Gold thread therapy (GTT) is a method in which a gold thread is inserted into the body using a gold thread injector (Fig. 1). It was performed as a folk remedy in the 1960s.

In the past, the gold threads used in GTT were 0.5 cm (maximum 0.6 cm) in length and were not injected into large vessels, ligaments, or deep parts of the body. A straight gold thread form was maintained, and 20 to 50 gold threads were injected [1]. However, the number of practitioners performing GTT (with insufficient understanding of the precautions) has increased and the previous methods have not been adhered to. Thus, many patients who have recently undergone GTT experience side effects such as skin granuloma and redness [2–7]. The concern about secondary risks such as infection caused by the gold threads and vessel damage caused by the indiscriminate use of injection has increased [8,9]. GTT can aid medical treatment when used correctly. It has been reported that GTT is therapeutic for Crow’s feet in plastic reconstruction surgery [10] and has been reported to be effective for female sexual dysfunction and vaginal laxity in obstetrics and gynecology [11].

Some patients with lumbar back pain choose Korean medicine treatment, whilst others undergo GTT at illegal private clinics. A history of GTT can be determined through patient statements and simple imaging tests, such as X-rays [2]. Caution is required during GTT treatment in the event that a patient has failed to report their history of GTT as they believe that GTT can affect their current treatment.

Moving cupping therapy, a type of cupping therapy, uses negative pressure and movement across subcutaneous layers of skin and the muscle beneath. The application of this therapy may cause tissue damage if foreign substances are present within the subcutaneous skin and muscle [3]. Therefore, before considering a treatment, Korean medicine doctors should bear in mind the risk of secondary damage in areas where gold thread injection has been performed. However, there is a lack of research into secondary risks of treatments following GTT and potential side effects [2]. We report a case of a patient who was at secondary risk after cupping therapy due to unreported previous history of GTT in the same area that cupping was performed..

Patient

Kim o o /F/79

Ethical consideration

A patient with chronic lumbar pain, previously treated with GTT in the 1970s, was included in this retrospective study. Informed consent was obtained from the patient for the publication of photographs and information from their medical records. This study was approved by the Institutional Review Board of Pusan National University Korean medical hospital (PNUKHIRB no.: 2022-05-005).

Chief complaints

Low back pain on the right and radiating pain on the right.

Onset

Chronic.

Present illness

The patient presented with low back pain which improved and worsened repeatedly. The patient’s history of low back pain began over 5 decades ago. In the 1970s, the patient had GTT where gold threads were injected into the lumbar region.

In 2009, she visited a local orthopedic hospital for a suspected sprain in her lower back. Magnetic resonance imaging was performed on her spine and the patient was diagnosed with a herniated disc at L4/5. Based on the results of lumbar spine radiography the patient underwent a discectomy.

In 2012, the patient’s condition worsened, and she visited the hospital where she received nerve block intervention. However, the patient’s condition showed no improvement.

In 2015, the patient experienced low back pain whilst picking up her luggage. She visited hospital where lumbar spine radiography and magnetic resonance imaging was performed and the patient was diagnosed with spinal stenosis at L1–3. A laminectomy was performed. However, the low back pain did not reduce following this procedure.

In 2021, on December 15th, the patient was admitted with low back pain to Pusan National University Korean Medicine Hospital for medical intervention.

Past medicine history

Osteoarthritis in the hands

Hypertension

Simple radiography images

• #. 2021-12-15 L-spine X-ray

  s/p Posterior decompression at L1–5

  Severe degenerative scoliosis of L-spine

• #. 2022-01-12 Pelvis/Tibia/Femur/Ankle X-ray

  Within normal limits (Figs. 2 and 3).

Treatment methods

Acupuncture

Acupuncture was performed using sterile 0.3 × 60 mm, 0.4 × 40 mm, and 0.5 × 50 mm stainless steel needles (Dongbang medical, Seongnam, Korea) twice a day for 10 minutes during the hospitalization period of 31 days. EX-B2 acupoints (low back) were needled to relieve the pain (Table 1).

Herbal medicine

Dokwhal-sokdan-tang (Table 2).

Moving cupping therapy

On January 5, 2022 moving cupping was performed using cups (Dongbang medical, Seongnam, Korea) with light suction for 10 minutes on the bladder channels (BL 40, BL 50–55).

Evaluation

To measure the severity of pain the numerical rating scale (NRS) was used where a score of 0 indicated no pain and 10 indicated unbearable pain.

Case findings

The patient mentioned having undergone GTT in the lumbar region but failed, during the assessments prior to the treatment for low back pain, to disclose that she had received GTT in her calves. The known areas where GTT had been performed were carefully avoided by the practitioners whilst conducting the moving cupping therapy.

Normally, reactions to moving cupping (e.g., redness, slight tenderness, and pain) disappear within 3 days following the procedure. However, it was observed that the patient had bruises (versus redness), severe tenderness, and pain in her calves that had not subsided 6 days after the moving cupping therapy (Table 3).

Doubting whether the side effects were caused by moving cupping therapy, the Korean medicine doctors asked the patient again about her history of receiving GTT. The elderly patient recalled that she had also received GTT in her both lower leg in the 1970s.

Diagnostic radiology, at a local medical center, was requested for the pelvis, femur, tibia, and ankle (Figs. 2 and 3). During treatment at Pusan National University Korean Medicine Hospital, observations were noted and the lesion in her calves at moving cupping site was treated daily, but the patient was discharged without a complete cure.

The NRS score for low back pain reduced from 4 to 2 at discharge. The NRS score for lower leg radiating pain reduced from 4 at the time of hospitalization to 1 on the 24th December but the lower leg pain increased to 5 following moving cupping therapy on the 5th January. A similar degree of pain (4 to 5 points) continued for at least 9 days (Fig. 4). Following moving cupping therapy bruise formation and tenderness were still observed in the lower leg until discharge.

Medical procedures such as cupping therapy, thermal therapy, and electrical therapies in patients who have undergone GTT are high risk. The location of the injected gold thread cannot be confirmed visually. It should be noted that moving cupping therapy may irreversibly change the shape and location of the gold thread as the cup rubs against the skin and muscle under negative pressure, and this may lead to muscle damage. The continued tenderness and bruising observed in the patient in this case indicates the risk of bleeding, hematoma formation, and secondary infection if external pressure is applied where GTT has been previously performed.

GTT, similar to embedding therapy and thread lifting, can be an effective treatment [2], however, it is an irreversible therapy which may be unsafe. Therefore, caution should be exercised while performing GTT. Furthermore, GTT is practiced illegally in private clinics where infection arising from GTT also needs to be considered [4–7].

Some Korean medicine treatments, such as cupping therapy, and thermotherapy affect the gold threads that are injected during GTT. However, data on physical reactions and side effects caused by GTT are insufficient [2].

Cupping therapy has been used effectively in Korean medicine to treat muscle stiffness and blood stasis (which is expressed as static blood and phlegm) and can be classified into flash cupping, stationary cupping, and moving cupping [2].

Recently, practitioners at Pusan National University Korean Medicine Hospital have begun to use moving cupping therapy to reduce radiating pain, especially in the lower leg. The normal reaction to moving cupping therapy involves redness, tenderness, and pain for approximately 3 days after the procedure, after which the symptoms disappear [3].

In this case, although the practitioner had appraised the procedure with the patient several times prior to the treatment, a full history of GTT was not given by the elderly patient and led to the Korean medicine doctor performing moving cupping therapy on the site where gold threads had previously been injected.

Severe bruising, tenderness, and pain lasted at least six days beyond the expected reaction period (1–3 days) for moving cupping therapy. Considering the continuous pain that the patient experienced, and the patient’s bruise on her calf, which was similar to a patient with hematoma (Fig. 5), was suggestive of bleeding within the muscle. In addition, the radiating pain and tenderness following moving cupping therapy did not show much improvement, except for a slight reduction in NRS score from 5 to 4 at discharge (nine days after treatment).

Moving cupping therapy performed in the vicinity of where patients received GTT are more susceptible to secondary risks and musculoskeletal issues as a result of negative pressure, and these risks are unpredictable. In addition, since the symptoms that occur following moving cupping therapy are similar to hematomas, the risk is greater in patients receiving thrombolytic drugs. It is believed that all Korean medicine treatments that apply pressure, such as interferential current therapy, dry cupping, and moving cupping therapy, should be avoided in such patients.

Recently, the Korean traditional medicine community has reported various side effects of GTT in patients with crow’s feet [10], female sexual dysfunction and vaginal laxity [11] and patients wanting facial rejuvenation [7] who received GTT, and warned of the risk of secondary infection and intense pain after undergoing GTT in patients.

In the Acupuncture and Moxibustion Medicine textbook [12], GTT is described as being an effective treatment for chronic conditions/diseases. However, it is advised that GTT is used carefully because problems may arise due to the injected gold thread which remains in the body [12]. There is a scarcity of research/reporting on the safety of GTT even though it is an irreversible treatment. In reporting this case, the hope is that similar incidents will be prevented in patients who have received GTT.

Gold thread and needle used for gold thread injection.

Lumbar spine X-ray scan.

X-ray scan of the leg. (A) pelvis; (B) femur; (C) tibia; and (D) ankle.

Numerical rating scale changes during the hospitalization period. Onset

Bruises observed 6 days following treatment.

Table 1. Standard for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA).

Table 2. Herbal Medicine.

Table 3. Changes in Tenderness.