in lumbar surgery in LBP patients [8].

EX-B2 is an acupuncture point for the treatment of LR [7], which is located on both sides of the vertebral body and is surrounded by both the multifidus muscle, which stabilizes and disperses the pressure on the intervertebral disc, and the rotator muscle, thus supporting rotational mobility of spinal segments. Acupuncture on this acupoint directly stimulates surrounding ligaments and muscles, providing stability to the spine and indirectly relieving pressure on the nerve roots [9-11].

Considering that manipulation and strong stimulation were reported to be useful for effective pain management in herniated intervertebral disc (HIVD) patients with LR [12], intensified stimulation on EX-B2 might have long-term clinical effects equivalent to existing western therapies that are often recommended as the first clinical option for the teratment of LR [7].

Furthermore, the G-shaped posture modified from the sitting posture was adopted in the clinical cases discussed herein to enhance the effects of acupuncture treatment, as it exposes the point of interest by relaxing tissues around the nerve root and prevents the muscle tension caused by the stimulus.

This study evaluated four clinical cases in which an effective acupuncture intervention on EX-B2 coupled with the G-shaped posture was applied and notable improvements of LR-related clinical symptoms were observed (Table 1 and Fig. 1). Unlike previous studies on LR [7,10,13-17], which used a relatively subjective numeric rating scale for measuring LBP and radiating pain, the present study used clinical measures including the Oswestry disability index (ODI), the manual muscle test (MMT), and neurological symptoms along with plantar photography showing the softness of the foot sole for the analysis of the clinical effects of traditional East-Asian medicine. Therefore, the current study might propose effective clinical procedures for LR treatment and could provide a foundation for understanding the mechanisms of acupuncture treatment.

*Lower back pain and radiating pain are indicated with a numerical rating scale..

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Clinical features of the patients at the time of hospital admission and hospital discharge.

Case number (days of treatment)Hospital admissionHospital discharge
Case #1 (19 days)
Low back pain*61
Radiating pain*--
Oswestry disability index126
Manual muscle test (R/L)Hip flexion (4+/4+)Hip flexion (5/5)
Neurological symptomsNoneNone
Adverse effectsNoneNone
Case #2 (18 days)
Low back pain71
Radiating pain41
Oswestry disability index147
Manual muscle test (R/L)Within normal limitWithin normal limit
Neurological symptomsParesthesia (+, sensation of flowing water in the thigh)Paresthesia (–)
Adverse effectsNoneNone
Case #3 (29 days)
Low back pain103
Radiating pain101
Oswestry disability index3023
Manual muscle test (R/L)Great toe dorsiflexion (4/3+)
Ankle plantar flexion (4/4)
Great toe dorsiflexion (5/5)
Ankle plantar flexion (5/5)
Neurological symptomsLimping antalgic gait (+)
Hypoesthesia (+, both calf)
Limping antalgic gait (–)
Hypoesthesia (–)
Adverse effectsNoneNone
Case #4 (31 days)
Low back pain51
Radiating pain71
Oswestry disability index3019
Manual muscle test (R/L)Ankle dorsiflexion (4+/5)
Great toe dorsiflexion (4/4+)
Ankle plantarflexion 4+/5
Ankle dorsiflexion (5/5)
Great toe dorsiflexion (5/5)
Ankle plantarflexion (5/5)
Neurological symptomsHypoesthesia (+, Right dorsum of foot)Hypoesthesia (–)
Adverse effectsNoneNone

*Lower back pain and radiating pain are indicated with a numerical rating scale..



Figure 1. Patient timeline for onset, admission, treatment, discharge, and follow-up.

PATIENTS AND PROCEDURES

1. Treatments applied to the patients

Two rounds of acupuncture treatments a day, five days a week, were applied to the LR patients, and treatment details are summarized in Table 2 following the STRICTA and CARES guideline [18].

Table 2

Traditional Korean medical interventions for lumbosacral radiculopathy patients in clinical cases based on the STRICTA checklist.

Contents
1. Acupuncture rationale
1a) Style of acupunctureClassic acupuncture theory.
1b) Reasoning for treatmentConfluence Points of the Eight Extraordinary Vessels.
1c) Varied treatmentSemi-individualized selection according to the patient’s symptoms and conditions.
2. Details of needling
2a) Number of needle insertions28 points; practitioner adjusted the number of needle insertions.
According to patient’s symptoms and conditions.
2b) Names of pointsLI4, TE5, LI11, LR3, GB41, and ST36 (1st round) and EX-B2 (lumbar region), BL40, BL57, and BL60 (2nd round).
2c) Depth of insertion10-20 mm (1st round) and 30-50 mm (2nd round) according to the expected tissue depth on acupuncture points.
2d) Response soughtSubjective De-qi sensation or local muscle twitch response.
2e) Needle stimulationManual stimulation of rotation, lifting and thrusting just after the insertion of needles.
2f) Needle retention time20 minutes (1st round) and no retention time (2nd round).
2g) Needle type0.25 × 40mm (1st round) and 0.50 × 60mm (2nd round) from Dong-bang stainless-steel disposable acupuncture needle.
3. Treatment regimen
3a) Number of treatment sessionsModified length of treatment following patients’ symptom and severity.
3b) Frequency and durationTwice a day, 5 days/week until discharge.
4. Other components of treatment
4a) Details of other interventionsHerbal medication (Doghwalsogdan-Tang, 111 g) were administered after 2 hours after each meal (3 times/day). It is composed of 12 g of Lonicera dasystyla and Forsythia koreana, 6 g of Aralia cordata, Ostericum koreanum, Angelica gigas, Paeonia japonica, Astragalus membranaceus, Salvia miltiorrhiza, and Clematis florida, 4 g of Phlomis umbrosa, Rehmannia glutinosa, Lonicera dasystyla, Wolfiporia extensa, Achyranthes asper, Eucommia ulmoides, Gentianae Macrophyllae, Asarumsieboldii Miq, Ledebouriella seseloides, and Cinnamomum verum, 3 g of Cervus elaphus, and 2 g of Glycyrrhiza glabra.
Herbal-steam therapy were applied to the lumber region with steamer (Healer Vivian, Eunhyae Trade, Korea) 2 times per day. Decoction of Mentha canadensis, Artemisia argyi and Agastache rugose was used for making steam.
5. Practitioner background
5) Description acupuncturistsTwo Korean medicine doctors. Resident trainee in acupuncture and moxibustion medicine with 3 years of experience, and Certified Clinical Specialist of acupuncture and moxibustion medicine with 15 years of experience.
6. Control or comparator interventions
6) Control or comparatorNot applicable.


The first round in the morning was performed by the resident (> 3 years of clinical experience) at points LI4, TE5, LI11, LR3, GB41, and ST36 of a patient in a supine posture using 0.25 × 40 mm needle (Fig. 2A) based on classic acupuncture theory with hand manipulation until needle sensation was reported (Table 2).

Figure 2. Acupuncture needle (A: 0.25 × 40 mm, B: 0.5 × 60 mm).

The second round in the afternoon was performed by the certified clinical specialist of acupuncture (> 15 years of clinical experience) using 0.50 × 60 mm needles (Fig. 2B) without retention time. The patient was asked to adopt the G-shaped posture on the edge of a bed with the support of side guards for widening the interspace of the vertebral body as shown in Fig. 3A, and the clinical specialist performed acupuncture treatment on the EX-B2 point of the lumbar region (Fig. 3B). Afterward, BL40, BL57, and BL60 were stimulated after changing the posture of patients to the prone posture with dorsal flextion to stretch the calf muscles.

Figure 3. Acupuncture points and G-shaped body posture for acupuncture treatment. (A) G-shaped posture of patient for acupuncture treatment. (B) Location of EX-B2 acupuncture point (lumbar region).

No adverse effects were reported after acupuncture treatments and the current case study was performed under the recognition of and institutional review board (E2019009) as retrospective chart review.

2. Measures for investigating the clinical symptoms of the patients

A numerical rating scale (NRS) [19] was used to subjectively rate the level of back pain and radiating pain from 0 (no pain or discomfort) to 10 (worst pain or the most severe pain). Moreover, the Oswestry Disability Index (ODI) [20] was used to quantify disability from LBP of patients with LR. The patients were asked to respond ten topics of the ODI concering pain intensity, disabilities related to everyday life such as walking, sitting, standing, social life, sleep, and travel, and each topic was separated into six scenarios with scores of 0 (least amount of disability) to 5 (the most severe disability) describing the situation of the patient. The scores for all ten topics were summed to obtain the ODI index ranging from 0 to 50.

The manual muscle test (MMT) [21] was incorporated to evaluate the loss of muscle strength of lower extremities from the nerve compression. A modified version of the Medical Research Council scale with numerical scale of 0 (no contraction) to 5 (normal power) was adopted to examine the clinical efficacy of acupuncture treatment and medication. The patients were asked to perform hip flexions, knee extensions, ankle dorsiflexions, great toe dorsiflexions, and ankle plantar flexions, which were representative motion of muscles controlled by the L1 to L5, and the inspectors placed resistance to examine the range of movement (ROM) and muscle strength from zero to five; 0 (no contraction), 3 (full ROM against gravity, but tolerates no resistance), 3+ (full ROM against mininal resistance and gravity), 4 (full ROM to medium resistance and gravity), 4+ (full ROM against medium-full resistance and gravity) and 5 (full ROM against gravity and full resistance). Neurological symptoms of numbness, paraesthesia, hypoesthesia, and limping antalgic gait were also measured to evaluate the occurrence and evolution of key complaints.

Plantar photography was used to illustrate the thickness of keratinization and stratum corneum, softness, and wetness of the foot sole. The patients were placed in a prone posture on their bed to take pictures of their feet.

The evaluation of adverse effects (AE) was conducted each day at 06:00 during hospitalization and AE from acupuncture treatments were inspected immediately after the treatments by an independent investigator. Moreover, LBP and radiating pain of patients as NRS, ODI, MMT, neurological symptoms, and plantar photographs were used to examine the patients’ symptoms at the date of admission and hospital discharge.

CASE PRESENTATION

1. Case #1

A 28-year-old male police man with non-specific medical history diagnosed as L-spine HIVD 10 years ago was hospitalized with the chief complaints of aggravated LBP and weakness of both lower extremities without radiating pain. The pain was reported to be intensified by extended sitting or walking causing sleep problems. Disc bulging at L4/5 and mild left-central disc protrusion at L5/S1 were found with computed tomography (CT), as shown in Fig. 4A.

Figure 4. CT and MRI picture of lumbar spine at the time of hospital admission. (A) Case #1, (B) Case #2, (C) Case #3, (D) Case #4.

The chief complaints (Table 1) were alleviated after the treatment (Table 2), and keratinization, softness, and wetness of the foot sole (Fig. 5A) were improved at the time of discharge and 8 months later.

Figure 5. Plantar photographs of four patients. The dates after the hospital admission (A+) are shown below the picture. Notice the decreased stratum corneum and increased skin softness during treatment progression. (A) Case #1, (B) Case #2, (C) Case #3, (D) Case #4.

2. Case #2

A 19-year-old female student seeking conservative treatment for a herniated intervertebral disc at L4/5 and L5/S1 from slipping down (Fig. 4B). The chief complaints were LBP, radiating pain on the left L5 dermatome area, and abnormal sensation on the lateral side of the thigh region. At the time of treatment, the patient was taking empagliflozin and melformin hydrochloride to treat her diabetes mellitus.

The treatment (Table 2) reduced pain and dissolved muscle imbalance and paraesthenia (Table 1). The plantar photograph revealed severe keratination and loss of moisture on the right side at the time of admission (Fig. 5B). However these symptoms improved significantly after a month and the foot sole remained soft and moisturized even after two years.

3. Case #3

A 66-year-old female housewife was hospitalized for LBP and radiating pain (Table 1). No professional treatment had been provided for the management of central and foraminal stenosis at L3/4 and L4/5 (Fig. 4C) for last three years. The patient was ultimately hospitalized due to sustained and aggregating pain, and the chief complaint was asthenia of the left great toe dorsiflexion muscle and limping gait. Amlodipine was prescribed to the patient by her primary care doctor to treat her hypertention and was administered during the treatment.

The treatment dramatically improved the chief complains and the patient could once again walk with a normal gait (Table 1). Dehydration and cracking of the skin of the foot soles intensified during the treatment. However, these symptoms improved (Fig. 5C) at the time of discharge and follow-up visit.

4. Case #4

A 59-year-old male laborer currently taking amlodipine and biphenyl dimethyl dicarboxylate for hypertension and bladder cancer was hospitalized to treat a sudden LBP from L2/3 and L4/5 HIVD (Fig. 4D) after lumbar flexion. The patient manifested radiating pain on the right side of the L5 dermatome region, asthenia on the right side of the leg, hypoesthesia on the foot, and night pains (Table 1). An overall improvement of chief complaints was observed after the treatment.

The plantar photograph showed severe keratination and dryness of sole (forefoot and big toe) at the time of admission, and dissolved keratination at the 16th day of hospitalization. Foot sweating was reported after 4 weeks of treatment (Fig. 5D).

The patients of the four cases reported that their respective treatments improved their overall quality of life. The alleviation of the pathologic pressure on the nerve root decreased the frequency of resting during walks to the local grocery store from 3-4 times to only once. Myasthenia and pain of the leg were relieved and the the feet were warmer, moistened, and softened. The patients also reported that their waist straightend and was more flexible when walking and moving.

DISCUSSION

The current case report on four LR patients demonstrated the usefulness of traditional East-Asian medicine in pain management, functional recovery, and patient satisfaction even after follow-up without notable adverse effects.

These patients were diagnosed with L-spine HIVD or lumbar spinal stenosis, and their key complaints were LBP, radiating pain, hypoesthesia, and muscle weakness. In contrast with previous studies on LR [7,13-16], which used subjective evaluation of VAS, the current clinical cases were evaluated based on objective and measurable endpoints. After treatment, NRS (a measure of pain) was reduced by 3-9 points and ODI (an indicator of range of motion) increased by 6-11 points. Moreover, the attenuation of the MMT of muscle strength and sensory abnormalities were significant.

Our findings suggest that the traditional East-Asian principle of LR treatment and effective stimulus on EX-B2 using the G-shaped posture might be clinically efficient. However, randomized controlled trials are still necessary to confirm our findings.

The EX-B2 acupuncture point is located on the dorsal multifidus and rotator muscles, which are responsible for the stabilization and rotational mobility of spinal segments [9]. The intensified stimulation of EX-B2 in current clinical cases showed substantial clinical improvement, which is consistent with previous reports of pain attenuation and alleviation of associated discomforts using acupuncture [12,22,23]. The mechanism of action might be related to the reported down-regulation of extracellular signal-regulated kinase in the anterior cingulate cortex, which heightened the pain withdrawal threshold and lowered pain-induced anxiety in rats with L5 spinal nerve ligation [22].

Interestingly, the intensified stimulation on EX-B2 as in the present study was found to be effective for pain management of L-spine HIVD patients compared to manual acupuncture [23], whereas weak stimulus (10 minutes per week) on EX-B2 was less effective than electro-acupuncture on nerve root [14]. These studies indicate that a strong stimulus is required to maximize the therapeutic value of acupuncture intervention.

The G-shaped posture modified from the sitting posture to enhance the clinical effects of acupuncture were introduced in current clinical cases. The posture of the patient is often modified according to the patient’s convenience, as well as to ensure the safety of the procedure and the efficiency of the practitioner. Particularly, the lateral, prone, or sitting postures have been commonly used for acupuncture treatment at the waist, hip, and lumbar regions [24].

The G-shaped posture is a sitting posture with maximized flexion of the upper body, which enlarges the interspace of the vertebral body, thus providing easy access to the anatomical structure compressing the nerve root. Additionally, this posture might prevent the contraction of muscles around the spine induced by acupuncture stimulation. Further clinical studies on the clinical usefulness of the G-shaped posture compared with prone and lateral postures might be required. However, the patients evaluated in this study were satisfied and did not report discomfort during the treatments.

Interestingly, notable changes of the foot sole in plantar photography were observed along with the attenuation of pathological symptoms in all four cases. The soles of the feet were extremely dry and a thick stratum corneum was observed at the time of admission. However, the patients reported profuse sweating of the feet during the treatment process, and subsequent removal of the dense and parched stratum corneum along with sustained high skin humidity was observed at the time of hospital discharge and follow-up.

This first reported clinical symptom on the foot soles is presumed to have occurred in the process of improving blood supply and recovering nervous activity on the sole as the pathologic pressure on the nerve root was attenuated by the acupuncture treatments. Nevertheless, no previous studies have thus far identified any correlations between lower back pain and the sole skin from impaired weight baring and foot posture [25].

Since the change in the sole of the foot is a subjective clinical experience, a standardized and organized procedure for taking plantar photographs, measuring skin humidity of the sole and thickness of the stratum corneum, and studies on the pathological mechanisms related to these clinical signs are needed to confirm the applicability and clinical relevance of these indicators.

In summary, the current study demonstrated the clinical usefulness of EX-B2 acupuncture stimulus with G-shaped posture on the LR patient using ODI, MMT, neurological symptoms, and plantar photography in four clinical cases. However, further clinical studies are required to characterize the clinical effects, mechanism of action, and clinical efficacy of acupuncture treatment for the treatment of LR patients.

STATEMENT OF ETHICS

The current case study was performed under the recognition of the institutional review board (E2019009) as retrospective chart review.

DATA AVAILABILITY

The data that support the findings of this study are available upon request from the corresponding author Gi Young Yang. The data are not publicly available, as this could compromise the privacy of the research participants.

FUNDING

This work was supported by a 2-Year Research Grant of Pusan National University.

AUTHORS' CONTRIBUTIONS

Conceptualization: Han Chae, Byung Ryul Lee, and Gi Young Yang; Data Curation: Yoona Oh and Gi Young Yang; Funding acquisition: Gi Young Yang; Formal analysis and Investigation; Yoona Oh, Ji Won Choi, Soo Kwang An, Yeon Hak Kim, Jun Hwan Lee, and Eunseok Kim; Project administration: Gi Young Yang; Visualization: Han Chae; Writing-original draft and Writing-review & editing: Han Chae, Yoona Oh, Jun Hwan Lee, Byung Ryul Lee, and Gi Young Yang.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Fig 1.

Figure 1.Patient timeline for onset, admission, treatment, discharge, and follow-up.
Journal of Acupuncture and Meridian Studies 2022; 15: 264-272https://doi.org/10.51507/j.jams.2022.15.4.264

Fig 2.

Figure 2.Acupuncture needle (A: 0.25 × 40 mm, B: 0.5 × 60 mm).
Journal of Acupuncture and Meridian Studies 2022; 15: 264-272https://doi.org/10.51507/j.jams.2022.15.4.264

Fig 3.

Figure 3.Acupuncture points and G-shaped body posture for acupuncture treatment. (A) G-shaped posture of patient for acupuncture treatment. (B) Location of EX-B2 acupuncture point (lumbar region).
Journal of Acupuncture and Meridian Studies 2022; 15: 264-272https://doi.org/10.51507/j.jams.2022.15.4.264

Fig 4.

Figure 4.CT and MRI picture of lumbar spine at the time of hospital admission. (A) Case #1, (B) Case #2, (C) Case #3, (D) Case #4.
Journal of Acupuncture and Meridian Studies 2022; 15: 264-272https://doi.org/10.51507/j.jams.2022.15.4.264

Fig 5.

Figure 5.Plantar photographs of four patients. The dates after the hospital admission (A+) are shown below the picture. Notice the decreased stratum corneum and increased skin softness during treatment progression. (A) Case #1, (B) Case #2, (C) Case #3, (D) Case #4.
Journal of Acupuncture and Meridian Studies 2022; 15: 264-272https://doi.org/10.51507/j.jams.2022.15.4.264

Table 1 . Clinical features of the patients at the time of hospital admission and hospital discharge.

Case number (days of treatment)Hospital admissionHospital discharge
Case #1 (19 days)
Low back pain*61
Radiating pain*--
Oswestry disability index126
Manual muscle test (R/L)Hip flexion (4+/4+)Hip flexion (5/5)
Neurological symptomsNoneNone
Adverse effectsNoneNone
Case #2 (18 days)
Low back pain71
Radiating pain41
Oswestry disability index147
Manual muscle test (R/L)Within normal limitWithin normal limit
Neurological symptomsParesthesia (+, sensation of flowing water in the thigh)Paresthesia (–)
Adverse effectsNoneNone
Case #3 (29 days)
Low back pain103
Radiating pain101
Oswestry disability index3023
Manual muscle test (R/L)Great toe dorsiflexion (4/3+)
Ankle plantar flexion (4/4)
Great toe dorsiflexion (5/5)
Ankle plantar flexion (5/5)
Neurological symptomsLimping antalgic gait (+)
Hypoesthesia (+, both calf)
Limping antalgic gait (–)
Hypoesthesia (–)
Adverse effectsNoneNone
Case #4 (31 days)
Low back pain51
Radiating pain71
Oswestry disability index3019
Manual muscle test (R/L)Ankle dorsiflexion (4+/5)
Great toe dorsiflexion (4/4+)
Ankle plantarflexion 4+/5
Ankle dorsiflexion (5/5)
Great toe dorsiflexion (5/5)
Ankle plantarflexion (5/5)
Neurological symptomsHypoesthesia (+, Right dorsum of foot)Hypoesthesia (–)
Adverse effectsNoneNone

*Lower back pain and radiating pain are indicated with a numerical rating scale..


Table 2 . Traditional Korean medical interventions for lumbosacral radiculopathy patients in clinical cases based on the STRICTA checklist.

Contents
1. Acupuncture rationale
1a) Style of acupunctureClassic acupuncture theory.
1b) Reasoning for treatmentConfluence Points of the Eight Extraordinary Vessels.
1c) Varied treatmentSemi-individualized selection according to the patient’s symptoms and conditions.
2. Details of needling
2a) Number of needle insertions28 points; practitioner adjusted the number of needle insertions.
According to patient’s symptoms and conditions.
2b) Names of pointsLI4, TE5, LI11, LR3, GB41, and ST36 (1st round) and EX-B2 (lumbar region), BL40, BL57, and BL60 (2nd round).
2c) Depth of insertion10-20 mm (1st round) and 30-50 mm (2nd round) according to the expected tissue depth on acupuncture points.
2d) Response soughtSubjective De-qi sensation or local muscle twitch response.
2e) Needle stimulationManual stimulation of rotation, lifting and thrusting just after the insertion of needles.
2f) Needle retention time20 minutes (1st round) and no retention time (2nd round).
2g) Needle type0.25 × 40mm (1st round) and 0.50 × 60mm (2nd round) from Dong-bang stainless-steel disposable acupuncture needle.
3. Treatment regimen
3a) Number of treatment sessionsModified length of treatment following patients’ symptom and severity.
3b) Frequency and durationTwice a day, 5 days/week until discharge.
4. Other components of treatment
4a) Details of other interventionsHerbal medication (Doghwalsogdan-Tang, 111 g) were administered after 2 hours after each meal (3 times/day). It is composed of 12 g of Lonicera dasystyla and Forsythia koreana, 6 g of Aralia cordata, Ostericum koreanum, Angelica gigas, Paeonia japonica, Astragalus membranaceus, Salvia miltiorrhiza, and Clematis florida, 4 g of Phlomis umbrosa, Rehmannia glutinosa, Lonicera dasystyla, Wolfiporia extensa, Achyranthes asper, Eucommia ulmoides, Gentianae Macrophyllae, Asarumsieboldii Miq, Ledebouriella seseloides, and Cinnamomum verum, 3 g of Cervus elaphus, and 2 g of Glycyrrhiza glabra.
Herbal-steam therapy were applied to the lumber region with steamer (Healer Vivian, Eunhyae Trade, Korea) 2 times per day. Decoction of Mentha canadensis, Artemisia argyi and Agastache rugose was used for making steam.
5. Practitioner background
5) Description acupuncturistsTwo Korean medicine doctors. Resident trainee in acupuncture and moxibustion medicine with 3 years of experience, and Certified Clinical Specialist of acupuncture and moxibustion medicine with 15 years of experience.
6. Control or comparator interventions
6) Control or comparatorNot applicable.

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