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The Use of Acupressure Tapping, an Attractor Field Technique, for a 65-Year-Old Patient with Post-Operative Cervical Pain: A Case Report

Aubrey Rohner Background and Purpose. The implementation of Acupressure Tapping, an Attractor Field Technique, to manage pain behaviors following a cervical surgical procedure has not been described in the literature. This lack of data creates a gap between traditional physical therapy interventions that are implemented to manage acute post-operative pain and alternative medicine. The purpose of this case report is to describe the use of Acupressure Tapping to complement traditional interventions in managing pain behaviors following a cervical laminoplasty and laminectomy in the skilled nursing facility setting. Case Description. A 65-year-old man status post a cervical laminoplasty and laminectomy completed a 10-day Acupressure Tapping (AFT) intervention. The patient reported neck pain, bilateral shoulder and upper arm pain, tingling in the digits of the right hand, low back pain, and sciatica at baseline. Outcomes. The patient completed 10, 10-15 minute treatment sessions in which Acupressure Tapping was provided in conjunction with traditional physical therapy. Overall, the patient reported decreased cervical pain and minimal to no change in bilateral shoulder, upper arm, low back, and sciatic pain following the intervention. Reduced heart rate and respiratory rate were observed, as well, in addition to frequent subjective reports indicating that the patient was in a more relaxed state post-intervention. Discussion. The patient experienced decreased cervical pain immediately following the intervention. While the mechanism of action of this intervention is theoretical, it is possible that Acupressure Tapping assisted in the down regulation of the patient’s central nervous system, impacting his pain perception. Randomized clinical trials are needed to evaluate the efficacy of Acupressure Tapping in patients with post-operative pain, as no literature exists to support the use of this intervention in clinical practice. Keywords: Acupressure Tapping, Attractor Field Technique, AFT Background and Purpose Research demonstrates that a cervical laminoplasty is an effective and safe method of treating multi-

level cervical spondylotic myelopathy, however, axial neck pain has been reported to be as great as 30-60% in

patients that have undergone this procedure.1,2 According to literature, psychological disorders, including

anxiety and depression, have been found to influence pain perception, whether acute or chronic.3,4

Approximately one out of every five primary care patients has at least one diagnosable anxiety or depressive

disorder.5 Physical therapists do not treat anxiety, however, treat patients’ musculoskeletal impairments that

may be heightened due to a phenomenon referred to as central sensitization, resulting in impaired pain

perception.3,4 Traditional physical therapy interventions that are implemented following a cervical surgical

procedure to reduce pain in the skilled nursing facility setting include cryotherapy, gentle active range of

motion, interferential current electrical stimulation, soft tissue mobilization to uninvolved musculature, and

patient education.6,7,8, Acupressure Tapping, an Attractor Field Technique, has been proposed to complement

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traditional physical rehabilitation in the management of post-operative cervical pain behaviors; however, there

is currently no literature to support the use of this intervention in the physical therapy setting.9

The Attractor Field Technique (AFT) is a manual technique referred to as Acupressure Tapping, which

was developed by Dr. David Hawkins in 1998.9 The underlying theoretical basis is founded in ancient Chinese

Medicine and resembles that of Acupuncture, as disease and distress result from disturbances in the mind-

body energy systems. It is theorized that each life stressor introduces “energetic errors in the body’s control

system,” resulting in disease and distress that starts in the mind and transforms into physical consequences.9

Hawkins describes AFT as a mechanism to tap into the meridian energy system, which serves as a “portal to

the energetic processes that direct our body’s development and control and coordinate the body’s

functioning.”9 The theory is that there are approximately 450 acupuncture points that comprise an energetic

signaling system, and when stimulated correctly, can “restore energetic functioning to distorted body energies

which underlie illness.”9 AFT involves tapping sequences of 23 meridian points that are located on the face,

head, and hands that compose over 100 physical and psychological condition-specific formulas including bone

pain, bone healing, joint pain, muscle spasms, nerve root irritation, anxiety, fear, grief, etc.9 Each point is to be

‘lightly tapped’ the designated number of times and double or triple tapped to increase the effectiveness by 10

to 50 times respectively, however the rate of tapping is insignificant. Dr. Hawkins' methodology explores the

use of meridian energy altering formulas for the elimination of energy fields and symptoms that result from

those energy fields, which are theorized to be the source of mental and physical disorders. The purpose of this

case report is to describe the use of Acupressure Tapping in managing pain behaviors following a cervical

surgical procedure.

Patient History and Review of Systems

The patient was examined and evaluated by the physical therapist prior to obtaining a written

informed consent to participate in this case report. The patient was a 65-year-old man who was admitted to

the skilled nursing facility five days after a C3-C6 cervical laminoplasty and C7 dome laminectomy due to

gradual, insidious multi-level cervical spondylotic myelopathy. He had received physical therapy during his

inpatient hospitalization. The patient was previously working full-time as a distributor for a retail store, but had

been off of work the last eight months due to extreme cervical and lumbar pain beginning in May 2014 and

generalized upper and lower extremity weakness. The patient lived alone in an apartment and was

independent prior to surgery, requiring a standard cane for ambulation due to weakness and impaired

balance. He had two adult daughters who lived nearby, but worked full-time and were unable to assist him at

home.

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The patient’s past medical history was remarkable for cervical stenosis, a herniated lumbar disc,

sciatica, depression, anxiety, insomnia, alcohol dependence, tobacco use disorder, addictive gambling, poor

eating habits, chronic pain, narcotic dependence, and smoking. The patient frequently stated that he had a lot

of anxiety about his current condition, socioeconomic status, returning home, and the loss of his wife in 2008

in the same facility. Additionally, the patient decided to quit smoking right before his surgery, and was

experiencing symptoms of nicotine withdrawal. He was referred for inpatient physical and occupational

therapy due to a progressive decline in upper and lower extremity strength, static and dynamic stability,

activity tolerance, and cervical pain and limited mobility. The patient’s chief complaint was constant 8-10/10

posterior neck pain and radiculopathy that increased with activity and reported intermittent tingling in the

digits of the right hand. The patient’s short-term goal for physical therapy was to return home without

cervical, lumbar, or bilateral leg pain with independence in his daily activities. The patient had hopes of

returning to fishing, exercising on a regular basis, and playing with his grandchildren in the long-term.

Examination

Objective measures were performed by the treating physical therapist at the patient’s initial physical

therapy visit and re-assessment was performed on a daily basis immediately following the intervention for the

2 ½ weeks that the patient was treated in the skilled nursing facility. During the patient’s initial physical

therapy visit, an ordinal self-report rating scale (Visual Analog Scale) was used to assess the intensity of the

patient’s pain at rest and with activity. The patient was asked to assign a score from 0-10 to describe his pain,

where 0 represented no pain and 10 represented the worst imaginable pain. Additional tests and measures

included vitals (heart rate and respiratory rate), and documenting negative or ‘catastrophizing’ thoughts

verbalized by the patient.

Clinical Impression

The patient consistently reported posterior neck pain greater than 5/10 on the visual analog scale that

radiated into his mid-upper back, bilateral shoulders, and upper arms. This pain increased with activity and

proved to be his primary limitation to returning home, as progression in physical and occupational therapy was

hindered. One-week post-operative, the patient reported low back pain and bilateral sciatica, as a result of the

herniated disc in his lumbar spine, which the patient had experienced prior to his operation. The patient also

demonstrated elevated heart rate and respiratory rate at rest and frequently spoke about his current condition

in a negative or ‘catastrophizing’ manner, which he attributed to his anxiety. The patient was receiving a

narcotic every four hours for pain management and anxiety medication two times a day, however, reported

that the effects of the medication were insignificant. Based on the patient’s widespread pain, consistently high

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pain ratings, and anxiety behaviors including elevated vital signs and frequent negative, ‘catastrophizing’

thoughts, he was determined to be an appropriate candidate for the Acupressure Tapping intervention. Table

1 demonstrates the patient’s comprehensive pain behaviors during his first week at the skilled nursing facility

(Post-operative day 5-11). The patient did not receive therapy services on the weekend.

Table 1. Patient characteristics at baseline

Days Post-Operative

Pain Location Pain Rating (VAS scale) (0-10/10)

Heart Rate (bpm)/ Respiratory Rate

(breaths/min)

Negative/Catastrophizing Thoughts

Day 5 Posterior neck, radiates into mid-upper back, bilateral shoulders, and upper arms

10 92 / 18

“I don’t even know what the surgeon did back there. He better not have messed me up more. Why is there pain in my arms? There is just so much pain. My wife died in this place 8 years ago. It just makes me nervous.”

Day 6 Posterior neck, radiates into mid-upper back, bilateral shoulders, and upper arms

9-10 90 / 18

“I don’t think my pain medication is working. Can you check to make sure my nurse is even giving them to me?”

Day 7 Posterior neck, radiates into mid-upper back, bilateral shoulders, and upper arms; Tingling in digits of right hand

8 Vitals not obtained “The surgeon told me I shouldn’t have tingling anymore. What if the surgery failed?”

Day 10 Posterior neck, radiates into mid-upper back, bilateral shoulders, and upper arms; Tingling in digits of right hand

9 Vitals not obtained “Why is this pain in my arms? What if it’s bone cancer?”

Day 11 Posterior neck, radiates into mid-upper back, bilateral shoulders, and upper arms; Tingling in digits of right hand; central low back and bilateral posterior leg pain

9 93 / 19 “Why is there so much pain in my shoulders? It’s a deep pain, deep in the joint. I think I tore my rotator cuff. The doctor told me this surgery could fix my sciatica and it is back. Now I will need surgery on that too.”

Intervention The patient’s pain was only temporarily relieved at rest with traditional physical therapy agents and

modalities including cryotherapy, pulsed diathermy, and electrical stimulation; therefore, indicating the

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implementation of Acupressure Tapping for long-term management of symptoms, both pain and anxiety

related. In addition, the patient reported that he was having a lot of anxiety, which was evidenced by his

elevated heart rate, respiratory rate, and frequent negative, ‘catastrophizing’ thoughts. The physical therapist

selected the following AFT formulas based on the patient’s physical and emotional symptoms and primary

complaints: Fear, Nerve Root Irritation, Back Pain: Cervical Muscle Spasms, Nerve Burning Pain: Sciatic, Back

Stiffness, Joint Pain: Upper Limb, and Arm Pain. Each diagnosis has an established energy field clearer and a

symptom remover formula that are both to be applied for maximum effectiveness per AFT [For detailed

meridian locations grid and condition-specific formulas refer to Appendix A].

On post-operative day 12, one-week after the patient’s admission to the skilled nursing facility, all of

the selected formulas were applied to determine his responsiveness to this intervention. The patient was

positioned in supine, with his neck supported by one pillow to maintain neutral spinal alignment. The physical

therapist educated the patient in the Acupressure Tapping technique and described the theorized effects. The

therapist began with the Fear formula and lightly tapped each meridian point in the sequence three times the

designated number (i.e.: 60 times) at the therapist’s selected pace. The patient was instructed to either rest

quietly or continue to vocalize his concerns. The physical therapist proceeded with each remaining formula

completing the energy field clearer formula first, followed by the symptom remover for each condition listed

above. The patient was most responsive to the Fear, Nerve Root Irritation, and Back Pain: Cervical Muscle

Spasms formulas as evidenced by the patient reporting decreased pain, thus indicating the continuation of

these formulas and discontinuing the remainder.

Acupressure tapping was implemented at the end of any treatment session in which the patient

reported cervical pain greater than or equal to 5/10, consuming 10-15 minutes of the patient’s 60-minute

treatment session, five days per week for the last week and a half of his stay. Acupressure tapping was used in

conjunction with therapeutic exercise to improve bilateral lower extremity strength and activity tolerance,

neuromuscular re-education to improve static and dynamic stability, therapeutic activity to improve

independence with stair negotiation, ambulation, and transfers, gait training to improve independence with

use of standard cane, and pulsed diathermy, cryotherapy, and interferential current electrical stimulation as

needed for pain control. The patient was also participating in occupational therapy for 45 minutes daily

consisting of bilateral upper extremity strengthening and scapular mobilizations.

Outcomes

Acupressure tapping was performed during 10 treatment sessions. The patient’s pain location, VAS

pain scale score, heart rate, and respiratory rate were obtained before and after the tapping formulas (Fear,

Nerve Root Irritation, Back Pain: Cervical Muscle Spasms) were performed. In addition, subjective comments

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were documented to track any change in mental state. Overall, the patient reported decreased pain at rest,

demonstrated reduced heart rate and respiratory rate, and frequently commented about his state of

relaxation following the Acupressure Tapping. Tables 2-4 demonstrate the patient’s comprehensive pain

behaviors before and after the implementation of the tapping intervention.

Table 2. Visual Analog Scale (VAS) Scores (0-10/10) Pre and Post Intervention

Days Post-

Operative

Pain Location PRE Pain Rating (0-10/10)

POST Pain Rating (0-10/10)

Day 12 Posterior neck, right of incision; mid-upper back “Deep ache” left arm

8 4

4 2

Day 13 Posterior neck, right of incision; mid-upper back Left shoulder and upper arm Low Back/Sciatica

8 6-7 4-5

0, “incision itches” 2-3 2

Day 14 Posterior neck, right of incision; mid-upper back Left shoulder Low Back/Sciatica

9, “sharp, shooting” 3 3

1, “itches” 3 3

Day 17 Posterior neck, right of incision Left shoulder

7 4

4 3

Day 18 Posterior neck, right of incision Left shoulder Low Back/Sciatica

8, “shooting” 4-5 3

3 3 1

Day 19 Posterior neck, right of incision; mid-upper back Left shoulder and upper arm

6-7 5, “aching”

2-3 2

Day 20 Posterior neck, right of incision Left shoulder Low Back/Sciatica

6 3 3

0 2 0

Day 21 Posterior neck Left Shoulder

6-7 2

2 2

Day 24 Posterior neck, mid-upper back 4-5 3

Day 25 Posterior neck, mid-upper back 5 2

Table 3. Heart Rate (bpm) and Respiratory Rate (breaths/min) Pre and Post Intervention

Days Post-Operative

PRE HR / RR

POST HR / RR

Day 12 87 / 17 76 / 15

Day 13 91 / 18 80 / 14

Day 14 84 / 15 77 / 14

Day 17 Vitals not obtained Vitals not obtained

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Day 18 86 / 16 78 / 13

Day 19 89 / 16 79 / 14

Day 20 Vitals not obtained Vitals not obtained

Day 21 Vitals not obtained Vitals not obtained

Day 24 85 / 14 73 / 12

Day 25 88 / 17 75 / 12

Table 4. Patient’s Subjective Report Pre and Post Intervention

Days Post-Operative

PRE Subjective Report

POST Subjective Report

Day 12 “When is this conference we are having? I cannot go home. If I go home this surgery will have been pointless. I will never be able to take care of myself.”

“I feel sleepy.”

Day 13 “The curve in my neck has never been right, which is why I have so much pain. Do you see my collarbone? The right one is bigger. Maybe that’s why my neck hurts so bad.”

“I feel relaxed. Seems like I’m breathing deeper.”

Day 14 “I will never be able to work again. My boss is going to fire me at the first opportunity.”

“That seems to be very relaxing. I feel calm.”

Day 17 No subjective report No subjective report

Day 18 “I think I have fibromyalgia. I can’t go home.” “I could take a nap right now.”

Day 19 “My grandson plays baseball. We won’t be able to play together ever again.”

“I felt my eyelids getting heavier.”

Day 20 “I never sleep anymore. My mind is always racing.”

“My shoulders still hurt.”

Day 21 “I’ll never be able to take care of myself. I’ll never be able to work again.”

“My pain is less. I’m scared it’s going to go up when I move.”

Day 24 No subjective report “My shoulders feel the same.”

Day 25 No subjective report “I’m not in as much pain when I’m more relaxed.”

Discussion

The purpose of this case report is to describe the use of Acupressure Tapping in managing pain

behaviors following a cervical surgical procedure. This case report has shown how Acupressure Tapping, a

manual Attractor Field Technique, performed by a physical therapist was used in conjunction with traditional

physical therapy in the rehabilitation of a 65-year-old male status post a C3-C6 laminoplasty and a C7

laminectomy with complaints of significant cervical, bilateral shoulders, upper arms, low back, and sciatic pain.

The patient completed the intervention along with traditional physical therapy with no complications and was

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educated and instructed in how to perform the tapping intervention on himself for long-term management of

his symptoms.

This case suggests that it is possible for patients with post-operative pain and anxiety behaviors to

benefit from Acupressure Tapping, however, we are unable to determine the efficacy of this intervention due

to multiple confounding variables. The patient’s symptoms could have improved due to his medical condition

improving as a result of progressing through the stages of healing. Also, the patient requested a high dosage

of narcotics every four hours, used cryotherapy every four to six hours, and requested electrical stimulation or

pulsed diathermy as needed during physical and occupational therapy. It is important to acknowledge that the

intervention provided temporary pain relief and the patient’s pain intensity generally increased upon rising

from supine to sitting and with activity, therefore, the long-term effects of this intervention are unknown.

While the mechanism of action of this intervention is theoretical, it is possible that Acupressure

Tapping assisted in the down regulation of the patient’s central nervous system, impacting his pain perception.

There is no literature to support the use of Acupressure Tapping in managing acute post-operative cervical

pain and anxiety behaviors. Future randomized clinical trials are required to determine the efficacy of this

intervention in managing post-operative pain, as no literature exists to support the use of this manual

technique in the physical therapy setting.

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Appendix A. Figure 1.

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Appendix A. Figure 2. Fear Formula

Cervical Nerve Root Irritation Formula

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Cervical Muscle Spasms Formula

Arm Pain Formula Joint Pain: Upper Limb Formula

Nerve-Sciatica Formula

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References

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2. Galbraith J, Butler J, Dolan A, O'Byrne J. Operative Outcomes for Cervical Myelopathy and Radiculopathy. Advances In Orthopedics [serial online]. January 2012;:1-8. Available from: Academic Search Premier, Ipswich, MA. Accessed March 6, 2015.

3. Meeus M., NIgs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

4. Gold M, Gebhart G. Nociceptor sensitization in pain pathogenesis. Nature Medicine [serial online]. November 2010;16(11):1248-1257. Available from: Academic Search Premier, Ipswich, MA. Accessed March 6, 2015.

5. Means-Christensen A, Roy-Byrne P, Sherbourne C, Craske M, Stein M. Relationships among pain, anxiety, and depression in primary care. Depression & Anxiety (1091-4269). July 2008;25(7):593-600. Available from: Academic Search Premier, Ipswich, MA. Accessed March 3, 2015.

6. Pastor D. Use of electrical stimulation and exercise to increase muscle strength in a patient after surgery for cervical spondylotic myelopathy. Physiotherapy Theory & Practice [serial online]. February 2010;26(2):134-142. Available from: Academic Search Premier, Ipswich, MA. Accessed March 6, 2015.

7. Van Zundert J, Huntoon M, Patijn J, Lataster A, Mekhail N, van Kleef M. 4. Cervical Radicular Pain. Pain Practice [serial online]. January 2010;10(1):1-17. Available from: Academic Search Premier, Ipswich, MA. Accessed March 6, 2015.

8. Boyles R, Toy P, Mellon Jr. J, Hayes M, Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Journal Of Manual & Manipulative Therapy (Maney Publishing) [serial online]. August 2011;19(3):135-142. Available from: Academic Search Premier, Ipswich, MA. Accessed March 6, 2015.

9. The Tree of Life Foundation. (2014). What is AFT? Retrieved on February 26, 2014 from http://the-tree-of-life.com.