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

TCM Classification of headache 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.

TCM Classification of headache 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-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

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.

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-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.

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

Pain in TCM

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