Whiplash in the light of meridianology

Merel SomerNijmegen, 17 oktober 2011

Qing Bai Academie, richting TuiNa en Acupunctuur

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Contents

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Acknowlegments

Traditional Chinese Medicine is a way of life to which I feel very dedicated! In the years I have learned that I can merely try to be a good student and practitioner in gestation.

I would like to thank prof. Dr. Li for being an inspiring teacher and a great friend. Meeting you made a huge difference in my life of which I hope I can pass through even a little to my surroudings.

Ki-jan Go has invested a lot of time and effort to teach TuiNa and Traditional Chinese Medicine to me as a student, therefore I am more than greatfull. Thank you Ki-jan. If I can ever do something in return, that would make me proud.

Introduction

‘Het meest extreme voorbeeld van wat ik vergeten ben, geeft aan hoe luchtig ik soms met dit fenomeen omga. Ik kom bij de bakker. Daar kennen ze mij. De verkoopster zegt dat ik die morgen al geweest ben, wat ik mij niet meer kan herinneren. Ik bedank haar en zeg: ‘Goed

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opgemerkt, want zo groot is onze vriezer niet. De eerstvolgende keer dat ik bij mijn huidige huisarts ben, vertel ik dit voorval.Een week later loop ik met twee broden onder mijn arm over de weg. Mijn huisarts komt naast me rijden en zegt: “Vandaag maar één keer brood halen, hoor”.’1

Translated:

People who have endured any neck trauma in which there was a sudden distortion of the neck can be familiar with a wide range of symptoms. Different sources speak of pain and stiffness of the neck, headache, pain in he back or limbs that is hard to classify. Furthermore complaints can be forgetfulness, severe trouble to concentrate, moodswings, tiredness, prickles in limbs or fingers and tinnitus. The term used for these neck injuries is whiplash.

Not only diagnosing whiplash is proven to be difficult. Very little is known about whiplash as the symptoms differ in severity and duration. While patients complain that they can not participate in society because they can not live up to expectations of personal or business life, the (western) medical field still has no answer in how to deal with whiplash disorders. Therefore patients not only have their complaints but also have to deal with a lot of incomprehension from doctors, employers, insurance companies, wives, husbands and children, etc.

This paper will investigate the aetiology , pathological mechanisms and the treatment of whiplash- syndrome with acupuncture and Tuina. The author thinks that Traditional Chinese Medicine can explain more about aetiology and pathological mechanisms of whiplash disorders. When understanding more about this specific trauma, the prognosis and the treatment of whiplash with acupuncture and Tuina will be investigated. The author wants to line out that by no means at all there is any intention to compare western medicine to traditional Chinese medicine, merely is she interested in how traditional Chinese medicine can help understand the whiplash disorder.

This paper is intended for students and practitioners in the field of Traditional Chinese Medicine. One must understand the basic concept to grasp the contents of this paper.

The methods used in progress of this paper are literature research.

1 Sijm, T. Whiplash de Baas, Zwaagdijk, Uitgeverij Simeon, 2008, p.24.

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

‘The most extreme example of what I have forgotten, shows how lightly I sometimes handle this phenomenon. I arrive at the baker. They know me. The assistant says that I’d already visited this morning, which I can not remember. I thank her en say: ‘Well noticed, because my freezer is not that big.” The next time I visit my recent general practitioner, I tell him this incident. A week later I am walking with two loaves of bread under my arm along the road. My G.P. drives next to me and says: “Today you better only buy one bread, ok?”.’

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First outline of the issues which will be addressed in this paper:

Chapter 1: aetiology of whiplash disorders What can be said about the epidemiology? What can be said about the aetilogy?

Chapter 2: pathological mechanism What happens to the tissues and there corresponding meridians? Can we classify different forms? What happens to the Shén, Zhi and Jing? What are pathological and clinical characteristics of whiplash? What are complications and consequences?

Chapter 3: Prognosis What is the prognoses for the different classifications of whiplash? What are consequences of depletion of Zhi and Jing? What is the prognoses when left untreated?

Chapter 4: Treatment proposal by TuiNa When do we start treating whiplash disorder with TuiNa? How can the pathology best be treated?

Chapter 5: Treatment proposal by Acupuncture When do we start treating whiplash disorder with Acupuncture? How can the pathology best be treated?

Chapter 6: ConclusionsAfter researching all above the author hopes to find answers to whether pathology mechanisms are explainable and predictable and correspond to the various symptoms patients may have. Whether whiplash needs to be treated and how this is best done according tot Traditional Chinese Medicine. Finally the author wants to comment to whether damage to meridians influences health of the body in its whole and how to prevent further illness. Even though we can not control being in an accident for example, the author would like to comment on whether there are certain precautions that can be taken to prevent neck trauma of worsening the symptoms and complaints.What for instance is the consequence of depletion of Zhi and Jing which is common for traumatic accidents for example. How is the prognosis for recovery and health in general when Zhi and Jing are not treated and does treating Zhi and Jing prevent further health issues that can occur later on in life.

1 Whiplash Whiplash is an idiopathic injury for Western Medicine seen in practice. Both Western Medicine and Traditional Chinese Medicine seem to believe that the cause of Whiplash is rooted in the sudden distortion of the head in which the tissues become damaged. Especially in Western Medicine this injury is

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debated because current technologies are not advanced enough to determine specific damage and chronic symptoms of Whiplash. Chronic symptoms can be pain and stiffness in the neck, back pain, headache, mouches volantes, sensory prickles in the arms, difficulty to concentrate, memory loss, moodswings, tiredness and tinnitus.To investigate Whiplash it is necessary to define this injury. The author adopts the term “Whiplash Associated Disorder” as defined by Spitzer et al.2: This disorder is caused by an acceleration and deceleration mechanism of energy transferred to the neck. It may result from rear-end or side impact motor vehicle collisions, but can also occur during diving and/or other mishaps. For example a shaken babysyndrome can also result in WAD. In this paper the emphasis will be on soft tissue injury of the neck resulting in WAD in adults arising from a traffic incident. There will be no further research to the cause of injury obtained as this will not influence the treatment of the injury including a significant existential fear. Prior illness and the influence of this will also not be discussed..

1.1 EpidemiologyThe best data concerning the scope of problems addressing whiplash in the Netherlands come from the data base of OBiN (accidents and movement in the Netherlands). OBiN is an annual internet and telephone inquiry over 11,000 Dutch. Which is about 6,6 % of inhabitants of the Netherlands. According to OBiN-data 2006-2009 the prevalence at each moment in that period states at approximately 70,000 persons having WAD which they have incurred in the past at a traffic accident. Per year the incidence of WAD is between 30,000 and the 50,000 persons by a traffic accident.3

The Dutch Whiplash Foundation reports 25,000 patients of WAD annually in the Netherlands and states that there is no full remission of WAD patients: For the whiplash syndrome no treatment exists which offers complete recovery.4 WAD creates more morbidity than mortality as this injury is a result and not the cause of an endanger situation. In account that research shows that 50 % of patients do not recover by three months5, it is fair to say that health and costs are a great problem for individual as well as society.

1.2 AetilogyThe author already suggested that WAD is an idiopathic injury because imaging methods can not convincingly show tissue damage. Although there are reports that stated that ligaments in the neck have degenerated, this is clinically hardly ever diagnosed. We could also suggest that Whiplash is a 2 Spitzer W O, Skovron M L, Salmi L R. et al Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redifining “whiplash” and its management. Spine 1995.20(suppl)8-73S.3 http://www.swov.nl/rapport/Factsheets/NL/Factsheet_Whiplash.pdf4 http://www.whiplashstichting.nl/nl/over-whiplash/behandeling.html5 Crouch R, Whitewick R, Clancy M, Wright P, Thomas, P, Whiplash associated disorder: incidence and natural history over the First month for patients presenting to a UK emergency department, Emergeny Medicine Journal 2006, 23 (2):114-118

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syndrome. Diagnosing WAD is based on patients reporting several symptoms following a car-accident. Clinically there is no visible disease or trauma that can explain the variety of symptoms. Therefore the author suggest we could also speak of Whiplash-syndrome. Nevertheless whiplash is mostly associated with car-accidents.

Looking further into the aetiology of trauma we can distinguish a total of four forces: direct force, indirect force, forced myotasis and chronic strain.6 Whiplash is a trauma caused by indirect external force and forced myotasis. We can conclude this because indeed there is a force which hits the car and gets transmitted and in this case the tendon injury is one of sprain. Secondly there is a strong contraction of the muscles because of great exertion, which indicates forced myotasis.

Traditional Chinese Medicine speaks of Jing Jin when referring to soft tissues. When Jing Jin of the different Jing Mai are damaged this may result in several symptoms. TCM is not dependant of imaging methods like X-rays, MRI, etc. When one feels pain in a certain area this is enough to diagnose a stagnant situation of for example Qi, Xue, Jin Ye.

Furthermore it is important to note that an accident usually also means people are in such a terrifying moment in life that one is experiencing existential fear. Which brings us to endogenous pathogenic factors. It is important to also look at the inner factors that are involved in the traumatic event. An emotion which is felt to strongly can be seen as an Xie- Qi and needs to be addressed in treatment. Besides this also ones constitution has to be held into account and the occurrence. In for example: Africa in a small village without cars there will be no Whiplash disorders due to car accidents

6 Guicheng, C. H., Qingrong, C. Z., Traumatology and orthopedics of traditional chinese medicine, Publishing House of Shanghai University, 2002, p.16

Whiplash is a result of trauma due to a rear-end collision in which distortion of the neck lead to damage of muscles, tendons and ligaments.

Whiplash is a result of trauma due to a side impact collision in which distortion of the neck lead to damage of muscles, tendons and ligaments.

Damage to soft tissues; muscles, tendons and ligaments are caused by hypertension and sprain.

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2 Pathogenesis of injury of muscle and tendon

Whereas the one author uses exclusion and elimination to distinguish damage to the sinews and suggests that in pattern identification first it is necessary to eliminate any other serious causes for damage such as fracture, dislocation or flowing Phlegm (Tán Líu: “a chronic destructive condition of the joints characterized by the formation of pus that can flow or spread to other parts, and that after rupture discharges like thin phlegm. Today, flowing phlegm is considered to be a form of headless flat abscess. It is most commonly observed in children and adolescents often found to have a history of consumption (pulmonary tuberculosis) and affects most commonly the hip bone or spine and less commonly the knee, ankle, shoulder, elbow or wrist7).8 The other author uses a classification according to the nature, severity, duration and whether the injury is a mucocutaneous rupture.

Although the whiplash disorder can be classified as a closed sprain injury with laceration which can be acute or chronic, there is little mentioning of location of the injury and the influence of emotions induced by trauma because all above is written for sinew damage in general instead of one injury in particular. Therefore the author would like to add this as it might give us insight in the development of the injury as well as the prognosis.

2.1 Soft tissues and corresponding meridians

By a damage of the exterior portion of the body; the soft tissues of the skin and muscles, the Wei Qi gets blocked or impaired.

7 Wiseman, N. Feng Ye, A Practical Dictionary of Chinese Medicine,Brooline MA, Paradigm, 19988 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.261/262

Jing Jin of the Bladder meridian, Small Intestine meridian, Galbladder meridian, Large Intestine meridian, Stomach meridian, San Jiao meridian are all located in the neck area.

The bladder- and small intestine meridian belong to Tai Yang.The Large Intestine- and Stomach meridian belong to Yang Ming.The Galbladder- and San Jiao meridian belong to Shao Yang.

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Chapter 3 of the Su Wen Sheng Qi Tong Tian Lun states: “There is Yang energy in human body like there is sun in th e sky. When the sun is not at its porper position, the heaven and earth become dark, and when the yang energy of a man is not at his proper position, he will die early. So the unceasing operation of heaven depends on the brightness of the sun, and the bodily health of a man depends on the clear and floating of Yang energy which guards against outside”9 This explanation of the human vital energy connecting with nature states that a loss of yang energy or wei Qi can result in the weakening of the body’s defence.

When Soft tissues of the neck are impaired then the Jing Jin of the neck is impaired. Jing Jin meridians are of an external portion of the body. Impairment can lead to stagnation of Qi, Xue and Jin Ye. The relationship between the body fluids and Qi en Xue is extremely close. If there is Qi stagnation, this can result in water collecting and not being transformed.10 When as a result meridians are blocked then organs or tissues becoming empty of Qi and/or swamped by Qi which leads to respectively pain, a lack of nutrition of tissues (and organs) and oedema. Long term stagnation of Qi, Xue and Jin Ye can lead to phlegm, giving rise to a different set of complaints and are more difficult to treat.

If looking to the pathogenesis of Qi en Xue in trauma we could classify this to damage to Qi giving rise to stagnation, blockage, deficienty or loss of Qi and secondly damage to Xue giving rise to stasis, deficiency and Xue Heat. In Acute injury of Whiplash most likely there is Qi en Xue stagnation and/or blockage when untreated the injury can become chronic in which case a Qi and Xue deficiency or even Xue Re.

From the Huang Di Nei Jing, 不通這痛,痛則不通 (bu tong ze tong, tong ze bu tong) translates roughly as: if there is no free flow, there is pain; if there is free flow, there is no pain.Therefore and for all mentioned above it is of importance to treat impairment of soft tissues in the neck.

2.2 Shén, Zhi and JingBesides trauma of the neck area during the accident it is necessary to look at the trauma to Shén, Zhi and the Jing. Being in an (car) accident one can feel great terror and fear. This emotion can act as an internal pathogene because of its excessive and overabundant character at the time of the accident. When doing so it will cause a decline of Zhi and Jing. Whereas the patient coud have been a real strong willed person who is able to focuse and persueing lifegoals one can lack will-power after this traumatic event. Because the Zhi

9 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.1910 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.261/262

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can not nurture the Shén one can endure emotional difficulty like being swayed from his or her lifegoals and be easily discouraged or lack motivation.11 Eventually this can result in mental depression. A decline of the Jing emphasise more on the physical state of being. When Jing is declining one can encounter the hair becoming more thin and or gray and the teeth will weaken or even become loose. If the declination of Shèn Qi and Jing is severe one’s can encounter organfailure due to lessening of Yuan-Qi not being able to drive physiological processes. Therefore the therapist should take notice of a decline of Zhi and Jing, as they are very important for a person’s health, wellbeing and the outcome of treatment.

2.3 DifferentiationThere are different ways of syndrome differentiation mentioned in literature and medical articles. Investigating literature we are offered a couple of standard differentiating methods. Zhang Zhong Jing used the eight principles in the diagnosis and the treatment of cold damage and miscellaneous disease.12 Therefore the Ba Gang is might not look very usefull; whiplash is not a disease at first, but trauma giving rise to external blockage which untreated lead to different pathogeneses and clinical manifestations.The Ba Gang can help us for instant to classify location, and kind of evil. Diseases caused by the six excesses generally have a relationship to seasonal weather, work or living circumstances.13 The only excess involved with Whiplash might be a large amount of traffic giving a higher risk to accidents. But more specifically there is in Whiplash at first not an external pathogen involved. The Shang Han Lun and the Wen Bing are besides a pattern identification in which also external pathogens are active more suitable for internal medicine then for traumatology. The Zang Fu differentiation might be useful when the Whiplash syndroms and clinical manifestions reach a chronic condition and organs are effected. But most suitable is meridian differentiation especially in acute situation.

Yellow Emperor said: “ One can determine the survival or death of the patient, can treat various diseases and find out whether the disease is of sthenic or asthenic according to the condition of the channel, and must understand it.”14 This means that the channels and networks have an important function in determining life and death, differentiating all disease and regulating vacuity and repletion.

11 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.9812 Deng, T., Practical Diagnosis in Traditional Chinese Medicine, Guangzhou China, Elsevier Churchill Livingstone, 1999, p.16513 Deng, T., Practical Diagnosis in Traditional Chinese Medicine, Guangzhou China, Elsevier Churchill Livingstone, 1999, p.16514 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.556

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Tietao Deng writes: This chapter goes on to explain the pathways of the channels and then differentiates the two patterns of disease arriving “when this is stirred” and “produced by this” Historically, explanations of “when this is stirred” and “produced by this” are all very different. In essence, there are several explanations:

1. Qi diseases and pre-heaven diseases are “when this is stirred”; blood diseases and after-heaven diseases are “produced by this” (see the Nan Jing: Er Shi Er Nan).

2. Diseases in Qi, in the skin, the flesh and the muscles are “when this is stirred”; diseases in the blood, in the tendons, viscera and bowels are “produced by this” (see Hua Shou’s Nan Jing).

3. Diseases in Qi and those due to external causes are “when this is stirred”; diseases in the channel and those due to internal causes are “produced by this” (see Zhang Zhi Cong’s Ling Shu Ji Zhu).

4. Diseases of the involved channel are “when this is stirred”; diseases caused by other channels are “produced by this” (see Zhang Zhi Cong’s Ling Shu Ji Zhu).

5. Disease caused by pathological stirring of the channels and networks are “when this is stirred”; disease of the vicera and the bowels are “produced by this” (see Gang Ben Yi Bao’s Shi Si Jing Fa Hui and Shi Si Jing Yu Chao).

6. Disease of the affected channel are “when this is stirred”; pathological changes in a channel caused by its ascription to a given viscera ir bowel that is diseased are “produced by this” (see Zhang Jing Yue’s Lei Jing).

Besides the above, there is also the thought that disease in yang, in the defense and ni the exterior are “when this is stirred”; while disease in yin, in the construction and in the interior are “produced by this”.15

Whiplash is a trauma which leads to disease in Qi, in the skin, the flesh and the muscle and tendons. There is an external cause, in which channels and networks are involved, and there fore is a disease arriving from “when this is stirred”. As we can see in the 6 explanations Diseases belonging to “when this is stirred” can evolve to a disease classified as “produced by this,” as will be visible in whiplash in chronic condition.

In medical articles the classification of the Quebec Task Force is referred to a lot. The Québec Task Force (QTF) has divided whiplash-associated disorders into five grades. Grade 0: no neck pain, stiffness, or any physical signs are noticedGrade 1: neck complaints of pain, stiffness or tenderness only but no physical signs are noted by the examining physician.

15 Deng, T., Practical Diagnosis in Traditional Chinese Medicine, Guangzhou China, Elsevier Churchill Livingstone, 1999, p.305

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Grade 2: neck complaints and the examining physician finds decreased range of motion and point tenderness in the neck.Grade 3: neck complaints plus neurological signs such as decreased deep tendon reflexes, weakness and sensory deficits.Grade 4: neck complaints and fracture or dislocation, or injury to the spinal cord.16

This classification is based on symptoms, and does not bring any insight to the cause, location, or treatment principles that should be used. One studie evaluated the concept of a Whiplash culture to explain more about why some people develop long-term symptoms after whiplash, whereas others do not, but concluded occurrence of WAD is without question not entirely caused by bio psychosocial issues, it is probably not entirely physical. There is almost certainly a tissue injury component in most chronic WAD victims that becomes aggravated in those who are susceptible to various bio psychosocial factors.17

There are different methods of syndrome differentiation of which meridian syndrome differentiation is most suitable. Meridians are the passages through which Qi en Xue circulates. There are two kinds of meridians. Channels are the trunk passages and the collaterals are the branches, like a network going anywhere to connect internally with the five zang- organs and externally with the four limbs and skeleton. The meridian is a special system to communicate the exterior and the interior, the upper and the lower parts, and to connect viscera and other organs.18

Because each meridian system has its own characteristics, but all are the passages through which Qi en Xue circulates the author wants to look into the Yang Ming, Shao Yang and Tai Yang area in the neck and distinguish the pathological and clinical patterns which go beyond the local injury.

2.3.1 Pathological and clinical characteristics

A re- examination of WAD states that whiplash is more than a specific, anatomically definable injury, the diverse cluster of post-whiplash symptoms that is, an illness in which symptoms arise from and are modulated by pathology, psychological responses, and social context. Their data indicate that beyond neck pain, symptoms such as low back pain, dizziness, nausea, both upper and lower limb numbness and tingling, tinnitus, and cognitive problems are common after a whiplash injury.19

16 http://en.wikipedia.org/wiki/Whiplash_(medicine)17 Haneline, Prof M.T.(September 2009), The notion of a “whiplash culture”; a review of the evidence, The Journal of Chiropractic Medicine, 8(3) pp 119-12418 Guicheng, C. H., Qingrong, C. Z., Traumatology and orthopedics of traditional chinese medicine, Publishing House of Shanghai University, 2002, p.6619 Ferarri R, Russell A.S., Carroll L.J., Cassidy J.D., A re-examination of the whiplash associated disorders (WAD) as a systemic illness, Hampshire U.K., Emergency Medicine Journal, 2006

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Whiplash was defined in 1995 by the Quebec Task Force as an injury mechanism that may result in bony or soft tissue injuries (whiplash injury), which in turn may lead to a wide variety of clinical manifestations; reduced balance, dyscoordination, increased muscular tension20 The author would like to adopt the clinical manifestations as mentioned on the website of whiplash pain in the neck, headache, shoulder pain and back pain. Trouble to concentrate, tiredness, dizziness, memory loss.21 Furthermore is the author addressing the difference in characteristic and prognosis for the yang ming, shou yang and the tai yang area in the neck in chapter 3.

2.3.2 Complications and consequences

Already the author has pointed out the importance of treating whiplash associated disorders. Let us look at complications when this trauma is not treated.

Earlier we concluded the whiplash disorder is a closed strain and sprain injury which can be acute or chronic. Also we spoke about blocked Wei Qi, Qi, Xue en Jin Ye which give rise to a certain set of complaints and carry a substantial risk to complications and consequences.

2.3.2.1 Acute condition “When this is stirred” The fact that this injury is closed lessens the chance of complications than an inury which is open and is prawn to infections and external pathogens but can nevertheless be dangerous. Closed lacerations or strains come in several groups; contusions, hematomas, crush injury and can be divided into chronic and acute. In whiplash disorder is contusion usually seen and possibly but less likely a hematomas. Acute or traumatic wounds are the result of injuries that disrupt the tissue and can lead up to a whole set of complications which will be addressed in chronic condition. A sprain injury refers to an injury in which muscle and tendons are not torn but are stretched beyond their capacity and maybe even further. Sprains can occur in almost every joint. Symptoms are swelling, bruising, decreased ability to move and pain.22

Wei-Qi circulates outside the meridians but inside the skin and muscles. The functions of Wei Qi are to protect the body from attack of exterior pathogenic factors, to warm, moisten and partially nourish skin and muscles. Wei-Qi adjusts the opening and closing of the pores and therefore regulates sweating and body temperature.When there is a loss or blockage of Wei- Qi one has less defense to exterior pathogenic factors and surrounding tissues are not warmed, moistened or

20 Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec Task Force on WAD: redefining «whiplash» and its management., Spine 1995; 20 Suppl 8: 1S–73S.21 http://www.whiplashstichting.nl/nl/over-whiplash/wat-is-whiplash.html22 http://en.wikipedia.org/wiki/Sprain

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nourished. When there is a loss of Wei- Qi, the Wei Qi can not hold the Jin fluids and one can feel sweaty or clammy.23

The functions of Qi are general flow, raising, down bearing, exiting and entering, and maintains the coordination of the functions of the viscera and bowels. When Qi is stagnant there is impeding movement, this results in pain and distention at the given area. Qi sometimes gathers and sometimes scatters, hence the location is not fixed, the pain and distention are sometimes present and sometimes not and they are sometimes mild and sometimes strong. Qi stagnation takes a loss of regularity of the QI dynamic of the viscera and bowels and obstruction as the primary pathological characteristics.24

The functions of Xue moistening and nourishing the entire body. When Xue is stagnant there is impeded movement of Xue; resulting in impeding of the Qi dynamic hence the area is swollen, distended and the pain refuses pressure. Static Xue remaining and obstructing and not dissipating results in the possible formation of concretion and conglomeration glomus lumps and pain in fixed location. When there is stasis inside, then new blood is not generated.25

The functions of Jin are to moisten and partially to nourish skin and muscles. Jin fluids is to become a component of the fluid part of Xue where it prevent Xue from becoming static. The Jin fluids also manifest as sweat, tears, saliva and mucus.The function of Ye are to moisten the joints, spine, brain and the bone marrow. They also lubricate the orifices of the sense orangs, i.e. eyes, ears, nose and mouth.26

When the functions of Jin Ye are impaired because of blockage and stagnation of Qi skin and muscles can “dry”, making the muscle fibres vulnerable and breakable.

2.3.2.2 Chronic condition “produced by this”

Besides swelling, bruising, pain stiffness and a possible moving disability contusion, strain and sprain can lead to hematomas, scar-tissue of the muscle, tendon and ligaments. Chronic contusion typically are an insufficiency in the circulation or other system support of the tissues causes it to fail and

23 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.4524 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.25525 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.25726 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.55

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disintegrate. Infections then takes hold of the site and can become an abcess. Once the infection hits a critical point, it can spread locally or become systemic (sepsis).27

Blockage will obstruct the circulation of Wei-Qi in the skin and muscles, blocking the pores leading up to an impairment of the Lung’s dispersing function. When Lung Qi is weak and Wei Qi is weak , the skin layers and the pores become flaccid and let sweat out. Because skin and muscles do not get warmed by the Wei- Qi one is prawn to Cold. The lung governs Qi and respiration, when Qi is deficient, breathing is short especially on excertion. The shortness of breath in this case is only slight. When the Qi can not descend it can cause cough. The Lung can not dominate he Waterpassage, so that fluids cannot be transformed in the upper burner and turn into sputum. When de gathering Qi gets weakened one gets a weak voice and dislikes to speak.28

Because the liver governs coursing and discharging, the lung governs Qi and governs diffusing and depurative down bearing, and the spleen and stomach govern the raising of the clear and the down bearing of the turbid, therefore the presence of a Qi stagnation pattern can eventually influence Liver, Lungs, Spleen and Stomach

When there is stasis inside new blood is not generated. What does this mean? Tietao Deng and Maciocia are merely stating this, and do not provide any explanation. Maybe we find the answer by looking into the viscera.

The heart governs blood, the liver stores the blood and the spleen is the source of the production and transformation of blood and can be affected by long term stasis.

Long term stasis can cause pathology of the Heart. The most important Heart functions are those of governing Blood and housing the Mind. Most of the pathological changes of the Heart reflect this and involve the Blood and the Mind. Governing Blood and housing he Mind are complementary functions, mutually influencing each other. Blood and Yin are the “residence” for the Mind: if Blood and Yin are flourishing, the Mind will be in a good state and the person will feel mentally happy and vital. If blood and Yin are deficient, the Mind will suffer, the person will feel unhappy, depressed and lack vitality. Conversely, if the Mind is disturbed from emotional upsets, this can induce a weakness of Blood and Yin and therefore lead to symptoms of Heart-blood or Heart-Yin deficiency.29

27 http://en.wikipedia.org/wiki/Sprain28 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.23329 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.201

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From this we learn that pathology of Xue has an influence on the mental abilities of the patient. What set of complaints can we expect when the Blood can not house the Shen? On the other hand we also learn that an emotional upset disturbs the Shen and can induce Blood or Yin deficiency.

There are different distubances of Shen. If looking at the clinical symptoms of Whiplash disorders it is most likely a depression of Shen. Depression refers to symptoms such as deepness and heaviness of the Heart-affect, uncommunicativeness and low spirits. Depression is due to damage of the seven affects, binding depression of Liver Qi and Qi failing to course and discharge, all of which can cause the `qi dynamic not to flow smoothly.30

When a man lies down, his blood turns towards the liver. The blood can nourish extremities and all parts of the body, so, when the eyes obtain the blood, they can see, when the feet obtain the blood, they can walk, when the palms obtain the blood, they can hold things, when the fingers obtain blood, they can fetch things. When one walks away to outside immediately after sleeping and is invaded by the blow of wind, if the blood is stagnation is on the surface of the skin, bi-syndrome will occur, when the blood stagnation is in the channels; it will cause the retardation of the blood flow, when the blood stagnation is in the feet, it will cause coldness of the lower extremities. All three kinds of diseases are due to the inability of the blood to flow back to the channel circulation. There are twelve main joints in the four extremities and three hudred and fifty four small bone joints in the human body, excluding the shu points in the twelve channels. All of them are the places for the Wei-erngy to stay, and are also the places for the evil-energy to reside, when one is attacked by the evil energy, it should be removed by acupuncture or by therapy with stone needle.31

The Su Wen is explaining us the functions of the Liver. In night-time the liver stores the blood, in day time the Liver (by Qi dynamic) is responsible for the coursing and discharging the blood in order to nourish extremities. When the Blood is still in the Liver instead of on the outside portion of the body, one is more prawn to external pathogen like Wind. External pathogens lead to stagnation; Blood stagnation can occur on the surface of the skin (cou li) Maybe leading to Bi Syndrome. When the Xue Yu is in the channels, it will cause retardation of the blood flow. The location of the blood stagnation will determinate the clinical manifestations. The channels and the joints is the location of Wei Qi but can also be invaded by pathology. In this case Acupuncture is a good treatment.

30 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.44331 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.65-66

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In a chronic condition we might encounter malnourishment of muscle and the four limps, visible bruising, weakened defence, Xue Xu, and possible worsening of the condition when invaded by external pathogens.

How does The spleen and Stomach become effected by blood stagnation? The spleen and the stomach are the root of the after-heaven and are involved in the production of Qi and Blood. The primary aspect of the pathology of the spleen and stomach are as follows: abnormalities in the governing of transportation and transformation cause a hindrance to the intake and transportation and transformation of food and water, resulting in no source for the engendering and transformation and the collection and amassment of water- damp. All of this results in manifestations of an insufficiency of Qi en Blood, the engendering of phlegm and the gathering of damp. Normally, the transportation of the spleen results in a source for the engendering and transformation and then there is sufficient Qi en Blood, hence the flesh and muscles are replete, the four limps are forceful and flexible and the lips are red and moist. If the spleen fails to transport, this results in withered and soft flesh and muscles, fatigued and forceless limps and pail white lips.32

When already there is Qi (and Xue) stagnation this may leads to Spleen Qi not going up, when Gu Qi combined with Kong Qi does not reach the Heart, new blood can not be formed. Also Maciocia speaks about the importance of Qi and in particular healthy Spleen Qi.

If spleen Qi is healthy, Blood will circulate normally, and stay in the vessels. If spleen Qi is deficient, Blood may spill out of the vessels resulting in haemorrhages. Besides controlling the Blood and preventing Haemorrhages, the Spleen also plays an important role in making Blood. In fact, the Spleen extracts Food Qi from food and this forms Blood in the Heart with the assistance of the Original Qi from the Kidney.33

In a chronic condition we might encounter Qi and Xue Xu manifesting in deep tiredness, blood seeping out of the vessels leading to haemorrhages, impaired transportation and transformation leading withered and soft flesh and muscle and forceless limps.

Long term Jin Ye insufficiencies can cause Xue static or aggravate xue yu. The cervical vertebrae, brain and the bone marrow do not get nourished, and the orifices of the sense organs can become dry and eventually painfull.

The vital substances are related to each other in many ways, pathology of Qi will have an effect on Xue and Jin Ye. Pathology of Xue has an effect on Qi en Jin Ye. Qi en Xue will be impaired by a pathology of Jin Ye. It is necessary

32 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.28333 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.90

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to address pathology of the vital substances to prevent aggravation of already existing complaints.

3 Prognosis

Yellow Emperor said: “I am told that the various parts of the skin belonging to the twelve channels respectively, in the distribution of vessels, some are vertical and some are horizontal, in the distribution of the tendons, there are knots and colleterals: in the distribution of bones, some of them are large and long, and some of them are small and short. The diseases stemmed from various organs are different, and they can only be distinguished by the parts of the skin which belong to various channels respectively, and besides, one must also take into account of the upper and lower, left and right positions, the attribute of Yin and Yang and the process of development of the disease.”34

From this not only we learn that we can use the various parts of the skin for diagnosing (for example also the internal disease which shows on the skin) but the location of the skin also explains to us which channel-system is involved and therefore we can prognose for acute as well as the chronic Whiplash. By using the Ba Gang as well as meridian differentiation we take into account the upper and the lower, left and the right positions, the attribute of Yin and Yang and the process of development of disease.In Chinese medicine, musculoskeletal disorders are generally referred to as bi zheng; “Pain Patterns.” The list of Western Diagnoses that can be associated with this category is quite broad, including various rheumatic illnesses, radiculopathies and peripheral neuropaties, strains and sprains, and generative disc disease.35 Whiplash can be seen as a pain pattern.

Treating musculoskeletal disorders can best be done using the Jing Jin.As the Jing Jin is to protect the body from exogenous pathogens, the Wei Qi circulates here.

This circulation begins at daybreak, issuing from the eyes at Bl 1, as they open and traveling distally down the legs and out the arms of the tai yang meridians. The Wei Qi continues to flow from the eyes throughout the day, radiating successively through the tai yang, shao yang, and the yang ming meridians. During the night, the Wei Qi returns to the interior of the body through the foot shao yin meridian and pours into the kidney viscus. From here it circulates sequentially through the heart, lungs, liver and spleen viscera before returning to the kidneys. At day break, the Wei Qi returns to BL1 to begin another cycle.36

34 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.252 35 Pirog E.J., The Practical Application of Meridian Style Acupuncture, Berkeley, California, Pacific View Press, 1996, p.219 36 Pirog E.J., The Practical Application of Meridian Style Acupuncture, Berkeley, California, Pacific View Press, 1996, p.221

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Pirog is telling us about the cycle of Wei Qi. After looking into the acute Whiplash, we can see now what can happen when the stagnation is more chronic and complaints develop over a longer time. Pirog is furthermore suggesting that chapter 13 of the Ling Shu, discussing the centripetal pathways, could also be a discretion of the evolution of pathogenic Qi. Maybe we will find answer to this when looking into the prognosis for the stagnation in the different meridian systems. Besides this he is mentioning a two level differentiation which explains about the acute and the chronic situation and gives insight about the vacous and repletion of the meridians.

Level 1 pattern (meridian sinew replete and the main meridian vacuous) Pathogenic Qi invades the meridian sinew while defence Qi rushes up from the main meridian to expel it. Ashi points are relatively superficial. Furthermore is suggested that the Wei Qi together with the pathogenic Qi is locked in mortal combat, causing localized energy stagnation and therefore localized pain. Level 2 pattern (meridian sinew vacuous and the main meridian replete) Pathogenic Qi overcomes the defence Qi and pushes into the main meridian. Ashi points are relatively deep. The invader has reached the main meridian, the level 2 disorder is overall more vacuous than the level 1 disorder, pain is more vague and diffusely, and more difficult to elicit by palpation.37

Classifying Whiplash Injury according to TCM in the light of the theory of musculo-tendino channels lesions, it was divided as three types: Yang Ming Type (unable to turn the neck), Shao Yang type (uncomfortably holding the neck with pulling sensation when turning the neck) and Tai Yang type (tightness and spasm of the muscles in the neck).38 Not only is this important for the treatment proposal but the author suggest that the three types can explain more about the prognosis of whiplash injury when left untreated. Pirog points out that in the classification of a level 1 or level 2 injury after the acute state the Jing Jin is empty and the meridiansystem is replete or in excess.In this chapter we investigate excess of the meridiansystem.

3.1 Qi en XueYu obstructing Yang Ming This trauma is most likely to occur after a collision with side-impact; which results in a motion to the lateral aspect of the neck. The impaired large intestine sinew will result in an inability to raise the shoulder and an inability to turn the neck to the left or to the right.39 But this pattern has already

37 Pirog E.J., The Practical Application of Meridian Style Acupuncture, Berkeley, California, Pacific View Press, 1996, p.22338 Yenming Chen, L. Ac., FICAE, President, New York College of Traditional Chinese Medicine, Acupuncture applied to treat pain due to Whiplash Injuries, Meridian Times, The Journal of the Acupuncture Society of New York, Summer 2005/Volume 14, Number 1, p20-2339 Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998, p.98

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developed and is no longer only a problem of the tendons. The hand and foot Yang Ming can be involved giving rise to a certain set of complaints. Let us investigate the coarse of the principal meridian in order to explain possible complaints.

The Large Intestine meridian of hand yang ming is paired with the stomach meridian of foot yang ming according to six channel theory.

The hand Yang Ming channel if Large Intstine starts from the tip of the forfinger, runs along the upper side of the forefinger (Erjian and Sanjian points)*, passes the Hegu point in the forked bone between the thumb and the forefinger to reach the cave-in between the two tendons on the wrist (Yangxi point)**, then runs along the upper part of the forearm (Pianli, Wnliu, Xialian and Shanglian points) to reach the outer flank of the upper arm (Zhouliao, Wuli and Binao points) to reach the shoulder (Jianyu) and the scapula***, and then converges with the varios Yang channels at the Dazhui point****, then, it descends to the supraclavicular fossa, communicates with the Lung*****, crosses through the diaphragm and links the large instestine******; its brach ascends to the neck from the supraclavicular fossa*******, passes the cheek to reach the seam of the lower teeth********, then turns back to make a detour to the uper lip and converges with the symmetrical Hand Yang Ming Channel of the other side at the nasolabial groove*********, then the left channel goes to the right and the right channels goes to the left to clip the two sides of the nostrils and connect the Foot Yangming Channel of stomach**********.40

So by reading the Yellow Emperor word for word, we learn about the the function of the Shou Yangming as well as we can understand more about the rising of complaints if the Shou Yangming can not nourish the different parts of our body-system.

Shou Yangming treats:*pain along the course of the channel, pain, stiffness or numbness of the forfinger and or thumb, the lower and the upperarm.**different wristproblems.***a variety of pathology of the shoulder as well as the scapula. ****Yangpathogenes i.e. heat and wind.*****Large Intestine by unblocking method and descending to Jeu Yin.******the diafragm and several epigastric problems.*******the Lungs and Wei Qi. ******** the neck and the supraclavicular fossa.********* Facial symptoms, cheeks, lower jaw, lower teeth and gum.**********the lips and the nose; blocked nose for instance.***********connect with the Zu Yangming.

40 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.557-558

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The foot Yangming channel of Stomach starts from Yingxiang point beside the nostril and runs into the Foot Taiyang channel beside, then, descend along the outer flank of the nose to enter into the seam of the upper teeth and comes out to encircle the lips and meets the symmetrical Foot Yangming channel of the other side at the Chengjiang point*, then, it runs along the rear of the cheek**, passes the Daying and Jiache points to reach the front of the ear***, and then, passes the Kezhuren point and runs along the hair line to reach the forehead****; its brach starts from the front of the Daying point, descends to the Renying point, passing the throat (Shuitu and Qishe points) to enter into the supraclavicular fossa*****, then descends again to cross the diaphragm, links the stomach and communicates with the spleen******. Another Foot Yangming channel which runs straightley forward, starts from the supraclavicular fossa to reach the inner side of the breast and near the navel (passing Tianshu, Wailing, Daju, Shuidao and Guilai points) to reach the Qijie point (Qichong) beside the pubic hair margin*******; another branch starts from the lower outlet of the stomach, runs along the inside of the abdomen and joins the channel which runs straightly forward stated above in front of the Qijie point (Qichong)********, then it runs along the thigh, passes the Futu point then along the knee cap and the outside of the tibia*********, passing the dorsum of the foot and reaches the inner side of the middle toe**********; another branch starts from the location three inches beneath the knee, and descends to the outer side of the second toe***********; another branch starts from the dorsum of the foot, runs into the big toe to connect the Foot TaiYin channel of the Spleen.************41

Zu Yangming treats:* nose, eyes (and connect to the Zu Taiyang), teeth, gums, lips and mouth.** facial symptoms; cheeks***ears****Forehead, frontal headache*****throat/neck and supraclavicular fossa******Diaphragm, Stomach and Spleen*******Breast and navel, Uterus/Gynaecologie problems********Abdominal pain or masses*********Thigh, Knee and lateral side of tibia**********Dorsum of the foot

Yang Ming is full of Qi and Xue. It should nourish but is also susceptibel for (stagnation) heat. If there is blockage in the neck at the Yangming level then Jing Qi of Yang Ming can not nourish the organs properly. Yang Ming becomes deficient.

3.1.1 Development over time

41 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.558-559

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If the Yangming type Whiplash does not get treated this can give rise to pain, stiffness and swollen neck with an inability to turn the neck to the left and right. There can be frontal headache and pain or prickles in de limbs along the course of Yang Ming. By excess in de Yang Ming meridians the organs do not get nourished properly. This means one can develop all sorts of complaints rising from the Stomach (and eventually the Spleen) and the Large Intestine. If Large Intestine Qi becomes weak the Large Intestine role to excrete waste food material becomes impaired, leading to constipation. The stagnation of food in the Large Intestine may impair the Long descending function giving rise to breathlessness.42 Emotionally the patient might find it hard letting things go.If Stomach Qi becomes weak one can encounter complaints because the food essences will be weak too and the Stomach can not transport them to the whole body so that the person will feel tired and suffer from weakness of the muscles.43 Emotionally one withdraws himself; shutting oneself in the house, closing all doors and windows, wanting to be by oneself.44

Because of the close relationship between the Stomach and the Spleen, most likely also the Spleen becomes affected. If Spleen Qi is weak, the refined Qi cannot be transported to the muscles and the person will feel weary, the muscles will be weak and in severe cases may athropy. The state of the Spleen is one of the most important factors to determining the amount of physical energy a person has. Tiredness is a common complaint and in these cases the Spleen must always be tonified. Thinking will be dull, Concentration will be slack and memory will be poor.45 It may seem that the Liver is invading the Spleen, but in fact really it is not so that the wood-element is overacting on the Earth element. It is the Earth element which has become deficient. It is for this reason the patient feels irritable or encounters “moodswings”.

3.2 Qi en XueYu obstructing Shao Yang This trauma is most likely to present itself with pain elicited by turning the neck or the lumbar from side to side. The Shao Yang meridians thus allow the body to pivot like the hinge of a door. It is often a mixture of Tai Yang and Yang Ming symptoms. The Shao Yang meridians act as a pivot for the body balance when walking. If the energy between the Shao Yang meridians on the left and the right hemispheres is in disharmony, there will be vertigo and a lateral swagger. Interestingly, the shao yang are the meridians most closely associated with the ear, and it is the inner ear which controls balance according to modern biomedicine.46

42 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.11543 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.11244 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.55945 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.91

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Shou Shao Yang starts from the tip of the ring finger, runs between the small finger and the ring finger (Yemen and Zhongzhu points) and the dorsum of the hand to reach the middle of the two bones of the outer flank of the forearm (Zhigou point), then ascends to cross the elbow, and runs along the outer flank of the upper arm and the shoulder (Passing the Naohui, Jianliao and Tianliao points)* crosses and runs behind the Zu Shao Yang channel of the Galbladder, then runs into the supraclavicular fossa, crosses the Tanzhong point and communicates with the pericardium**, then descends to the diafphragm and links the upper, middle and the lower warmers complehensively***; another branch seperates from the location of the Tanzhong point, passes the supraclavicular fossa and the neck****, ascends behind the ear to reach the upper part of the ear (passing Yifeng, Chimai and Luxi points), then turns down to reach the forehead and under the orbit; another branch starts from the rear end of the ear, runs into the ear and comes out from the front of the ear*****, passes the front of the Kezhuren point and joins the branch stated above the cheek******, then it reaches the outer canthus and connects the Zu Shao Yang channel of Galbladder.*******47

Shou Shao Yang treats:*pain, prickles or other complaints, of ringfinger, dorsum of the hand, forearm, elbow, upper arm and shoulder**the pericardium***the diaphragm, lower, middle and upper warmers****the neck, throat*****the ear******the cheek*******the eyes

Zu Shao Yang of Galbladder starts from the outer canthus*. It ascends to the corner of the forehead**, then turns down to the rear of the ear and runs along the neck***, crosses the Shou Shao Yang channel of triple warmer and runs behind it to reach the shoulder****, and then, enters into the suprclavicular fossa; its branch starts from the outer canthus, descends to the location near Daying point and connects the Shou Shao Yang channel of Triple Warmer, then runs to the lower orbit, passes the Jiache point, descends to the neck and joins the channel which enters the supraclavicular fossa stated above*****, then it descends to the chest******, crosses the diaphragm, communicates with the liver, links he gallbladder, runs along the hypochondrium*******, passes the Qijie point, bypasses the pubic hair margin to reach the greater trochanter horizontally********; the Zu Shao Yang channel which runs straightly forward starts from the Qeupen point to the armpit*********, ascends along the chest and ribs join the branch stated above at the great trochanter**********, then runs along the outer side of the upper thigh to reach Yanglingquan point************, and descends in front of the 46 Pirog E.J., The Practical Application of Meridian Style Acupuncture, Berkeley, California, Pacific View Press, 1996, p.4947 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.565

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fibula to reach the Yangfu point below, then comes out from the front of the outer ankle to run along the dorsum of the foot and reach the middle between the small toe and the fourth toe************; its branch starts from the dorsum of the foot to pass along the forked bone of the big toe to reach the tip of the big toe, then turns back to penetrate into the nail and comes out of the rear of the toe’s nail to connect the Zu Jeu Yin channel of the Liver*************. 48

Zu Shao Yang treats:*pain in the outer canthus and eyes**pain at the side of the head radiating to the forehead***ears and the neck****shoulders*****communicates with the San Jiao channel******the chest******* problems of the diaphragm, Liver, Gallbladder and the hypochondrium******** genitals, gynaecology and the hip joint (i.e. trochanter)********* pain and swelling of the armpit********** pain of the chest as well as the ribcage*********** thigh************ lateral leg; knee, fibula, ankle, the dorsum of the foot and toes*************Communicates with the Zu Jeu Yin and can treat LeverQi Yu and the nails

Shao Yang is full of Qi and less blood. This level is located midway between the front-interior and back-exterior, acting as a pivot or hinge. Shao Yang is referred to as lesser yang. In part, the title is descriptive of the narrow surface which the gall bladder and the triple burner meridians occupy, positioned on the coronal plane of the body as if they were seams connecting the posterior and anterior bodily hemispheres. The intermediate position of Shao Yang is reflected in the function of its associated organ, the gall bladder. Storage of clear liquids is otherwise an exclusive function of the comparatively deep viscera, and thus the Gall Bladder can be said to hold an intermediate position between the functions of the viscera and the bowels. The indication of the Shao Yang meridians is often a mixture of Tai Yang en Yang Ming symptoms.49

3.2.1 Development over time

If the Shao Yang type Whiplash does not get treated this can give rise to pain, stiffness of the neck area which is elicited by turning the head left to right or turning the lumbar region. Because of the close connection with the ear, the patient can experience vertigo. There can be one-sided headache or lateral headache which radiates to the forehead, maybe accompanied with prickles or pain in the shoulders and arms along the course of the Shao Yang 48 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.56649 Pirog E.J., The Practical Application of Meridian Style Acupuncture, Berkeley, California, Pacific View Press, 1996, p.48-49

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meridians. If Shao Yang Qi is not flowing freely the organs can lack nourishment. When San Jiao is malfunctioning this will manifest as a blockage of the various types of Qi or fluids in the three stages: a blockage of Wei Qi in the Upper Burner (impairment of the Liung dispersing function), a blockage of Nutritive Qi in the Middle Burner (impairment of the Spleen function of transportation) and a blockage of Body fluids in the Lower Burner (impairment of the Bladder function of Qi transformation). These situations would cause sneezing, abdominal distention and retention of urine respectively.50 If the Pericard lacks Qi because of malnourishment this will influence the area at the centre of the thorax. Maybe the person experiences difficulties in relations with other people.51

The Gall Bladder is the Yang aspect of the Liver, and it is said in Chinese Medicine that Liver-Yang can only be in excess, never deficient. However, in this case, this pattern describes a state of deficiency of the Gall Bladder. More than a “ pattern” this is really the description of a certain character or personality. The Key feature of this “ pattern” is the character of the person, i.e. the lack of courage, timidity and lack of initiative. The Liver houses the Hun and its weakness can be manifested with timidity and fear. Other clinical manfiestion can be dizziness, blurred vision, nervousness, timidity, propensity to being easily startled, sighing.52

Liver Qi Yu is by far the most common of the Liver patterns and also one of the most common patterns in general. I have arranged the manifestions in five different groups to highlight the different pathology of each group. Obviously not all the manifestion need to be present to warrant a diagnosis of Liver-Qn stagnation. Clinical manfestions are:

1. Feeling of distention of hypochondrium and chest, hypochondriac pain, sighing, hiccup.

2. Melancholy, depression, moodiness, fluctuation of metal state.3. Nausea, vomiting, epigastric pain, poor appetite, sour regurgitation,

belching, feeling of pulsation in epigastrium, “churning feeling in the Stomach” , abdominal distention, borborygmi, diarrhoea.

4. Unhappiness, “feeling wound up”, feeling of lump in the throat, feeling of difficulty in swallowing.

5. Irregular periods, painfull periods, pre-menstrual tension an d irritability. Key symptoms are hypochondriac and chest distention, depression, moodiness.53

50 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.11851 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.10352 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.284-28553 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.217

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3.3 Qi en XueYu obstructing Tai Yang This trauma is most likely to occur after a head-tail collision, which results in a motion of the head to the front and the back. Pathological syptoms of the Small Intestine sinew channel are tension of the neck sinews that leads to sinew athrophy and swelling of the neck.54 Pathological symptoms of the Bladder sinew channel are spasm and tension of the nape of the neck with an inability to raise the shoulder.55 This pattern “ when this is stirred” can develop in a level 2 pattern; in which the sinew become deficient and the merdians are in excess. Let us therefore investigate the Tai Yang meridians.

Shou Tai Yang starts from the tip of the small finger, it runs along the outer flank of the hand to enter into the wrist above and comes out from the styloid process of ulna*, runs along the ulnar side of the arm to reach the middle of the bones beside the elbow (Xiaohai point), then, ascends along the rear and the outer flank of the upper arm**, comes from the seam posterior to the bone (Jianzheng point), bypasses the shoulder and meets the symmetrical Tai Yang channel of the other side above the shoulder (Dazhui point)***, passes the supraclavicular fossa and the armpit to communicate with the heart****; the Hand Taiyang Channel that runs straightly forward descends along the pharynx to cross the diaphragm below and links the Stomach and the Small Intestine*****; its branch seperates from the supraclavicular fossa, ascends along the neck (Tianchuang, Tianrong and Quanliao points) to reach the outer canthus and turns into the ear******; another branch starts from the upper orbit, the cheek to reach the nose and then, reaches the inner canthus*******.56

Shou Tai Yang treats:*the small finger, outer flank of he hand, the wirst**the ulnar side of the forearm, the elbow and the ulnar side of the upperarm***the shoulder and meets all yang meridians at Dazhui****the armpit and the Heart*****pharynx, diaphragm, Stomach and Small Intestine******Neck and outer canthus of the eye, and ear.*******Cheek, Nose and eyes

Zu Tai Yang starts from the inner canthus*, it passes the forehead above and joins the symmetrical Zu Taiyang Channel of the other side of the top of head**; its branch starts from the top of the head to reach the upper part of the ear***; the Zu Tai YangChannel runs straightly forward and communicates with the brain from the top of the head****; its branches to reach the neck below*****, runs along the lower part of the shoulder to press close to the vertebrae and enters into the body******, then, penetrates into the muscle of 54 Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998, p.22955 Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998, p.25356 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.561

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the spine to communicate with the Kidney and links the Bladder*******, another branch runs along the loin, descends to the anus********, passes through the buttock and reaches the popliteal fossa*********; another branch starts from the inner side of the shoulder, descends to pass the greater trochanter*********, runs along the rear of the outer flank of the tigh to reach the popliteal **********, the, passes the calf of the rear of the outer ankle***********, then, runsalong the fifth metatarsal bone on the lateral aspect of the foot to reach the tip of the outer flank of the small toe, and then, connect the Zu Shao Yin Channel************.57

Zu Tai Yang treats:*the eye**the forehead/head***the upper part of the ear****the brain*****the neck******Shoulder and vertebrae/spine*******the Kidney and Bladder********the anus*********the greater trochanter**********outer flank of the thigh as well as the popliteal crease of the knee***********the ankle************the small toe and communicates with the Zu Shao Yin channel

The Tai Yang meridians might be considerd “greater” yang in the sens that they have the most yang (read:exterior) location. There are practical advantages to this distribution; the Tai Yang meridians exterior placement provides the acupuncturist with the most immediate access to the body as a whole, including the internal organs- thus explaining the location of the shu-back points on the Zu Tai Yang meridian. The same superifical location also leaves the Tai Yang meridians vulnerable to the attack of exogenous pathogens.58

Tai Yang has more Blood and less Qi. Tai Yang should disperse and diffuse the Wei-Qi and open to the exterior to repel external pathogens. If Tai Yang can not open to the exterior or protect the body from external pathogens. This can make the patient prawn to colds and day-time sweating. The merdians can become deficient or blocked and cannot nourish the organs properly.

3.3.1 Development over time

If the Tai Yang type Whiplash does not get treated this will give rise to pain, stiffness or swelling of the neck, which is elicited most by bending the head and raising the shoulders. Headache can develop from the occiput but also from the top of the head, or experienced from the inside of the head as the 57 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.56258 Pirog E.J., The Practical Application of Meridian Style Acupuncture, Berkeley, California, Pacific View Press, 1996, p.48-49

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meridian of Zu Tai Yang enters the brain. The eyesight can obtain different like vouches moulantes for instance. The patient can develop complaint like prickles or pain in the arm or shoulders and back along the course of the Shou Tai Yang and the Zu Tai Yang meridians. One of the main functions of the Heart is to house the Shen. If the Heart is not able to house the Shen, the patient can experience problems with mental activities (including emotions), consciousness, memory, thinking and sleep. Some of the Heart’s function in relation to Shen correspond to the Brain’s mental activities from a modern medical view.59 Other complaints due to malfunctioning of the Heart can be palpitations, sweating, tiredness and listlessness.60 The Brain originates from the Kidneys and depend on the Heart. The brain lacking nourishment will results in dizziness, tinnitus, blurred vision, fatigue and a great desire to lie down.61 Because of the relationship of the Kidney, the Brain and Shen, this will be further discussed in chapter 3.4. If Stomach Qi becomes weak one can encounter complaints because the food essences will be weak too and the Stomach can not transport them to the whole body so that the person will feel tired and suffer from weakness of the muscles.62 Emotionally one withdraws himself; shutting oneself in the house, closing all doors and windows, wanting to be by oneself.63

Because of the close relationship between the Stomach and the Spleen, most likely also the Spleen becomes affected. Leading to several complaints already discussed in chapter 3.1.1. The Small Intestine receives food and drink after digestion by the Stomach and Spleen. This it transforms further by separating a “ clean” from a “ dirty” part. From a psychological point of view, the Small Intestine has an influence on mental clarity and judgment. Whereas the Gall Bladder has an influence on the capacity and courage to take discisions, the Small Intestine gives us the power of discernment, that is the ability to distinguish relevant issues with clarity before we make a decision.64 Kidney already being under al lot of strain during the accident can also lack nourishment trough blockage of the Zu Tai Yang, Kidney Qi and Yuan Qi are weak, the Kidneys cannot provide enough Qi to the Bladder for its function of Qi transformation, hence the urine cannot be held and this causes frequent urination, incontinence, enuresis, weakstream urination and dribbeling after urination. It cannot hold the sperm or vaginal secretion in women, and this causes spermatorrhoea, premature ejaculation, nocturnal emissions without dreams and chronic vaginal discharge. There is urination at night because Yang qi is not firm, Yang cannot control the Yin at night, hence Yin

59 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.7260 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.20261 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.12462 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.11263 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.55964 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.114

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predominates and the person needs to urinate during the night. When the Kidney Yang is deficient, it fails to nourish the Spleen which, in turn, fails in its function of raising Qi, hence the prolapse of the uterus. The chronic vaginal discharge can also be seen to be a manifestion of the sinking of Qi from chronic Kidney and Spleen deficiency.65

The Bladder receives the Qi for its function from the Kidneys; in disease, therefore Bladder deficiency often results from Kidney-Yang deficiency. However, the Kidney does not have a pattern of Excess, so all Excess patterns pertaining to the urinary system fall under the category of Bladder patterns. From this point of view, the Bladder patterns are very important, as they fill a gap within the urinary disease patterns. Accumulation of Dampness is the most common pathological factor in Bladder Patterns. The Bladder is prawn to emotions of fear or feelings of suspicion or jealousy bottled-up over a long period of time.66

3.4 Shen Xu and Depletion of Zhi and JingThe seven emotions are the seven sentimental changes, which include joy, anger, grief, pensiveness, worry, fear and fright, and reflect the mental state of human beings. The seven emotions represent human reactions to objective reality, and do not cause disease under normal circumstances. However, the may cause disease when there is sudden, strong or lasting sentimental stimulation which surpasses a human being’s physiological endurance and disturbes the function of Qi and the coordination of Yin and Yang, Qi and Blood, and zang-viscera and Fu-viscera. When the seven emotions become the seven evils they cause internal impairment which are called: “ The seven emotional evils causing endogenous injury”.67

Further investigating the emotions there is a difference made in fear or fright. Both do show signs of Heart and Kidney damage. The difference between both is that fear is damage pattern resulting in dispersal of the spirit Qi and fright damage pattern resulting in chaotic Qi. Fear damage pattern is a disease pattern that refers to excessive fear damaging the Heart and Kidney which manifest in Kidney Qi not securing and containing. Fright damage pattern is a disease pattern that refers to receiving excess fright causing failure of the Heart spirit to confine itself and failure of the kidney to secure and contain.68 So Qi movement can be different, whereas fear lower the Qi, fright scatters the Qi. Fear gives a deep pulse and fright gives a stirred pulse, for both emotions is the effect and on the Kidney nearly the same; in both cases the Qi can not be secured or contained.

65 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.25466 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.257-25867 Beijing University of Traditional Chinese Medicine, Basic Theories of Traditional Chinese Medicine, Beijing China, Beijing University, 1998, p. 17568 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.198

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The primary pathological characteristics of disease of the Kidney and urinary bladder manifest as abnormal functioning of the Kidney’s storage of essence, and governing of reproduction, growth and development.69

The physiological function of the Kidney in storing Jing is extremely important. It is the foundation for the preservation and the production of the human body. The Kidney Jing can be changed into the vital energy, called Kidney Qi and is responsible for the continuing health of the body. With age increase, the Kidney Jing may change from abundant to insufficient. In old age, the essential Qi of the Kidney declines, the reproductive ability and sexual function disappear gradually, and the body degenerates. In adults, excessive impairment of the Kidney Jing may cause premature senility, characterized by loss of hair, looseness of teeth, dizziness, tinnitus, poor memory, decline of sexual function, etc.70

69 Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999, p.29570 Beijing University of Traditional Chinese Medicine, Basic Theories of Traditional Chinese Medicine, Beijing China, Beijing University, 1998, p. 93-95

6 e

mo tio ns

K o n g

The physiology of our emotions follow the Jing sequence because Jing is the root. Besides they can not be seperated; fear is always the underlying emotion. We are afraid for death. We get angry because we are afraid, we are sad because we are afraid, we overthink because we are afraid, we overjoy because we are afraid.

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The brain originates from Kidney Jing, it is important we can understand that the existential fear at the time of the accident can have a great effect on the functioning of the brain; as well as there can be blockage of the Zu Tai Yang leading to deficiency of “ the sea of Marrow”. Disfunction of the Brain can therefor manifest in dizziness, tinnitus, blurred vision, fatigue and a great desire to lie down.71

Not only premature senility is a worry in the case of not treating weakened Kidney Jing. The physique of a woman turns from prosperity to decline gradually after the age of thirty five (5 x 7). So by this time, her Yang Ming channel turns to debility, her face becomes withered, and her hair begins to fall. By the age of forty two (6 x 7) her three Yang channels (Tai Yang, Yangming, Shao Yang) all begin to decline. By this time, her face complexion becomes wane, and her hair begins to turn white. After the age of forty nine (7 x 7) her Ren and Chong channels are both declining, her menstruation severs as her Taingui being exhausted. Her physique turns old and feeble, and by then, she can no more conceive.72

For man the kidney energy turns gradually from prosperous to decline by the age of forty (5 x 8). As a result, his hair begins to fall and teeth begin to wither. By the age of forty eight (6 x 8) his kidney energy decline even more. As the kidney energy is the source of Yang energy, the Yang energy of the whole body begins to decline due to the decline of Kidney energy. As a result, his complexion becomes withered and his hair becomes white. After the age of fifty six (7 x 8) his liver energy decline in the wake of the deficiency of the Kidney energy (the liver energy stems from kidney energy) .As the Liver determines the condition of the tendon, the deficiency of kidney energy will cause malnourishment to tendons which will becom rigid and fail to act so nimbly. After the age of sixty four (8 x 8) his Tiangui being exhausted, his essence and vital energy being reduced, and his Kidney energy becomes weak. As Kidney determines the condition of the bone, the debility of Kidney causes weakness of the tendons and bones. Thus, at this stage, his essence and vital energy turn to utmost decline, his teeth fall off, and every part of his body becomes decrepit.73

If there is declination of Kidney Jing the patient may encounter tendon problems due to declination of Leverblood, early menopause by exhausted Tiangui and early aging in every life event of the natural law of physiology following the cycle of 7 years in women and 8 years in men. Only already for this reason we should pay attention to the state of the Kidneys and treat them in order to preserve life.

71Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.124 72 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.973 Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine, U.S.A., China Science & Technology Press, 1997, p.10

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If the Kidneys are weak the Zhi is also effected. Zhi will be lacking and the Shen will be easily discouraged and swayed from its aims. Lack of Zhi and motivation are often important aspect of mental depression and tonification of the Kidney will often give very good results.74

4 Treatment Chapter 3 has been an investigation in the different types of Whiplash disorders, an external disease and to what extent this can become an internal disease. It not only shows the importance of treating Whiplash, or any stagantion in the neckarea for that matter, in this chapter there will be suggestions for effective treatment corresponding to the complaints patients may have.

TuiNa therapy and Acupuncture can be used to subdue stagnation in the meridians and collaterals, to promote and to regulate the free flow of Qi en Xue, to harmonise the Yin-yang balance, to remove pathogenes and to strengthen body resictance.

When there is sprain Acupuncture can remove bloodstasis by puncturing the skin and to prick the luovessels. TuiNa is an external therapy which is best used in the acute phase and early chronic stage. Not only can TuiNa help the muscles and tendons to recover, TuiNa also can prevent the second stage; a chronic situation in which the meridians become vacous leading to all sorts of complaints and further illness. Besides the prevention we can also look at the location of the complaint. Whiplash disorder is in early stage a complaint of muscles and tendons leading to neckpain, stiffness, prickles along the course of involved meridians and headache. TuiNa is an external treatment which is applied to muscles and tendons. The extent of manipulation cover a larger portion of the Pi Bu and is therefore more suitable than Acupuncture.

Acupuncture treatment is far more precise than TuiNa and can therefore easily reach acupuncture points, even ones that are unavailable to TuiNa because there location is to deep or narrow. Acupuncture can therefore influence several meridiansystem at once and use more acupuncturepoints at the same time. Acupuncture treatment is therefore very suitable in case of meridianpathology.

When chronic situations lead to ZangFu pathology one must consider the effect of Acupuncture and ask himself if this is still the right treatment for patients. A lot can be done by Acupuncture, but what tot think about Shen Xu? Is Acupuncture the most effective way to nourish the Kidney? In Western Society we do not have the same knowlegde as the Chinese docters, sutdying TCM for years an years fulltime. Our patients do not nearly have the same amount of treatment as patients in China visit hospital every day if

74 Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989, p.98

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neccessary. The intake of herbs can be less invasive for the patient. Therefore the author suggest to include herbal treatment for depletion of organs and ongoing Shen or emotional disturbances.

Whiplashstage layer therapyAfter trauma Jing Jin replete RestAcute (first 6 weeks) Jing Jin replete and

meridian vacousTuiNa

Chronic (after 6 weeks) Jing Jin becoming vacous and meridian becoming in excess

TuiNa and Acupuncture

Organpathology/ emotional problems

ZangFu Herbal therapy and Acupuncture

It is important for the therapist to distiguish the depth of the pathology. Only by knowing the depth of the disease the illness can be treated effectively. The Skin is of course the most external layer. When Whiplash does not get treated stagnation can give rise to problems in deeper layers of the body and eventually after the bone level become ZangFu disorder.

Depth of treatment 75

Bone pertains towater

The tendons pertain to wood-jin

Muscles pertain to earth-rou

The vessels pertain to fire- mai

The Skin pertains to Metal- Pi Bu

Treatment proposal:

Tuina, Acupuncture

Tuina,Acupuncture

Tuina Cuppen, bleeding technique

Guasha, no bleeding!

In the next chapter the author would like to include some proposals to the Wyplash type disorders as investigated in this paper. These proposals are merely a suggestion to the treatment by TuiNa and Acupuncture, knowing that for TCM enery patient is an individual and therefore every treatment should be assigned to the patient, the internal and external conditions and seasonal situation for example at the time of establishing the right treatment.

4.1 Treatment with TuinaSprain is sometimes treated by cold packing. This treatment which is applied ussualy in the first 24 hours helps to reduce the swelling. The side effect of cooling the muscle and tendons is that it lowers the movement and free flow 75 Li, J., Classical Needling lesson 1, Meridianology

33

of Qi and Xue. Therefore TuiNa should be started as soon as possible after the first swelling and stiffness of the trauma itself. In the next paragraghs there is a suggestion made for excess of the Jing Jin of the three types Whiplash disorders, it does not include treatment for ZangFu pathology or emotional disturbances.

4.1.1 Neckpain due to Qi en Xue Xu in Yang Ming meridians

Treatment principle: Move Qi en Xue, reduce pain and promote the free flow in the Yang Ming meridians

= sitting position =Ca Fa Neck and shoulders Even 1 min.Gun Fa Neck and shoulders Even 10 min.Bo Fa Ashi Xie 2,5 min.Ya Rou Fa Ashi Xie 2,5 min.He Ti Neck Neck Xie 2 min.Na Fa 3 Yang Arms Xie 2 min.Ya Fa L.I. 4/ Liv 3 1 min.4 Finger Ti 1 min.Hold Elbow turn Neck 1 min.Tui Fa Neck and Shoulders Xie 1 min.Da Fa Neck/Shoulders/Arms 1 min.

Treatment time: 25 min.

Analysis:Ca Fa is used to warm the bodyparts for treatment, it balances Qi and Xue and activates the meridians, opens the Luo Mai and withdraws cold from the meridians. Gun Fa is used as a main technique and has an opening character, it dispels Xue Yu, opens the meridians, loosens muscles and stops cramps. Bo Fa is used mainly in the neck on Ashi points in order to subdue stagnation, spread accumulation and loosening of tension. Ya Rou Fa is used sedative on Ashi of shoulders to subdue stagnation, and stop pain, It activitates meridians and warms the muscle. It therefore promotes the free flow of Qi and Xue. He Ti Neck stimulates the Blood circulation, stops pain and activitate the meridian. It dissolves stagnation and blockage but also is in the believe of the Author a technique in which the area of Yang Ming is easily reached. Na Fa of the Shou Yang meridians regulates Qi and Xue, balances the Stomach and Intestine and treats prickles in the arms because of blockage of Neck. Ya Fa L.I. 4 and possible Liv 3 activitate the free flow of Qi, and the Yuan Source of the Large Intestine has an effect on the Neck and Head; and can be used to distal point. 4 Finger Ti and Hold Elbow turn neck are used to open the cervical spine and the meridians. Tui Fa resolves obstruction in muscles and Da Fa is used here as an ending to the treatment. Besides this Da Fa pushes Xie Qi out,

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regulates Qi and Xue and can be used to treat pain and prickles or numbness of limbs.76

4.1.2 Neckpain due to Qi en Xue Xu in Shao Yang meridians

Treatment principle: Move Qi en Xue, reduce pain and promote the free flow in the Shou Yang meridians

= sitting position=Ca Fa Neck and Shoulders Even 1 min.Gun Fa Neck and Shoulders Even 10 min.Bo Fa Neck and Shoulders Xie 3 min.Ya GB 21 and turn Neck GB 21 Xie 2 min.Da Fa Neck and Shoulders XieYa Rou GB 20 GB 20 Xie 1 min.

= supine position =Pull and turn neck Neck and Shoulders Xie 5 min.Na Fa 3 Yang arms Xie 2 min.Ya Fa SJ 5 Xie 1 min.

Treatment time: 25 min.

Analysis:Ca Fa is used to warm the bodyparts for treatment, it balances Qi and Xue and activates the meridians, opens the Luo Mai and withdraws cold from the meridians. Gun Fa is used as a main technique and has an opening character; it dispels Xue Yu, opens the meridians, loosens muscles and stops cramps. Bo Fa is used on the neck and shoulders on Ashi points in order to subdue stagnation, spread accumulation and loosening of tension. Ya Rou GB 21 and turn neck treats the Shao Yang meridian. It opens ans resolves stagnation, gives flexion to the neck and shoulder muscles. GB 21 is also a meeting point for the Gallbladder meridian and San Jiao meridian and one of its indications is stiffness and pain in the nech, pain in the shoulder and back.77 Pull and turn neck activitates the meridians, lossens the joint, dissolves cramp in the muscle, stops pain and relocates the cervical vertebrae. is used sedative on Ashi of shoulders to subdue stagnation, and stop pain, Na Fa of the Shou Yang meridians regulates Qi and Xue, and treats prickles in the arms because of blockage of Neck. Da Fa pushes Xie Qi out, regulates Qi and Xue and can be used to treat pain and prickles or numbness of limbs.78 Ya Fa SJ 5 activitates the San Jiao channel and alleviates pain; and one of its indications is pain of the shoulder and back and stiff neck.79

76 Fluitsma, M., Go, K., Klavers, N., Tuina lesmateriaal 2009-201077 Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998, p.43878 Fluitsma, M., Go, K., Klavers, N., Tuina lesmateriaal 2009-201079 Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998, p.438

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4.1.3 Neckpain due to Qi en Xue Xu in Tai Yang meridians

Treatment principle: Move Qi en Xue, reduce pain and promote the free flow in the Tai Yang meridians

= sitting position =Ca Fa Neck and shoulders Even 1 min.Gun Fa Neck and shoulders Even 10 min.Bo Fa Ashi Xie 2,5 min.Ya Rou Fa Ashi Xie 2,5 min.He Ti Neck Neck Xie 2 min.Na Fa 3 Yang Arms Xie 2 min.Ya Fa S.I. 3/Bl 10 1 min.4 Finger Ti 1 min.Hold Elbow turn Neck 1 min.Tui Fa Neck and Shoulders Xie 1 min.Da Fa Neck and Shoulders 1 min.

Treatment time: 25 min.

Analysis:Ca Fa is used to warm the bodyparts for treatment, it balances Qi and Xue and activates the meridians, opens the Luo Mai and withdraws cold from the meridians. Gun Fa is used as a main technique and has an opening character, it dispels Xue Yu, opens the meridians, loosens muscles and stops cramps. Bo Fa is used mainly in the neck on Ashi points in order to subdue stagnation, spread accumulation and loosening of tension. Ya Rou Fa is used sedative on Ashi of shoulders to subdue stagnation, and stop pain, It activitates meridians and warms the muscle. It therefore promotes the free flow of Qi and Xue. He Ti Neck stimulates the Blood circulation, stops pain and activitate the meridian. Na Fa of the Shou Yang meridians regulates Qi and Xue, treats prickles or numbness in the arms because of blockage of Neck. 4 Finger Ti and Hold Elbow turn neck are used to open the cervical spine and the meridians. Tui Fa resolves obstruction in muscles and can be used to drain Tai Yang. Da Fa is used here as an ending to the treatment. Besides this Da Fa pushes Xie Qi out, regulates Qi and Xue and can be used to treat pain and prickles or numbness of limbs.80

Ya Fa S.I. 3 is applicable as a distal point to treat stiffness and pain in the Neck and difficulty in turning the neck. It activates the channel and alleviates pain. Bl 10 is used as a local point to treat the Neck and Shoulders, it can also be used with GB 20 for dizziness. S.I 3 and Bl 10 together can assist each other in treating headache.81

80 Fluitsma, M., Go, K., Klavers, N., Tuina lesmateriaal 2009-2010

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In order to deside the right basic and special technique the therapist could look at the location which ought to be treated, as well as the character of the manipulation and to whether this is conform the treatment principle. For example the He Ti Neck and Pull and Turn neck technique are well applicable in all of the above treatment proposals. Possibly the therapist would like to add techniques because of other complaints which need to be addressed.

If the therapist wants to add acupuncture points it would be interesting to consider the S.I. 18 en GB 13. Eventhough S.I. 18 i.e. is more often used for the treatment of facial disorders, this point could be considered when more than meridians in the Neck are involved. Why?Because the tendino-muscular meridians gather around:

Benshen (GB 13) for the three Hand Yang Quanliao (SI 18) for the three foot yang82

GB 13 is more often choosen for headache, and stiffness and pain in the neck.

4.2 Treatment proposal by AcupunctureIn the Chronic stage of Whiplash disorder it can be very usefull to use Acupuncture as pathology has developed complaints become more diverse and the pathology is located in a deeper level of the body-system. As TuiNa can be used to prevent illness, so can Acupuncture prevent ZangFu disorder.

Drainage technique aanhalen

En les 2 classical needling.

4.2.1 Neckpain due to Qi en Xue Yu in the Yang Ming meridians.

Treatment principle: Move Qi en Xue, reduce pain and promote the free flow in the Yang Ming meridians

Emperor DM 14Minister L.i. 11Assistent GB 13

81 Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998, p.263-26482 Solinas, H., Mainville, L., Auteroche B., Atlas of Chinese Acupuncture meridians and collaterals, Quebec, Canada, Publishing Canada, 1998, p.28

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4.2.2 Neckpain due to Qi en Xue Yu in the Shao Yang meridians.

Treatment principle: Move Qi en Xue, reduce pain and promote the free flow in the Shao Yang meridians

Emperor DM 14Minister L.i. 11Assistent GB 13

4.2.3 Neckpain due to Qi en Xue Yu in the Tai Yang meridians.

Treatment principle: Move Qi en Xue, reduce pain and promote the free flow in the Tai Yang meridians

Emperor DM 14Minister L.i. 11Assistent GB 13

5 DiscussionFor practitioners already it is known that the criticism of western medicine is that traditional medicine is not scientifically founded. What happens when disease or injury is not visible? How can one cure an injury which is not acknowledged nor understood? Technology can enlarge details profoundly but can also forget to see the patient as a whole individual. Maybe because

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tcm has an holistic view on practicing medicine it is why WAD is an injury which is understood and treatable.

In modern society we have forgotten how important it is to take care of our body and our health. We do not take the time to take care of our body. People have all sorts of reasons or occupations to not cherish and nurture the life. We rather take a painkiller and move on. Eventually this attitude will lead to severe healthproblems.

When Traditional Chinese Medicine imposes Western research standards in their studies it is not TCM anymore. Therapy according to Traditional Chinese Medicine is tailored to pathology and constitution of each individual. To use standard acupuncture formula for different patients and for a western diagnosis can not prove TCM is a good treatment, can cause unreliable and failing testresults, and can not be seen as TCM treatment.

Trauma to muscle and tendons can lead to an invasion of exogenous pathogenic wind and cold on the neck. Because blockage of External pathogens, Qi and Xue can become stagnant resulting in more rigidity, pain and dysfunction of the neck.

So why do some speak of inconsequently about vessels and or channels? As vessels and channels are implying that they can be seen. Where as in al scientific and anatomical research there is no vessel or channel ever seen. Therefore the name meridian is best applied; like the meridians of the earth are there but can not be seen.

If we acknowledge the fact that emotions if felt greatly are a pathological symptom and organs all have there belonging emotion we can discuss why there is hardly any mentioning of the emotion belonging to the San Jiao. Maybe the emotions of grieve, overthinking and fear belong to the upper burner, middle burner and lower burner respectively. But if we look at functional meaning of the San Jiao in controlling the water passages and the avenue for the Yuan Qi we might also consider blockage; as not flowing freely the emotion pertaining to this is one of anger. Another considerations might be that Shen holding all emotions and is depended on Qi and Jing; as all emotions derive from fear and the communication of all this is depending on flourishing San Jiao as it is an organ without form. As all emotions should be received, digested, transformed, transported and excreted.

Even though it is usefull to divide 3 Whiplash types; Yang Ming, Shao Yang en Tai Yang, we have to acknowledge the fact that meridians are not absolute, there is no border in between where muscles stop and The Qi-street theory connect the meridians, even when there is no intersection. Therefore meridians can “contemnate” each other, in example: blockage in the Zu Tai Yang also cause Zu Shao Yang to stagnate.

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In the Tuina treatment the autor suggest a variety of manipulation techniques. It is in the believe of the autor that longer and repetitive manipulation is more effective than a variety of techniques. This has also to do with the quality of the therapist as well as the technique being more refined after years of experience.

Moxibustion and Herbs can puts energy into the body, bleeding takes energy out of the body; and TuiNa and Acupuncture moves energy within the body.

To measure the progess made in the treatment of Whiplash we can ask the patient to give a rating. Patients know best!

6 ConclusionsA Whiplash disorder pertains to YangMing-, Shao Yang- , Tai Yang- type disorder or a combination in the Neck area. Not every YangMing-, Shao Yang-, Tai Yang disorder is a whiplash but pertains to many disorders. We can explain many of the symptoms by just looking to the trajectory of meridians. All other symptoms that are reported by patients correspond to Shen disorder or malnourishment of the Brain.

When emotion problems derive from malnourishment of organs not being reached by meridians, we already speak of an internal pattern which finds its offspring in organpathology in TCM point of view. This is very much different from Western point of view. Where al lot of the complaints patient with Whiplash report can not be linked to the syndrome. Also they do not recognize emotions can be internal pathology leading to physical illness. Both medicine have a different opinion on what can be seen as organ-related failure.

Whiplash Disorder should be treated to prevent damage to ZangFu and preserve life. This is best done as early as possible. The author suggest that level 1 pathology, “when this is stirred” meaning that the Jing Jin is in excess and the meridian is vacous is treated by Tuina and a level 2 pathology, “ produced by this” meaning the Jing Jin is vacous and the Meridian is in excess is treated with Acupuncture. ZangFu pathology is best treated with Herbs, maybe assisted by Acupuncture and in all cases the Kidneys should be taken into account. If there is any disbalans then this should be treated to prevent illness in the different life-cycles like fertility or menopause.

Besides this Zhi- willpower can influence the motivation in practice and treatment, and should therefore be nourished.

Even though we can not always control being in an accident, the author would like to comment there are certain precautions that can be taken to prevent neck trauma of worsening in symptoms and complaints.

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Literatuurlijst

Boeken: Wu, N.L., Wu, A.Q., Bing Wang Yellow Emperor’s Canon Internal Medicine,

U.S.A., China Science & Technology Press

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Solinas, H., Mainville, L., Auteroche B., Atlas of Chinese Acupuncture meridians and collaterals, Quebec, Canada, Publishing Canada, 1998

Deadman, P., Al-Khafji M. with Baker, K., A manual of Acupuncture, Hove, England, Journal of Chinese Medicine Publications, 1998

Maciocia, G., The Foundations of Chinese Medicine, New York U.S.A., Churchill Livingstone Inc., 1989

Beijing University of Traditional Chinese Medicine, Basic Theories of Traditional Chinese Medicine, Beijing China, Beijing University, 1998

Deng, T., Practical Diagnosis in Traditional Chinese Medicine,Guangzhou China, Elsevier Churchill Livingstone, 1999

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

Guicheng, C. H., Qingrong, C. Z., Traumatology and orthopedics of traditional chinese medicine, Publishing House of Shanghai University, 2002

Wiseman, N. Feng Ye, A Practical Dictionary of Chinese Medicine,Brooline MA, Paradigm, 1998

Sijm, T. Whiplash de Baas, Zwaagdijk, Uitgeverij Simeon, 2008

Artikels: Yenming Chen, L. Ac., FICAE, President, New York College of Traditional

Chinese Medicine, Acupuncture applied to treat pain due to Whiplash Injuries, Meridian Times, The Journal of the Acupuncture Society of New York, Summer 2005/Volume 14, Number 1

Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec Task Force on WAD: redefining «whiplash» and its management., Spine 1995; 20 Suppl 8: 1S–73S

Ferarri R, Russell A.S., Carroll L.J., Cassidy J.D., A re-examination of the whiplash associated disorders (WAD) as a systemic illness, Hampshire U.K., Emergency Medicine Journal, 2006

Haneline, Prof M.T.(September 2009), The notion of a “whiplash culture”; a review of the evidence, The Journal of Chiropractic Medicine, 8(3)

Crouch R, Whitewick R, Clancy M, Wright P, Thomas, P, Whiplash associated disorder: incidence and natural history over the First month for patients presenting to a UK emergency department, Emergeny Medicine Journal 2006, 23 (2)

Lesmateriaal: Fluitsma, M., Go, K., Klavers, N., Tuina lesmateriaal 2009-2010 Li, J., Advanced Classical Meridianology based on the Huang Di Nei Jing Ling

Shu, 2010-2011 Fluitsma, M., Ham, K., Differentiatie volgens Jing Luo 2009-2010

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Internet: http://en.wikipedia.org/wiki/Sprain http://www.whiplashstichting.nl/nl/over-whiplash/wat-is-

whiplash.html http://en.wikipedia.org/wiki/Whiplash_(medicine ) http://www.swov.nl/rapport/Factsheets/NL/Factsheet_Whiplash.pdf http://www.whiplashstichting.nl/nl/over-whiplash/behandeling.html

Bijlage 1

Whiplash (medicine)From Wikipedia, the free encyclopedia

Whiplash is a non-medical term describing a range of injuries to the neck caused by or related to a sudden distortion of the neck[1] associated with extension.[2]

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Whiplash is commonly associated with motor vehicle accidents, usually when the vehicle has been hit in the rear;[3] however, the injury can be sustained in many other ways, including falls from stools, bicycles[citation needed] or horses.[citation needed] It stands out as one of the main injuries covered by the car insurers.[citation needed] In the United Kingdom, 430,000 people made a claim for whiplash in 2007 (75% of the UK's motor insurance claims), accounting for 14% of every driver's premium.[4]

Before the invention of cars, whiplash injuries were called “railroad spine” as noted mostly during train collisions. After the invention of cars, the number of whiplash-related injuries have risen sharply due to an increase in rear-end motor vehicle collisions. The first case of severe neck pain arising from a train collision was documented around 1919.[5] Given the wide variety of symptoms that are associated with whiplash injuries the Quebec Task Force on Whiplash-Associated Disorders, coined the phrase, Whiplash-Associated Disorders.[5]

Signs and symptoms

Symptoms reported by sufferers include: pain and aching to the neck and back, referred pain to the shoulders, sensory disturbance (such as pins and needles) to the arms & legs and headaches. Symptoms can appear directly after the injury, but often are not felt until days afterwards.[3] Whiplash is usually confined to the spinal cord, and the most common areas of the spinal cord affected by whiplash are the neck, and the mid-back (middle of the spine).

Cause

The exact injury mechanism that causes whiplash injuries is unknown. A whiplash injury may be the result of impulsive stretching of the spine, mainly the ligament: anterior longitudinal ligament which is stretched or tears, as the head snaps forward and then back again causing a whiplash injury.[6][citation needed]

Whiplash may be caused by any motion similar to a rear-end collision in a motor vehicle, such as may take place on a roller coaster [7] or other rides at an amusement park, sports injuries such as skiing accidents, other modes of transportation such as airplane travel, or from being hit, kicked or shaken.[8][citation needed]Shaken baby syndrome can result in a whiplash injury.[6][citation needed]

Whiplash symptoms might not always have any pathological (injury) explanation. "Volunteer studies of experimental, low-velocity rear-end collisions have shown a percentage of subjects to report short-lived symptoms", which can not be attributed to any pathogenic effect on the subjects neck.[9]

Diagnosis

Diagnosis occurs through a patient history, head and neck examination, X-rays to rule out bone fractures and may involve the use of medical imaging to determine if there are other injuries.[10]

Québec Task Force

The Québec Task Force (QTF) has divided whiplash-associated disorders into five grades.[11][citation needed]

▪ Grade 0: no neck pain, stiffness, or any physical signs are noticed▪ Grade 1: neck complaints of pain, stiffness or tenderness only but no physical signs are

noted by the examining physician.▪ Grade 2: neck complaints and the examining physician finds decreased range of motion

and point tenderness in the neck.

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▪ Grade 3: neck complaints plus neurological signs such as decreased deep tendon reflexes, weakness and sensory deficits.

▪ Grade 4: neck complaints and fracture or dislocation, or injury to the spinal cord.

Prevention

Protection efforts are hampered by lack of knowledge about the causes of whiplash injuries. The focus of preventive measures to date has been on the design of car seats, primarily through the introduction of headrestraints, often called headrests. This approach is potentially problematic given the underlying assumption that purely mechanical factors cause whiplash injuries - an unproven theory. So far the injury reducing effects of head restraints appears to have been low, approximately 5-10%, because car seats have become stiffer in order to increase crash-worthiness of cars in high-speed rear-end collisions which in turn could increase the risk of whiplash injury in low-speed rear impact collisions. Improvements in the geometry of car seats through better design and energy absorption could offer additional benefits. Active devices move the body in a crash in order to shift the loads on the car seat.[3][dead link]

Some car manufacturers have begun to implement various whiplash protection devices in their products in order to reduce the risk for and severity of injury, such as

▪ Mercedes-Benz A-Class Active Head Restraint (AHR)[3][12][citation needed],▪ Saab (Responsible for the first active head restraint), Opel, Ford, Nissan, Subaru,

Hyundai, and Peugeot - Active Head restraint (SAHR)[3][13][citation needed],▪ Volvo and Jaguar - Whiplash Protection System/Whiplash Prevention System (WHIPS)

[14][citation needed], and▪ Toyota - Whiplash Injury Lessening (WIL).[3][citation needed]

Whether or not such devices offer a substantial benefit over vehicles without them remains controversial. In a test undertaken by the Swedish National Road Administration and an insurance company (Folksam), one test showed that a whiplash protection device was no guarantee against injury and that the degree of protection varies between vehicles both with and without whiplash protection devices.[15] One study found that an active head restraint system helps reduce the risk of neck injuries by up to 75% in rear-end collisions.[16]

Treatment

According to the recommendations made by the Quebec Task Force, treatment for individuals with whiplash associated disorders grade 1-3 should include manipulation, mobilizations and range of motion exercises. Non-narcotic analgesics and non-steroidal anti-inflammatory drugs may also be prescribed in the case of WAD 2 and WAD 3, but their use should be limited to a maximum of 3 weeks. A cervical collar should not be used for longer than 72 hours as it may lead to prolonged inactivity. Return to normal activities of daily living should be encouraged as soon as possible to maximize and expediate full recovery.[17][citation needed]

A different approach is taken by the National Institute for Neurological Disorders and Stroke, who suggest that treatment for individuals with whiplash may include pain medications, nonsteroidal anti-inflammatory drugs, antidepressants, muscle relaxants, and a cervical collar (usually worn for 2 to 3 weeks). Range of motion exercises, physical therapy, and cervical traction may also be prescribed. Supplemental heat application may relieve muscle tension.[18]

Prognosis

The consequences of whiplash range from mild pain for a few days (which is the case for most people),[19] to severe disability caused by restricted head movement or of the cervical spine, sometimes with persistent pain.[citation needed]

Alterations in resting state cerebral blood flow have been demonstrated in patients with chronic pain after whiplash injury. [20]

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Bijlage 2 Pain rating scales

Visual analogue scale (VAS)

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Instructions for producing a VAS Bedside card:

OPTION 1

Double-side print or photocopy the next two diagrams ensuring that the lines are exactly 10cm in length and superimposed

Laminate the VAS Bedside card for patient use

LEASE NOTE: For purposes of double-sided print, the numbers on this scale are reversed.

OPTION 2

Print or photocopy the next two diagrams on an A4 sheet ensuring that the lines are exactly 10cm in length

Fold at the dotted line Do not show the patient the numbered scale

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Numerical rating scale (NRS)

Faces rating scale (FRS)

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Behavioural rating scale

For patients unable to provide a self-report of pain: scored 0–10 clinical observationFace 0

Face muscles relaxed

1Facial muscle tension, frown, grimace

2Frequent to constant frown, clenched jaw

Face score:

Restlessness 0Quiet, relaxed appearance, normal movement

1Occasional restless movement, shifting position

2Frequent restless movement may include extremities or head

Restlessness score:

Muscle tone* 0Normal muscle tone

1Increased tone, flexion of fingers and toes

2Rigid tone

Muscle tone score:

Vocalisation** 0No abnormal sounds

1Occasional moans, cries, whimpers and grunts

2Frequent or continuous moans, cries, whimpers or grunts

Vocalisation score:

Consolability 0Content, relaxed

1Reassured by touch, distractible

2Difficult to comfort by touch or talk

Consolability score:

Behavioural pain assessment scale total (0–10) /10

* Assess muscle tone in patients with spinal cord lesion or injury at a level above the lesion injury. Assess patients with hemiplegia on the unaffected side.** This item cannot be measured in patients with artificial airways.

Pain rating scales instructions

Subjective pain score

All patients are to have a functional activity score recorded in addition to the chosen subjective score.

Visual analogue scale (VAS)Instruct the patient to point to the position on the line between the faces to indicate how much pain they are currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst pain ever’.

Numerical rating scale (NRS)Instruct the patient to choose a number from 0 to 10 that best describes their current pain. 0 would mean ‘No pain’ and 10 would mean ‘Worst possible pain’.

Faces rating scale (FRS)Adults who have difficulty using the numbers on the visual/numerical rating scales can be assisted with the use of the six facial expressions suggesting various pain intensities. Ask the patient to choose the face that best describes how they feel. The far left face indicates ‘No hurt’ and the far right face indicates ‘Hurts worst’. Document number below the face chosen.

Behavioural rating scale

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The behavioural pain assessment scale is designed for use with non-verbal patients unable to provide self-reports of pain.

Rate each of the five measurement categories (0,1 or 2). Add these together. Document the total pain score out of 10.

Functional activity scoreThis is an activity-related score. Ask your patient to perform an activity related to their painful area (for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain).

Observe your patient during the chosen activity and score A, B or C.A – No limitation meaning the patient’s activity is unrestricted by painB – Mild limitation means the patient’s activity is mild to moderately restricted by painC - Severe limitation means the patient ability to perform the activity is severely limited by pain

*Relative to baseline refers to any restriction above any pre–existing condition the patient may already have.

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