scriptieacuJelenaKasteelChronicmusculoskeletalpain

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Acupuncture treatment ofchronic musculoskeletal

pain comparison ofdifferent approaches

By Jelena Kasteel


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Acupuncture treatment ofchronic musculoskeletal pain

- comparison of different approaches

An essay presented to theAcademy for Traditional Chinese Medicine

Qing-Bai

For the purpose of obtaining the certificate of acupunctureSeptember 2009, Amersfoort

By Jelena KasteelSupervision by Marijke Fluitsma


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Contents

Preface 5Summary 6Introduction 7

1. Physiology and pathology of chronic musculoskeletal pain 8

1.1 Physiology of pain 81.1.1 Pain as seen in Western medicine 81.1.2 Pain in Chinese medicine 8

1.2 Bi Syndrome (Painful Obstruction Syndrome) 9

1.3 How to address the chronic nature of musculoskeletal pathology 111.3.1 Treating the underlying condition 111.3.2 Treating different meridian layers 11

2. A short inquiry into the nature of the meridians 13

2.1 Chasing the meridians 132.2 Are meridians linear? 142.3 Meridians under microscope 15

3. Different approaches in acupuncture of musculoskeletal conditions 173.1 TCM approach 19

3.1.1 The role of meridian palpation 193.1.2 The use of the local and Ah Shi points 193.1.3 The use of the distal points 203.1.4 Treatment according to the meridian layers 21

3.2 Meridian approach 233.2.1 The role of meridian palpation 23

3.2.2 The use of the local points 233.2.3 The use of the distal points 243.2.4 Treatment according to the meridian layers 25

3.3 The trigger points approach 273.3.1 The concept of trigger points 273.3.2 Diagnosis and palpation of trigger points 283.3.3 The treatment of trigger points the view on the local and

distal points and needling techniques 29


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3.4. Ear acupuncture 31

3.4.1 General overview of the ear acupuncture 313.4.2 Nogiers phase models in the treatment of chronic

musculoskeletal pain 32

3.4.3 Chinese model of ear acupuncture in the treatmentof chronic musculoskeletal pain 33

4. Conclusion: The best of both worlds 34

Literature 35


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Preface

In a lecture at Academy Qing-Bai in spring 2009 Dr. Li Jie compared TCM to a round

balloon that has been squeezed into a square vase. As a result my imagination wasfuelled as to what the round balloon might look like.

I wish to thank all my teachers at Qing-Bai for giving me insight into TraditionalChinese Medicine in such a way that I looked forward to each lesson. They inspiredme by teaching in an enlightened manner that encouraged an open mind to differenttreatment styles.Special thanks to Marijke Fluitsma for reading and evaluating this essay.I am grateful to Sophie for being my faithful companion in the study of acupuncture;studying is even more fun when done together.I am indebted to Ingrid for proof-reading and commenting on this writing.

Last but not least, I wish to thank Boris for all his love, support and caring.


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Summary

This writing is about different approaches in acupuncture treatment of chronic

musculoskeletal pain. First the physiology of pain is discussed and the diagnosticsignificance of it. Musculoskeletal pathology is primarily a meridian pathology; it isclassified under the broader category of Bi syndromes, which are shortly highlighted.The chronic aspect of it can be approached from two different angles: differentiatingand treating the underlying pathology and/or exploring and treating the full spectrumof superficial energetics. That means using not only main meridians, but also tendino-muscular meridians, Luo vessels and extraordinary meridians. This writing focuseson the latter aspect, the diagnosis and treatment of different layers of meridiannetwork.

I pose a question about the nature of the meridians and take a short look into few

aspects of it, like how substantial meridians are and if they really have a linearnature. I believe that the way meridians are seen could influence the way meridianpathology is treated.

For the purpose of exploring the different possibilities of the treatment ofmusculoskeletal pathology I chose to compare four different approaches: TCMacupuncture, meridian acupuncture, trigger points approach and ear acupuncture.I compare them on basis of the use of local and distal points and the use of meridianpalpation as a diagnostic tool, especially for determining the place of the Ah Shipoints.

TCM acupuncture and meridian acupuncture have the same roots in the Classics ofChinese medicine. Their theory in treatment of musculoskeletal conditions doesntdiffer much, but the applications of that theory does: there are differences in the useof meridian palpation and in the stress on local or distal points.

Trigger points approach involves from the perspective of Western medicine onlyneedling of Ah Shi points, although it can be incorporated in meridian perspective byadding distal points. The concept of referred pain is explained and methods oflocating and needling the Ah Shi points are highlighted.

The ear acupuncture doesnt fit neatly in my comparison model due to its specificnature as a microsystem acupuncture. I included it in my research especiallybecause of the Nogiers phase model that allows for the differentiation between acuteand chronic conditions.


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Introduction

Chronic musculoskeletal pain can be a debilitating condition that interferes with good

night sleep and with many daily activities. It is one of the most common complaintsthat brings people to the general practitioner. Yet it is a condition that often remainsunresolved by the conventional medical approach. So in search for relief of their painmany people turn to the so called alternative therapies. In my short career as aShiatsu therapist I regularly came across this type of pathology; sometimes I wasable to help people with chronic musculoskeletal pain, at other times my efforts werefruitless. Studying acupuncture I felt the need to better understand the nature of thispathology and to see beyond the standard point prescriptions.

To understand a particular subject, it may be helpful to look at it from different angles.Combining the different perspectives can give one better insight into the subject. For

the purpose of better understanding the pathology and acupuncture treatment ofchronic musculoskeletal pain, I decided to compare different possibilities ofacupuncture treatment of it. For that I chose four different approaches: TCMacupuncture, meridian acupuncture, trigger point approach and ear acupuncture.They are not the only possible approaches, but as this writing is based on deskresearch, I chose approaches that were best available to me in the form of books.

My greatest interest at this point is to explore the surface energetics of the humanbody and the methods to influence it. For this purpose I will compare the fourapproaches on the basis of the following parameters:

the use of palpation as a diagnostic method

the manner in which local/Ah Shi points and distal points are chosen

In chapter one I will look shortly into the physiology of pain, as seen in Westernmedicine as well as in the TCM. I will discuss the physiology and pathology ofmusculoskeletal pain in the context of Bi Syndromes. I will look into ways to addressthe chronic nature of this pathology and the ways to address it.

Since musculoskeletal pathology is per definition a meridian pathology, the waymeridians are seen could influence the way the pathology is treated and howpalpation is used as a diagnostic method. In chapter two I will therefore focus on thenature of the meridians as a theoretical background of my research. I will pose a fewquestions on the nature of the meridians without aiming for the clear answers;unfortunately, it is the subject underrepresented and under valuated in the literature.

Chapter three forms the core of this writing. There I will highlight the acupuncturetreatment of chronic musculoskeletal pain as it is used by the four differentapproaches, first placing them in a broader context to understand the angle fromwhich the musculoskeletal pathology is seen and then comparing them according tothe above mentioned parameters. The sections on the trigger points approach andear acupuncture are not subdivided in the same manner as the first two, due to theirdifferent origin and specific nature.


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1. Physiology and pathologyof chronic musculoskeletal pain

1.1 Physiology of pain

1.1.1 Pain as seen in Western Medicine

Pain is not a well understood phenomena and many theories have been proposed toexplain it. In Western medicine it is usually explained by neural or biochemicalmechanisms. It is stressed that chronic pain is not simply a repetition of acute pain; itis different from and less understood than acute pain. Still by convention, chronicpain is defined as being longer than six months in duration.1

There is a distinction to be made between pain threshold and pain tolerance. Thepain threshold is the least stimulus intensity needed for an individual to perceive painand is proven to be much the same in everyone. Pain tolerance is defined as theemotional response to the pain stimulus and it strongly depends on emotional, socialand cultural factors. The difficulty in assessing and measuring the character andintensity of pain and effectiveness of anti-pain treatment is its subjective character;one has to rely on the verbal description of the patient.

There are three types of pain as defined by western medicine: psychogenic pain (due

to a disorder of the mind), neuropathic pain (as a result of damage to either central orperipheral nervous system) and nociceptive pain (because of the primary activationand sensitisation of nociceptors they are the sensory neurons that register pain).2The pain present in the chronic musculoskeletal pathology is nociceptive pain.

In chronic musculoskeletal pain, when only soft tissue is involved and there is noevidence of tissue damage to be detected by x-rays or other standard methods, thereis a danger of dismissing the chronic pain as purely psychogenic in origin. That iswhy the nature of the so called referred pain has particular importance inmusculoskeletal pathology. It means that the cause of the pain can be located somedistance away from the area where the patient experiences pain and can be easily

overlooked. This I will further explore in chapter 3.3.

1.1.2 Pain in Chinese Medicine

In Chinese medicine pain is explained by the saying obstruction causes pain; if thereis no obstruction there is no pain.3In other words, pain is seen as a subjectivefeeling of the obstruction in the free flow of Qi and Blood. However, moving Qi andBlood will not necessarily address the underlying causeof the obstruction of the free

1

Marcus, A, 20042Baldry, P.E, 2005

3Maciocia, G, Diagnosis in Chinese Medicine,2004


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flow. This aspect is described by the terms Ben (root) and Biao (manifestation). Inthis case, pain is only the manifestation of the underlying cause. Establishing thecause of pain determines the treatment principle. The causes of musculoskeletal painwill be explained in the following section on Bi syndromes.

In chronic musculoskeletal pain conditions, pain is obviously the chief complaint ofthe patient; on the other hand, inquiring into the nature of pain is one of thediagnostic tools in Chinese medicine. Specific characteristics of pain can helpdifferentiate the presenting condition according to the eight parameters. Inmusculoskeletal pathology we can ask about the following characteristics :4

Location of painThe precise location of pain is important to determine meridian(s) involved. Thesignificance of the pain distribution is further elaborated in section 1.3. If the pain iswandering, it indicates Wind.

Nature of painThe nature of pain indicates excess (strong, sharp) or deficiency (dull, aching, sore)of the condition. Precise nomenclature of the different types is not so important as thepatients choose their own words to describe the pain and it is up to the practitioner toclassify it accordingly.

Time of painDaytime pain is usually caused by Qi or Blood deficiency and pain at night is mostlydue to Qi stagnation. Blood stasis causes continuous pain that can be worse at night.

Factors affecting painThere are several factors that can affect pain: pressure, temperature andmovement/rest.

Pain that is aggravated by pressure indicates excess (pathogenic factor or Qiand/or Blood stagnation), whereas pain alleviated by pressure indicatesdeficiency.

Pain alleviated by application of warmth is due to Cold or Yang deficiency;usually no pain is alleviated by application of cold except acute joint sprains.5Pain from invasion by Cold gets worse in Cold weather and pain from Heatgets worse by application of heat.

Pain that gets worse with movement and better with rest indicates deficiency

of Qi or Blood; if it gets better with movement and worse with rest it indicatesstagnation of Qi, Cold or Blood stasis.

1.2 Bi Syndrome (Painful Obstruction Syndrome)

In Chinese Medicine, musculoskeletal pain is classified under the broader category ofBi syndrome. It indicates pain, soreness or numbness of muscles, tendons and joints

4Maciocia, G, Diagnosis in Chinese Medicine,2004

5

I noticed that general practitioners recommend prolonged application of cold compresses againstpain and swelling in acute cases of musculoskeletal conditions. In my opinion that can only causefurther stagnation of Qi and Blood and slow down the recovery.


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from invasion of external Wind, Cold or Dampness. Although all three of thepathogenic factors are usually involved, one of them is predominant. Strictlyspeaking, Bi refers to the invasion of the external pathogens, but it includes as wellobstruction caused by trauma, sport injuries and overuse.6

The aetiology of Bi Syndromes is already seen in the definition: the invasion of theexternal pathogens. However the chronic conditions have other possible causes:

- old traumas: the remaining Qi en Blood stagnation predisposes one todevelopment of Bi after exposure to the pathogenic factors or additional stresson the muscles

- overwork in general or overuse of a single muscle group leads to deficiency ofQi en Blood in general or in a particular area; this leaves the meridiansrelatively vacuous and prone to development of Bi

- emotional stress and bad posture, causing Qi stagnation or Qi and Blooddeficiency

- especially important in chronic cases, the pathology of Zang fu.

It is interesting to notice that Chinese literature emphasizes the invasion of theexternal pathogens and western literature on the subject emphasizes trauma andoveruse.

There are different possible classifications of the Bi syndrome, the usual one beingclassification according to the predominant pathogenic factor, i.e. Wind Bi, Cold Bi orDamp Bi. Heat Bi develops from the previous three types when they turn into theHeat in the interior. Their characteristics are as follows:7

Wind Bi (or Wandering Bi), caused by Wind: pain and soreness of musclesand joints, pain moving from joint to joint; there is limitation of movement

Damp Bi (or Fixed Bi), caused by Dampness: pain, soreness and swelling inmuscles and joints; pain is fixed in one place and aggravated by dampweather, there is a feeling of heaviness and numbness of the limbs

Cold Bi (or Aching Bi), caused by Cold: severe pain, usually unilateral, in ajoint or muscle, there is limitation of movement

Heat Bi, caused by transformation of any of the previous factors, occurring onthe background of a Yang constitution or Yin deficiency: pain, redness andswelling of the joints, limitation of movement 8

An other classification is the one according to the organ and tissue involved: Skin Bi(feeling of cold), Muscle Bi (causing muscle weakness), Sinew Bi (causing stiffness),Blood-vessels Bi (causing Blood stasis and intense pain) and Bone Bi (causing bone

deformities). Chronic conditions are often equalled with Bone Bi; however, chronicmusculoskeletal pain doesnt have to involve bone Bi. Some patients suffer for yearsfrom meridian pathology that is not detectable as joint swelling or bone deformities.

6Maciocia, G, The Practice of Chinese Medicine,2008

7

Maciocia, G, The Channels of Acupuncture, 20068Syllabus Qing Bai Acu 2


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1.3 How to address the chronic nature ofmusculoskeletal pathology

There is not always a distinction made between acute and chronic nature of

musculoskeletal pathology; they are usually differentiated and treated according tothe presenting symptoms. Still, there are two ways in which chronic aspect can beaddressed: treating the underlying internal condition and treating according to themeridian layer involved. They are not mutually exclusive.

1.3.1 Treating the underlying condition

The question why has the body failed to restore the balance by itself and developeda chronic pathology has to be properly addressed. When dealing with chronicmusculoskeletal conditions it is important to make an integral diagnosis and treat the

internal condition (the root or Ben) as well. The most common factors present inchronic Bi are summed up by Maciocia as follows:

General deficiency of Qi and Blood predisposing the body to invasionsof external pathogenic factors

The formation of Phlegm in the joints in the form of swellings due toimproper transformation of Body Fluids

Stasis of Blood due to the long-standing obstruction by the externalpathogenic factors and by Phlegm

Deficiency of Liver and Kidneys, which leads to malnourishment of

sinews and bones, the former causing ache and stiffness, the lattercontributing to the settling of Phlegm in the joints9

The treatment principle for acupuncture of chronic musculoskeletal pain is to expelthe pathogen (if present) from the meridians, remove the Qi and/or Blood stagnationthat causes the pain and restore meridian dynamics, but it is necessary as well tonourish or move Blood, resolve Phlegm, tonify Liver and Kidneys, depending on thepredominant underlying condition. Despite of its importance, treating the underlyinginternal pathology is beyond the scope of this writing.

1.3.2 Treating different meridian layers

... treating chronic musculoskeletal conditions can be like peeling an onion,with each new layer revealing a new pattern10.

The chronic aspect of musculoskeletal pathology can be addressed by exploring thefull scope of the superficial human energetics in all its layers. Tendino-muscular (TM)meridians and Luo vessels are per definition involved, but in chronic cases Main

9Maciocia, G, The Practice of Chinese Medicine, 2008, p. 982

10

Pirog, J.E, 1996, p. 228


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meridians and extraordinary vessels can also play a role. The characteristics of theinvolvement of particular meridian layer in musculoskeletal pathology can besummed up as follows:11

General characteristics Distribution of painLuo vessels Joint pain, eventually swelling;

In deep Luo: discoloration ofthe skin, rigidity and intensepain

Symptoms are local, but involveboth yin and yang meridians

TM meridians Muscle ache and stiffness,spasm, feeling of heaviness ofmuscles

Mostly unilateral, involving oneor more meridians, but notcrossing the yin-yang border

Main meridians Pain les intense and morevague than in TM meridians

Diffusely located, the patient isunable to pinpoint the source

Extra meridians Chronic pain, masses and heat,

trigger-points, loss of function(frozen joints)

Deep and scattered across

broad surfaces, sometimesinvolving both upper and lowerlimbs

12

In chapter 3. I will focus entirely on the use of meridian dynamics and on how thedifferent layers of meridian network can be explored to treat chronic musculoskeletalpain.

11Pirog, J.E, 1996, Maciocia, G, 2006

12Pirog, J.E, 1996, p. 230


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Emphasis on acupuncture points and subsequently on the main meridians carries adanger of disregard for the so called secondary meridians which stayed as a part ofthe theory of TCM, but lost their proper place in the practice of acupuncture andtreatment of musculoskeletal pathology. Seem even states that the modes of

treatment of secondary meridians totally differ from the treatment of regularmeridians.17I noticed that secondary meridians are often depicted in acupuncturebooks schematically as clearly delineated levels or layers of different depths. That isin contrasts to the verbal descriptions of their extent and function which portraymeridian layers much more intertwined.

2. 2 Are meridians linear?

Whilst a typical chart of the acupuncture channels, therefore, illustrates onlythe superficial pathways of the twelve primary channels, we should rememberthat the channel network is considerably more complex than this, and there isno part of the body, no kind of tissue, no single cell, that is not supplied by thechannels. Like a tree, the trunk and main branches define the main structure,whilst ever finer branches, twigs and leaves spread out to every part.

18

If we would make the visual representation of the above described meridian networkin every detail, even only the very superficial part of it, it would resemble a three-dimensional replica of the body. This is in contrast to the standard acupuncturecharts that were meant only as a didactic tool so they dont depict the superficialpaths of the 14 meridians (as described in acupuncture books), but indeed only the

theoretical connections between acupuncture points. This accounts for the quiteawkward trajectory that Yang meridians in part describe. Once we imprint in ourmemory the pathways of the main meridians as depicted in acupuncture charts andatlases, there is a danger of forgetting that they represent the functional modelof themeridian structure and not reality itself.19Living human body is, after all, no TongRen.

A typical characteristic of meridians representation is that they are seen as lines;vertical lines in case of organ meridians an horizontal branches when we speak ofLuo vessels. Even the eight extraordinary vessels are depicted as lines (6 of themconnecting acupuncture points that they share with the organ meridians) in spite of

the saying from Nan Jing that main meridians are like rivers and extraordinaryvessels are like lakes, suggesting not only their reservoir function, but perhaps alsotheir spatial extent.

However, there is a very interesting remark on the pathway of the Gallbladdermeridian that I found in a footnote in Tietao Dengs Practical Diagnosis:

As with the kidney channel, it is interesting to note that Chinese texts do notdescribe the channel as travelling behind the ear and then returning back up

17

Seem, M.D, 2004, p. 2018Deadman, P et al., 2007, p. 11

19The Zen masters repeatedly warn their students not to confuse the Map with the Reality.


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the head and then turning and descending back down to feng chi (Wind Pool,GB-20), as the pictures draw it. I believe that this convention of thinking aboutthe path of the channel in this way stems from the modern system ofnumbering the points on the channel and then connecting the dots. It is moreappropriate to think of the channel as a larger, broader entity that simply is

scattered over the area in front of and behind the ear and that there are pointsin that area. However, the points do not necessarily follow a numericalsequence that creates two lines, as we have come to understand thegallbladder channel.20

This clearly suggests that the nature of even organ meridians is not so linear as weare accustomed to think, but it might be instead rather fractal (see coverillustration).21Unfortunately I dont have access to more Chinese texts to furtherexplore this idea.

2.3 Meridians under microscope

There have been attempts to find the material substrate of meridians. Usually themeridians were compared with anatomical structures like the vascular system orneural network .22It may not come as a surprise that the discrepancies betweenthem were too big to give the meridians any anatomical reality. The reason why theseattempts failed can be found in the fact that they used the outdated, yet stillpredominant paradigm of material reductionism to explain the energy concepts ofChinese medicine.

Yet there is a different paradigm, that of system-thinking and non-linear dynamicsthat is much more qualified for the job. Modern energy medicine investigated bodyprocesses that couldnt be explained with conventional concepts of neural,biochemical and endocrine mechanisms and discovered that there were other,evolutionary much older systems in the body that transferred the energy andinformation much faster. Here were are talking about the connective tissue.23

To summarize, we suggest that neither the Jing nor the Luo, nor all of theircountless branches are mystical entities but instead are material pathwayslocated within the connective tissue/cytoskeletal fabric. At the microscopiclevel, this branching network reaches to the surfaces of cells and extends

across those surfaces, where it is continuous with the cytoplasmic matrix,nuclear matrix, mitochondrial matrix and the interiors of other organelles. Thelong-sought substance of the meridians consists of an intricate set of proteinand other molecules, as well as an adhering film of water.

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I would like to stress at this point that I am not interested in finding the materialsubstrate of the meridians; I am looking for ways to see beyond the standard

20Deng, T, 2005, p. 322

21Fractal is a mathematical model, a geometric shape that repeats the same pattern (or the same type

of pattern) on all scales.22

Baldry, P.E, 200523Oschman, J.L, 2003

24Ibid, p. 133


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acupuncture charts for a more complete meridian picture and get a better insight inthe meridian dynamics and meridian pathology.

I believe the way in which meridians are perceived will influence the way the meridianpathology is being treated. If we consider meridians to be just a theoretical

connection between the acupuncture points, the treatment will rely heavily on treatingthe acupuncture points. If, on the other hand, we give more reality to the meridians,the treatment will be concentrated on meridians and meridian systems themselves,albeit via acupuncture points, but not limited on them and the role of meridianpalpation will get a more prominent role.


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3. Different approaches in acupuncturetreatment of musculoskeletal conditions

In the 19thcentury and a big part of the 20thcentury almost the exclusive applicationof the acupuncture in the West was for combating pain. It was mostly limited to theneedling of the Ah Shi points, applied without real knowledge of the Jing Luo or theZang Fu. In this way it is applied even today in so called medical acupuncture thatuses needling according to the western neuroanatomical concepts and not accordingto the theory of Chinese medicine and knowledge of meridians. On the other hand,the diagnosis and the treatment of the musculoskeletal pain in TCM is quite forwardand often seen as less interesting than the more fancy pathologies of the internalorgans diseases.

What interests me in musculoskeletal pathology and treatment of it, is the way theacupuncture points are chosen and combined. The combination of points in generalis directed by two basic principles: selecting a point according to its particular action,function, nature and quality and selecting a point according to its position anddynamics within the meridian system. These two principles are by no means mutuallyexclusive; usually both approaches are combined.25

The stress placed on needling technique is based on a point-centred view ofacupuncture, whereas the stress placed on the combination of points is basedon a channel-centred view of acupuncture.

26

Acupuncture treatment of chronic musculoskeletal pain is based in short on thecombination of local points, including Ah Shi points and distal points and, especiallyimportant in chronic cases, points according to the underlying pattern. Inmusculoskeletal conditions pathology can be situated distally, so proximal points maycoincide with distal points or distal points from paired meridians of the same polaritymay be chosen instead.

The use of the distal points is unique for acupuncture; it reflects the meridiandynamics of the system as a whole. Distal points open the meridian, eliminatestagnation of Qi and/or Blood and help to expel pathogenic factors.27In acute cases their action is strong; they are combined with local points that support

the eliminating action of the distal points and focus it on the specific area. In chroniccases the meridian dynamics is more severely impaired and the overall condition isgenerally more vacuous; distal points work less strong and local points become moreimportant. Local points are in the area where Qi en Blood stagnation or pathogensare lodged and treating them is needed to restore meridian dynamics and relievepain.

Seem described balancing local and distal points on the basis of excess ordeficiency:

25

Maciocia, G, The Channels of Acupuncture, 200626Maciocia, G, The Practice of Chinese Medicine, 2008, p. 1134

27Maciocia, G, The Channels of Acupuncture, 2006


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In excess conditionsSelect more distal points, which are the main points to calm hyperactivity of anenergetic orb. Use less local points, which are selected to direct the calmingaction of the distal points. Apply dispersing techniques to the distal points and

neutral technique to the local points.

In deficiency conditionsSelect more local points, which are the main points to tonify deficient energeticfunction. Apply tonification techniques to these points (warming techniquesincluding moxibustion). Use less distal points and apply neutral techniques tothese points, to harmonize the local tonifying action.

28

Again, as chronic cases are more vacuous in nature than acute cases, the strategyfor deficiency conditions can be employed.

In the following chapters I will focus on meridian palpation as a diagnostic method inmeridian pathology and subsequently on the use of Ah Shi points. I will concentrateon the choice of the local and distal points as well as the emphasis on one or theother as it is employed in the different schools of acupuncture. In a separate section Iwill examine the use of the different meridian layers in meridian pathology. Books orchapters on the musculoskeletal pathology usually present extensive lists of pointsaccording to the body area, meridians and pathogen involved. I will not repeat manyof these lists as I found that there are more differences between the particularauthors and not so many between different schools. The treatment of the underlyingcondition, albeit being very important for chronic conditions, is not a part of thiswriting.

28

Seem, M.D, 1987, p. 47


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3.1 TCM approach

3.1.1. The role of meridian palpation

TCM acupuncture is a modern version of Chinese acupuncture, developed to allowthe practitioners to treat many patients per day, which is definitely a bonus in China.Even in The Netherlands I have seen Chinese practitioners diagnosing and treatingnew patient every 20, or even every 15 minutes (of course they have assistants to dothe administrative side of the work). In that short time there is simply no time forcareful palpation; they have to rely on their theoretical knowledge and experience.Western practitioners trained in the TCM acupuncture usually take more time for theirpatients, yet the stress of the treatment is still based on the same premises.

Palpation is one of the four traditional examination methods; in TCM it is focusedprimarily on the palpation of the pulse. In TCM literature there is mention of thepalpation of body parts, skin and acupuncture points to determine temperature,texture and tenderness, but explicit palpation of the meridians is not often included.

Tietao Deng mentions pressing examination29to examine patients head and neck,hands, feet, chest, abdomen, skin and transport points to determine whether the areais hot or cold, slippery or rough, soft or hard, hurts with pressure or has lumps orother abnormalities. This information can add to the diagnosis of the location andnature of the disease. Yet there is no mention of meridian palpation.

In his more than 1000 pages thick Diagnosis in Chinese Medicine30, Maciocia

dedicates 12 pages to the palpation of the meridians. He discusses briefly palpationof the Luo vessels and superficial Luo vessels by touching, stroking and pressing todetermine temperature, moisture, firmness and possible masses. Palpation of TMmeridians is limited to firm pressure to reveal consistency of the muscles. Maciociafurthermore mentions the palpation of meridians in Bi syndrome to reveal the Ah Shipoints as to determine the meridian (most) involved.He proceeds to the palpation of the meridians and states that there are two aspectsto it: palpation of the blood vessel overlying the channel and palpation of the skin. Forthe latter, three aspects are distinguished: temperature, texture and tenderness. For

each meridian he mentions specific (point) areas that should be examined and thediagnostic significance of the findings. For example, the palpation of the Gallbladdermeridian is limited to the palpation of the area around GB-2 Tinghui, which is a rathersmall portion of the total superficial trajectory of the meridian.

29Deng, T, 2004, p. 155

30Maciocia, G, Diagnosis in Chinese Medicine, 2004


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3.1.2 The use of local and Ah Shi points

The local acupuncture points have dominance over Ah Shi points in TCMacupuncture of musculoskeletal pathology.31They are chosen according to the areaof pain. There are standard lists of points recommended for the use as local points

for the specific area; these lists can vary according to different authors and areultimately dependant on the specific case. As the total amount of the needled pointshas to be limited, there are few local points chosen. In musculoskeletal conditionsneedling is performed less deep than for the internal conditions and needlemanipulation can be performed.

Ah Shi points dont get a significant role in the treatment of the musculoskeletalconditions. They are determined by palpation, usually only of the body part wherepatient complains of pain. For example in the bookAcupuncture case histories fromChina32 there are fourteen cases of Painful Obstruction Syndrome and only in five ofthem Ah Shi points are mentioned as part of the acupuncture prescription. In Treating

Pain with Traditional Chinese Medicine33, in chapters dealing with musculoskeletalpain there is no mention of the Ah Shi points.

Apart from needling, other techniques can be used to cover bigger local area:cupping, guasha en moxa, depending on the present pathogen and desired effect.Cupping removes Cold and stagnation of Qi en Blood from the meridians; it alsoexpels Wind from the muscles. Guasha eliminates Cold from the muscles. Moxa canbe used for its action on expelling Cold and moving Blood and in chronic cases fortonifying the vacuous TM meridians.

3.1.3 The use of distal points

The descriptions in the following two sections are based largely on the MaciociasThe Channels of Acupuncture.

34

Distal points are per definition located on the limbs, below elbows and knees, andcan treat pathology further up the meridian. They are used with reducing method inacute cases and even method in chronic cases.35 They are chosen according to themeridian involved and area involved. Generally, the more distal along the meridianthe point is, the further up the meridian it extends its action, but there are exceptions

to this rule.

When pathology is situated distally, local and distal points may coincide. In that case,distal points may be chosen from the paired meridian of the same polarity; thisapplies especially for the Yang meridians (Tai Yang, Shao Yang and Yang Ming). Inthat case one chooses according to the correspondence of joints in the upper andlower limbs: shoulder = hip, elbow = knee and wrist = ankle.36

31Pirog, J.E, 1996

32Jirui, C, 1988

33Riley, D, 2003

34

Maciocia, G, The Channels of Acupuncture, 200635Ibid., p. 655

36Ibid., p. 657


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There are again standard lists of distal points according to the meridian involved andaccording to the area involved. Distal points can also be chosen to address andexpel the specific pathogen as follows:

- Wind: the Jing-Well point- Cold: the He-Sea point- Dampness: the Shu-Stream or Jing-River point

3.1.4 Treatment according to the meridian layers

In The Channels of Acupuncture37Maciocia differentiates the musculoskeletalpathology according to the meridian layers involved as follows: the TM meridians andLuo vessels are per definition involved; however in chronic pathology main meridiansand extraordinary meridians can be involved as well. It is often difficult to separatepathology of one from the other. The more chronic the pathology, the deeper in themeridian system the pathogen penetrates.38

TM meridiansThe main distal points for activating the TM meridians are Jing-Well points. As TMmeridians overlap and communicate with each other, chronic musculoskeletalpathology usually involves more than one neighbouring meridian. In that case onecan use upper meeting points of the TM meridians. They strengthen the effect of thedistal points and regulate Qi between different meridians. The upper meeting points

of the TM meridians are as follows: three Yang of the leg: SI 18

three Yang of the arm: GB 13

three Yin of the arm: GB 22

three Yin of the leg: Ren 3

Luo vesselsIn musculoskeletal conditions the pathology of the Luo vessels is intertwined with TMmeridians. The superficial Luo vessels are the first layer of penetration of pathogens;after they pas the TM meridian layer, they can get lodged in the deep Luo layer. Thediscoloration of the skin and the venules that can be seen on the skin surface merely

reflect the pathogens in the deep Luo layer. Trauma or invasion of pathogenic factorsin Luo vessels can cause blood stasis. Luo points are primary points for treating Luovessels.

Extraordinary meridiansWhen chronic symptoms overlap different meridians and stretch over larger surfacesof the body, extraordinary meridians may be involved. They absorb the excess fromthe main meridians.

37Maciocia, G, The Channels of Acupuncture, 2006

38Ibid.


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Du Mai is used to treat neck or backache when it is located on the midline oron the midline radiating to both sides (but not unilateral). The opening point ofthe Du Mai SI 3 and the coupled point Bl 62 are used as distal points.

Dai Mai gets mentioned in The Channels of Acupuncture39 only for treatment

of hip pain; the opening and coupled points are needled. In Neijing Suwen40

Dai Mai is listed in chapter 41 for the treatment of back pain if the patient isunable to arch the back.

Both Yang Qiao Mai en Yang Wei Mai can be used in the treatment ofbackache; the symptoms involving Yang Qiao Mai stretch mainly over theBladder meridian and the symptoms involving Yang Wei Mai follow mainly theGallbladder meridian.

Yang Qiao Mai is indicated when pain involves several neighbouringmeridians, for example in sciatica when the pain involves the Bladder,Gallbladder and Stomach meridians. The opening point of Yang Qiao Mai Bl62 is needled on the affected side and coupled point SI 3 on the opposite side.In case of pronounced stiffness, the Xi-Cleft point of the Yang Qiao Mai can beused as wel: Bl 59.

Yang Wei Mai can be used to treat Bi-syndrome especially when it involvesthe lateral side of the limbs or lateral side of the neck. The opening point TB 5and the coupled point GB 41 can be used as distal points, eventually addingthe Xi-Cleft point: GB 35.

Although Yang extra meridians are present more often in musculoskeletal pathology(the same as the Yang main meridians), there are cases when Yin Qiao Mai and YinWei Mai are involved:

Yin Qiao Mai can be used in certain cases of Wei syndrome (atrophy

syndrome) when the muscles of inner aspect of legs are more tense than themuscles of the outer aspect of legs and the feet of the patient turn inward.

Yin Wei Mai can be used in Bi syndromes with a generalized ache in the jointswith numbness and tingling, but without any swelling or heat in the joints41

Differentiation according to the meridian layer is not always applied in TCM; Riley42and Jirui43use only main meridians for the treatment of musculoskeletal pathology.

39Ibid.

40The Yellow Emperors Classic of Medicine1995

41

Maciocia, G, The Channels of Acupuncture, 200642Riley, D, 2003

43Jirui, C, 1988


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3.2 Meridian approach

Although meridian style acupuncture originally referred to the Japanese acupuncture,the term has since been extended to mean any form of acupuncture that derives itsstrategies from classical energetic theory as found in the Nei Jing and Nan Jing,rather than the herbalised theories of modern TCM.44

Generally, meridian style acupuncture uses more needles, thinner needles, shallowerinsertion and milder stimulus than modern TCM acupuncture. There is also lessmanipulation of the needle and distending sensation is not deemed necessary. Thischapter is based mostly on Pirogs The Practical Application of Meridian StyleAcupuncture.

45

3.2.1 The role of meridian palpation

In books on the meridian approach great stress is placed on importance of thoroughpalpation of meridians. Yet they leave out the descriptions of the techniques for themeridian palpation. Apparently, it is considered as something one must learn inpractice from a good teacher. Here is what Pirog writes on meridian palpation:

In modern meridian style acupuncture the traditional concept of ashi pointsbas been extended to include any points that exhibit abnormal texture,temperature, or appearance, even if there is no actual tenderness. Japaneseacupuncturists, for example, place great emphasis on kori, points that are hardor rubbery to the touch but not necessarily painful. Many meridian therapists

will search for subtle changes in skin temperature or for distended capillaries.The region of palpation has also been extended, with some therapistssearching for ashi points far from the original site of pain. Since ashi pointsand kori are supposed to be sites where energy stagnates and accumulates,some acupuncturists believe that these points can be found entirely throughintuition. These practitioners will lightly touch the patients skin or hold theirhands above it, feeling for a tingly sensation or draft in their fingers.46

Obviously, there is great diversity in meridian palpation methods, depending on aparticular acupuncture school and particular teacher.

3.2.1 The use of local and Ah Shi points

The choice of the local points in meridian approach seems to differ most from theTCM use of local points.

- It is determined by careful palpation for tenderness or tissue change.- All of the painful points must be needled, not just a few strong points in the

vicinity of the pain.

44

Pirog, J.E, 199645Ibid.

46Ibid., p. 5


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- If pain or tenderness is located near but not on a standard acupuncture point,the exact spot where pain or tenderness is found is needled, not theacupuncture point. So the local points are determined uniquely in each patient.

In other words, there are no other local points used in musculoskeletal pathology

than Ah Shi points and they can be great in number, depending on the character andchronicity of the condition.

3.2.2 The use of distal points

Distal points are chosen on the basis of distribution of local/Ah Shi points todetermine the meridian that is most involved. They are not chosen according to thespecific target area; usually the most powerful distal points are chosen. Distal pointsare considered to be more draining than local points; one needles as many localpoints as deemed necessary, but distal points are limited to one on the upper limbs

and two to three on the lower limbs. As the points with most powerful distal effect, thefollowing can be chosen:47

To fine-tune the treatment, distant points can be chosen whose qualities best matchthe condition being treated, according to the theory of Five Shu-Transporting points.Some points that are usually avoided in TCM acupuncture due to the insertion paincan be still be used because of the use of thinner needles and shallower insertiondepth. The properties of the distant points used for the treatment of Bi Patterns aresummed up in the following table:48

Jing-well points Support point used to release severe repletion or blockage in themeridian

Ying-springpoints, includingBa Feng en BaXie points

Used to expel pathogens out of the meridian (Heat and Cold)

Shu-streampoint of Yangmeridians

1. Bi patterns in general; often used together with the Ying-spring points2. for acute episodes of chronic Bi patterns

Shu-streampoint of Yinmeridians

1. chronic Bi patterns where the primary pathogen is dampness;can be used even if pain is not on the trajectory of the yinmeridian

47Pirog, J.E, 1996, p. 9

48Ibid., p. 227

Large Intestine: LI 4, LI 11 Lung: Lu 7, Lu 5

Triple Burner: TB 5 Pericardium: Pc 6

Small Intestine: SI Heart: Ht 7

Stomach: St 36, St 44 Spleen: Sp 6, Sp 9

Gall Bladder: GB 34, GB 39, GB 41 Liver: Liv 3

3Urinary Bladder: UB 40, UB 58, UB 60 Kidney: Ki 3


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2. chronic Bi patterns involving weakness of the internal organs(common in chronic knee and lower back pain)

Jing-riverpoints of Yangmeridians

General Bi patterns, especially when pain is in the limb or whenspasm is present

Jing-riverpoints of Yinmeridians

Primary treatment point for pain located in the yin meridians

He-sea points Bi patterns in yang meridians; especially useful if the pain is inthe more proximal regions of the meridian (shoulders, hips, neckor back) or if Bi patterns coincide with Zang Fu disorders

Xi-cleft points 1. most commonly for severe acute pain2. stubborn stagnant or painful conditions

Group Luopoints

Pain involving more than one meridian of the same Yin-Yangpolarity of the same limb

Luo-connectingpoints

1. pain with swelling and visible local capillaries2. blood stasis or phlegm in the meridian3. pain involves both Yin and Yang paired meridians4. pain associated with the Luo vessel

3.2.3 Treatment according to meridian layers

In theory, the treatment of the different meridian levels involved in the chronicmusculoskeletal pain does not differ much from the TCM approach. Again, there is a

great stress on palpation and finding of Ah Shi points. The distribution of Ah Shipoints and the character of pain helps to determine which meridian layer is involved.

TM meridiansIf the pain is clearly localized and can be elicited with light palpation, the pathogen isstill lodged in the TM meridians. This is the typical pathology seen in acute cases andsometimes even in chronic cases. However, chronic pathology usually leaves TMmeridians vacuous; the pain becomes more diffuse and it is difficult to pinpoint thesource. The basic treatment involves tonifying TM meridians by superficial needlingand/or moxa and treating the main meridians as described below.

Main meridiansIn chronic cases, the pathogen invades the main meridians which now becomerelatively replete, leaving the TM meridian relatively vacuous. The struggle betweendefense Qi and the pathogen is less intense. The pain is more vague and morediffusely located and often cannot be localized without deep pressure; it usuallyinvolves several meridians on the same side of the same limb. Is important todetermine the single meridian that most underlies the problem for the choice of theappropriate distal points that need to be drained. Alternatively group Luo points canbe added to the distal treatment because they connect all the meridians on the sameside of the same extremity. They can also be used as the only distal point.


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Luo vesselsThe involvement of the Luo vessels in chronic cases is characterized by the painoccurring on both the Yin en Yang meridians in the same region on the same limb.The treatment consists in supplementing the local painful points on both Yin andYang meridians with needles and/or moxa. As the distal point that needs to be

drained, the Luo point on the Yang meridian is recommended; if that does not help,the Luo point on the Yin meridian is treated.

Extraordinary meridiansChronic pain is an indication for involvement of the extraordinary vessels inmusculoskeletal pathology. The Ah Shi points are again the basis for diagnosis andtreatment. Careful palpation will reveal masses and painful points scattered acrossbroad surfaces of the body and may involve both upper and lower extremities. Themuscle tissue at these points often shows a hard, rubbery quality; bone spurs may bepresent. Knowledge of the extraordinary meridians pathways is required to diagnosethe extraordinary meridian involved and to determine the opening and coupled points

that are used as distal points.


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3.3 The trigger points approach

3.3.1 The concept of trigger points

Trigger points is a concept from western medicine. It came from the realization thatthe cause of the musculoskeletal pain can often be located some distance away fromthe area where a patient experiences pain. In terms of TCM we would say that therelevant Ah Shi points can be located not only locally, but adjacent to or evenproximal or distal to the area of the pain. Trigger points are known to cause othersymptoms than musculoskeletal pain, such as for example headache or dizziness.

In plain words, trigger points are local and permanent contractions in the musclefibers that on palpation feel as taut bands or nodules and are responsible for thetypical pain patterns. Detailed medical explanation of the trigger point mechanism is

not necessary for this writing, but it is interesting to note that Travel and Simonsmention impairment of energy metabolism andimpaired circulation

49 in TCM wordsQi en Blood stagnation.

The concept of referred pain plays an important role in the pathology of trigger points.It means that the pathology that causes pain (in this case trigger points) notnecessary coincides with the area where patients report pain. This concept has beenknown in Chinese medicine for a long time. Referred pain is explained in medicalliterature by neural mechanisms, as errors occurring in the spinal cord or perceptualerrors in the sensory cortex.50Referred pain is often difficult to localize and maymove and change as the disease progresses. Initially, it is felt close to the origin ofsymptoms, later it moves distally or proximally to the initial area. So this concept isespecially important in chronic cases of musculoskeletal pain.

The concept of Trigger points has been pioneered by Kellgren in 1938 andextensively researched and published by Travell and Simons in the, by now, classicwork Pain and Dysfunction, The Trigger Point Manual.

51 Travell and Simons statethat muscle pathology is the major cause of pain and dysfunction, yet the physiciansfocus their attention on bones, joints, bursae and nerves.52The major problem for amedical explanation is that trigger point pain pattern does not follow the nervepathways nor does it necessary occur within the same dermatome, myotome or

sclerotome.

53

Yet the trigger-point referred pain follows a predictable pattern,researched and described by dr. Travel.

As the main causes of the activation of trigger-points the following are stated:

trauma to the muscles, tendons and/or joints

chronic stresses on muscles, whether by overuse, bad posture or involuntarymuscle tension due to emotional stress54

49Travel, J, and Simons, D.G, 1983, p. 34

50Marcus, A, 2004

51Travell, J, and Simons, D.G, 1983

52

Ibid., p. 553Ibid., p. 14

54Trigger points of this origin are often seen in women in upper trapezius muscle.


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exposure to cold, damp weather and drafts (in TCM: external pathogens)As indirect causes the following are mentioned:

other trigger points

visceral diseases

nutritional deficiency, periodic hypoglicemia

food and inhalant allergies

The above list resembles the aetiology of Bi syndromes. I believe that trigger pointsapproach fits easily into the meridian perspective. Trigger point pain patterns havebeen extensively researched and published, yet to someone with knowledge of themeridian pathways it soon becomes obvious that these pain patterns often follow thepathways of meridians (especially the tendino-muscular meridians or main meridiansor otherwise, I suppose, the minor meridian pathways not described in acupunctureatlases). So by following the pathway of the meridians passing through the area ofreferred pain, one comes a long way in finding trigger points responsible for that painpattern.

3.3.3 Diagnosis and palpation of trigger points

There are different types of trigger points, not all of them being active (causingpain), so it is important to identify the right trigger points responsible for the painpattern in question. As Travel and Simons state,

A precise pictorial representation of the patients pain is critical for an accuratediagnosis of myofascial pain; verbal descriptions are often imprecise and

misleading: a blank body form is used routinely to record the patients pain.55

56

55Travel, J, and Simons, D.G, 1983, p. 46


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Details are important, such as which side of the limb hurts, and whether thepain skips or concentrates in a joint. It does injustice to the patient and to thediagnosis to accept vague generalizations at face value.57

Once the involved muscle or muscle group is identified, careful palpation is needed tolocate the taut bands and nodules in the muscle fibers that are tender on pressureand may induce the patients referred pain pattern. The usual palpation technique isperformed on the slightly stretched muscle: the fingers of the practitioner gently rollthe skin over the muscle, perpendicular to the muscle belly. The pressure shouldstart light to asses superficial muscles and slowly increase to reach deeper muscles.Objective tissue changes are more significant than patients verbal or physicalreaction to the pressure.58 I found this description to be most straight-forward andvery useful.

3.3.4 The treatment of trigger points the view on the local and distalpoints and needling techniques

There are different possibilities of treatment of the trigger points; here I will describeonly the acupuncture treatment. In so-called medical acupuncture or physiotherapyacupuncture only local points - the sites of trigger points - are needled. Thatprocedure has been named dry needling. It actually means that the needles are usedaccording to the principles of western anatomy, not according to the principles ofChinese medicine and knowledge (or use) of the meridians. This way of needling hasproven to be quite effective; however, using distal points according to the meridian

theory should only increase the effectiveness of the trigger point needling.

For an effective treatment it is deemed important to address the precise spot of thetrigger point:

Trigger point needling is an acquired art. The point must be accurately locatedand manually stabilized. This is done with the practitioners non-needlingthumb. Firm pressure is applied just to the side of the tight-band/Kori so thatwhen the needle approaches the trigger, the muscle fibers do not roll away.

59

The needling can be performed deeply, like it is done in TCM acupuncture. However,clinical practice showed that the superficial needling to the depth of about 5-10 mm,not reaching the trigger point itself, and needles left in situ for no longer than 30seconds gives equally good results, but with much less pain to the patient.60

56Travel, J, and Simons, D.G, 1983

57Ibid., p. 47

58

Marcus, A, 2004, p. 60659Ibid., p. 607

60Baldry, P.E, 2005, p. 133


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Trigger point needling61

Marcus proposes several protocols for treating trigger points, for example thefollowing one:62

1. First mark the points.2. Activate the involved tendino-muscular meridian (by needling Jing-Well point)3. Treat the appropriate spinal segment (or TCM meridian, Organ, Shu or Mu

points associated with the involved muscle) to address the root of theproblem

4. Needle the triggers superficially, with very mild needle stimulation and leavethe needle in place shortly. If some positive affect is achieved, this process isrepeated in the next few sessions.

If the patient does not respond to the mild treatment, deeper needling may beapplied, with more vigorous needle manipulation. One can needle in several

directions to cover the entire area of the tight band around the trigger. Muscleattachments may be explored and needled if needed.63

According to Pirog64, trigger points are the chronic meridian pathology at the level ofthe extraordinary meridians. In view of that statement, the best choice for distal pointswould not be the points on the main meridian passing through or nearby the triggerpoint, but the opening en coupled point of the involved extraordinary meridian (seeprevious chapter).

61Marcus, A, 2004, p. 607

62

Ibid., p. 60763Ibid., p. 608-609

64Pirog, J.E, 1996


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3.4 Ear acupuncture

3.4.1 General overview of the ear acupuncture

Auriculotherapy is stimulating the external surface of the ear, or auricle, to treatpathological condition elsewhere in the body. Besides using acupuncture, stimulationof the auricle can be done by other modern methods such as electrical, magnetic orlaser stimulation. I will further discuss only the acupuncture treatment of the auricle. Iwill leave aside the specific details of diagnosis and treatment and focus only on thetheoretical side in general and on the treatment of the musculoskeletal disorders inparticular.

Historically, acupuncture points on the auricle were used in ancient China and in the

Middle east for therapeutic purposes; however the father of the modernauriculotherapy is the French physician Paul Nogier. Through meticulous research hedeveloped a so called inverted fetus map on the external ear which inspired manyfurther studies throughout he world. After his discovery reached China it instigated amassive study of the reflex points on the ear which confirmed and complementedNogiers map, although the localization of some points may differ from the originalNogiers model.65

The auricle is one of the several micro systems in the body that can be used as acomplete system for diagnosis and therapy, following the principle that inside reflectsthe outside and a part reflects the whole. The term local and distal points cannot beapplied literally on the ear acupuncture. In a way, all ear points are distal points, notin classical sense as being located on the extremities, but they are more or lessdistant from the area of corresponding pathology.

In auriculotherapy models the auricle is divided into different areas, each of themrepresenting a specific part of the body, internal organ or a more general bodyfunction. Yet the points on the auricle are not a permanent feature (like the points ofthe body acupuncture which can be found on precisely anatomically definedlocations); they can be detected within certain areas only when there is somepathological process in the corresponding body part. The ear points are found

through changed reactivity in the particular point: increased or decreased pressuresensitivity or diminished skin resistance to electrical stimulation.66If we leave theelectrical devices aside, the points on the auricle are detected through carefulpalpation. So we could say that all ear points are Ah Shi points.

Ear acupuncture is a self sufficient system of diagnosis and treatment, but it caneasily be combined with other treatment methods. From the practical standpoint thereare certain advantages of the ear acupuncture such as treating the body part that istemporarily not accessible or simply too painful for body acupuncture. The use of

65Rubach, A, 2001

66Ibid.


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semi-permanent needles or pallets on the auricle can provide a more continuousstimulus for a prolonged therapeutic result.

3.4.2 Nogiers phase models

in the treatment of chronic musculoskeletal pain

With further research Nogier discovered different auricular maps than his original onebased on the inverted fetus pattern. They differed considerably from the earlier modelas they assign different auricle zones to different body parts than the original map.Nogier referred to this different models as phases:67

- Phase I: the original inverted fetus model represents the tissues and organs ofthe physical body. From a Chinese perspective it represents acute, excessYang conditions. Phase I points relate to sensory aspects of pain.

- Phase II: the upright man model represents the pathology degenerativeconditions and chronic illnesses. It is related to Yin degenerative conditions.

- Phase III: the horizontal man model represents excess Yang, inflammatoryconditions.

- Phase IV: located on the posterior side of the auricle and is basically the samemicrosystem represented by Phase I. The phase IV is used to treat musclespasm aspects of a condition.

68

Both Phase I and IV are used to treat acute pain or acute conditions, and the othertwo are used for more chronic pain. According to Frank and Soliman69, the different

67Oleson, T, 2003

68Ibid., p. 73


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phases do not so much represent the degree of chronicity, but the degree ofdegenerative condition. The mildest conditions are represented by phase I, followedby phase III and the most degenerative conditions are represented by phase II.

Some authors, like Rubach70for example, choose to ignore auricular phases, while

others consider them to be most valuable. It seems to me that different phases modelcan be of a particular importance in the treatment of chronic musculoskeletal pain.While paying attention to Phase I could only bring some palliative results, examiningand treating Phases II and III could get into the heart of the problem.

The treatment protocols for chronic musculoskeletal pain include primarily the area ofthe corresponding body part. In the Phase I the segmental approach is applied,which I will not further describe. If Phase I does not yield results, the correspondingpoints are searched according to the Phase II or III.71 Next, the points with analgesic,anti-inflammatory or muscle relaxing effect are examined and some other points witha general regulatory function. According to the previous diagnosis specific points can

be employed to complete the treatment. Each session the points are examined againand reactive points are treated accordingly.

3.4.3 Chinese model of ear acupuncturein the treatment of chronic musculoskeletal pain

The Chinese researchers were inspired not only by Nogiers model, but also by thequotation from Classic of Internal Medicinethat states that all of the Yang channelspass through the ear and the Yin channels meet in the ear.72The working of the

auricular points is thus explained by the connection of the ear to the meridian system.That still leaves unanswered the question how the particular points on the eartransmit their influence to the corresponding parts of the body.

The differences between the original Nogiers inverted fetus model and the Chinesemodel is usually explained by the assumption that the points on the Nogiers modelcorrespond to the physical body parts and the points on the Chinese modelcorrespond to the energetic functions and connections according to the Chinesephysiology theories. In that manner, Chinese ear acupuncture works by regulating Qiand promoting proper organ function.

According to Frank and Soliman,73

the Chinese system offers a simple model that isbest suited for a technical approach to treatment. Treatment depends on thelocalization of pain together with meridian(s) involved in the pathology, so the zone ofthe corresponding body part and the zone of the organ corresponding with theinvolved meridian is treated. Depending on the previous diagnosis made on basis ofthe eight parameter and internal organs differentiation, further zones of the ear canbe treated. In combination with body acupuncture, the appropriate local and distalpoints are needled.

69Frank, B.L, and Soliman, N.E, 2006

70Rubach, A, 2001

71

Oleson, T, 200372Marcus, A, 2004, p. 344

73Frank, B.L, and Soliman, N.E, 2006


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Conclusion : the best of both worlds

The purpose of this writing was to get a better understanding of chronic

musculoskeletal pain and acupuncture treatment methods used for it. For thatpurpose I chose to compare four different approaches: TCM acupuncture, meridianapproach, trigger point approach and ear acupuncture. Again, my goal was tocompare them, not to judge their effectiveness.

If I have learnt anything from watching the various therapeutic approaches inaction, it is that there are countless ways of perceiving what is going on withthe person who is in front of you and who needs your help and that there aremany ways of stimulating healing responses. (Oschman 2003, p. Xxviii)

Based on this writing I came to the conclusion that for the treatment of

musculoskeletal pathology and especially for the chronic cases, it is important toexplore the whole array of the superficial energetic structure; not only the mainmeridians, but the secondary vessels and extraordinary meridians as well. To do that,one needs theoretical knowledge of the pathways and characteristics of the layers ofmeridian network, but at least as much important is the use of palpation to identify theprecise spots where Qi and Blood stagnates. Needling those places dissipates thestagnation and/or tonifies resulting deficiency and addresses directly the cause ofpain.

It is usually recommended not to mix or confuse different models of differentiationand treatment of a pathology. In the case of chronic musculoskeletal pain I believe

one can learn from all four different approaches. One can integrate differentiation andtreatment of underlying pathology, which is the strong point of TCM acupuncture, witha meridian oriented approach to address the exact place of the pathology. Triggerpoint approach can provide a practical and accurate methodology of identifyingplaces of Qi and Blood stagnation and a straight-forward and easy to learn palpationmethod. Combining that with an independent system of diagnosis and treatment likeear acupuncture should only increase the success rate of a treatment.

In short, one can combine the intellectual or scientific approach with the palpatoryand more intuitive approach. The latter seems to be the shortcoming of most Westerndoctors. TCM acupuncture does not need to match the Western medical science inscientific rigor; it can offer much more by relying on its ancient wisdom and trust inthe intuitive.

Do j do yfi hng do y. (Chapter 1, Do D Jing)74

74Study material Academy Qing-Bai, BVO study year 2006-2007; in translation: The Tao that one can

speak of is not the eternal Tao.


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Literature

Books: Baldry, P. E.,Acupuncture, Trigger Points and Musculoskeletal Pain,Edinburgh etc.: Elsevier/Churchill Livingstone, 2005

Deadman, P., Al-Khafaji, M., Baker, K.,A Manual of Acupuncture, Hove:Journal of Chinese Medicine Publications, second edition 2007

Deng, T., Practical Diagnosis in Traditional Chinese Medicine, Edinburghetc.: Elsevier/Churchill Livingstone, 1999

Ellis, A., Wiseman, N., Boss, K., Fundamentals of Chinese Acupuncture,Brookline, Massachusetts: Paradigm Publications, 1991

Frank, B.L. & Soliman, N.E,Auricular Therapy: a Comprehensive Text,Bloomington: Author House, 2006

Jirui, C.,Acupuncture case histories from China, Seattle: EastlandPress,1988

Maciocia, G., Diagnosis in Chinese Medicine, Edinburgh etc.:Elsevier/Churchill Livingstone 2004

Maciocia, G., The Channels of Acupuncture, Spain: Elsevier/ChurchillLivingstone, 2006

Maciocia, G., The Practice of Chinese Medicine, Edinburgh etc.:Elsevier/Churchill Livingstone, 2ndedition 2008

Manaka, Y., Itaya, K., Birch, S., Chasing the Dragons Tail, Massachusetts:Paradigm Publications, 1985

Marcus, A., Foundation for Integrative Musculoskeletal Medicine, Berkley:North Atlantic Books, 2004

Norris, C. M.,Acupuncture Treatment of Musculoskeletal Conditions, Oxfordetc.: Butterworth Heinmann 2001

Oleson, T.,Auriculotherapy Manual, China: Elsevier/Churchill Livingstone,third edition 2003

Oschman, J.L., Energy medicine in Therapeutics and Human Performance,Edinburgh enz.: Butterworth-Heinmann, 2003

Pirog, J. E., The Practical Application of Meridian Style Acupuncture, Berkley:Pacific View Press, 1996

Riley, D., Treating Pain With Traditional Chinese Medicine, Brookline

Massachusetts etc.: Paradigm Publications, 2003 Rubach, A., Principles of Ear Acupuncture, Stutgart etc.: Thieme, 2001

Seem, M.D., Acupuncture Energetics: a workbook for diagnostics andtreatment,Rochester, Vermont: Healing Arts Press, 1987

Travell, J. & Simons, D.G., Myofascial Pain and Dysfunction. The TriggerPoint Manual, Baltimore: Williams and Wilkins, 1983

The Yellow Emperors Classic of Medicine, translation by Ni, M., Boston etc.:Shambhala, 1995


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Websites:

www.chinesemedicinetimes.com: Reid, T., The Neglected Art of ChannelPalpation, 20 May 2009

www.books.google.nl

www.yinyanghouse.com

Study material of Academy Qing-Bai:

BVO, study year 2006-2007

ACU 1, study year 2007-2008

ACU 2, study year 2008-2009

Documents

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