Die Behandlung von Sehnen Erkrankungen
Das folgende Essay war Teil einer Semesterarbeit während des Studiums an der NJUCM und richtet sich an Therapeuten. Inhaltlich werden verschiedene Behandlungsmethoden zum sogenannten Sehnen Bi beschrieben und dargestellt. Das Sehnen Bi ist ein Überbegriff der chinesischen Medizin für Erkrankungen, welche den Bewegungsapparat betreffen und ohne Behandlung progredient verlaufen. Häufig wird dieser Begriff auch synonym mit rheumatischen Erkrankungen verwendet, geht aber weit über diese Erkrankungen hinaus. Erkrankungen wie ein Golferarm, Tennisarm, Meniskusbeschwerden und oder das Lumbago-Ischias-Syndrom fallen demnach ebenso unter diesen Überbegriff.
Analysis and Acupuncture Treatment of Tendon Bi – Essay
If a practitioner looks at the treatment protocols for Tendon Bi he will see that there are many possible acupuncture points to use. The given treatment protocols are grounded in the Traditional Chinese Medicine (TCM) which is a modern didactic way to teach students.
The method at those points is to regulate and support the tendons and eliminate wind, cold, damp. The so called External Pathogenic Factors (EPF). Because a Tendon Bi is usually a prolonged disease it can be also necessary to strengthen the Zheng-Qi.
Those methods are a root treatment but sometimes in clinic it is also necessary to cure the branch. In a Bi-syndrome this would be to move Qi and blood to reduce pain. Other symptomatic treatments can aim to strengthen the muscle function, reduce numbness or to calm the Shen because of nightmares. If everything should be treated according to the textbooks many acupuncture points will be needled.
In the classics it seems that there is a different approach. Therefore the aim of this essay is a try to broaden the view on the treatment of a Tendon Bi in reference to the classics. The guiding question is how to use less needles for the same treatment. It will also develop new ideas about the concept of pain and about the anatomical Wu Xing connection in acupuncture.
How to treat and regulate the Tendons in the classics
In the treatment of Tendon Bi the depth of needling is important. Chapter 62 of the Su Wen (SW) simply says if the disease is at the tendons, regulate the tendons but how to do that is not answered in this chapter.1 In the Jia Yi Jing written by Huangfu Mi the treatment method for regulating the tendons is explained. The practiotioner should needle arround a joint to puncture the ligaments and tendons. This corresponds to the liver.2 Typical symptoms are pain, inability to walk and spasm. During the needling the tendon should feel warm.3
Anatomically around the joints there are much ligaments or tendons and few muscles. Therefore needling in this area treats the tendons locally and in the whole body due to the Wu xing corespondence. It is also possible to regulate the tendons with the gathering point for the tendons Gallbladder 34.
The close connection between Gallbladder 34 and the tendons
At the gathering point for the tendons Gallbladder 34 there are two muscles with their tendinous origin at the Fibular head and at the Fibular. The Musculus Peroneus longus and the Musculus Extensor digitorum longus. Additionally there is the Membrana Interossea Cruris between the Fibular and the Tibia. Therefore there a many membranes and tendons in this area. The tendons are linked to the liver.
In this way, doing acupuncture at this point stimulate these tissues. If one looks at the musculoskeletal system at Gallbladder 34 it is possible stimulate tendons, ligaments, subcutaneous fat, fascias and nerves with one needle.
Other points with a connection to the tendons
It might be ask if it is possible to use other points close to a tendon to treat tendon issues. For example San Jiao 3 and 4 are very close to tendons too. The same can be applied to Ashi points. Usually Ashi points are tender points in a local area and are not necessary on a channel. They can be very close to a tendon. They are used to treat pain and regulate the Qi and blood circulation in a local area.4 To treat Tendon Bi the concept of Ashi points can be broaden to needle at the depth of the ligaments and tendons.
Needling points close to tendons can treat this tissue but in general distal points are used for treating the channel itself or to treat the end of the channel.
The closer the points are at the knee or elbow joint their function is more related to internal physiology and pathology. The He-sea points regulate the Fu-organs and Gallblader 34 is the He-sea point of the gallbladder. The gallbladder is internal-external paired with the liver. Therefore regulating the gallbladder has an effect on the Liver. The liver nourish the tendons with the liver blood, this is an internal process. Therefore needling the tendons at the distal parts of a channel is not enough. The correspondence of the tissues can be used clinically but apart from that to regulate the tendons at an internal level with Gallbladder 34 is necessary.
A broader view on Ashi points
One further possibility would be that Ashi points can be found not only locally but also far away from the painful area, in the related pathway of the channel.5 This way of searching can be combined with the guideline from the SW, chapter 70 „if the illness is above, take it from below, and if the illness is below, take it from above“6 or the concept of Miu Ci needling.
The way of looking at points in relation to their anatomical enviroment and the Wu Xing connection of the tissue explains some point indications as well. This can be used to regulate the tendons but further pathomechanisms needs to be treated. The EPF attacking the Yang channels first therefore point pairs for treating the Yang channels would be an additionally treatment for Tendon Bi.
Point pairs for treating the Yang channels from Ling Shu
In the HNJ there are several quotes about point pairs. In reference to the the reatment of Yang channels LS, chapter 4 says one has to use the Ying- spring and Shu-stream points at the arm together to treat the external channel.7
The Ying-spring points at the Yang channels are water points and the Shu-stream points are wood points. From the Wu Xing correspondence they are able to treat cold which is in correspondence to the water and wind which is in correspondence to the wood.
Anatomically both points are in an area with much bones and ligaments. Therefore with an appropriate needling depth the treatment can be focused on these tissues.
At both points the channel Qi is quite slow and needling here will increase the channel Qi and disperse stagnation of Qi and blood or to dispel EPF. LS, chapter 44 further elaborate this point pair.
If a disease is sometimes alleviated and aggravated the Ying-spring points are recommended. A Tendon Bi is a chronic, progredient disease with waxing and waning in severity. The pain is sometimes more or less, which hows that the Wei Qi is still fighting with the Xie Qi.8 The Xie Qi is disturbing the Ying and Wei Qi.
For regulating the Ying and Wei Qi the Ying-spring and Shu-stream points are recommended again in LS, chapter 34.9 According to this chapter If there is a disturbance in Ying and Wei Qi in the arms and legs first remove the blood stagnation from the extremities and than needle those points at the Shao Yang and Yang Ming channel. As a result the EPF are dispelled and the tendons and channels are regulated.
According to the HNJ this point pair can be used to treat Tendon Bi however in the Chinese Medicine it was always important to look a the treatment methods from famous acupuncturists to connect their knowledge with the writings in the classics .
How does other Acupuncturist treat Tendon Bi or Bi-syndrome in general?
During the last decades the Chinese Medicine system developed a lot. Under Mao Zedong the whole educational medicine system was innovated and changed to Traditional Chinese Medicine (TCM). One of the fathers of this lineage is the famous Cheng Dan-An.10
Another one is Dr. Shi Neng-Yun, who was an adjunct professor at the Xiamen University and the head of the acupuncture department at the Xiamen Chinese Medicine Hospital during the 1980’s .11
Dr. Cheng Dan-An used the point pair Gallblader 34, Gallbladder 39 and Blader 11 with local points at the extremities for the treatment of a Bi-syndrome. He did not any further differentiation according to the stage of Bi, therefore this is a general treatment.12
Both of them used Gallbladder 34 and Gallbladder 39. The first point is quite obvious. It is the gathering point of the tendons as mentiond above. Gallbladder 39 is another gathering point but his usage comes from a different nature.
Gallbladder 39 is also the intersecting point of the 3 foot Yang channels. The area which is covered by these channels is large and include the legs, whole back, the side and the front of the trunk and the head. An EPF first attacks the Yang channels and will than penetrate deeper into the tissues and Zangfu organs. In treating the Tendon Bi dispelling EPF is necessary. If this one point is used with a draining needling technique the EPFs are dispelled from the body. Therefore those two points together seems to be highly important in treating a Tendon Bi.
Gallbladder 34 and 39 are both on the Shao Yang channel. Therefore this is a chain-lock combination which will make the the effect more lasting. The channel Shao Yang channel is like a pivot, it is located half exterior, half interior, to transport between these two. There is a saying from the SW, chapter 6 that Yang guards the muscles and the viscera are nourished by the Yin internaly.13
If the Shao Yang channel is regulated this will prevent that the EPF penetrate deeper into the body. Another famous point pair for this would be the confluence point combination San Jiao 5 and Gallbladder 41 to regulate and open the Yang Wei Mai. The Yang Wei Mai encompasses all Yang channels and is therefore extremly usefull to dispel EPF from the body with just a few needles.
At the arms there is another intersecting point for the arm Yang channels, it is San Jiao 8. This point seems to be very effective in treating the area around the head, neck and shoulders because the hand Yang channels are going from the fingers to the head. This point is effective in the treatment of Tendon Bi in the neck area.
Bladder 11 is another point used from Cheng Dan-An. This point has some specific functions. First it is the gathering point for the bones. Second it is a crossing point with the small intestine channel. Both channels together are the Tai Yang channel.
According to Ling Shu (LS), chapter 33 Bladder 11 is also the upper point from the Chong Mai, the sea of blood.14
Acupuncture at this point can dispel EPF from the Tai Yang channel and protects the bones. Additionally this point is able to move blood due to his connection to the sea of blood. This is quite important. The Tai Yang channel in general has more blood and less Qi and pathogenic Wind is the leading pathogen in Bi-syndrome.15
There is a saying in Chinese Medicine: to treat wind first treat the blood; once blood moves wind will be dispelled. Therefore if blood is moved due to Bladder 11 the combination of this few points treat a wide aspect from the Tendon Bi. With local points the treatment will be more precise.
Dr. Shi Neng-Yun used a quite similar point group, also without any further differentiation. In a Bi-syndrome at the arms, he used Large Intestine 4, 11, 15 and at the legs Gallbladder 30, 31, 34, 39. In a Bi-syndrome in the whole body he used Bladder 18, 20 and 23.16 At all points he first used a draining needling technique and than a supplementing needling technique.
The additional points from Dr. Shi Neng-Yun are Gallbladder 30, 31. Gallbladder 30 is a crossing point with the foot Tai Yang bladder channel and it is one of the twelve Ma Dan Yang points. As mentioned above crossing points can broaden the treatment to different channels and areas.
Therefore acupuncture at this point broaden the effect of the treatment from the Shao Yang channel with Gallbladder 30 into the Tai Yang channel.
Characteristically Ma Dan Yang mentioned in his Song Twelve Points Shinning Bright as the Starry Sky and Able to Heal all the Many Diseases that Gallbladder 30 is the point for a Bi-syndrome due to wind, damp and cold in the legs.17 The point Gallbladder 31 is famous for expelling Wind. As mentioned before this is crucial in treating a Bi-syndrome.
The points Large intestine 4, 11, 15 are used for the treatment of a Bi-syndrome at the arms. Large intestine 4, a Yuan source point, is one of the main points to regulate the Wei-Qi and dispel EPF. The He and earth point Large intestine 11 is one of the main points for dispel Heat from from the body. Therefore this point combination seems to be more useful in case of a Bi-syndrome with heat. This seems to be logical because heat tends to affect the upper body first.
The last point Large intestine 15 is a crossing point with Yang Qiao Mai and the sinew channel from the Lung and bladder.
The divergent channel from the large intestine and the Luo channel from the small intestine channel is going through this point. Therefore the area which if affected by this point is wide. In combination with the other two points as a chain-lock combination it will dispel the EPF wind, damp, cold and heat from the upper extremities if needled with a draining technique. With a supplementing technique the channels and tendons will also be regulated due to their tissue connection.
If there is a Bi-syndrome in the whole body Dr. Shi Neng-Yun used different points (Bladder 18, 20, 23). All of them are Shu-back points and all of them are on the foot Tai Yang bladder channel.
These Shu-back points are related to the liver, the spleen and the kidney. In the Wu Xing corespondence the associated tissues to these organs are tendons, muscles and bones. In reference to a Bi-syndrome those tissues are affected easily by wind, damp or cold. Therefore an acupuncutre at this point dispel those EPF from those tissues and organs. This can therefore be used for a Tendon Bi too. As a chain-lock combination on the Tai Yang channel the effect will cover the whole body and due to the supplementing needling technique it will prevent the progression of this pattern.
One can see in the treatment of a Bi-syndrome mainly the Yang channels are used to dispel the EPF. Additionally the affected tissues should be regulate via gathering or Shu-back points but also with an appropriate needling technique. These approaches minimizes the needle number to a minimum.
Can a practitioner use an opposite needling technique at the same points during one session?
Interestingly Dr. Shi Neng-Yun first used a draining and than a supplementing needling technique at the same points. The explanation is that the development of a Bi-syndrome is related to weak Zheng-Qi and a strong Xie-Qi. The weak Zheng-Qi can not stop the progression from the EPF penetrating deeper into the body. From that point of view it is necessary to strengthen the Zheng-Qi in the second and third stage of a Bi-syndrome. Dispelling the EPF and regulating the tendons is important but preventing that the disease gets more severe is important too. Therefore Dr. Shi Neng-Yun used draining to dispel the EPF and than a supplementing needling technique to strengthen Zheng-Qi. The supplementation can also be seen as a regulation of the relevant tissues if the right depth in needling is used.
Some practitoners might argue that doing a different needling technique in the same session at the same points will have no effect. From theory this argument seems to be logical, like plus one and minus one is zero. Therefore nothing will happen.
As long as Chinese Medicine is an empirical medicine this theoretical discussion is not sufficient. Dr. Wang Ju-Yi once said, theory has to follow the clinical practice and not the other way.18 This seems to be true in reference to the roots of the Chinese Medicine. The HNJ is a compilation of the used medicine 2000 years ago. First there was the treatment, than the writing.
Further treatment methods for a Tendon Bi
From the HNJ the weakness of the Zheng Qi is not the only factor which will lead to a chronic Tendon Bi. The development of phlegm or blood stasis will further complicate the situation and the way of healing.
In LS chapter 6 there is the phrase „In the protracted Bi-syndrome of which the evil energy is retaining, it should inspect the superficial venunles and remove the extravasted blood as far as possible“.19
This phrase shows that a Bi-syndrome produce blood stagnation in the tissue. This stagnation is fullness according to the eight principles and should be removed. The relevevant treatment therefore is blood letting.
There are at least three main points to drain blood. The first way is to bleed where the small vessels show on the surface as Spider Naevi. Secondly it is possible to bleed the Luo-points because a chronic Bi diseases will move into the Luo.
The third points for bleeding are the Jing-well-points. According to LS, chapter 13 those points have a connection to the sinew channels because they are the root of them.2021 Therefore bleeding at this points will dispel EPF from the sinews. Significantly the pathological changes of all sinews channels included stiffness, pain and motor function impairment, the main symptoms of a Tendon Bi. With bleeding blood stagnation will be eliminated and the EPF will be dispelled but regulating the tendons is still necessary. Another aspect would be to reduce the feeling of pain as a branch treatment.
Pain in the chinese and western medicine and the development of the Pain memory
In LS Chapter 74 there is a famous saying that pain, itching and sore are related to the heart.2223 One main symptom in a Tendon Bi is chronic pain. The pain is caused by the lingering invasion of the EPF and a stagnation of Qi and blood in the channels.
In the western medicine pain is described as an „unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage“.24 If the pain is chronic the so called Pain Memory will be developed due to cortical reorganisation. This will lead to more intense reaction with a high sensitivity to pain.2526
Both views seem to be different but can be synthesized to deepen the understanding how to treat pain. In TCM the heart dominates the blood and the blood vessels. If there is a change in the blood and Qi flow due to the channel system the heart will be informed about this issue. The heart also houses the Shen which is related to counciousness and selfawareness. The feeling of pain is a reaction from Shen to the stimmulus due to the Qi and Blood stagnation.
From the point view of the TCM the development of Pain Memory can be explained in different ways. All changes in the Qi and blood flow will guided to Shen. Therefore the Pain Memory might be a sign that the Qi and blood stagnation due to EPF is getting worse and the Shen is just reacting to this intense stimulus.
On the other hand one might hypothesise that the emotions play a major role in developing the Pain Memory in the Chinese Medicine.
Hypothesis how emotions create intense pain
It is possible to say that the accumulation of the EPF in the channels and the related Qi and blood stagnation will transform first into heat and than into fire. Fire as a Yang pathogen tends to flare up and will disturb the Shen in the upper Jiao. If the heart is affected by fire it will induce further pathological changes. These changes will lead to a unsettled Shen and more pain.
Fire impairs the Qi and consumes the body fluid. Therefore the heart blood will be deficient and the Qi in the heart will be deficient too.27
The heart Qi is in charge of circulating the blood in the vessels. Therefore the Qi deficiency will lead to a more severe Qi and blood stagnation in the channels. If the stagnation in the channels is more severe there will be more heat and fire.
Due to the heart blood deficiency the Shen is not anchored and more sensitive to the seven emotions. Because of the chronic nature of the the pain in a Tendon Bi there will be emotions like fear, anger or worry.
Each of these emotions can have a specific reaction on the Qi mechanism in the body and on a specific Zangfu. Usually the Qi ascends or descends and enters or exits to fullfill the Qi mechanism physiologically. This will lead to a smooth flow of Qi.
Fear makes the kidney Qi descend, anger cause the liver Qi to rise up and worry will lead to a knotted spleen Qi.28
Each disturbance in the Qi mechanism due to the emotions will increase the Qi stagnation. The consequence is there will be an intense feeling of pain and more heat and fire. The fire will impair the heart blood and Qi much more. As a result the Shen will be disturbed more.
Additionally as long as the Qi mechanism is impaired due to intense emotions the production of Qi and blood from the Zangfu will be weak.
This vicious circle between pain and emotions need to be treated. It is very analog to the western term Pain Memory. The treatment method for the pain Pain Memory would be therefore to calm the mind, nourish the heart blood, clear heat or to drain fire and to regulate the Qi mechanism. It is a branch treatment in chronic pain as in Tendon Bi. The root treatment is to reduce the Qi and blood stagnation, regulate the tendons and dispel the EPF.
Which points can be used to treat the Shen?
In the HNJ there are just a few points which are used to treat the Shen and the heart. According to LS, chapter 1 and chapter 71 the source point of the heart is Pericardium 7 and Heart 7 should be used if the heart channel is in emptiness or fullness.29
According to LS, chapter 34 both points together used to treat a disturbance in the heart when the Ying and Wei Qi is moving in a contrary way.30 This is a disturbed Qi mechanism.
Both points are Yuan source, Shu and earth points. As Yuan source points they tonify the channel and strengthen the Yuan Qi. Addtionally they used to treat the Zang. The connection between the Zang and the emotions are quite close. Emotions can effect the Zang and the Qi mechanism directly but also the other way arround is possible. Therefore treating the Zang is easing the emotions.
Both points should be needled with the Dao Yin needling technique. As earth points the tend do drain the heart but if needled with the Dao Yin technique the Zang will be regulated not tonified or drained. This method is an even method which can be used to regulate the Qi mechanism.
Heart 7 itself will regulate the Shen and tonfiy the heart blood. Pericardium 7 is on of the main points to clear heat or to drain fire from the heart. It is evident that both points together can treat the mechanism behind the Pain memory however the root treatment in a Tendon Bi is stil necessary.
Conlusion
In the reflection about the classics it was possible to show that a few specific acupuncture points were used to treat the pathomechanism of Tendon Bi. Especially if they are needled according to their anatomical structure to regulate the tendons. This can be used according to the Wu Xing connection to minimize the amount of needles. Different point pairs seem to be more useful. A Crossing points or intersecting point together with the gathering point for the tendons Gallbladder 34 is one of the leading combination to dispel the EPF. Their effect on broad areas highlight their importance.
Due to the chronicity of the Tendon Bi blood stagnation need to be treated and the Shao-Yang and Yang-Ming should be needed at the Ying-spring and Shu-stream points. Both points together adresses the waxing and waning of the sverity of a Tendon Bi and regulate the channels. The chain-lock combination is one further tool to strengthen the treatment effect.
When the Shen is disturbed treating the Shen with Pericardium 7 and Heart 7 is usefull to break the vicious circle of pain and the emotions.
If less needles are used the Qi and blood from the body will not be drained over a critical amount. This is important because in a Tendon Bi the Zheng Qi in general is weak and the Xie Qi is strong. Therefore just drain the Xie Qi and not the Zheng Qi with the right points and the right needling technique.
These advises from the classics can be used to questioning the own way of treating to be a better acupuncturist.
Bibliography
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1Wang, page 292
2Mi, page 280
3Mi, page 580
4Wang Qi-Cai, page 405
5Nugent-head, page 5-12
6Unschuld, page 351
7Wang, page 522
8Peilin, page 21
9Wang, page 653
10Buck, page 317
11Shi, page ix
12Wu, page 165-168
13Wang, page 46
14Wang, page 650
15Wang, page 132
16Shi, page 52
17Bertschinger, page 175
18Personal correspondence
19Wang, page 533
20Wang, page 582-589
21Wang Qi-Cai, page 351-356
22Peilin, page 20
23Wang, page 458
24IASP’s Proposed New Definition of Pain Released for Comment
25Main, page 37-38
26Garland, page 561-571
27Liu, page 121-125
28Maciocia, page 143-148
29Wang, page 499, 774
30Wang, page 652-653
