Diagnosis and Treatment of Musculo-skeletal Pain

Transcription

1 Diagnosis and Treatment of Musculo-skeletal Pain TCM Bi Syndromes

2 Radha Thambirajah -MD(china) graduated from Shanghai Military Medical college, 970 (specialised in TCM and Acupuncture) -Founded Academy of Chinese Acupuncture in Sri - Lectures in Europe Lanka in Practitioner (in Birmingham) - Book author of Energetics in Acupuncture - Cosmetic Acupuncture and Dermatological Diseases (English, Spanish and German)

3 A Bi Syndrome Is an obstruction in the flow of blood, energy or fluid in the main and luo meridians, causing stagnation in the joints, ligaments, muscles and tendons.

4 WIND COLD DAMP This obstruction is caused by various climatic pathogenic factors that invade the body

5 Bi Syndrome It is believed that these pathogenic factors are from the outside and inside, and once lodged in the interior - cause pain, stiffness, numbness and heaviness.

6 Treating the Pain - Bi Syndromes. These could be external or internal problems:.purely external causes no interior reasons/symptoms Local & distal points, moxa or cupping etc. locally 2. Exterior causes with some internal complications Treat exterior locally and balance interior. 3.Internal condition with some external signs and symptoms Balance mainly the interior with minimum attention to exterior CHRONIC ACUTE! SUB-ACUTE

7 Bi Syndromes.. This is often an acute situation with a short history of less than 30 days, Sedation of the excess energy, or elimination of blocked energy or bleeding should be given. 2. This is more likely to be a sub-acute condition, within -6 months, has some excess and some deficiency symptoms. Sedation of yang and tonification of yin (or vice versa) will balance this. 3. This is largely a chronic disease, with severe deficiencies of blood or Qi, and needs to be tonified. There could be recurrent periods of excesebation.

8 Fullness (Shi) The body s anti-pathogenic factor is strong; it is able to fight back with power. Symptoms: Protective spasm, Heat or swelling of inflammation fever Emptiness (Xü) Deficiency of blood or Qi; Chronic condition with insufficient energy for the body to react to pathogenic factors. Symptoms: paleness, cold, Weakness, atrophy, dull pain, and weak pulse.

9 Point Choice - Muscular-Skeletal Pain Local and Distal Points (with appropriate extra-ordinary therapy) Adjacent and Referred Points Symptomatic Points Influential Points Energy-balancing Points Treat the Person

10 Example Backache (UB) with Sciatica/left side Local UB 28, 54, Gb 30 Distal UB 37, 40, 60 Influential Gb 39 (nerve); Gb 34 (muscle) If patient cannot sleep add Du 20 If patient is very tensed add Liv 3 If pain is very localised add ear points If pain is more generalised treat interior Sedate UB yang if recent pain; or tonify UB yin if chronic

11 For one-sided back or neck pains with no exterior causes Treatment of Longer Leg Syndrome Treatment of Longer Leg Syndrome With patient lying on his side with the With patient lying on his side with the longer leg on top longer leg on top Needle points Gb 30, Bl 37 and 57 deep Needle points Gb 30, Bl 37 and 57 deep with good needle sensation with good needle sensation Leave one minute per cm. Leave one minute per cm. Remove needles and make patient walk one minute before measuring the legs again. Remove needles and make patient walk one minute before measuring the legs again.

12 3 Questions to ask the Patient: Where is your pain? Describe your pain How long have you suffered with this pain? The answers will tell you: Which meridian to treat Is this a hot, cold, damp or a wind pain and so what extra-ordinary therapy should be used Is this an acute or chronic pain and should the energy be treated at all, then tonified or sedated

13 WHERE IS YOUR PAIN?

14 Exterior or Interior Problem? If pain is localised or along one or two meridians EXTERIOR local treatment +Influential points Influential should be points used Gb 34 for muscle & It is a meridian problem tendons Bl for bone Gb 39 for marrow If pain is generalised, or in many meridians- INTERIOR the associated organ should be treated, And less local points should be used. It is an organ problem

15 Simple Rule: One/two meridians affected balance the meridian and give local points with appropriate extra ordinary therapy. Many meridians affected balance the organ energy and less local points or treatment. Pain in bones and cartilage balance organ Kidney Pain in muscle and tendon balance organ Liver Pain in joints balance organs Kidney and Liver

16 Example Fibromyalgia (pain in many areas) According to ACR: Widespread pain over 3 months On both sides, up and down, along the spine of 8 tender points along muscle and tendons With fatigue, headache, morning stiffness, numbness or tingling, sleep disturbance

17 Fibromyalgia pain in neck, shoulder, back and legs is a generalised problem. Treating areas of pain individually is not possible or effective The correct therapy would be to balance the Liver as the organ governing the well being of muscles and tendons as an interior problem If the pain in fibromyalgia is of a wandering nature, then balancing the Liver will also calm the internal wind in the body - Very few local points and local therapies are used.

18 DESCRIBE YOUR PAIN

19 In the example of backache with sciatica. If pain worsens on standing and walking- Give electro stimulation on points along pain; If pain worsens on lying or sitting Give hot needles along the pain points; If pain worsens on starting to move after rest give cupping along pain area; If pain wanders between back and leg Give wind-eliminating points in the area COLD DAMP HOT! WIND

20 Muscular-Skeletal Pain - 4 TYPES HOT PAIN Sharp, incapacitating, Radiating, worse in activity or tensing, better at rest or relaxing May be inflamed Treatment: Cool, rest (immobilise) Electrical stimulation on or around pain Bleeding Few local, many distal points Balance Meridian (sedate yang/ tonify yin)

21 HOW LONG HAVE YOU SUFFERED WITH THIS PAIN?

22 EIGHT IMBALANCED STATES OF YIN AND YANG Acute state -30 days Sub-acute (-6 months) Or Recurrent Excess Sedate Excess & Deficiency Sedate & Tonify Chronic state Over 6 months Deficiency Tonify

23 Sub-acute and Chronic Hot Pains On a Meridian: Backache or sciatica on Bl meridian- Sub acute: K 4 (luo) and UB 64 sedation Treat Kidney points or Ren meridian points on the anterior aspect of the pain Chronic: Tonify K 7, Ren 3(Mu), UB 40

24 Generalised Hot Pains in Joints Joints are related to Kidney and Liver or Rheumatoid arthritis K 4 Luo point, Liv 5 Luo point. (Sedation UB 64 Yuan point; Gb 40 Yuan point) Tonify only K 7/0 Liver yin will become automatically tonified Avoid heat foods, drink water, gentle exercise in water, cook in water

25 Muscular.. Cold Pain Worse at rest and after rest Better during movement and when warm Deep pain, tense Treatment: Many local points Few distal points Local heat, moxa, Massage, exercise Keep warm Balance meridian Sedate yin/tonify yang

26 Localised Cold Pains Many local needles, less distal points Local Heat, Moxa, Massage, exercise On affected meridian : or or Backache UB meridian Acute: sedate K 5; UB 63(Xi-cleft) Sub-acute: Sedate K 3 (Yuan) & Tonify UB 58(luo) Chronic: Tonify UB 67 or 66(House element point)

27 Generalised Cold Pain in Joints Joints relate to Kidney and Liver In Kidney and Liver: Eat warm, dress warm, avoid raw & cold food or or Sedate Liver 3/2 Sedate Liv 3 & Tonify UB 58 Tonify K 3, UB 67, UB 23

28 Muscular Damp pain Worst at beginning of movement from rest Takes 2-3 hours of movement to improve Stiffness, edema Pressure pain Treatment: Local and distal Local cupping St 40 (Sp 9) Treat also hot or cold if there is any.

29 Chronic & Sub-Acute Damp Pains are treated as DAMP STAGNATION CHRONIC Excessive dampness or thick fluid, blood stagnation, obesity (excessive nutrition) Qi, function, circulation, elimination Yin, water, coolness, structure

30 Treat Sub-acute and Chronic Damp Pain with. Luo-Connecting point of Yang meridian and Back-Shu point of affected Meridian Example: Low Backache on UB UB 28 and UB 58(luo) Pain on medial knee on Sp UB 20 and St 40 Trochanter bursitis (Gb) UB 9 and Gb 37

31 Damp-heat pains Damp-cold Pains Treat damp as before; Treat heat with.bleeding or 2.Electro stimulation 3.One point therapy 4.Cool and rest Treat damp as before; Treat cold with-.moxa or heat 2.Hot needles 3.Exercise 4.Massage

32 Wind Pain Wandering Paroxysmal Or after wind exposure Can be hot or cold Can originate from Liver Blood or yin Muscular. Treatment: Local and distal Wind eliminating points for the Area. Treat hot or cold Avoid sour, alcohol Balance Liver

33 Liv blood deficiency Pale, dizzy, weak muscles, blurred vision Easily sleeping extremities, long menstrual cycles with scanty bleeding Poor endurance in muscle function Headaches after menstruation or stress Wind symptoms Liv yin deficiency Dry, dry gritty eyes, burning with recurrent conjunctivitis Tension, cannot control anger, aggression, nervousness, nervous tremor or tic Contracture and rupture of tendons, brittle nails Headaches during menstruation or stress Excessive and spontaneous bleeding (heat symptom)

34 Liv blood deficiency Liv yin deficiency Pale tongue sides Red, cracked tongue sides Weak, empty pulse left middle position Ren 4, UB 5, 7, Sp 0, Liv 8 Eat protein, meat, chicken soup, iron Thin wiry pulse left middle position Liv 5, Liv 4, K 7, Lu 7, Lu, Du 20 Drink water, relaxation, breathing exercise

35 Wind Eliminating Points Gb 20 - Head and Face SI 2 - Shoulder and Arm Gb 3 - Hip and Leg Ba Xie - Hands Ba Feng - Feet UB 2 - Back, Lungs and Skin

36 Wind elimination Sedation In wandering pains of a severe nature. Appear suddenly Radiating hot pains Incapacitating Worse on activity, better with rest Worse in menopause, with red meat and coffee, red wine More common in the upper body Wind Elimination Tonification Wandering pains of a dull nature Deep, cold or damp pains Stiffness on beginning of movement, improves slowly Better with activity, worse at rest Bad in winter, with lack of exercise More common in lower body

37 Wind Elimination Sedation Wind Elimination Tonification! Needle the point Twirl thumb away from centre and back x 6 One thrust and three lifts x 6 Scrape handle away from body x 6 Leave needle 5 minutes Remove when exhaling Needle the point Twirl thumb towards the centre and back x 9 Three thrusts and one lift x 9 Scrape handle towards body x 9 Leave needle 5 minutes Remove during inhaling

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39 One Point Therapy for Pain Symptom Affected Treated Point Meridian Meridian Facial pain GB TW TW 6 LI St St 44 St LI LI 4 Shoulder LI St St 38 Pain TW GB GB 34 SI UB UB 58 Backache UB SI SI 7 Du SI 3

40 One Point Therapy Symptom Affected Treated Point Hypochondral GB TW TW 8 Hip Pain GB TW TW 5 Pain in leg UB SI SI 7 And Knee St LI LI 0 Sp Lu Lu 6 Liv Pe Pe 7 Pain in heel K Pe Pe 7 For sedation of excess in meridian, not in deficiency states!

41 How it is done:.decide which meridian/meridians are affected; 2.Do your local treatments, Master points etc. 3.After 20 minutes, remove all needles, cups. 4.Use one point on the affected side and vibrate the needle constantly, while the patient moves the painful area gently. There should be reduction on the pain scale each ½ minute, up to 2 minutes. Remove needle, end of treatment

42 One Point Therapy should produce lasting pain relief, though some percentage of the pain may return later. It should be used only in the first 5 or 6 treatments, as it is a strong sedation therapy. It could be used as a diagnostic method. It could be the only needle used. It is a very efficient method for acupuncture analgesia.

43 FIBROMYALGIA Common in middle-aged women; pain in many areas of muscles and tendons; sometimes wandering/sometimes fixed pains; many associated symptoms including exhaustion, depression and heat. Poor response to medication. Good example for chronic interior imbalances with some exterior manifestations, where the person (interior) and the problems (exterior) have to be treated simultaneously. Initially, it is more important to treat the person and only a few needles for the pain; as the person improves, you could concentrate more on the pain therapy.

44 3 Sub-groups of typical patients with fibromyalgia. The pere-menopausal woman 2. The depressive and exhausted Patient 3. The damp, oedematous type TREAT THE PAIN, TREAT THE PERSON!

45 .The pere-menopausal woman Symptoms: Hot flushes, night sweating Restless sleep Hair loss, dryness Tinnitus, dizziness Quickly exhausted Kidney yin deficiency with ascending heat to the upper warmer Treatment: Tonify Kidney yin K 4, Ren 3, Bl 40 Sp 6 descending technique Water (drink, use, cook in) Mid-day rest Avoid coffee, red meat and direct exposure to heat

46 3. Damp, oedematous type Symptoms: Edema in eyelids, hands and feet (or in face, arms and legs), Stiffness and reduced mobility when starting to move from rest, Fullness in the middle, Semi solid stools Heaviness of limbs Sp Qi with stagnation of body fluid Treatment: Tonify Sp Qi, circulate and eliminate dampness Sp 9, St 40, Bl 20 needle and cupping, Bl 39 Avoid sugar, fats, refined carbohydrate, Fatty milk products. Eat cooked and warm, and light, small meals in the evenings

47 2. The depressive, exhausted Patient Symptoms: Pale, cold, hunched Endogenous depression Easily sleeping extremities Dizziness, weakness Always tired Tearful Heart & Lung blood & Qi deficient, empty pulse in upper warmer, Liver blood deficient Tonify blood, tonify upper warmer For depression P 6, Ren4,Bl 5, Lu, Bl 3 For Blood tonify heart, Bl 7, Sp 0, Gb 39 For Energy- Ren 6, Bl 24, St 36

48 Extra-ordinary Therapies -Moxibustion Artemisia Vulgaris Mugwort Moxa Cigar Moxa on Needle Hot Needle Moxa Wool Smokeless Moxa Moxa Essence

49 Use of Moxibustion. Warming treatment use in Cold Syndromes Pain worsening in cold weather, better in warm Pain worsening at rest, better at movement Stiffness when beginning to move, improves with activity Cold to touch Deep seated, contracting pain Contra-indicated in febrile conditions

50 Moxa Cigar Moxa cigar can be lighted and used close to the skin ( 2 cm.) It can be used on a point K, Pe 8, Ren 2, Ren 22 Or on a line - Du meridian, fingers Or in an area over the knee, for example

51 Use of Moxibustion Hot Needle commonly used in large joint pains - carries the heat and herbal effect deeper - effective in cold and damp-cold pains - therapist may leave the room during treatment -many hot needles used on one area Used in shoulder pain, hip pain, back ache, knee pain

52 Cupping Therapy Derived from the ancient horn method Used dry or with bleeding- Suction method Dry cupping good for pains in general; special against oedema and fluid stagnation. Use local or on Back-shu points of organs Bleeding cup used to remove heat or blood stagnation. Used local for pain, and on back-shu points for organs

53 Cupping On all localised hot pains in muscle; In heat or inflammation of internal organs on the Back-shu points; Not to be used in patients taking anticoagulating medication On all musculo-skeletal pains with edema; On a bursa, baker s cyst; Bach ache, joint pain with limited mobility and stiffness; On back-shu points of organs with fluid, tumours In ascitis on Ren 5, 9

54 Electrical Stimulation Therapy A modern equipment to avoid manual stimulation Different Frequencies can be used the intensity is always as comfortable to the patient. Uses Pain therapy - Paralysis therapy - Acupuncture Analgesia in surgery

55 Different Frequencies in Stimulation Continuous Frequency Intermittent Frequency Dense-Disperse Frequency

56 .Continuous Frequency -with equal intervals both at high and low; - speed can be from Herz. - Mainly used in pain relief, (sedation effect) - Higher frequency offers greater pain relief - can cover large areas of pain - can treat inflammation avoiding local needling - can be used as analgesia for surgery - can use up to 0 needles at a time

57 Advantages in Electrical Stimulation Labour saving Very effective Patients and therapists prefer it to moxa Can cover large areas of pain Contra-indication Should not be used in patients with Pace maker

58 Plum Blossom Needle Therapy The plum-blossom Needle is basically a hammer with many short needles, which is used to hammer the skin in different areas of the body. It is used mostly in treatment of skin diseases, or problems of connective tissue, tendons and muscle. It is not generally used in problems of the internal organs, but can help to activate organs.

59 Tapping can be done with varied strength:.light Tapping just enough to create a red skin reaction. This is in order to bring blood and energy to the area which is tapped. - to firm the connective tissue in sagging; - to treat vitiligo - to treat stiffness of muscle and tendon, which worsens with passiveness - to treat numbness - to treat on para-vertebral lines to improve organ function - to treat myopia in children

60 2. Heavy Tapping intention is to cause bleeding on the skin surface (small area) to eliminate heat from that area. - to eliminate wind-heat in neuro-dermatitis or heat-type psoriasis - in alopecia areata or baldness in one area - the tapped and bleeding areas are left open and not covered after treatment

61 Neck, shoulder pain Yang Type Thin,long neck, small upper. Body, tensed person Pain worse in first half of night & second half of day Associated headaches at same times Tender points along hairline Stress related, pale person Treatment: Few local points-along hairline-tw 7, Gb2, Gb 20, Bl 0 Lu 7-Area Distal,Le 3- tension Energy-balance: Tonify upper warmer- Ren 4, Bl 5 for Heart Lu, Bl 3 for Lung

62 Neck, shoulder Pain YIN TYPE Thick, swollen appearance of neck, shoulder Pain and reduced mobility worse in second half of night and first half of day Hunched forward, oedema on C 7 vertebral prominence Dislike pressure on neck Treatment: Many local points and cupping St 40, Sp 9 Lu 7 Physiotherapy Less fatty foods