Acupuncture treatment of chronic musculoskeletal

pain – comparison of different approaches

By Jelena Kasteel

2

Acupuncture treatment of chronic musculoskeletal pain

- comparison of different approaches

An essay presented to the Academy for Traditional Chinese Medicine

Qing-Bai

For the purpose of obtaining the certificate of acupuncture September 2009, Amersfoort

By Jelena Kasteel

Supervision by Marijke Fluitsma

3

Contents Preface 5 Summary 6 Introduction 7 1. Physiology and pathology of chronic musculoskeletal pain 8

1.1 Physiology of pain 8 1.1.1 Pain as seen in Western medicine 8 1.1.2 Pain in Chinese medicine 8 1.2 Bi Syndrome (Painful Obstruction Syndrome) 9 1.3 How to address the chronic nature of musculoskeletal pathology 11 1.3.1 Treating the underlying condition 11 1.3.2 Treating different meridian layers 11

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

2.1 Chasing the meridians 13 2.2 Are meridians linear? 14 2.3 Meridians under microscope 15

3. Different approaches in acupuncture of musculoskeletal conditions 17 3.1 TCM approach 19 3.1.1 The role of meridian palpation 19 3.1.2 The use of the local and Ah Shi points 19 3.1.3 The use of the distal points 20 3.1.4 Treatment according to the meridian layers 21 3.2 Meridian approach 23

3.2.1 The role of meridian palpation 23 3.2.2 The use of the local points 23 3.2.3 The use of the distal points 24 3.2.4 Treatment according to the meridian layers 25

3.3 The trigger points approach 27 3.3.1 The concept of trigger points 27 3.3.2 Diagnosis and palpation of trigger points 28

3.3.3 The treatment of trigger points – the view on the local and distal points and needling techniques 29

4

3.4. Ear acupuncture 31 3.4.1 General overview of the ear acupuncture 31

3.4.2 Nogier’s phase models in the treatment of chronic musculoskeletal pain 32

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

4. Conclusion: The best of both worlds 34 Literature 35

5

Preface In a lecture at Academy Qing-Bai in spring 2009 Dr. Li Jie compared TCM to “a round balloon that has been squeezed into a square vase”. As a result my imagination was fuelled as to what the “round balloon” might look like. I wish to thank all my teachers at Qing-Bai for giving me insight into Traditional Chinese Medicine in such a way that I looked forward to each lesson. They inspired me by teaching in an enlightened manner that encouraged an open mind to different treatment styles. Special thanks to Marijke Fluitsma for reading and evaluating this essay. I am grateful to Sophie for being my faithful companion in the study of acupuncture; studying is even more fun when done together. I am indebted to Ingrid for proof-reading and commenting on this writing. Last but not least, I wish to thank Boris for all his love, support and caring.

6

Summary This writing is about different approaches in acupuncture treatment of chronic musculoskeletal pain. First the physiology of pain is discussed and the diagnostic significance of it. Musculoskeletal pathology is primarily a meridian pathology; it is classified under the broader category of Bi syndromes, which are shortly highlighted. The chronic aspect of it can be approached from two different angles: differentiating and treating the underlying pathology and/or exploring and treating the full spectrum of superficial energetics. That means using not only main meridians, but also tendino-muscular meridians, Luo vessels and extraordinary meridians. This writing focuses on the latter aspect, the diagnosis and treatment of different layers of meridian network. I pose a question about the nature of the meridians and take a short look into few aspects of it, like how substantial meridians are and if they really have a linear nature. I believe that the way meridians are seen could influence the way meridian pathology is treated. For the purpose of exploring the different possibilities of the treatment of musculoskeletal pathology I chose to compare four different approaches: TCM acupuncture, meridian acupuncture, trigger points approach and ear acupuncture. I compare them on basis of the use of local and distal points and the use of meridian palpation as a diagnostic tool, especially for determining the place of the Ah Shi points. TCM acupuncture and meridian acupuncture have the same roots in the Classics of Chinese medicine. Their theory in treatment of musculoskeletal conditions doesn’t differ much, but the applications of that theory does: there are differences in the use of meridian palpation and in the stress on local or distal points. Trigger points approach involves from the perspective of Western medicine only needling of Ah Shi points, although it can be incorporated in meridian perspective by adding distal points. The concept of referred pain is explained and methods of locating and needling the Ah Shi points are highlighted. The ear acupuncture doesn’t fit neatly in my comparison model due to its specific nature as a microsystem acupuncture. I included it in my research especially because of the Nogier’s phase model that allows for the differentiation between acute and chronic conditions.

7

Introduction Chronic musculoskeletal pain can be a debilitating condition that interferes with good night sleep and with many daily activities. It is one of the most common complaints that brings people to the general practitioner. Yet it is a condition that often remains unresolved by the conventional medical approach. So in search for relief of their pain many people turn to the so called alternative therapies. In my short career as a Shiatsu therapist I regularly came across this type of pathology; sometimes I was able to help people with chronic musculoskeletal pain, at other times my efforts were fruitless. Studying acupuncture I felt the need to better understand the nature of this pathology and to see beyond the standard point prescriptions. To understand a particular subject, it may be helpful to look at it from different angles. Combining the different perspectives can give one better insight into the subject. For the purpose of better understanding the pathology and acupuncture treatment of chronic musculoskeletal pain, I decided to compare different possibilities of acupuncture treatment of it. For that I chose four different approaches: TCM acupuncture, meridian acupuncture, trigger point approach and ear acupuncture. They are not the only possible approaches, but as this writing is based on desk research, I chose approaches that were best available to me in the form of books. My greatest interest at this point is to explore the surface energetics of the human body and the methods to influence it. For this purpose I will compare the four approaches on the basis of the following parameters:

° the use of palpation as a diagnostic method ° the manner in which local/Ah Shi points and distal points are chosen

In chapter one I will look shortly into the physiology of pain, as seen in Western medicine as well as in the TCM. I will discuss the physiology and pathology of musculoskeletal pain in the context of Bi Syndromes. I will look into ways to address the chronic nature of this pathology and the ways to address it. Since musculoskeletal pathology is per definition a meridian pathology, the way meridians are seen could influence the way the pathology is treated and how palpation is used as a diagnostic method. In chapter two I will therefore focus on the nature of the meridians as a theoretical background of my research. I will pose a few questions on the nature of the meridians without aiming for the clear answers; unfortunately, it is the subject underrepresented and under valuated in the literature. Chapter three forms the core of this writing. There I will highlight the acupuncture treatment of chronic musculoskeletal pain as it is used by the four different approaches, first placing them in a broader context to understand the angle from which the musculoskeletal pathology is seen and then comparing them according to the above mentioned parameters. The sections on the trigger points approach and ear acupuncture are not subdivided in the same manner as the first two, due to their different origin and specific nature.

8

1. Physiology and pathology of chronic musculoskeletal pain

1.1 Physiology of pain 1.1.1 Pain as seen in Western Medicine Pain is not a well understood phenomena and many theories have been proposed to explain it. In Western medicine it is usually explained by neural or biochemical mechanisms. It is stressed that chronic pain is not simply a repetition of acute pain; it is different from and less understood than acute pain. Still by convention, chronic pain is defined as being longer than six months in duration.1 There is a distinction to be made between pain threshold and pain tolerance. The pain threshold is the least stimulus intensity needed for an individual to perceive pain and is proven to be much the same in everyone. Pain tolerance is defined as the emotional response to the pain stimulus and it strongly depends on emotional, social and cultural factors. The difficulty in assessing and measuring the character and intensity of pain and effectiveness of anti-pain treatment is its subjective character; one has to rely on the verbal description of the patient. There are three types of pain as defined by western medicine: psychogenic pain (due to a disorder of the mind), neuropathic pain (as a result of damage to either central or peripheral nervous system) and nociceptive pain (because of the primary activation and sensitisation of nociceptors – they are the sensory neurons that register pain).2 The pain present in the chronic musculoskeletal pathology is nociceptive pain. In chronic musculoskeletal pain, when only soft tissue is involved and there is no evidence of tissue damage to be detected by x-rays or other standard methods, there is a danger of dismissing the chronic pain as purely psychogenic in origin. That is why the nature of the so called referred pain has particular importance in musculoskeletal pathology. It means that the cause of the pain can be located some distance away from the area where the patient experiences pain and can be easily overlooked. This I will further explore in chapter 3.3. 1.1.2 Pain in Chinese Medicine In Chinese medicine pain is explained by the saying “obstruction causes pain; if there is no obstruction there is no pain”.3 In other words, pain is seen as a subjective feeling of the obstruction in the free flow of Qi and Blood. However, moving Qi and Blood will not necessarily address the underlying cause of the obstruction of the free

1 Marcus, A, 2004 2 Baldry, P.E, 2005 3 Maciocia, G, Diagnosis in Chinese Medicine, 2004

9

flow. This aspect is described by the terms Ben (root) and Biao (manifestation). In this case, pain is only the manifestation of the underlying cause. Establishing the cause of pain determines the treatment principle. The causes of musculoskeletal pain will be explained in the following section on Bi syndromes. In chronic musculoskeletal pain conditions, pain is obviously the chief complaint of the patient; on the other hand, inquiring into the nature of pain is one of the diagnostic tools in Chinese medicine. Specific characteristics of pain can help differentiate the presenting condition according to the eight parameters. In musculoskeletal pathology we can ask about the following characteristics :4 Location of pain The precise location of pain is important to determine meridian(s) involved. The significance of the pain distribution is further elaborated in section 1.3. If the pain is wandering, it indicates Wind. Nature of pain The nature of pain indicates excess (strong, sharp) or deficiency (dull, aching, sore) of the condition. Precise nomenclature of the different types is not so important as the patients choose their own words to describe the pain and it is up to the practitioner to classify it accordingly. Time of pain Daytime pain is usually caused by Qi or Blood deficiency and pain at night is mostly due to Qi stagnation. Blood stasis causes continuous pain that can be worse at night. Factors affecting pain There are several factors that can affect pain: pressure, temperature and movement/rest.

° Pain that is aggravated by pressure indicates excess (pathogenic factor or Qi and/or Blood stagnation), whereas pain alleviated by pressure indicates deficiency.

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

° Pain that gets worse with movement and better with rest indicates deficiency of Qi or Blood; if it gets better with movement and worse with rest it indicates stagnation of Qi, Cold or Blood stasis.

1.2 Bi Syndrome (Painful Obstruction Syndrome) In Chinese Medicine, musculoskeletal pain is classified under the broader category of Bi syndrome. It indicates pain, soreness or numbness of muscles, tendons and joints

4 Maciocia, G, Diagnosis in Chinese Medicine, 2004 5 I noticed that general practitioners recommend prolonged application of cold compresses against pain and swelling in acute cases of musculoskeletal conditions. In my opinion that can only cause further stagnation of Qi and Blood and slow down the recovery.

10

from invasion of external Wind, Cold or Dampness. Although all three of the pathogenic factors are usually involved, one of them is predominant. Strictly speaking, Bi refers to the invasion of the external pathogens, but it includes as well obstruction caused by trauma, sport injuries and overuse.6 The aetiology of Bi Syndromes is already seen in the definition: the invasion of the external pathogens. However the chronic conditions have other possible causes:

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

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

- emotional stress and bad posture, causing Qi stagnation or Qi and Blood deficiency

- especially important in chronic cases, the pathology of Zang fu. It is interesting to notice that Chinese literature emphasizes the invasion of the external pathogens and western literature on the subject emphasizes trauma and overuse. There are different possible classifications of the Bi syndrome, the usual one being classification according to the predominant pathogenic factor, i.e. Wind Bi, Cold Bi or Damp Bi. Heat Bi develops from the previous three types when they turn into the Heat in the interior. Their characteristics are as follows:7

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

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

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

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

An other classification is the one according to the organ and tissue involved: Skin Bi (feeling of cold), Muscle Bi (causing muscle weakness), Sinew Bi (causing stiffness), Blood-vessels Bi (causing Blood stasis and intense pain) and Bone Bi (causing bone deformities). Chronic conditions are often equalled with Bone Bi; however, chronic musculoskeletal pain doesn’t have to involve bone Bi. Some patients suffer for years from meridian pathology that is not detectable as joint swelling or bone deformities.

6 Maciocia, G, The Practice of Chinese Medicine, 2008 7 Maciocia, G, The Channels of Acupuncture, 2006 8 Syllabus Qing Bai Acu 2

11

1.3 How to address the chronic nature of musculoskeletal pathology

There is not always a distinction made between acute and chronic nature of musculoskeletal pathology; they are usually differentiated and treated according to the presenting symptoms. Still, there are two ways in which chronic aspect can be addressed: treating the underlying internal condition and treating according to the meridian layer involved. They are not mutually exclusive. 1.3.1 Treating the underlying condition The question why has the body failed to restore the balance by itself and developed a chronic pathology has to be properly addressed. When dealing with chronic musculoskeletal conditions it is important to make an integral diagnosis and treat the internal condition (the root or Ben) as well. The most common factors present in chronic Bi are summed up by Maciocia as follows:

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

° The formation of Phlegm in the joints in the form of swellings due to improper transformation of Body Fluids

° Stasis of Blood due to the long-standing obstruction by the external pathogenic factors and by Phlegm

° Deficiency of Liver and Kidneys, which leads to malnourishment of sinews and bones, the former causing ache and stiffness, the latter contributing to the settling of Phlegm in the joints9

The treatment principle for acupuncture of chronic musculoskeletal pain is to expel the pathogen (if present) from the meridians, remove the Qi and/or Blood stagnation that causes the pain and restore meridian dynamics, but it is necessary as well to nourish or move Blood, resolve Phlegm, tonify Liver and Kidneys, depending on the predominant underlying condition. Despite of its importance, treating the underlying internal pathology is beyond the scope of this writing. 1.3.2 Treating different meridian layers

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

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

9 Maciocia, G, The Practice of Chinese Medicine, 2008, p. 982 10 Pirog, J.E, 1996, p. 228

12

meridians and extraordinary vessels can also play a role. The characteristics of the involvement of particular meridian layer in musculoskeletal pathology can be summed up as follows:11 General characteristics Distribution of pain Luo vessels Joint pain, eventually swelling;

In deep Luo: discoloration of the skin, rigidity and intense pain

Symptoms are local, but involve both yin and yang meridians

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

Mostly unilateral, involving one or more meridians, but not crossing the yin-yang border

Main meridians Pain les intense and more vague than in TM meridians

Diffusely located, the patient is unable to pinpoint the source

Extra meridians Chronic pain, masses and heat, trigger-points, loss of function (frozen joints)

Deep and scattered across broad surfaces, sometimes involving both upper and lower limbs

12

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

11 Pirog, J.E, 1996, Maciocia, G, 2006 12 Pirog, J.E, 1996, p. 230

13

2. A short inquiry into the nature of the meridians

2.1 Chasing the meridians Musculoskeletal pathology is per definition a meridian pathology. But what are meridians actually? Next to the internal organs and basic substances they are the fundaments of the Chinese physiology and pathology, yet I found very little written on their very nature. There are writings about the historical development of the meridian theory. The layered structure of meridians and the types of Qi it transports are part of every book on the fundamentals of Chinese medicine and acupuncture. The meridian pathways are more or les extensively described, but what are those pathways? Can we say more than that they are pathways of Qi en Blood circulation? The old discussion about “points first or meridians first” seems to conceal the more fundamental question about the very nature of the meridians. There are short clues scattered through literature like the following one:

Perhaps the channels operate as software, as emergent properties of the body’s hardware.13

Modern TCM acupuncturists see meridians as theoretical connections between the acupuncture points; as imaginary pathways with no anatomical reality, contrary to the properties of the acupuncture points.14 On the other hand, different massage therapists and practitioners of Qi Gong consider meridians as palpable units that can be clearly felt under active or passive manipulation, independent of the specific acupuncture points. There are indications that the latter view is the older one:

Acupuncture began as an attempt to understand the invisible currents of energy that gave life to the world and vitality to the human body. Since these currents flowed in channels or “meridians”, acupuncture was originally a form of meridian therapy. The acupuncture points themselves were merely the vehicles for adjusting the meridian, functioning like the holes of a flute that could be open or closed to alter the “tone” of the meridian flow.15

Some authors16 suggests that the lack of attention for the nature of the meridians in modern literature could be the result of the so called herbalisation of the acupuncture. In the course of history of the acupuncture there have been tendencies to unite acupuncture and herbal medicine theory. In post-revolutionary China acupuncture theory was revised to conform with pattern-identification according to eight-parametesr, the Zang-fu and the Qi-Blood-Body Fluids, and the acupuncture treatment became increasingly based on point-prescriptions, much like herbal-prescriptions. 13 Manaka et al. 1985, p. 54 14 Study material Academy Qing- Bai: ACU 1, study year 2007-2008 15 Pirog, J.E, 1996, p. Xv 16 Ibid.

14

Emphasis on acupuncture points and subsequently on the main meridians carries a danger of disregard for the so called secondary meridians which stayed as a part of the theory of TCM, but lost their proper place in the practice of acupuncture and treatment of musculoskeletal pathology. Seem even states that the modes of treatment of secondary meridians totally differ from the treatment of regular meridians.17 I noticed that secondary meridians are often depicted in acupuncture books schematically as clearly delineated levels or layers of different depths. That is in contrasts to the verbal descriptions of their extent and function which portray meridian layers much more intertwined. 2. 2 Are meridians linear?

Whilst a typical chart of the acupuncture channels, therefore, illustrates only the superficial pathways of the twelve primary channels, we should remember that the channel network is considerably more complex than this, and there is no part of the body, no kind of tissue, no single cell, that is not supplied by the channels. Like a tree, the trunk and main branches define the main structure, whilst ever finer branches, twigs and leaves spread out to every part.18

If we would make the visual representation of the above described meridian network in every detail, even only the very superficial part of it, it would resemble a three-dimensional replica of the body. This is in contrast to the standard acupuncture charts that were meant only as a didactic tool so they don’t depict the superficial paths of the 14 meridians (as described in acupuncture books), but indeed only the theoretical connections between acupuncture points. This accounts for the quite awkward trajectory that Yang meridians in part describe. Once we imprint in our memory the pathways of the main meridians as depicted in acupuncture charts and atlases, there is a danger of forgetting that they represent the functional model of the meridian structure and not reality itself.19 Living human body is, after all, no Tong Ren. A typical characteristic of meridians representation is that they are seen as lines; vertical lines in case of organ meridians an horizontal branches when we speak of Luo vessels. Even the eight extraordinary vessels are depicted as lines (6 of them connecting acupuncture points that they share with the organ meridians) in spite of the saying from Nan Jing that main meridians are like rivers and extraordinary vessels are like lakes, suggesting not only their reservoir function, but perhaps also their spatial extent. However, there is a very interesting remark on the pathway of the Gallbladder meridian that I found in a footnote in Tietao Deng’s Practical Diagnosis:

As with the kidney channel, it is interesting to note that Chinese texts do not describe the channel as travelling behind the ear and then returning back up

17 Seem, M.D, 2004, p. 20 18 Deadman, P et al., 2007, p. 11 19 The Zen masters repeatedly warn their students not to confuse the Map with the Reality.

15

the head and then turning and descending back down to feng chi (Wind Pool, GB-20), as the pictures draw it. I believe that this convention of thinking about the path of the channel in this way stems from the modern system of numbering the points on the channel and then ‘connecting the dots’. It is more appropriate to think of the channel as a larger, broader entity that simply is scattered over the area in front of and behind the ear and that there are points in that area. However, the points do not necessarily follow a numerical sequence that creates two lines, as we have come to understand the gallbladder channel.20

This clearly suggests that the nature of even organ meridians is not so linear as we are accustomed to think, but it might be instead rather fractal (see cover illustration).21 Unfortunately I don’t have access to more Chinese texts to further explore this idea. 2.3 Meridians under microscope There have been attempts to find the material substrate of meridians. Usually the meridians were compared with anatomical structures like the vascular system or neural network .22 It may not come as a surprise that the discrepancies between them were too big to give the meridians any anatomical reality. The reason why these attempts failed can be found in the fact that they used the outdated, yet still predominant paradigm of material reductionism to explain the energy concepts of Chinese medicine. Yet there is a different paradigm, that of system-thinking and non-linear dynamics that is much more qualified for the job. Modern energy medicine investigated body processes that couldn’t be explained with conventional concepts of neural, biochemical and endocrine mechanisms and discovered that there were other, evolutionary much older systems in the body that transferred the energy and information much faster. Here were are talking about the connective tissue.23

To summarize, we suggest that neither the Jing nor the Luo, nor all of their countless branches are mystical entities but instead are material pathways located within the connective tissue/cytoskeletal fabric. At the microscopic level, this branching network reaches to the surfaces of cells and extends across those surfaces, where it is continuous with the cytoplasmic matrix, nuclear matrix, mitochondrial matrix and the interiors of other organelles. The long-sought substance of the meridians consists of an intricate set of protein and other molecules, as well as an adhering film of water.24

I would like to stress at this point that I am not interested in finding the material substrate of the meridians; I am looking for ways to see beyond the standard 20 Deng, T, 2005, p. 322 21 Fractal is a mathematical model, a geometric shape that repeats the same pattern (or the same type of pattern) on all scales. 22 Baldry, P.E, 2005 23 Oschman, J.L, 2003 24 Ibid, p. 133

16

acupuncture charts for a more complete meridian picture and get a better insight in the meridian dynamics and meridian pathology. I believe the way in which meridians are perceived will influence the way the meridian pathology is being treated. If we consider meridians to be just a theoretical connection between the acupuncture points, the treatment will rely heavily on treating the acupuncture points. If, on the other hand, we give more reality to the meridians, the treatment will be concentrated on meridians and meridian systems themselves, albeit via acupuncture points, but not limited on them and the role of meridian palpation will get a more prominent role.

17

3. Different approaches in acupuncture treatment of musculoskeletal conditions

In the 19th century and a big part of the 20th century almost the exclusive application of the acupuncture in the West was for combating pain. It was mostly limited to the needling of the Ah Shi points, applied without real knowledge of the Jing Luo or the Zang Fu. In this way it is applied even today in so called medical acupuncture that uses needling according to the western neuroanatomical concepts and not according to the theory of Chinese medicine and knowledge of meridians. On the other hand, the diagnosis and the treatment of the musculoskeletal pain in TCM is quite forward and often seen as less interesting than the more “fancy” pathologies of the internal organs diseases. What interests me in musculoskeletal pathology and treatment of it, is the way the acupuncture points are chosen and combined. The combination of points in general is directed by two basic principles: selecting a point according to its particular action, function, nature and quality and selecting a point according to its position and dynamics within the meridian system. These two principles are by no means mutually exclusive; usually both approaches are combined.25

The stress placed on needling technique is based on a point-centred view of acupuncture, whereas the stress placed on the combination of points is based on a channel-centred view of acupuncture.26

Acupuncture treatment of chronic musculoskeletal pain is based in short on the combination of local points, including Ah Shi points and distal points and, especially important in chronic cases, points according to the underlying pattern. In musculoskeletal conditions pathology can be situated distally, so proximal points may coincide with distal points or distal points from paired meridians of the same polarity may be chosen instead. The use of the distal points is unique for acupuncture; it reflects the meridian dynamics of the system as a whole. Distal points “open” the meridian, eliminate stagnation of Qi and/or Blood and help to expel pathogenic factors.27 In acute cases their action is strong; they are combined with local points that support the eliminating action of the distal points and focus it on the specific area. In chronic cases the meridian dynamics is more severely impaired and the overall condition is generally more vacuous; distal points work less strong and local points become more important. Local points are in the area where Qi en Blood stagnation or pathogens are lodged and treating them is needed to restore meridian dynamics and relieve pain. Seem described balancing local and distal points on the basis of excess or deficiency:

25 Maciocia, G, The Channels of Acupuncture, 2006 26 Maciocia, G, The Practice of Chinese Medicine, 2008, p. 1134 27 Maciocia, G, The Channels of Acupuncture, 2006

18

In excess conditions Select more distal points, which are the main points to calm hyperactivity of an energetic orb. Use less local points, which are selected to direct the calming action of the distal points. Apply dispersing techniques to the distal points and neutral technique to the local points. In deficiency conditions Select more local points, which are the main points to tonify deficient energetic function. Apply tonification techniques to these points (warming techniques including moxibustion). Use less distal points and apply neutral techniques to these points, to harmonize the local tonifying action.28

Again, as chronic cases are more vacuous in nature than acute cases, the strategy for deficiency conditions can be employed. In the following chapters I will focus on meridian palpation as a diagnostic method in meridian pathology and subsequently on the use of Ah Shi points. I will concentrate on the choice of the local and distal points as well as the emphasis on one or the other as it is employed in the different schools of acupuncture. In a separate section I will examine the use of the different meridian layers in meridian pathology. Books or chapters on the musculoskeletal pathology usually present extensive lists of points according to the body area, meridians and pathogen involved. I will not repeat many of these lists as I found that there are more differences between the particular authors and not so many between different schools. The treatment of the underlying condition, albeit being very important for chronic conditions, is not a part of this writing.

28 Seem, M.D, 1987, p. 47

19

3.1 TCM approach 3.1.1. The role of meridian palpation TCM acupuncture is a modern version of Chinese acupuncture, developed to allow the practitioners to treat many patients per day, which is definitely a bonus in China. Even in The Netherlands I have seen Chinese practitioners diagnosing and treating new patient every 20, or even every 15 minutes (of course they have assistants to do the administrative side of the work). In that short time there is simply no time for careful palpation; they have to rely on their theoretical knowledge and experience. Western practitioners trained in the TCM acupuncture usually take more time for their patients, yet the stress of the treatment is still based on the same premises. Palpation is one of the four traditional examination methods; in TCM it is focused primarily on the palpation of the pulse. In TCM literature there is mention of the palpation of body parts, skin and acupuncture points to determine temperature, texture and tenderness, but explicit palpation of the meridians is not often included. Tietao Deng mentions pressing examination29 to examine patients head and neck, hands, feet, chest, abdomen, skin and transport points to determine whether the area is hot or cold, slippery or rough, soft or hard, hurts with pressure or has lumps or other abnormalities. This information can add to the diagnosis of the location and nature of the disease. Yet there is no mention of meridian palpation. In his more than 1000 pages thick Diagnosis in Chinese Medicine30, Maciocia dedicates 12 pages to the palpation of the meridians. He discusses briefly palpation of the Luo vessels and superficial Luo vessels by touching, stroking and pressing to determine temperature, moisture, firmness and possible masses. Palpation of TM meridians is limited to firm pressure to reveal consistency of the muscles. Maciocia furthermore mentions the palpation of meridians in Bi syndrome to reveal the Ah Shi points as to determine the meridian (most) involved. He proceeds to the palpation of the meridians and states that there are two aspects to it: palpation of the blood vessel overlying the channel and palpation of the skin. For the latter, three aspects are distinguished: temperature, texture and tenderness. For each meridian he mentions specific (point) areas that should be examined and the diagnostic significance of the findings. For example, the palpation of the Gallbladder meridian is limited to the palpation of the area around GB-2 Tinghui, which is a rather small portion of the total superficial trajectory of the meridian. 29 Deng, T, 2004, p. 155 30 Maciocia, G, Diagnosis in Chinese Medicine, 2004

20

3.1.2 The use of local and Ah Shi points The local acupuncture points have dominance over Ah Shi points in TCM acupuncture of musculoskeletal pathology.31 They are chosen according to the area of pain. There are standard lists of points recommended for the use as local points for the specific area; these lists can vary according to different authors and are ultimately dependant on the specific case. As the total amount of the needled points has to be limited, there are few local points chosen. In musculoskeletal conditions needling is performed less deep than for the internal conditions and needle manipulation can be performed. Ah Shi points don’t get a significant role in the treatment of the musculoskeletal conditions. They are determined by palpation, usually only of the body part where patient complains of pain. For example in the book Acupuncture case histories from China32 there are fourteen cases of Painful Obstruction Syndrome and only in five of them Ah Shi points are mentioned as part of the acupuncture prescription. In Treating Pain with Traditional Chinese Medicine33, in chapters dealing with musculoskeletal pain there is no mention of the Ah Shi points. Apart from needling, other techniques can be used to cover bigger local area: cupping, guasha en moxa, depending on the present pathogen and desired effect. Cupping removes Cold and stagnation of Qi en Blood from the meridians; it also expels Wind from the muscles. Guasha eliminates Cold from the muscles. Moxa can be used for its action on expelling Cold and moving Blood and in chronic cases for tonifying the vacuous TM meridians. 3.1.3 The use of distal points The descriptions in the following two sections are based largely on the Maciocia’s The Channels of Acupuncture.34 Distal points are per definition located on the limbs, below elbows and knees, and can treat pathology further up the meridian. They are used with reducing method in acute cases and even method in chronic cases.35 They are chosen according to the meridian involved and area involved. Generally, the more distal along the meridian the point is, the further up the meridian it extends its action, but there are exceptions to this rule. When pathology is situated distally, local and distal points may coincide. In that case, distal points may be chosen from the paired meridian of the same polarity; this applies especially for the Yang meridians (Tai Yang, Shao Yang and Yang Ming). In that case one chooses according to the correspondence of joints in the upper and lower limbs: shoulder = hip, elbow = knee and wrist = ankle.36 31 Pirog, J.E, 1996 32 Jirui, C, 1988 33 Riley, D, 2003 34 Maciocia, G, The Channels of Acupuncture, 2006 35 Ibid., p. 655 36 Ibid., p. 657

21

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

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

3.1.4 Treatment according to the meridian layers In The Channels of Acupuncture37 Maciocia differentiates the musculoskeletal pathology according to the meridian layers involved as follows: the TM meridians and Luo vessels are per definition involved; however in chronic pathology main meridians and extraordinary meridians can be involved as well. It is often difficult to separate pathology of one from the other. The more chronic the pathology, the deeper in the meridian system the pathogen penetrates.38 TM meridians The main distal points for activating the TM meridians are Jing-Well points. As TM meridians overlap and communicate with each other, chronic musculoskeletal pathology usually involves more than one neighbouring meridian. In that case one can use upper meeting points of the TM meridians. They strengthen the effect of the distal points and regulate Qi between different meridians. The upper meeting points of the TM meridians are as follows:

° three Yang of the leg: SI 18 ° three Yang of the arm: GB 13 ° three Yin of the arm: GB 22 ° three Yin of the leg: Ren 3

Luo vessels In musculoskeletal conditions the pathology of the Luo vessels is intertwined with TM meridians. The superficial Luo vessels are the first layer of penetration of pathogens; after they pas the TM meridian layer, they can get lodged in the deep Luo layer. The discoloration of the skin and the venules that can be seen on the skin surface merely reflect the pathogens in the deep Luo layer. Trauma or invasion of pathogenic factors in Luo vessels can cause blood stasis. Luo points are primary points for treating Luo vessels. Extraordinary meridians When chronic symptoms overlap different meridians and stretch over larger surfaces of the body, extraordinary meridians may be involved. They absorb the excess from the main meridians.

37 Maciocia, G, The Channels of Acupuncture, 2006 38 Ibid.

22

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

° Dai Mai gets mentioned in The Channels of Acupuncture39 only for treatment of hip pain; the opening and coupled points are needled. In Neijing Suwen40 Dai Mai is listed in chapter 41 for the treatment of back pain if the patient is unable to arch the back.

° Both Yang Qiao Mai en Yang Wei Mai can be used in the treatment of backache; the symptoms involving Yang Qiao Mai stretch mainly over the Bladder meridian and the symptoms involving Yang Wei Mai follow mainly the Gallbladder meridian.

° Yang Qiao Mai is indicated when pain involves several neighbouring meridians, for example in sciatica when the pain involves the Bladder, Gallbladder and Stomach meridians. The opening point of Yang Qiao Mai Bl 62 is needled on the affected side and coupled point SI 3 on the opposite side. In case of pronounced stiffness, the Xi-Cleft point of the Yang Qiao Mai can be used as wel: Bl 59.

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

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

° Yin Qiao Mai can be used in certain cases of Wei syndrome (atrophy syndrome) when the muscles of inner aspect of legs are more tense than the muscles of the outer aspect of legs and the feet of the patient turn inward.

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

Differentiation according to the meridian layer is not always applied in TCM; Riley42 and Jirui43 use only main meridians for the treatment of musculoskeletal pathology. 39 Ibid. 40 The Yellow Emperor’s Classic of Medicine 1995 41 Maciocia, G, The Channels of Acupuncture, 2006 42 Riley, D, 2003 43 Jirui, C, 1988

23

3.2 Meridian approach Although meridian style acupuncture originally referred to the Japanese acupuncture, the term has since been extended to mean any form of acupuncture that derives its strategies from classical energetic theory as found in the Nei Jing and Nan Jing, rather than the “herbalised” theories of modern TCM.44 Generally, meridian style acupuncture uses more needles, thinner needles, shallower insertion and milder stimulus than modern TCM acupuncture. There is also less manipulation of the needle and distending sensation is not deemed necessary. This chapter is based mostly on Pirog’s The Practical Application of Meridian Style Acupuncture.45 3.2.1 The role of meridian palpation In books on the meridian approach great stress is placed on importance of thorough palpation of meridians. Yet they leave out the descriptions of the techniques for the meridian palpation. Apparently, it is considered as something one must learn in practice from a good teacher. Here is what Pirog writes on meridian palpation:

In modern meridian style acupuncture the traditional concept of ashi points bas been extended to include any points that exhibit abnormal texture, temperature, or appearance, even if there is no actual tenderness. Japanese acupuncturists, for example, place great emphasis on kori, points that are hard or rubbery to the touch but not necessarily painful. Many meridian therapists will search for subtle changes in skin temperature or for distended capillaries. The region of palpation has also been extended, with some therapists searching for ashi points far from the original site of pain. Since ashi points and kori are supposed to be sites where energy stagnates and accumulates, some acupuncturists believe that these points can be found entirely through intuition. These practitioners will lightly touch the patient’s skin or hold their hands above it, feeling for a tingly sensation or draft in their fingers.46

Obviously, there is great diversity in meridian palpation methods, depending on a particular acupuncture school and particular teacher. 3.2.1 The use of local and Ah Shi points The choice of the local points in meridian approach seems to differ most from the TCM use of local points.

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

vicinity of the pain.

44 Pirog, J.E, 1996 45 Ibid. 46 Ibid., p. 5

24

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

In other words, there are no other local points used in musculoskeletal pathology than Ah Shi points and they can be great in number, depending on the character and chronicity of the condition. 3.2.2 The use of distal points Distal points are chosen on the basis of distribution of local/Ah Shi points to determine the meridian that is most involved. They are not chosen according to the specific target area; usually the most powerful distal points are chosen. Distal points are considered to be more draining than local points; one needles as many local points as deemed necessary, but distal points are limited to one on the upper limbs and two to three on the lower limbs. As the points with most powerful distal effect, the following can be chosen:47

To fine-tune the treatment, distant points can be chosen whose qualities best match the condition being treated, according to the theory of Five Shu-Transporting points. Some points that are usually avoided in TCM acupuncture due to the insertion pain can be still be used because of the use of thinner needles and shallower insertion depth. The properties of the distant points used for the treatment of Bi Patterns are summed up in the following table:48 Jing-well points Support point used to release severe repletion or blockage in the

meridian Ying-spring points, including Ba Feng en Ba Xie points

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

Shu-stream point of Yang meridians

1. Bi patterns in general; often used together with the Ying-spring points 2. for acute episodes of chronic Bi patterns

Shu-stream point of Yin meridians

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

47 Pirog, J.E, 1996, p. 9 48 Ibid., p. 227

Large Intestine: LI 4, LI 11 Lung: Lu 7, Lu 5 Triple Burner: TB 5 Pericardium: Pc 6 Small Intestine: SI Heart: Ht 7 Stomach: St 36, St 44 Spleen: Sp 6, Sp 9 Gall Bladder: GB 34, GB 39, GB 41 Liver: Liv 3 3Urinary Bladder: UB 40, UB 58, UB 60 Kidney: Ki 3

25

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

Jing-river points of Yang meridians

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

Jing-river points of Yin meridians

Primary treatment point for pain located in the yin meridians

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

Xi-cleft points 1. most commonly for severe acute pain 2. stubborn stagnant or painful conditions

Group Luo points

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

Luo-connecting points

1. pain with swelling and visible local capillaries 2. blood stasis or phlegm in the meridian 3. pain involves both Yin and Yang paired meridians 4. pain associated with the Luo vessel

3.2.3 Treatment according to meridian layers In theory, the treatment of the different meridian levels involved in the chronic musculoskeletal pain does not differ much from the TCM approach. Again, there is a great stress on palpation and finding of Ah Shi points. The distribution of Ah Shi points and the character of pain helps to determine which meridian layer is involved. TM meridians If the pain is clearly localized and can be elicited with light palpation, the pathogen is still lodged in the TM meridians. This is the typical pathology seen in acute cases and sometimes even in chronic cases. However, chronic pathology usually leaves TM meridians vacuous; the pain becomes more diffuse and it is difficult to pinpoint the source. The basic treatment involves tonifying TM meridians by superficial needling and/or moxa and treating the main meridians as described below. Main meridians In chronic cases, the pathogen invades the main meridians which now become relatively replete, leaving the TM meridian relatively vacuous. The struggle between defense Qi and the pathogen is less intense. The pain is more vague and more diffusely located and often cannot be localized without deep pressure; it usually involves several meridians on the same side of the same limb. Is important to determine the single meridian that most underlies the problem for the choice of the appropriate distal points that need to be drained. Alternatively group Luo points can be added to the distal treatment because they connect all the meridians on the same side of the same extremity. They can also be used as the only distal point.

26

Luo vessels The involvement of the Luo vessels in chronic cases is characterized by the pain occurring on both the Yin en Yang meridians in the same region on the same limb. The treatment consists in supplementing the local painful points on both Yin and Yang meridians with needles and/or moxa. As the distal point that needs to be drained, the Luo point on the Yang meridian is recommended; if that does not help, the Luo point on the Yin meridian is treated. Extraordinary meridians Chronic pain is an indication for involvement of the extraordinary vessels in musculoskeletal pathology. The Ah Shi points are again the basis for diagnosis and treatment. Careful palpation will reveal masses and painful points scattered across broad surfaces of the body and may involve both upper and lower extremities. The muscle tissue at these points often shows a hard, rubbery quality; bone spurs may be present. Knowledge of the extraordinary meridians pathways is required to diagnose the extraordinary meridian involved and to determine the opening and coupled points that are used as distal points.

27

3.3 The trigger points approach 3.3.1 The concept of trigger points Trigger points is a concept from western medicine. It came from the realization that the cause of the musculoskeletal pain can often be located some distance away from the area where a patient experiences pain. In terms of TCM we would say that the relevant Ah Shi points can be located not only locally, but adjacent to or even proximal or distal to the area of the pain. Trigger points are known to cause other symptoms than musculoskeletal pain, such as for example headache or dizziness. In plain words, trigger points are local and permanent contractions in the muscle fibers that on palpation feel as taut bands or nodules and are responsible for the typical pain patterns. Detailed medical explanation of the trigger point mechanism is not necessary for this writing, but it is interesting to note that Travel and Simons mention impairment of energy metabolism and impaired circulation49 – in TCM words Qi en Blood stagnation. The concept of referred pain plays an important role in the pathology of trigger points. It means that the pathology that causes pain (in this case – trigger points) not necessary coincides with the area where patients report pain. This concept has been known in Chinese medicine for a long time. Referred pain is explained in medical literature by neural mechanisms, as errors occurring in the spinal cord or perceptual errors in the sensory cortex.50 Referred pain is often difficult to localize and may move and change as the disease progresses. Initially, it is felt close to the origin of symptoms, later it moves distally or proximally to the initial area. So this concept is especially important in chronic cases of musculoskeletal pain. The concept of Trigger points has been pioneered by Kellgren in 1938 and extensively researched and published by Travell and Simons in the, by now, classic work Pain and Dysfunction, The Trigger Point Manual.51 Travell and Simons state that muscle pathology is the major cause of pain and dysfunction, yet the physicians focus their attention on bones, joints, bursae and nerves.52 The major problem for a medical explanation is that trigger point pain pattern does not follow the nerve pathways nor does it necessary occur within the same dermatome, myotome or sclerotome.53 Yet the trigger-point referred pain follows a predictable pattern, researched and described by dr. Travel. As the main causes of the activation of trigger-points the following are stated:

° trauma to the muscles, tendons and/or joints ° chronic stresses on muscles, whether by overuse, bad posture or involuntary

muscle tension due to emotional stress54

49 Travel, J, and Simons, D.G, 1983, p. 34 50 Marcus, A, 2004 51 Travell, J, and Simons, D.G, 1983 52 Ibid., p. 5 53 Ibid., p. 14 54 Trigger points of this origin are often seen in women in upper trapezius muscle.

28

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

° other trigger points ° visceral diseases ° nutritional deficiency, periodic hypoglicemia ° food and inhalant allergies

The above list resembles the aetiology of Bi syndromes. I believe that trigger points approach fits easily into the meridian perspective. Trigger point pain patterns have been extensively researched and published, yet to someone with knowledge of the meridian pathways it soon becomes obvious that these pain patterns often follow the pathways of meridians (especially the tendino-muscular meridians or main meridians or otherwise, I suppose, the minor meridian pathways not described in acupuncture atlases). So by following the pathway of the meridians passing through the area of referred pain, one comes a long way in finding trigger points responsible for that pain pattern. 3.3.3 Diagnosis and palpation of trigger points There are different types of trigger points, not all of them being “active” (causing pain), so it is important to identify the right trigger points responsible for the pain pattern in question. As Travel and Simons state,

A precise pictorial representation of the patient’s pain is critical for an accurate diagnosis of myofascial pain; verbal descriptions are often imprecise and misleading: a blank body form is used routinely to record the patient’s pain.55

56 55 Travel, J, and Simons, D.G, 1983, p. 46

29

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

Once the involved muscle or muscle group is identified, careful palpation is needed to locate the taut bands and nodules in the muscle fibers that are tender on pressure and may induce the patient’s referred pain pattern. The usual palpation technique is performed on the slightly stretched muscle: the fingers of the practitioner gently roll the skin over the muscle, perpendicular to the muscle belly. The pressure should start light to asses superficial muscles and slowly increase to reach deeper muscles. Objective tissue changes are more significant than patient’s verbal or physical reaction to the pressure.58 I found this description to be most straight-forward and very useful. 3.3.4 The treatment of trigger points – the view on the local and distal

points and needling techniques There are different possibilities of treatment of the trigger points; here I will describe only the acupuncture treatment. In so-called medical acupuncture or physiotherapy acupuncture only local points - the sites of trigger points - are needled. That procedure has been named dry needling. It actually means that the needles are used according to the principles of western anatomy, not according to the principles of Chinese medicine and knowledge (or use) of the meridians. This way of needling has proven to be quite effective; however, using distal points according to the meridian theory should only increase the effectiveness of the trigger point needling. For an effective treatment it is deemed important to address the precise spot of the trigger point:

Trigger point needling is an acquired art. The point must be accurately located and manually stabilized. This is done with the practitioner’s non-needling thumb. Firm pressure is applied just to the side of the tight-band/Kori so that when the needle approaches the trigger, the muscle fibers do not roll away.59

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

56 Travel, J, and Simons, D.G, 1983 57 Ibid., p. 47 58 Marcus, A, 2004, p. 606 59 Ibid., p. 607 60 Baldry, P.E, 2005, p. 133

30

Trigger point needling61 Marcus proposes several protocols for treating trigger points, for example the following one:62

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

points associated with the involved muscle) – to address the root of the problem

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

If the patient does not respond to the mild treatment, deeper needling may be applied, with more vigorous needle manipulation. One can needle in several directions to cover the entire area of the tight band around the trigger. Muscle attachments may be explored and needled if needed.63 According to Pirog64, trigger points are the chronic meridian pathology at the level of the extraordinary meridians. In view of that statement, the best choice for distal points would not be the points on the main meridian passing through or nearby the trigger point, but the opening en coupled point of the involved extraordinary meridian (see previous chapter).

61 Marcus, A, 2004, p. 607 62 Ibid., p. 607 63 Ibid., p. 608-609 64 Pirog, J.E, 1996

31

3.4 Ear acupuncture 3.4.1 General overview of the ear acupuncture Auriculotherapy is stimulating the external surface of the ear, or auricle, to treat pathological condition elsewhere in the body. Besides using acupuncture, stimulation of the auricle can be done by other modern methods such as electrical, magnetic or laser stimulation. I will further discuss only the acupuncture treatment of the auricle. I will leave aside the specific details of diagnosis and treatment and focus only on the theoretical side in general and on the treatment of the musculoskeletal disorders in particular. Historically, acupuncture points on the auricle were used in ancient China and in the Middle east for therapeutic purposes; however the father of the modern auriculotherapy is the French physician Paul Nogier. Through meticulous research he developed a so called inverted fetus map on the external ear which inspired many further studies throughout he world. After his discovery reached China it instigated a massive study of the reflex points on the ear which confirmed and complemented Nogier’s map, although the localization of some points may differ from the original Nogier’s model.65 The auricle is one of the several micro systems in the body that can be used as a complete system for diagnosis and therapy, following the principle that “inside reflects the outside and a part reflects the whole”. The term local and distal points cannot be applied literally on the ear acupuncture. In a way, all ear points are distal points, not in classical sense as being located on the extremities, but they are more or less distant from the area of corresponding pathology. In auriculotherapy models the auricle is divided into different areas, each of them representing a specific part of the body, internal organ or a more general body function. Yet the points on the auricle are not a permanent feature (like the points of the body acupuncture which can be found on precisely anatomically defined locations); they can be detected within certain areas only when there is some pathological process in the corresponding body part. The ear points are found through changed reactivity in the particular point: increased or decreased pressure sensitivity or diminished skin resistance to electrical stimulation.66 If we leave the electrical devices aside, the points on the auricle are detected through careful palpation. So we could say that all ear points are Ah Shi points. Ear acupuncture is a self sufficient system of diagnosis and treatment, but it can easily be combined with other treatment methods. From the practical standpoint there are certain advantages of the ear acupuncture such as treating the body part that is temporarily not accessible or simply too painful for body acupuncture. The use of

65 Rubach, A, 2001 66 Ibid.

32

semi-permanent needles or pallets on the auricle can provide a more continuous stimulus for a prolonged therapeutic result. 3.4.2 Nogier’s phase models

in the treatment of chronic musculoskeletal pain With further research Nogier discovered different auricular maps than his original one based on the inverted fetus pattern. They differed considerably from the earlier model as they assign different auricle zones to different body parts than the original map. Nogier referred to this different models as phases:67

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

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

- Phase III: the “horizontal man” model represents excess Yang, inflammatory conditions.

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

68 Both Phase I and IV are used to treat acute pain or acute conditions, and the other two are used for more chronic pain. According to Frank and Soliman69, the different 67 Oleson, T, 2003 68 Ibid., p. 73

33

phases do not so much represent the degree of chronicity, but the degree of degenerative condition. The mildest conditions are represented by phase I, followed by phase III and the most degenerative conditions are represented by phase II. Some authors, like Rubach70 for example, choose to ignore auricular phases, while others consider them to be most valuable. It seems to me that different phases model can be of a particular importance in the treatment of chronic musculoskeletal pain. While paying attention to Phase I could only bring some palliative results, examining and treating Phases II and III could get into the heart of the problem. The treatment protocols for chronic musculoskeletal pain include primarily the area of the corresponding body part. In the Phase I the segmental approach is applied, which I will not further describe. If Phase I does not yield results, the corresponding points are searched according to the Phase II or III.71 Next, the points with analgesic, anti-inflammatory or muscle relaxing effect are examined and some other points with a general regulatory function. According to the previous diagnosis specific points can be employed to complete the treatment. Each session the points are examined again and reactive points are treated accordingly. 3.4.3 Chinese model of ear acupuncture

in the treatment of chronic musculoskeletal pain The Chinese researchers were inspired not only by Nogier’s model, but also by the quotation from Classic of Internal Medicine that states that all of the Yang channels pass through the ear and the Yin channels meet in the ear.72 The working of the auricular points is thus explained by the connection of the ear to the meridian system. That still leaves unanswered the question how the particular points on the ear transmit their influence to the corresponding parts of the body. The differences between the original Nogier’s inverted fetus model and the Chinese model is usually explained by the assumption that the points on the Nogier’s model correspond to the physical body parts and the points on the Chinese model correspond to the energetic functions and connections according to the Chinese physiology theories. In that manner, Chinese ear acupuncture works by regulating Qi and promoting proper organ function. According to Frank and Soliman,73 the Chinese system offers a simple model that is best suited for a technical approach to treatment. Treatment depends on the localization of pain together with meridian(s) involved in the pathology, so the zone of the corresponding body part and the zone of the organ corresponding with the involved meridian is treated. Depending on the previous diagnosis made on basis of the eight parameter and internal organs differentiation, further zones of the ear can be treated. In combination with body acupuncture, the appropriate local and distal points are needled. 69 Frank, B.L, and Soliman, N.E, 2006 70 Rubach, A, 2001 71 Oleson, T, 2003 72 Marcus, A, 2004, p. 344 73 Frank, B.L, and Soliman, N.E, 2006

34

Conclusion : the best of both worlds The purpose of this writing was to get a better understanding of chronic musculoskeletal pain and acupuncture treatment methods used for it. For that purpose I chose to compare four different approaches: TCM acupuncture, meridian approach, trigger point approach and ear acupuncture. Again, my goal was to compare them, not to judge their effectiveness.

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

Based on this writing I came to the conclusion that for the treatment of musculoskeletal pathology and especially for the chronic cases, it is important to explore the whole array of the superficial energetic structure; not only the main meridians, but the secondary vessels and extraordinary meridians as well. To do that, one needs theoretical knowledge of the pathways and characteristics of the layers of meridian network, but at least as much important is the use of palpation to identify the precise spots where Qi and Blood stagnates. Needling those places dissipates the stagnation and/or tonifies resulting deficiency and addresses directly the cause of pain. It is usually recommended not to mix or confuse different models of differentiation and treatment of a pathology. In the case of chronic musculoskeletal pain I believe one can learn from all four different approaches. One can integrate differentiation and treatment of underlying pathology, which is the strong point of TCM acupuncture, with a meridian oriented approach to address the exact place of the pathology. Trigger point approach can provide a practical and accurate methodology of identifying places of Qi and Blood stagnation and a straight-forward and easy to learn palpation method. Combining that with an independent system of diagnosis and treatment like ear acupuncture should only increase the success rate of a treatment. In short, one can combine the intellectual or scientific approach with the palpatory and more intuitive approach. The latter seems to be the shortcoming of most Western doctors. TCM acupuncture does not need to match the Western medical science in scientific rigor; it can offer much more by relying on its ancient wisdom and trust in the intuitive.

Dào jù dào yě fēi héng dào yě. (Chapter 1, Dào Dé Jīing)74

74 Study material Academy Qing-Bai, BVO study year 2006-2007; in translation: The Tao that one can speak of is not the eternal Tao.

35

Literature Books:

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

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

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

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

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

° Jirui, C., Acupuncture case histories from China, Seattle: Eastland Press,1988

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

° Maciocia, G., The Channels of Acupuncture, Spain: Elsevier/Churchill Livingstone, 2006

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

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

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

° Norris, C. M., Acupuncture Treatment of Musculoskeletal Conditions, Oxford etc.: Butterworth Heinmann 2001

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

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

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

° Riley, D., Treating Pain With Traditional Chinese Medicine, Brookline Massachusetts etc.: Paradigm Publications, 2003

° Rubach, A., Principles of Ear Acupuncture, Stutgart etc.: Thieme, 2001 ° Seem, M.D., Acupuncture Energetics: a workbook for diagnostics and

treatment, Rochester, Vermont: Healing Arts Press, 1987 ° Travell, J. & Simons, D.G., Myofascial Pain and Dysfunction. The Trigger

Point Manual, Baltimore: Williams and Wilkins, 1983 ° The Yellow Emperor’s Classic of Medicine, translation by Ni, M., Boston etc.:

Shambhala, 1995

36

Websites:

° www.chinesemedicinetimes.com: Reid, T., The Neglected Art of Channel Palpation, 20 May 2009

° www.books.google.nl ° www.yinyanghouse.com

Study material of Academy Qing-Bai:

° BVO, study year 2006-2007 ° ACU 1, study year 2007-2008 ° ACU 2, study year 2008-2009