Pain in TCM

An Asian American Perspective Pain In Traditional Chinese Medicine

Disclosure
Conflict of Interest and Financial Disclosure
Pain in Traditional Chinese Medicine
Cathryn Hu, Ph.D., O.M.D., L.Ac.
President of Advanced Acupuncture, Inc.
Professor of Advanced Acupuncture Institute
NONE

Objectives
To relate:
The history and philosophy of Traditional Chinese Medicine (TCM) as it relates to pain management and healing;
The interface between body-mind medicine, cultural and religious practices, and spirituality within Asian-American communities;
The role of Qi (vital energy) in managing pain; and
The contraindications and precautions associated with TCM.

History of TCM in US
1972 - China fever
Dr. Li-Beijing treats American
New York news report
Legalized Acupuncture practice in U.S.
Population of Practitioner in Asian American community

Flavor of Asia
People
Culture
Religion
Medicine
Thousands Hands of Buddha

History of TCM
Traditional Chinese Medicine
Acupuncture
Moxibustion
Medicinal Herbs
Cupping
Gua Sha

TCM Methods
Traditional Chinese Medicine
Acupuncture
Moxibustion
Medicinal Herbs
Cupping
Gua Sha

Philosophies of TCM
Natural Law
Holistic Approach
External & Internal
Normal Qi vs. Evil Qi
www.holistictouchreiki.co.uk/images/chakra-lo

Yin & Yang
Yin and Yang Theory :
The Opposition
The Interdependence
The inter-consuming supporting relationship
The inter-transforming relationship
The infinite divisibility
Cheng, 13-15
www. feandft.com

Yin & Yang
Clinical Applications :
Organic structure
Physical function
Pathological changes
Clinical diagnosis
Assessment/treatment plan
Cheng, Xinnong. Chinese Acupuncture and Moxibustion . 5 th ed. P16-19, Beijing: Foreign Languages Press, 2004
Altmed.latp.org.ua

Five Elements
Theory :
Wood, Fire, Earth, Metal and Water
Law of movement
Clinical applications
Pathological relationships between organs
Guide to clinical diagnosis and treatment
Cheng 20-26
www. lisaliclinic.com

Zang Fu (Organs)
5 Zang organs: Heart, Liver, Lung, Spleen, Kidney
6 Fu organs : Gallbladder, Stomach, Small intestine, large intestine, urinary bladder and triple energizer
Extra Fu organs : Brian, Uterus
The relationship between Zang organs
The relationship between Fu organs;

Qi- Vital Energy
Classification of Qi:
Primary Qi
Pectoral Qi
Nutrient Qi
Defense Qi
Function of Qi:
Promoting Checking
Warming Activating
Defensive Nourishing
Cheng, Xinnong. Chinese Acupuncture and Moxibustion . 5 th ed. P50-54, Beijing: Foreign Languages Press, 2004

Meridians www.acupuncture-medicine.co.uk
The basic concept of meridians
The Twelve main meridians
The Eight Extra meridians
The Twelve divergent meridians
The Fifteen collaterals
Cheng 60-112

Acupuncture Points Classification Nomenclature Point location Properties of the points Cheng, Xinnong. Chinese Acupuncture and Moxibustion . 5 th ed. Beijing: Foreign Languages Press, 2004

Traditional Chinese Diagnostic Techniques
Inspection
Smelling/Listening
Questioning
Palpation
Weiner, Richard. Innovations in Pain Management. P31-32 to 31-34 Orlando: Paul M. Deutach Press, Inc. 1993
www. dkimages.com

Tongue Diagnosis
Inspect tongue’s size, color, moisture and shape as objective findings
www.sacredlotus.com

Pulse diagnosis Checking the radial artery pulse to feel the rate, strength and quality www. Compassontedragon.com Weiner, Richard. Innovations in Pain Management. P 31-35 Orlando: Paul M. Deutach Press, Inc. 1993 Pulse Cun Guan Chi Left Heart Liver Kidney Right Lung Spleen Kidney

Differential diagnosis
Eight Principles:
Qi and Blood:
Zang Fu organs:
Yang Superficial Hot Excessive Yin Interior Cold Deficiency Qi Blood Deficiency Hypo-function Insufficiency Stagnation Obstruction (pain) Hematemesis, (pain) Zang Heart Liver Lung Spleen Kidney Fu S. Int. G.Blad L.Int. Stoma. U. Bla. Tri. Bu.

Pain in TCM www. tcmchinese.com Bi syndromes = muscular rheumatism or collagen disease Cheng, Xinnong. Chinese Acupuncture and Moxibustion . 5 th ed. P474-475, Beijing: Foreign Languages Press, 2004 Wind Cold Damp Heat Wandering Bi Painful Bi Fixed Bi Heat Bi

Pain Management by Acupuncture Clinical Aspect of TCM

Acupuncture Pain Management
Overview of scientific bases of acupuncture
Mechanisms of pain management
Current researches and clinical trials
Pain Scores and evaluation methods

Scientific Bases of Acupuncture
Neurohumoral
Morphogenetic
Nerve Reflex Theory
The gate control theory of pain
Endorphin theory

Neuro-humoral Approach
Peripheral nervous system to be crucial in mediating the acupuncture analgesia
Meridian-Cortex-Viscera correlation hypothesis

Neurohumoral Approach
Acupoint-brain-organ
Acupuncture stimulates to brain cortex and nerve system, then control the chemical or hormone release to the disordered organs.

Morphogenetic Theory
Acupuncture points are singular points in surface bioelectric field
The role of electric field in growth control and morphogenesis
Organizing centers have high electric conductance
Acupuncture points originate from organizing centers
Shang C. China, 1989

Nerve Reflex Theory
Autonomic nervous system extending thru the internal organs
Viscera-mutinous reflex
Cutanous –Viscera reflex
Acupuncture utilize these reflexes for restoring the homeostasis of the body and acceralate the healing process.
-Ishikawa and Fujita et al, Japan, 1950s

The Gate Control Theory
Model for acupuncture pain relief
Specific nerve fibers that transmit pain to the spinal cord (substantia gelatinous)
Balance between Stimulation & inhibitory fibers
Short term block pain by acupuncture (did not explain the prolong effect)
Drs Melzack and Wall, 1965

Endorphin Theory
Natural Morphine
Acupuncture trigger the release of endorphin into the central nervous system
Only deal with pain
Corticoids and Substance P also released along with endorphin
Dr. Pomeranz, Canada, 1996
www.pyung-an.com

Therapeutic Mechanisms of Acupuncture

Acupuncture Mechanisms of Action
Conduction of electromagnetic signals
Activation of opioids systems
Changes in brain chemistry-release of neurotransmitters and neurohormones.

Meridian-Cortex-Viscera Correlation Hypothesis
1. The meridian system is and connected the nervous system to the cerebral cortex.
2. It acts through neurohumoral mechanisms
3. Acu-point-Brain-organ model: stimulates the brain cortex/nervous system, then controlling the chemical or hormone release to the disordered organs for treatment.

Morphogenetic Singularity Theory
Acupuncture points are singular points in surface bioelectric field
Converging points of surface current for change in electric current flow.
Abrupt transition from one state to another.
Eg: BaiHui (Du 20)

Physical characteristics of the acupuncture points-WHO
Points are corresponds to the high electrical conductance points on the body surface
High density of gap junctions at the epithelia of the acupuncture points.
Gap junctions are hexagonal proteins that facilitate intercellular communication and increase electric conductivity.

Research on Auricular points
WHO found 43 points have proven therapeutic value
Therapeutic effect can be achieved by needling, temperature variation, laser, ultrasound, and pressure.

Effects of Acupuncture on the Brain
UCI-Use functional MRI to investigate the mechanisms of acupuncture analgesia
Stimulates Li 4 revealed activation of visual cortex.
Needling Tin Hui revealed auditory cortex activation

Effects of acupuncture on the Brain-auditory cortex

Why acupuncture has fewer side effects?
May indirect adjust the process and restore normal function by activating the network of organizing centers in the organism
The activation of the self-organizing activity is less likely to cause the side effects resulted from directly antagonizing a pathological process which often overlap with other normal and beneficial physiological processes.

The role of electric field in growth control and morphogenesis
Enhanced cell growth toward cathode and reduced cell growth toward anode in electric fields of physiological strength
Fast growing cells tend to have relative negativity polarity.
The polarity is due to the increased negative membrane potential generated by mitochondria at high rate of energy metabolism

Efficacy, effective, safety and costs of acupuncture for chronic pain
Evaluated 304,674 patients over 10,000 physicians and received 10+ acupuncture for pain
Results: acupuncture was an effective and safe treatment
The effects attributed to specific or nonspecific mechanisms and depend on the diagnosis-results a large research initiative.

Mechanisms of Acupuncture for Pain Relief
Polymodal receptors
(PMRs) in the acupuncture points are sensitized for the immediate action.
Action mediated by endogenous opioids
Potent stimulus for activating the analgesic systems

Therapeutic Mechanisms of Acupuncture
Inserting a needle provokes an acute defensive inflammatory response
Afferent nociceptive (pain) neurons distribute to the dorsal horn of the spinal cord
Trigger the gamma loop efferent in the ventral horn and activate neurons that cross over the spinal cord to the brain
Activate somatic motor nerves
To muscles, and autonomic motor nerves to peripheral blood vessels and to the internal organs
Dr.D. Kendall, 1980

Acupuncture Pain Management
Part II: Clinical applications
Differential diagnosis and treatment for
Headache & migraines, Trigeminal neuralgia,
Carpal Tunnel Syndromes, Arthritis, Neck
pain, Fibromyalgia, lumbago and sciatic
neuralgia.

Etiology of Headache
Blood Vessels that become dilated enlarged or constricted
Muscles in the neck and head become tight or tense
Muscles around the eyes the become strained due to overwork
Sinuses became swollen due to allergies or infections
Nerves that transmit abnormal pain signals
Joints in the jaw and neck are overused or damaged.

Types of Headache - Western Medicine
Vascular headache (Migraines)
Muscle contraction headache
Combined vascular & muscle contraction headache
Headache of nasal vasomotor reactions
Headache of delusional conversion or hypochondriacal states

Migraine Headache
Classic Migraine
Common migraine
Cluster headache
Hemiplegic and ophthalmoplegic migraine
Lower half headache

Headache Principle acupuncture points
G 20
Taiyang
Li 4
GV 20
Liv 3
G 8
T 3

TCM Classification of headache
Headache due to invasion of pathogenic wind into the channels and collateral:
Headache occurs often, especially on exposure to wind.
The pain may extend to the nape of the neck and back region.
Tongue white coating, pulse floating

2. Headache due to upsurge of liver-yang:
Headache distension of the head, irritability, hot temper, dizziness, blurred vision,
Tongue red with thin and yellow coating
Pulse thin wiry and rapid.

3. Headache due to deficiency of qi and blood:
Lingering headache, dizziness, blurred vision, lassitude, pale complexion
Tongue pale with thin white coating’
Pulse thin and thread

Trigeminal Neuralgia (TN)
Causation:-blood vessels compressing the Trigeminal nerve root as it enters the brain stem
Peripheral pathology-neurovas compression
Central pathology- hyperactivity of the trigeminal nerve nucleus

Classifications of TN
Western Medicine:
Typical
Atypical
Pre-TN
MS-related TN
Secondary or tumor related
TN neuropathy
Post traumatic TN
Eastern Medicine
Pathogenic wind and cold
Ascending of Liver and stomach fire
Deficiency heat due to liver yin deplete
Damp/heat or damp cold accumulation

TN-Pathogenic Wind & Cold
Clinical manifestation:
Acute onset
Usually affects V1 sensory
Aversion of wind & cold or aggravated by
Pain like cutting, boring and electric shock but transient ( few minutes)s
Wind cold or wind heat symptoms

Tx-TN Pathogenic wind & cold
Acupuncture:
Yang bai, (GB14)
Taiyang, (extra)
Zan Zhu (Bl 2)
Wai guan (SJ5)
He Gu (Li 4)
Herbal formula:
Jin Fang Bai du San plus Ginger

TMJ-Tempro mandibular joint Dysfunction syndrome
Symptoms:
Grinding teeth,
Joint pain,
Headache
Ringing in the ears
Unable to open his or her month wide or hear a “pop” upon opening

TN-acupuncture treatment
Li 3 or Li 4 plus
Temporal branch:
Taiyang, G 3 & G 14
Maxillary branch:
G1, St2, SI18, and ST3
Mandibular branch:
St6, St 5, and G2

TMJ (TMD)

TMJ-Etiology
1. Muscle spasm- pain
Masseter & temporalis
2. Meniscus-cartilage, buffer between the jaw and skull. Caused “pop”

TMJ-Acupuncture points
ST 7
SI 19
T 17
Li 4

Osteoarthritis
Arthritis due to destruction of the cartilage, bone and ligaments
Causing deformity of the joints
Damage to the joints can occur early in the disease and be progressive

Rheumatoid Arthritis
Auto-immune disease
Chronic inflammation of the tissue around joints , organ and body
Body tissues attacked by own antibodies in the blood level which causes inflammation.
Women to men: 3:1

Osteoarthritis
90% of arthritis
Destruction of the cartilage, bone and ligaments causing deformity of the joints
Damage to the joints can be progressive

Differential Dx of RA/OA

Principle Acupuncture Points for Arthritis Temporo-mandibular ST7, SI 19, T 17, Li 4 Shoulder joints: LI 15, T14, SI 11, T3,G 34 Elbow joints: Li 11, T10, Li 4 Wrist & joints: T5, Li 10., LI. 4 Lumbar spinal joints: Huatuoparaspinal acupoints, UB37 and UB 40 Lumbosacra Joints: GV3, B30, B 25, B40 B 60 Sacroiliac Joints: B 27, B28 Hip joints: G 30, G 29, G34, G39 Hip joints: G30, G 29, G34, G39 Knee joints: St 34,St 36, Sp 9, G 34 Ankle joints: ST 41, T 40, K3, B50, G 35 K8 Metatarsophala-ngeal joints : Sp 4, B 65, G 38, Sp 5

Causation of Carpal Tunnel Syndrome
Painful neuropathies of the hand and wrist are from nerve compression, most often compression of the median nerve in the carpal tunnel.

Anatomy of CTS

Diagnosis of CTS
Numbing pain in the distribution of the median nerve but not limited to it.
Phalen’s sign positive
Tinel’s sign positive
Light touch/vibratory touch positive
Muscle weakness and atrophy
EMG: slowed conduction velocity across the CT.

Etiology of CTS
Median nerve compression by tendonitis
Usually due to repetitive motion of the wrist and hands.

Carpal Tunnel Release
Surgery:

Carpal Tunnel Syndrome Principle acupuncture points
P 6
P 5
T 4
T 5

Cervical Spondylosis Principle acupuncture points
SI 3
G 39
B 64
B 11
G 21
GV 16
T 10
B 10

Rotator Cuff Syndrome Principle acupuncture points
Li15
Si 11
T14
Li 16
Li12
Li4
L 7
L 9
T 9
T 4

DX of Lateral Epicondylitis (Tennis elbow)
History of tennis elbow use
Pain just distal to the prominence of the lateral epicondyle
Radiological study negative

Knee Tendonitis
Patellar Tendonitis

Achilles Tendonitis
Runner’s injury

Lower back pain-Etiology
Herniated Disk (bulging)
Facet joint syndrome
Sacroilliac joint syndrome
Myofascial syndrome

Low Back Pain-diagnosis
Clinical history
Physical examination
Pain sensitive structures
Pain generators
Radiological studies

Low Back Pain-X-ray

Low Back Pain-MRI
Imaging study to evaluate the entire lumbar bones, discs, soft tissues and nerves.
CT, myelography, and discography use to complement MRI

Referred and Interactive Low Back Pain

Referred and Interactive Low Back Pain
The frequent referral of “ somatic pain into the limbs
Cause of the cause: Identify the source of symptoms.
Make realistic prognosis based on the stage, severity, stability and irritability of the dysfunction

Referred and interactive- Low Back Pain

Low back pain Principle acupuncture points
B 40 & K2 (basic)
L5, B 40, G34, B 65, B 60, B 34, K7, L 5, Li 11, Li 4, Sp6, Liv. 2, Li 10.

Sciatic Neuralgia Principle acupuncture points
B 23
B 30
G 30
B 36
B 37
B 40
G 34

Traumatic Injury-Brain-TBI
Clinical manifestations:
Altered mental status
Communication disorders
Emotional and psychitric disorders
Related paralysis or paresthesia
Dx: Refer to physician for further investigation.

Cause of Neck Pain

Radiological Findings of Neck Pain

Diagnosis of Fibromyalgia
Widespread aching > 3 months
Skin roll tenderness & hyperemia
Disturbed sleep with morning fatigue and stiffness
Absence of lab. Evidence of inflammation or muscle damage
Bilateral tender points in at least 6 areas.

Contraindications & Precautions
Contraindications:
Pregnancy- limited points (Lee & Liao, 1990)
Cardiac pacemaker (Lee & Liao 1990)
Precautions:
Epilepsy- cautiously managed (Weiner, 1993)
Drunk, exhausted, weak, or fasting (Weiner, 1993)

Risk and complications
Non sterile needle
Improper techniques
Vasovagal reaction
Misdiagnosis

Resources
Cheng, Xinnong. Chinese Acupuncture and Moxibustion . 5 th ed. Beijing: Foreign Languages Press, 2004
Hu, Cathryn. Developing a California Acupuncture Residency Program .
Riverside : La Sierra University. 2002
Weiner, Richard. Innovations in Pain Management. Orlando: Paul M. Deutach Press, Inc. 1993
Wiseman, Nigel and Feng Ye. A Practical Dictionary of Chinese Medicine . 2 nd ed. Brokline : Paradigm publications, 1998

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Pain in TCM

by yusiye on Sep 16, 2008

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