Generals of manual reflexotherapy. Acupressure. Local barotherapy. Superficial multineedle acupuncture.
Acupuncture has been used in traditional Chinese medicine to relieve pain and cure a variety of diseases for more than 2500 years. The ancient Chinese were aware of an increased sensitivity of certain skin areas (called acupoints) when an organ or function was impaired. Through experience, 361 acupoints were gradually identified to form a network of 14 channels, called meridians. The whole system of meridians brings about the integrity of the body by connecting the internal organs with the superficial parts of the body.
Acupuncture was introduced to the West by Jesuit missionaries to
The interest in acupuncture is growing in the United States, Europe (especially France, Italy, the United Kingdom, Germany, Russia, and some Eastern European nations), and Argentina, but it also has been the object of scientific study in East Asia (China, Japan, and Korea). Acupuncture was brought to the attention of American medical professionals in 1971 when James Reston reported that acupuncture analgesia relieved post appendectomy complications he suffered in
A World Health Organization (WHO) interregional seminar drew up a provisional list of 47 diseases that are amenable to acupuncture treatment. Of these 47 disease, 16 are neuromusculoskeletal disorders. Learning acupuncture may be simplified by limiting its use to therapy for neuromusculoskeletal disorders rather than for all fields.
THE SCIENTIFIC BASIS OF ACUPUNCTURE POINTS
Acupoints can be easily determined by anatomic landmarks or by the measurement with subject’s own hand or finger called “own body scale.” In 1950, Nakatani found that the electric impedance at an acupoint is 1/20 to its surrounding skin area, an area that is easily measured with a simple impedance detector.
Acupoints have been reported with different sizes, from small points to large areas (100-400 um), and are located subcutaneously, intramuscularly, or in the viscera. Nearly all of them are closely related to nerves, and 84.36% of them are near blood vessels. Local infiltration with an anesthetic agent blocks the effect of acupuncture analgesia only when the anesthetic is injected to a certain depth, depending on the point treated. The depth varies from several millimeters at digits or toes, to several centimeters at proximal parts of the limbs.
Other than the 361 classical acupoints, other groups of acupoints exist that are effective in treating particular symptoms. They were named in Chinese in accordance with their position or function. The Chinese names are easier to remember than their English translations, but the difficulties in proper translation may be overcome by readily available commercialized computer programs. Another group of acupoints, called Ah’s points (remembered by the phrase “Ah yes, this is the trigger point”), have the same characteristics and locations that are similar to the trigger points of myofascial pain syndrome, but were discovered independently and labeled differently.
NEUROMODULATION OF ACUPUNCTURE
The word acupuncture is derived from two Latin words, acus (“needle”) and punc-tura (“puncture”). However, the structure of an acupuncture needle differs from the ordinary injectioeedle in its fineness (gauge 30-36) and in its blunt tip, which separates the tissue rather than sharp cutting during twirling.
The characteristic sensation of acupuncture needling, which is called de qi, is a prerequisite for effectiveness. It can be evoked only with puncturing and twirling at the acupoint. In general, the manual needling evokes activity in type II and type III fibers. Electrical acupuncture stimulation mainly excites type II fibers. Type III and IV fibers might be excited when heavy needing techniques are applied, which may cause resultant occurrence of pain.
The sensations evoked by acupuncture applied to points on a limb to be amputated were recorded by Lu and colleagues and Lin and associates. In general, sensations described as “numbness” are evoked by direct stimulation of nerves, and “soreness” by needling tendons or periosteum. “Heavy” or “numb” sensations are evoked by acupuncture stimulation of muscles, whereas pain is altered when perivascular nerve filaments are stimulated by acupuncture. The propagated sensation according to Cajal is a quasi-nervous structure that entwines blood vessels and is related to the neurilemma or the sheet of Henle. It is believed to be related to the sympathetic innervation of skeletal muscles. Another possibility is that propagated sensation is the result of processes similar to the spread of excitation in the central nervous system.
The development of electroacupuncture provides good effect on pain control and muscle stimulation. The use of skin electrodes at the acupoint has increased public acceptance in recent years. With surface electrodes, the side effects of acupuncture including local pain, hemorrhage, infection, pneumothorax, brokeeedle, and syncope (0.2% incidence) can also be avoided.
ACUPUNCTURE
Acupuncture involves stimulating specific anatomical points in the body for therapeutic purposes. The Florida Statutes, Chapter 460 define acupuncture as follows: Acupuncture is a modality of diagnosing and treating disease, pain or physical conditions by stimulating various points on or within the body or interruption of the cutaneous integrity by needle insertion to secure a reflex relief of the symptoms by nerve stimulation. Acupuncture is recognized as a modality of treatment, which is an adjunct to chiropractic. We utilize sterile, non-corrosive, disposable needles for your safety. You should always inform your doctor of the medications you are currently taking, whether or not you are or could be pregnant, if you have a cardiac pacemaker, and if you have received cosmetic implants.
Acupuncture is often used along with other medical care to increase their benefits. It is used for pain control after other medical and dental procedures are performed. It is used for improving health generally as well as promoting healing and lessening the side effects of many drugs including chemotherapy.
Acupuncture is a method of promoting natural healing and improving function within the body. It is done by inserting needles and applying heat and/or electricity at various precise acupuncture points. Chinese explain acupuncture as Qi or energy traveling through channels in the body surfaces. These channels called meridieans are like rivers that run through the body and nourish the tissue. Any obstruction of movement of this energy is like a dam which backs up the flow in one part of the body and restricts the flow in other parts. An obstruction or blockage or deficiencies of energy (Qi), blood and moisture would lead to dysfunction.
Meridians can be influenced by acupuncture needling, unblocking the obstruction of the dams within the meridian circulation releasing the regular flow of Qi, blood and fluid, moisture through these meridians. Acupucture treatments can be helpful for internal organs, conective tissue and promoting digestion absorption and energy production.
Modern science explains the function of acupuncture in the following ways. Needling of acupuncture points stimulates the nervous system to release neuroproteins and neuroinformation packets in the muscles, spinal cord and brain particularly the release of endorphin, enkephalins and dynorphins have been identified in the mid-brain. These chemicals modulate the perception of pain and the physiological function of the neural-endocrine-hormonal system. They trigger the release of the body’s own internal influences on regulating and harmonizing health.
A common form of needleless acupuncture is auricular therapy which is manual electrical stimulation of the acupucture points of the ear. The ear is a micro-system of the entire body with over 200 acupuncture points available for diagnosis and treatment.
Acupuncture is thousands of years old and is based on the principles of Traditional Chinese Medicine (TCM). It is a unique system of healthcare that aims at harmonizing the Mind, Body & Spirit.
The basic tenants of TCM come from the concept of energetic balance. An energy known as Qi (chee) that is essential for health, flows through the body in distinct pathways, called meridians. Each meridian connects with a specific organ and shares its energy.
Any imbalance in flow of Qi through an organ or its associated meridian leads to symptom development and subsequent illness. The flow of Qi can be affected by stress, imbalanced diet, over exertion, lack of physical activity, excess emotions as well as environmental and other life style factors.
The goal of acupuncture is to re-establish the balance of Qi in the body and to address the causes of imbalance. Acupuncture treatments will be combined with diet therapy, acupressure and Qi-Gong breathing techniques specially designed for you.
This holistic treatment will help you achieve optimal results and will promote health and harmony of the Mind, Body and Spirit.
Acupuncture techniques
Acupuncture stimulates the flow of energy through insertion and manipulation of fine, sterile disposable needles at selected acupuncture points.
Acupressure & Tuina Chinese Massage uses a pinch, pull & rolling massage technique and pressure with the finger tips on selected acupuncture points and meridians, to promote the circulation of Qi & blood. It can be used in lieu of acupuncture if there is fear of needles.
Chinese Diet Therapy is based on the concept of Traditional Chinese Medicine. A personalized diet plan will be selected depending on each individual’s pattern of imbalance.
Cupping uses small jars suctioned to the body. It produces a local vasodilation to promote blood circulation, to disperse any blockage of Qi and to release toxins and excess heat.
Moxibustion involves burning the dried herb Mugwort above the acupuncture point to warm and stimulate the energy when it is deficient.
Electrical Modalities may be applied to the needles utilizing different frequencies and intensities to accentuate the treatment.
Acupressure promotes and regulates the flow of Qi and blood by applying pressure on the acupuncture points with the fingers tips.
Qi-Gong Exercise is an energy cultivation exercise utilizing Yin & Yang breathing techniques and the mind to direct the vital energy within specific areas in the body. Personalized exercises will be provide to enhance treatment.
Principle and technique of acupuncture
The principle and technique of acupuncture involve a knowledge of how qi and blood flow through the meridians and organs and how to improve flow using the insertion of needles at certain points. When qi and blood become stagnant, pain occurs. If too much qi and blood are in a certain area, a syndrome of heat and excess can occur; too little qi and blood in an area results in a deficiency syndrome.
During an acupuncture treatment, the body undergoes a normalizing process. Areas with too much qi and blood transfer these vital substances to areas that are deficient, and vice versa. The end result is a kind of homeostasis in which the body’s innate wisdom brings about a self-regulatory effect.
For example, the same acupuncture point can be used to treat either high or low blood pressure; similarly, another point is needled to treat both a rapid or slow heartbeat. This is one of the reasons acupuncture rarely causes side effects. It doesn’t force the body to do anything; it only assists the body in performing its normal functions.
Many people are surprised to learn that acupuncture is relatively painless. Unlike hypodermic needles, which are hollow and much larger, acupuncture needles can be as fine as a human hair. Many times, a patient is not even aware a needle has been inserted, especially when it is placed in areas with relatively few sensory nerves, such as the back.
In a typical acupuncture treatment, the patient lies down, and the practitioner inserts needles in points that have the desired effect on the body. The patient senses heaviness, movement, or an “electrical” impulse that signals the “arrival of qi.” After a few minutes, the patient typically feels a sense of calmness and well-being; many people fall asleep. After a period of 20 minutes to an hour, the practitioner removes the needles and advises the patient to avoid strenuous activity for a few hours to let the treatment settle in.
Depending on the individual and the condition, one treatment might be sufficient, or the patient may need to return a number of times. Results can range from mild improvement to seemingly miraculous recovery. In almost all cases, however, the patient feels calmer and more peaceful after receiving acupuncture.
Those who think acupuncture’s success is merely a placebo effect or the patient’s imagination should consider that acupuncture is exceptionally effective in animals. An increasing number of veterinarians specialize in acupuncture, and their results are quite dramatic. In certain situations, acupuncture is inappropriate. It should not be performed if the patient is extremely hungry or full, intoxicated, or extremely fatigued. In these cases, the treatment may not be as effective or the person might experience dizziness or exhaustion.
People with bleeding disorders such as hemophilia should also avoid acupuncture therapy, although careful application of acupressure or moxibustion is safe. A number of points should not be used during pregnancy due to their tendency to induce labor. Acupuncture is generally not used in children younger than 6 years of age. Although acupuncture originated in China, a number of different branches of the field have evolved in other countries. Sophisticated systems have evolved in Japan and Korea, and development of new techniques has also occurred in Western countries such as France and England.
Although extensive research has been conducted all over the world, two conclusions are commonly reached: First, acupuncture definitely works. Second, nobody is exactly sure how and why it works. This is certainly a testimonial to the brilliant clinicians who developed this miraculous healing practice over the past 2,000 years!
Clean Needle Technique
Infection Control – Practitioner’s Hygiene
Physical cleanliness includes not only adequate hand washing but it also includes such things as wearing clean clothes (i.e. lab coat), long hair being tied back, and nails being kept clean and short. Cuts/abrasions should be covered by and band-aid and/or glove. Do not work with an upper respiratory condition.
Hand Washing –
A practitioner should wash their hands before and after each patient contact. Soap with an antibacterial agent is preferred and strongly recommended. Clean paper towels should be used to dry the hands. When washing your hands, friction and running water are very important to help remove surface germs from the epidermal layer of the skin.
Germ Theory –
If a sterile object touches a non-sterile surface, the object is no longer sterile. All needles must be properly sterilized for needle insertion. The shafts of the needle, especially longer needles, can be stabilized with a sterile cotton ball or sterile gauze. If the needle touches any object (i.e. pants, clothing, bed) or if it is dropped on the floor, the needle is considered contaminated and should not be used. All used alcohol swabs and needle packaging must be disposed of from the clean area. Suction cups that come in contact with the skin require either sterilization or disinfection prior to each use.
Packaging –
All needles that are packaged should be checked for sterilization expiration dates. Any package that is wet, torn or expired is no longer considered sterile.
Types of Sterilization
1. Steam
2. Boiling
3. Dry heat sterilization
4. Chemical sterilization
Disinfection
3 Types of Disinfection
1. Halogen – includes chlorine and
2. Phenol – pure phenol is derived from coal tar
3. Alcohol – two types of alcohol: Isopropyl and Ethyl
Antisepsis
There are 3 types of Antisepsis
1. Iodine
2. Alcohols
3. Hexachlorophenes
Iodine is a popular antiseptic, and it is used in concentrations of 70%-90%. Be careful with using iodine, as it can leave permanent stains on clothing. Isopropyl Alcohol is an effective antiseptic as well. Always keep lids of alcohol bottles closed to keep the 100% concentration. When swiping the skin, the cotton ball or swab should be applied in one fluid wipe. Do not swipe the skin in a back and forth or circular motion. Alcohol should not be applied to mucous membranes or open wounds.
Needle Disposal
All needles must be discarded in proper sharps containers according to Public Health Regulation. Alcohol swabs or cotton balls should be discarded into the trash unless they are completely soaked in blood.
Iatrogenic Complications
1. Forgotten Needle: There have been instances where a practitioner has forgotten to take a needle out. Practitioners should try to keep a needle count. This may reduce the risk of forgotten needles. A forgotteeedle could cause possible harm/injury.
2. Broken Needle: Very thieedles (> 34 gauge) are more susceptible to break during insertion. A brokeeedle with the shaft visible above the skin may be safely removed in a sterile clamp, but if a needle has broken and it is beneath the surface of the skin, it will require a medical referral.
3. Locked or Stuck Needle: Locked or a stuck needle can result from muscle spasms or if the patient moves. The result in a stuck needle because the muscle tissue around the needle spasms and locks the needle in place. When this occurs the needle should never be forcibly removed. You must stop the electro-acupunctoscope and allow the patient to rest. Gently massage the area or meridian of the stuck needle helps with the release of the needle. If the stuck needle is a result of the patient moving, the patient should assume original position then the needle can be taken out.
Pneumothorax
It is one of the most commonly reported complications of Acupuncture in the Medical Literature. A pneumothorax occurs when the surface of the lung is punctured, allowing air to leave from the lung into the pleual cavity. The most common point involved is GB21 and points around the neck and shoulder girdle. The best prevention is the use of correct needle depth and angle.
Blood Vessel
Puncture of small superficial veins is not uncommon. When this occurs, one must apply pressure on the affected site for about one minute. The Practitioner should always inform the patient of a hematoma. Arterial puncture is more serious. You must apply firm pressure for about 3-5 minutes for bleeding of a small artery.
Organ Puncture
All organs are susceptible to being punctured if needled incorrectly. The organs that are more susceptible to being punctured are the bladder, kidneys, enlarged spleen or liver. And the peritoneal cavity. If one is needling lower abdominal points, as the patient to empty their bladder.
Spinal Cord Trauma
Loss of sensation or movement can result from a needle that penetrates the spinal cord.
Neuritis
Inflammation of the nerve can result from needling directly over nerves or from needling using strong electric stimulation. If the nerve is inflamed, the patient could experience numbness, electrical sensation or motor weakness.
Infection
Allergic Dermatitis
Signs and symptoms include redness of skin, an itching/burning sensation, and pain or discomfort at the site of insertion. Acupuncture needles containing nickel and chromium have been known to cause allergic dermatitis.
Miscellaneous Infections
Miscellaneous infections that can occur, include septicemia, osteomylitis, bacterial endocarditis, meningitis and hepatitis. The only methods of prevention for these conditions are the use of sterile needles and identification of high-risk patients.
Other Complications or Side Effects
1. Nausea – nausea may be experienced by the patient if strong parasympathetic stimulation occurs during needling. Needles should be withdrawn immediately if nausea or vomiting persist.
2. Normal Side Effects – You will often hear comments such as “I feel light-headed” or “mild disorientation” or “euphoria”. These are all normal side effects of acupuncture. Sometimes the patient may also feel cold with prolonged needle retention (more than 20-30 minutes).
Contraindications to Treatment
People who are under the influence of drugs or alcohol, those with an empty stomach, those who are emotionally unstable or those who have just finished physical exertion should not be treated with acupuncture.
Contraindications of Electro-acupuncture
When using the electro-acupunctoscope, the current should never cross the back or the chest. The two branches of the same electrode should always be on the same side of the patient’s body. Electro-acupuncture is contraindicated during pregnancy and in those patients with any type of cardiac pacemaker.
Pregnancy
Traditional Chinese Medicine recommends against needling during any asymptomatic, normal pregnancy. If there are symptoms, needling specifically towards the symptom is allowed.
Electrical Stimulation and Acupuncture
Waveform/Frequency/Intensity
Specifications for model AWQ-104E
• Pulse Shape: Biphasic Rectangular Wave
• Pulse width: 350 uS at X1, 40us at X10
• Pulse rate (frequency): 1-120Hz at X(1) 10-1200Hz at X(10)
• Wave form: adjustable, dense-disperse, intermittent
• Output current (intensity): 0-18mA (Lo) 0-40mA(Hi)
• Channel: 4
• Point detector
Manipulation
• Make sure that you examine the electro-acupunctoscope before each use.
• Insert the needle (with metal handle) and get Qi sensation
• Make sure all the knobs are turned to zero before hooking the electro-acupunctoscope to the needles.
• Connect the electrical stimulator with needles.
• Turn power on.
• Adjust the electro-acupunctoscope to the appropriate waveforms and frequency
• Adjust the intensity to a comfortable level.
• If intensity “Hi-Lo”switch, or frequency “1-10″switch, or polarity need to be changed, the output intensity (and frequency sometime) should be turned down to zero.
• Treatment should last 15-20min
• Make sure all the knobs to zero before turning off the power and take away the conducting wire.
Notes:
• 2 needles complete a circuit
• Connect negative end to primary point, positive end to secondary point
Waveforms
Dense wave (continuous)
High frequency: 50-100 pulses per second
Function and indications:
Inhibit sensory nerves and motor nerves
Relieve pain, calms the mind, relieve spasm of the muscles
Disperse /Sparse wave (continuous)
Low frequency: 2-5 pulses per second
Function: Induce the contraction of muscles, and enhance the tension of muscle and ligament.
Indication: injury of muscle, ligament and joints.
Dense-disperse wave
Disperse wave and dense wave appear alternately, each last about 1.5 s. Prevent the body’s adaptation
Function:
Relieve pain, improve function of the organs, improve qi and blood circulation, improve nourishment of tissues, reduce inflammation
Indication: Pain, trauma, sprain, arthritis, sciatica, facial paralysis, weakness of muscles, etc.
Intermittent wave
A wave appears on and off rhythmically. Interval: 1.5s
Function: Stimulate the muscles
Indication: Paralysis.
Precautions/Contraindications
• Turn up the intensity of the electro-acupunctscope gradually so we can avoid incidences such as muscle contraction, brokeeedle and bent needle resulting from increased intensity.
• Number one priority is to keep the patient comfortable at all times.
• Mild stimulation is required when applying electro-acupuncture near the spine and brain stem.
• When applying electro-acupuncture on chest and back area in the region of the heart, do not connect points across two sides of the body to avoid the current passing through the heart.
• Do not apply stimulation in the region of the heart.
• Do not apply stimulation to patients with pacemakers or other electronic implants.
• Use electro-acupuncture cautiously for patients have heart diseases, seizure, and pregnant women.
• Electro-acupuncture should be used cautiously for patients who are aged or weak.
Disease treatment
Advantages
1. Better for nerve related problems
2. Stimulation is more measurable than manual
3. Many points can be stimulated at the same time (manual can stimulate only one at a time)
4. Stimulation can last longer. A typical treatment is usually 20 minutes. If you are stimulating manually, you usually only stimulate for a couple of minutes at the most.
• Points are selected in pairs
• Usually unilaterally
(Pair on same side left or right Do not cross from one side to another as that may interfere with heart action)
BLEEDING PERIPHERAL POINTS:
An Acupuncture Technique
Piercing a vein or small artery at the tip of the body-finger tips, toes, or top of the ears-is a technique well-known among acupuncturists. To the uninitiated Westerner, this therapy may seem even stranger than standard needling that is explained as a method of adjusting the flow of qi in the vessels. In this case, a few drops of blood let out from one or more peripheral points by quickly stabbing the skin with a lance is said to have significant effects. As mentioned in Fundamentals of Chinese Acupuncture, “The procedure should be thoroughly explained to the patient before it is performed to allay his or her fears.”
Letting out blood is among the oldest of acupuncture techniques. Indeed, it has been speculated that acupuncture started as a method of pricking boils, then expanded to letting out “bad blood” that was generated by injuries or fevers, and finally allowing invisible evil spirits and perverse atmospheric qi (most notably “wind”) escape from the body. Only later, perhaps as the needles became more refined and as scholars developed of a more subtle theoretical framework, were thin filiform needles used as the primary acupuncture tools for the purpose of adjusting the flow of qi and blood, without necessarily releasing something from the body.
The Lingshu (Spiritual Pivot) and its companion volume, the Suwen (Simple Questions), written around 100 B.C., established the fundamentals of traditional Chinese medical ideas and acupuncture therapy. Originally, there was a set of 9 acupuncture needles, which included the triangular lance, sword-like flat needles, and fairly large needles. In the Lingshu these ancient needles are numbered and the needle designs and qualities are associated with what the numbers represent. Regarding the fourth needle, which has a tubular body and lance-like tip, the text states: “This can be used to drain fevers, to draw blood, and to exhaust chronic diseases.” The seventh needle is described as being hair fine (corresponding in form to the most common of the current needles); it is said to “control fever and chills and painful rheumatism in the luo channels.” In modern practice, using the lance as a means to treat chronic diseases has been marginalized (except to treat acute flare-ups of chronic ailments), while the applications of the hair-fine needle has been greatly expanded beyond malarial fevers and muscle and joint pain.
The Lingshu has several references to the use of blood-letting. In the chapter on hot diseases, it states:
For a hot disease with frequent frights, convulsions, and madness, treat the blood channels. Use the number four lance needle. Quickly disperse when there is an excess. When there is insanity and a loss of hair, treat the blood and the heart.
The use of the lance needle to treat the blood channels is a reference to blood-letting. The indications of blood-letting for alleviating heat, convulsions, and mental distress has persisted to modern times. For example, when treating the jing (well) points at the beginning or end of the meridians, the general indication that has come down to us today is for fevers and mental illness.
The lance needle is also recommended, in the same chapter of the Lingshu, for treatment of a hot disease where the whole body feels heavy and the center of the intestines is hot, and when there are spasms around the navel, and the chest and ribs are full. Among the points suggested to be bled are “those points on the cracks of the toes.” Drawing blood, which is mentioned repeatedly in this chapter of the Lingshu, is usually accompanied by instructions that one should drain it from the luo vessels, which are described in this text as visible vessels, apparently corresponding to veins. For example, it is said that one should examine above the anklebone to see if the luo channels are full; if so, drain until blood is seen.
An entire chapter of the Lingshu is devoted to the luo vessels in which questions are answered about blood-letting therapy. It is said that: “When the blood and qi are both abundant and the yin qi is plentiful, the blood will be slippery so that needling will cause it to shoot out.” On the other hand, “When much bleeding takes place with needling, but the color does not change and there are palpitations and depression, it is because needling the luo channel causes the channel to empty.” The change in color that is anticipated occurs when the bad blood, which is described as thick and black, has been eliminated and normal red blood appears.
The Suwen also has a chapter on treating the luo vessels. It makes three references to blood-letting, all in association with the point ranggu (KI-2); in general, the ranggu point is needled, and then the capillary in front of the point is to be bled. This is used in treatment of swollen throat and for abdominal swelling and fullness that accompanies either heart pain or injury. Similarly, in the Lingshu chapter on water swelling, a case of abdominal swelling-where the skin is tight like a drum-is described; the therapy recommended is to draw blood from the luo channels. The location of blood-letting is not specified, though it is stated that the problem should be treated in the lower part of the body.
In the Suwen chapter about needling of the channels properly, it is said that:
When one administers acupuncture during the spring, it is appropriate to needle shu (stream) points. In fact, bloodletting is a preferred technique….In the summer, one can also practice bloodletting, but it is preferable to use superficial luo points. Allow the bleeding to stop by itself, so that the pathogen will be completely eliminated.”
In the Suwen chapter on seasonal organ pathology, blood-letting is mentioned for excess conditions, and the key therapeutic technique is usually to address an entire channel, which is sometimes done at or near its peripheral points. Thus, it says, for excess of the liver, bleed the jueyin and shaoyang channels; for excess of the spleen, one is instructed to bleed points of the taiyin, yangming, and shaoyin; for excess of the lung, bleed the shaoyin channel; for excess of the kidney, bleed the shaoyin and taiyin channels. Only the excess of the heart is treated somewhat differently: one is instructed to needle and bleed points under the tongue (jinjin and yuye) and at yinxi (HT-6).
The Suwen chapter on malaria-like illnesses has an interesting instruction for needling the finger tips:
When malaria begins to flare-up, it will start at the extremities. If the yang has already been injured, the yin will be affected as well. Before the flare-up, therefore, one should tie the ten fingers with string. This way, the pathogen cannot enter more deeply and the yin cannot come out. After tying the fingers, observe the luo channels. Where purple stagnation appears in the channels, perform blood-letting.
Thus, one looks for those specific veins that are congested in order to apply this therapy, rather than picking certain points or channels theoretically. The particular practice described here, of trying to avert the flare-up by locating the stagnation and draining the blood is described as “ambushing the enemy before being confronted.” The approach to making the veins stand out is one that is still mimicked today, with massaging and pressing to assure that when the vein is lanced blood will flow out, though the original purpose was also diagnostic-determining which vessel had the pathogen to be let out.
The most comprehensive traditional text on acupuncture is the Jia Yi jing (Systematic Classic of Acupuncture), published in 1601, though attributed to work originally done by Mi Huangfu in the 3rd century. It includes an extensive explanation of the №4 needle used for blood-letting:
The number four pertains to the four seasons. When a person, after having been struck by one of the winds of the eight directions and four seasons, develops a chronic illness where the evil has invaded and penetrated the channels and connecting vessels [luo], then this condition is treated by the sharp needle….It has a cylindrical body and a pointed end of three blades and is one cun and six fen in length. It is used to drain heat and let out blood to dissipate and drain chronic diseases. Accordingly, it is said that, if the disease is securely housed within the five viscera, the sharp needle should be selected and draining technique applied to the well [jing] and brook [shu] points according to the seasons.
As with the earlier texts, blood-letting is mainly recommended in Jia Yi jing for conditions of abdominal swelling, malarial-type diseases with alternating fever and chills (Chinese: nue), and certain painful conditions, particularly lower back pain. The main idea is to eliminate bad blood, as in this case of treating an injury:
The unraveled vessel causes people to suffer from splitting lower back pain with irascibility….Needle the unraveled vessel at weizhong (BL-40), pricking the binding connecting vessel there which is like a millet grain. Upon being pricked, the vessel will ejaculate black blood and, once the blood turns red, the treatment may be stopped.
In sum, for excess type syndromes, bleeding is recommended because it can drain the excess, alleviate congestion and stasis, and remove the pathogens. As described in Fundamentals of Chinese Acupuncture, the function of blood-letting therapy is “to drain heat or quicken the blood and qi and relieve local congestion.” The method of carrying out blood-letting is described:
This procedure is done by first applying pressure to restrict the blood flow of the area, to increase the visibility of the veins and to cause the blood to flow out more easily when the vein is pricked. The point is then swiftly and decisively pricked to a superficial depth of about 0.1 cun and a few drops of blood are allowed to escape. Lastly, the point is pressed with sterile cotton until the bleeding ceases.
The last instruction, which is a modern practice, differs from the ancient one in which the bleeding is allowed to continue until it stops on its own. In the Jia Yi jing, there is a discussion of treating alternating chills and fever, in which blood-letting is recommended and the amount of blood to be let out is “appropriate to the fatness or thinness of the patient,” thus a relatively larger amount for heavier persons.
In Essentials of Acupuncture (6), the use of the three-edged needle (lance) is said to be used for high fever, mental disorders, sore throat, and local congestion or swelling. As to technique, the point to be bled is pricked superficially, just 0.05-0.1 cun (inches) deep, which should be light and superficial and the amount of bleeding to be “determined by the pathological condition.” Vigorous pricking is not permissible. In general, acupuncturists are cautioned about using bleeding therapy for persons who have weakness of their yin or yang qi, because the treatment can “strip” away these essences. Virtually all acupuncture texts mention contraindications for blood-letting therapy in persons who have already suffered from hemorrhage (including post-partum) and for those who are quite weak. This method is not recommended for pregnant women. Today, blood-letting is most often recommended for peripheral points.
PERIPHERAL POINTS BLOOD-LETTING
Peripheral blood-letting today is mainly carried out at the fingers and toes. At the tips of the toes, for example, are the qiduan points, located 0.1 cun behind the nails. These are said to be useful for emergency treatment for stroke or for numbness of the toes, also for redness, swelling, and pain of the instep of the foot. Near the toe webbing, there is another set of points, the bafeng (eight wind) points, four on each foot. These can be needled either by standard procedure with shallow oblique insertion, or they can be pricked to cause bleeding. The points are indicated for swelling of the legs, toe pain, snake bite to the foot or lower leg, and swelling and pain of the dorsum of the foot.
Similarly, at the tips of the fingers are the shixuan points, located 0.1 cun behind the nails. Pricking these points to let out blood is said to be useful for coma, epilepsy, high fever, and sore throat. A little further down, at the finger creases (the lower of the two creases along the finger joints), are the sifeng points (four wind points; the thumb, which has only the one crease, is not included. Pricking these to let out plasma fluid that is yellowish white, is said to treat malnutrition and indigestion in children and whooping cough. Finally, points between each pair of fingers, at the top of the webbing joining the fingers, are the baxie points. These can be acupunctured with shallow insertion of 0.5-0.8 cun depth or pricked to cause bleeding, used to treat snakebite of the hand.
The terminal jing points, known by some as ting points, are also pricked to let out blood. These “well” points, of which there are 12, are mainly located at the tips of the fingers and toes (the exception is KI-1); below are some of the indications for bleeding these points:
Shaoshang ) LU-11: thumb, radial side): sore throat, epistaxis, pain of fingers, febrile disease, mental disorders, loss of consciousness.
Shangyang (LI-1: index finger, radial side): toothache, sore throat, numbness of fingers, febrile disease, loss of consciousness.
Zhongchong (PC-9: middle finger, at fingertip): cardiac pain, irritability, loss of consciousness, aphasia with tongue stiffness, febrile disease, heat stroke, infantile convulsions, feverish sensation of the palm.
Guanchong (TB-1: ring finger, ulnar side): headache, redness of eyes, sore throat, stiffness of the tongue, febrile disease, irritability.
Shaochong (HT-9: little finger, radial side): cardiac pain, pain in chest, mental disorder, febrile disease, loss of consciousness.
Shaoze (SI-1: little finger, ulnar side): febrile disease, loss of consciousness, sore throat, corneal disease.
Yinbai (SP-1 : big toe, medial side): abdominal distention, uterine bleeding, mental disorder, dream disturbed sleep, convulsions.
Dadin (LV-1: big toe, lateral side): prolapse of uterus, hernia, uterine bleeding, enuresis.
Lidui (ST-45: 2nd toe, lateral side): facial swelling, toothache, distending sensation of chest and abdomen, cold in leg and foot, febrile disease, dream disturbed sleep, mental confusion.
Yonguqan (KI-1: sole of foot, between metatarsals 2-3): pain in vertex of the head, dizziness, blurring of vision, sore throat, aphonia, dysuria, dyschesia, infantile convulsion, loss of consciousness, feverish sensation in the sole.
Qiaoyin (GB-44: 4th toe, lateral side): one-sided headache, ophthalmalgia, deafness, pain in the hypochondriac region, dream disturbed sleep, febrile disease
Zhiyin (BL-67: little toe, lateral side): headache, nasal obstruction, epistaxis, ophthalmalgia, feverish sensation in the sole.
Finally, there is pricking of the ear apex (tubercle) to let out blood, as a similar basic technique. All these peripheral point bleeding treatments are used for heat and excess syndromes. As an example, treating the ear apex by bloodletting has been recommended to treat hordeolum, an eye infection.
Peripheral blood-letting is distinguished from a practice of pricking the skin to release blood prior to applying cups, that provide an additional stimulus to the area and cause more blood to be extracted. However, like the peripheral point bleeding, it is used to let out pathogens and heat. A report on treatment of acute diseases with blood-letting followed by cupping suggested that the technique would remove toxic heat from the interior. In general, the author believed that:
The combination of bleeding and cupping aims at eliminating the toxic factors and removing stagnation, promoting resuscitation, and clearing heat, activating qi and blood circulation in the meridians and collaterals, relieving swelling and pain in order to facilitate the elimination of pathogenic qi and the restoration of good health.
He gave examples of blood-letting and cupping at dazhui (GV-14), taiyang (Extra-2), and weizhong (BL-40). Weizhong, at the back of the knee, is probably the most frequently mentioned non-peripheral point for bleeding therapy, with or without cupping; quze (PC-3), at the corresponding point in the crease of the elbow, is next most frequently used. Dazhui (GV-14), the meeting point of all six yang channels with the governing vessel, is treated for many acute heat syndromes, with standard acupuncture, blood-letting, and cupping.
Some of the peripheral blood-letting applications are easy to understand, at least theoretically, from the basic concept of letting out tainted blood; for example, to treat a poisonous snake bite where venom has been injected into the nearby portion of the limb. Similarly, swelling and pain of the foot by letting out blood at the toes is conceptually understandable within this paradigm. The treatment of stroke (apoplexy), coma, mental dysfunctions, and epilepsy by this method may be related to the concept that a vicious wind penetrates to the center and causes severe disruption to the normal brain function; the wind turbulence generates heat in the blood; alternatively, a disease with high fever can cause these damaging sequelae. This heat may be released by causing bleeding from these points, under the concept that the blood is a vehicle for carrying out the excess heat. In the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (10) under the condition called wind-stroke, in addition to several acupuncture points to be treated by standard needling, the authors mention using a three-edged needle to cause bleeding at the jing-well points. The Encyclopedia states that “pricking the 12 jing-well points helps to eliminate heat and bring resuscitation.”
The problems of high fever, bleeding, sore throat, and headache might also be understood in terms of being treated by letting out heat via the removal of bad blood or excess blood. In the English-Chinese Encyclopedia, pricking the jing-well point shaoshang (LU-11), is mentioned as one of the treatments for severe cough due to wind-heat affecting the lungs; the jing-well point zhongchong (PC-9), as well as the non-peripheral points at the limb joints, quze (PC-3) and weizhong (BL-40), are indicated for pricking to release blood for treatment of high fever with heat in the ying and blood levels. shixuan points at the fingertips, as well as PC-3 should be pricked, the book suggests, for treatment of heat stroke (summer heat disturbing the heart and requiring resuscitation). Bleeding at the jing-well point zhongchong (PC-9) is also suggested for treatment of syncope of the excess type, while pricking of the 12 jing-well points is part of the therapy for severe sun stroke. Another recommendation for treating sunstroke is the combination of quze (PC-3), weizhong (BL-40), and dazhui (GV-14) as well as the 12 jing-well points all being pricked to cause bleeding.
MODERN VIEWS
Blood-letting is a method of therapy that is difficult to explain in modern terms. Aside from the traditional theoretical basis for these treatments in letting out heat and excess factors, a key issue is whether it actually produces the claimed effects. Many Western acupuncturists have stated informally that they get dramatic results from this treatment method, but, unfortunately, there is no evidence presented to support such contentions. Despite the frequent mention of treating peripheral points by blood-letting in both ancient and modern Chinese medical texts, there is little reference to this technique in Chinese medical journal reports. Very few articles focus specifically on use of this technique. Further, descriptions of therapies for the disorders that peripheral blood-letting is supposed to successfully treat rarely include that method. Instead, standard acupuncture techniques without blood-letting, as well as herbal therapies, are described. Therefore, the effectiveness of the technique must be questioned, at least until further evidence has accumulated.
When the method of peripheral blood-letting is used, it is usually combined with other therapies (e.g., standard acupuncture or even Western drugs) that might be sufficient to explain the claimed beneficial effects. In a report on treating hordeolum by bleeding the ear tubercle mentioned in the previous section, the eyes were also treated with antibiotics. In an article on treatment of patients with persistent hiccup (1 to 15 days) with bleeding of jing-well points, the treatment was accompanied by standard acupuncture at several points (BL-13, BL-17, BL-21, ST-44, ST-45, LI-1, and LI-4). It was reported that 95 out of 131 patients were cured after one treatment (9). It is difficult to know how much of a contribution was made by the peripheral blood-letting.
A Chinese physician who has used the blood-letting at the hand jing-well points extensively for emergency cases wrote a report on his experience (see Appendix 1). In his general analysis of treatment strategies and in two case presentations, he described use of standard acupuncture therapy, particularly needling of LI-4, along with bleeding the hand jing-well points bilaterally. It was not possible to tell whether the same results could have been attained without the blood-letting portion of the treatment. One of the claims commonly made by Western acupuncturists is that blood-letting at the jing-well points or at the ear can rapidly decrease blood pressure. Yet, in a clinical study conducted in
Today, we know that the peripheral blood has the same content as the rest of the blood that circulates in the body, and that there is no reason to expect that the blood let out by this method is “bad blood,” other than in a purely symbolic role. While standard acupuncture therapy is depicted as being effective, in part, by releasing various transmitter substances (e.g., endorphins), by stimulating local blood flow (e.g., by dilating vessels), and by producing changes in the brain that may have both systemic and highly specific effects, letting out a small amount of blood (usually just a few drops) remains without a suitable explanation for the potent effects claimed. The technique used to let out the blood is one of quick and light pricking to pierce the skin and vein. Unlike standard acupuncture, this method does not involve getting a qi reaction or other evidence that the body is responding on a deep level.
Blood-letting occurs iumerous contexts in the modern world. Millions of people donate a pint of blood, sometimes regularly; millions more prick fingertips every day to get a blood sample for diabetes testing. While these experiences are not as specific as aiming for certain acupoints to release blood, the large number of points at the periphery indicated for blood-letting in the Chinese literature, often with overlapping indications, suggests that the technique does not necessarily require a high degree of specificity for the location. Do diabetics and blood donors suffer substantially less from syndromes of heat and excess?
Therefore, acupuncturists should be somewhat cautious in making claims of effectiveness and should request clinical trials to evaluate the method, especially now that funding for acupuncture trials is being provided in the
Blood-letting is an ancient therapy that was an essential part of traditional acupuncture practice described in the original texts and which persists today, particularly for treatment of emergency cases, such as loss of consciousness, high fever, and swellings. Most of the blood-letting therapy relies on treating peripheral points of the fingers and toes. Its purpose is to alleviate excess conditions, particularly heat syndromes and fluid swelling, and to promote resuscitation. A traditional concept was that the release of blood would draw out the excess. This therapy is somewhat difficult to explain in modern terms, and, therefore, requires some investigation and research before any substantial claims of effectiveness can be made. Practitioners ofteote what appear to be prompt and dramatic results from the therapy, suggesting that its efficacy should be easy to confirm using short-term trials. In most cases, peripheral blood-letting (or other blood-letting therapy) is accompanied by standard acupuncture, especially with points that are not far from the blood-letting points, such as the hand/wrist points LI-4, LU-7, and PC-6 and the foot/ankle points LV-2, LV-3, and KI-3, suggesting that these other points may contribute significantly to the observed therapeutic outcome. As a symbolic therapy-of letting out excess, bad blood, toxins, or heat-blood-letting is a potent technique for both the practitioner and the patient, and its use represents a continuation of the earliest traditions of acupuncture.
APPENDIX 1. Clinical Application of Twelve Well Points by Duan Gongbao.
The following brief report was edited slightly for readability and to avoid repetition:
In many years’ clinical practice, I used blood-letting method of “Twelve Well-Points” to treat emergencies such as coma, syncope, acute infantile convulsion, wind-stroke syndrome, hysteria, epilepsy, etc., and have achieved immediate results. Twelve Well-Points refer to bilateral hand well points: shaoshang (LU-11), shangyang (LI-1), zhongchong (PC-9), guanchong (TB-1), shaochong (HT-9) and shaozhe (S-I 1) which belong to the three yin and three yang meridians of the hand and are located at the finger tips. The 6 well-points of the yang meridians belong to metal and are the beginning points of the three yang meridians of the hand, while the other 6 well-points of the yin-meridians belong to wood and are the ending points of the three-yin meridians of the hand.
The indications of the Twelve Well-Points are acute febrile diseases, cerebrovascular diseases, wind-stroke syndrome, syncope, acute infantile convulsion, manic and depressive psychosis, etc. The Twelve Well-Points can be used for eliminating heat, resolving phlegm, restoring consciousness, and promoting resuscitation. It is recorded in the classic book Lingshu that psychiatric diseases are related to the five zang-organs, so, the well-points are often used. It also says that blood diseases are related to the heart, thus, blood-letting can eliminate pathogenic heat and cause resuscitation. Therefore, pricking for bleeding and twirling-reducing or twirling-pricking of the well-points can be used to treat mental disorder, excess type of wind-stroke syndrome, acute infantile convulsion resulting from attack of pericardium by heat, heart disturbed by phlegm-fire, or mental confusion due to phlegm, syncope due to high fever, etc. After routine sterilization with 75% alcohol, hold a sterilized three-edge needle to prick these well-points rapidly, then squeeze the local point forcefully to let a few drops of blood out.
When the patient falls into sudden mental changes, loss of consciousness or mental disorder, the Twelve Well-Points are treated to induce resuscitation, as follows:
Accumulation of phlegm-heat in the lung and heart confused by phlegm: in case of invasion of the pericardium by pathogenic factors, it is treated by ventilating the lung and resolving phlegm, clearing away pathogenic heat from the heart to cause resuscitation. The 12 well-points are used in combination with chize (LU-5), shenmen (HT-7) and daling (PC-7), which are punctured and stimulated with the reducing method.
Attack of the pericardium by pathogenic summer-heat: in case of heatstroke due to accumulation of pathogenic heat to block qi flow, it is treated by clearing away pathogenic heat from the heart to cause resuscitation, restoring the consciousness. The well-points are selected in combination with reducing shenmen (HT-7) and pricking quze (PC-3) to let a bit blood out.
Wind-stroke: in case of excess syndrome of stroke, it is treated by clearing away heat, inducing resuscitation and waking up the patient from unconsciousness. The 12 well-points are punctured in combination with needling by the reducing method yongquan (KI-1) and hegu (LI-4).
Interior heat-syndrome: in case of acute infantile convulsion due to high fever and wind stirring inside, it is treated by clearing away heat and toxic materials, eliminating pathogenic heat from the heart, calming the liver to stop the wind, and by using well-points combined with needling by the reducing method hegu (LI-4) and taichong (LV-3).
As an example, Mr Wang, aged 58 years, a farmer, suddenly fell into coma; he had flushed complexion, lockjaw, deviation of the eyes, rigidity of both hands, rattling sound in the throat due to phlegm, full and taut pulse. His syndrome was heart stirred by phlegm-fire, producing an excess type of wind-stroke syndrome. Therapeutic principles applied were eliminating heat, resolving phlegm, causing resuscitation, and restoring consciousness. Acupoint selection included the Twelve Well-Points pricked to let a bit of blood out; hegu (LI-4) and taichong (LV-3) were punctured and stimulated with reducing method (needles retained for 10 minutes). After treatment, the patient was restored to consciousness immediately, accompanied with slight deviation of the mouth and eyes, weakness of the upper and lower limbs on the left side. Thereafter, acupoints on the face and limbs were punctured continuously. Half a month later, he returned to normal.
As another case, a male baby, aged 2 1/2 years, experienced high fever, convulsion, lockjaw, muscular spasm of the four limbs, and loss of consciousness. Differentiation of syndromes indicated acute infantile convulsion due to excessive interior heat and wind stirring inside. Therapeutic principles applied were dispelling wind and removing heat, calming the internal wind and relieving convulsion and spasm. Acupoint selection included the Twelve Well-Points which were pricked to let a bit of blood out, combined with puncturing and stimulating hegu (LI-4), taichong (LV-3), and jiexi (ST-41) with the reducing method. After treatment, the baby was restored to consciousness immediately. Half an hour later, his fever abated and he spoke and laughed as usual.
The effects of the Twelve Well-Points in causing resuscitation, clearing away heat from the heart and tranquilizing the spirit, ventilating the lung, and regulating yin and yang are derived mainly from the combined application of the Three Yin and Three Yang Meridians of the hand. Shaoshang (LU-11) and shangyang (LI-1) serve to ventilate the lung, remove heat from the throat, regulate the wei qi to relieve the exterior syndrome, and reduce fever. Zhongchong (PC-9) can function in clearing away heart-fire and accumulated heat of the pericardium, tranquilizing, inducing resuscitation and restoring consciousness. Guanchong (TB-1) can clear away the pathogenic fire of the upper-jiao and remove the accumulated heat in the shaoyang meridian. Shaochong (HT-9) is used to clear away heart fire, tranquilize, and regulate heart qi. Shaozhe (SI-1) serves to remove heart fire, ease mental anxiety, and eliminate accumulation of heat in the taiyang meridian. The aforementioned acupoints are only suitable for recuperating depleted yang and rescuing the patient from collapse, rather than for prostration (deficiency) syndrome due to sudden exhaustion of yang of emergence or due to exhaustion of qi from chronic disease because of excessive weakness of the primordial qi. Therefore, the Twelve Well-Points should be used according to differentiation of syndromes. Otherwise, erroneous application of these acupoints will bring the patient with unfavorable influence and even miss the opportunity for emergency treatment because of delay.
APPENDIX 2. Clinical Application of Blood-Letting Therapy by Yang Haixia
The following report includes the full text of the physician’s instructions on treatment, and then his case reports, which are shortened considerably for presentation here.
The operator needs to massage the determined area for blood-letting to cause local congestion, and clean the skin area for disinfection according to the routine procedure. Fix the acupuncture point or vein in the blood-letting area with one hand, and hold a sterilized three-edged needle with the other hand to prick the point or vein 1-
Case 1. Chronic headache caused by hyperactivity of yang. Extra points taiyang and yintang were pricked to let out a few drops of blood. Shortly after treatment, the pain disappeared suddenly, without relapse.
Case 2. Apparent small stroke, causing sudden deviation of mouth, left eye being closed, and chewing dysfunction. An obviously distended vein in the mouth was pricked to cause bleeding, once per week. Body acupuncture with electric stimulation was used additionally, every other day. After 30 days treatment, facial muscles returned to near normal.
Case 3. Apparent small stroke with rigidity, pain, and numbness of tongue accompanied by dysphasia. Extra points jinjin and yuye of the lingual vein were pricked for bleeding. Two treatments resolved the disorder.
Case 4. Intermittent dizziness, tinnitus, and heaviness of the head due to hypertension. Blood-letting was done on the ear apex on both sides and the groove on the back of the ears to let out a few drops of blood. After five treatments, the blood pressure was stabilized at a lower level with relief of symptoms.
APPENDIX 3. Summary of Major Blood-Letting Points
The following tables are derived from the Advanced Textbook on Traditional Chinese Medicine and Pharmacology.
Summary of Peripheral Points for Blood-Letting
This table does not include the jing-well points, which are manly used for the same indications as the other points listed here, except for the unique pediatric therapy of the sifeng points.Point Name Distribution of Blood Vessels Indications
shixuan at the fingertips, network of the proper palmar digital arteries and veins fever, coma, sunstroke, unconsciousness, numbness of the hands and feet
Shierjing behind the corner of the fingernails, network of the proper palmar digital arteries and veins fever, coma, sore throat, tonsillitis
sifeng network of the proper palmar digital arteries and veins infantile malnutrition, dyspepsia, pertussis (squeeze out yellowish-white fluid)
Yuji (LU-10) reflux branch of the cephalic vein in the thumb fever, sore throat, tonsillitis
Bafeng and qiduan dorsal venous network of the foot swelling, pain and numbness of the foot, snakebite
baxie dorsal subcutaneous network of hand swelling, pain and numbness of the hand, snakebite
Ear apex, supratragic apex, and earback posterior auricular artery and vein fever, tonsillitis, red and swollen eyes, hypertension
Summary of Body Points for Blood-letting
This table does not include the point dazhui (GV-14), which is also often used in blood-letting, especially accompanied by cupping. Dazhui has he indications of treating various heat syndromes and fevers, and epilepsy.Point Name Distribution of Blood Vessels Indications
Chizi (LU-5) cephalic vein sunstroke, acute vomiting and diarrhea
Quze (PC-3) cephalic vein sunstroke, suffocating feeling in the chest, fidgets
Weizhong (BL-40) great and small saphenous veins of the popliteal fossa sunstroke, acute vomiting and diarrhea, systremma
Yintang branches of the medial frontal artery and vein headache, dizziness, red and swollen eyes, rhinitis
Taiyang venous plexus inside temporal fascia headache, red and swollen eyes
Baihui (GV-20) anastomotic network of the left and right superficial temporal artery and vein and occipital artery and vein fever, tonsillitis, red and swollen eyes, hypertension
jinjin and yuye lingual vein apoplexy, stiff tongue, and stuttering
Myofascial Pain Syndrome. Manual methods of muscle correction. Manual therapy (chiropractic).
Principles of modern reflexology.
Myofascial Pain Syndrome
Myofascial Pain Syndrome (or MPS) is a term used to describe one of the conditions characterized by chronic, and in some cases, severe, pain. It is associated with and caused by “trigger points” (TrPs), which are localized and sometimes extremely painful contractures (‘knots’) found in any skeletal muscle of the body. The symptoms can range from referred pain through myofascial trigger points to specific pains in other areas of the body.
MPS may be related to a closer-studied complex condition known as fibromyalgia. By accepted definition, the pain of fibromyalgia is generalized, occurring above and below the waist and on both sides of the body. On the other hand, myofascial pain is more often described as occurring in a more limited area of the body, for example, only around the shoulder and neck, and on only one side of the body.
Neither MPS or FMS is thought to be an inflammatory or degenerative condition, and the best evidence suggests that the problem is one of an altered pain threshold, with more pain reported for a given amount of painful stimuli. This altered pain threshold can be manifest as increased muscle tenderness, especially in the certain areas, e.g., the trapezius muscle. These syndromes tend to occur more often in women than in men, and the pain may be associated with fatigue and sleep disturbances.
The precise cause of MPS is not fully understood and is undergoing research in several medical fields but there are some systemic disorders, such as connective tissue disease, that can cause MPS. Unfortunately, many practitioners consider it too generalized and, since physicians’ specializations have become so narrow, they do not want, nor have the necessary current information, to treat the condition.
A fairly new form of therapy called Myofascial Release, using gentle fascia manipulation and massage, is believed by some to be beneficial and pain-relieving.
Myofascial pain syndromes can arise of distinct, isolated areas of the body, an example being Urologic Chronic Pelvic Pain Syndromes. (UCPPS).
People who suffer from this syndrome are many times in “unbearable” pain which moves at will from one point in the body to the next. It has been found that mild pressure on “trigger point” areas may relieve some of the discomfort by calming down the nerve pain. (UCPPS).
Myofascial Pain. The Symptoms and Causes
Myofascial pain syndrome is a chronic local or regional musculoskeletal pain disorder that may involve either a single muscle or a muscle group. The pain may be of a burning, stabbing, aching or nagging quality. Importantly, where the patient experiences the pain may not be where the myofascial pain generator is located. This is known as referred pain. The pathophysiology of myofascial pain remains somewhat of a mystery due to limited clinical research; however, based on case reports and medical observation, investigators think it may develop from a muscle lesion or excessive strain on a particular muscle or muscle group, ligament or tendon. It is thought that the lesion or the strain prompts the development of a “trigger point” that, in turn, causes pain.
In addition to the local or regional pain, people with myofascial pain syndrome also can suffer from depression, fatigue and behavioral disturbances, as with all chronic pain conditions.
How to Diagnose and Treat Myofascial Pain Syndrome
Myofascial pain syndrome can be considered, at least partially, a side effect of our modern lifestyles. It is caused by numerous factors: trauma, tension, inflammation, overuse, overload, poor posture, stress, repetitive strain, poor sleep, emotional stress, or other medical conditions, such as nerve entrapment, thyroid dysfunction, vitamin insufficiencies, metabolic dysfunctions. Myofascial pain is pain localized in the muscles and surrounding tissues. The constellation of symptoms includes achiness, fatigue, poor sleep, chronic muscle tightness, and limited range of motion. Sometimes, myofascial pain can produce numbness and sensory disturbances. If myofascial pain occurs in the neck, it can cause ringing in the ears, loss of balance, or chronic headaches.
Trigger points:
Trigger points are commonly associated with myofascial pain. In a study of 200 asymptomatic young adults, 54% of females and 44 % of males had latent trigger points. Latent trigger points are not painful unless they are pressed. In adult populations with complaints of pain, 86-93% of people had active trigger points. Active trigger points cause pain with or without applied pressure. Trigger points are hypersensitive, painful “knots” in taut muscle bands. When pressed, the trigger point often causes localized or referred pain. The trigger point may cause numbness, tingling, increased sweating, muscle spasms, or radiating pain to other areas. Infact, the trigger point can mimic nerve related (neuropathic) pain.
Ergonomics and Posture:
Because this is often a chronic condition, treatment requires multiple repeated therapies. Because of our sedentary lifestyles and numerous hours seated at a desk, the small muscles of the neck and upper back are under considerable strain. Being cognizant of one’s posture as well as ergonomic considerations may be helpful in decreasing the intensity and frequency of painful episodes. Intermittent stretching and regular relaxation techniques can help quell the pain, improve range of motion, and promote more restful sleep.
Therapeutic options:
Passive therapeutic options include physical therapy which includes, application of deep heating modalities such as ultrasound, electrical stimulation, and ice or hot packs. Other physical therapy techniques include range of motion, stretching, and, after the pain has subsided, strengthening exercises. Massage therapy helps to manually break up the muscle “knots” and relax the muscle fibers. Massage therapy also causes release of local endorphins into the bloodstream to create a relaxed mood. Chiropractic care and acupuncture may be also be used for treatment.
Trigger point injections:
Another important therapeutic treatment option includes trigger point injections. Trigger point injections employ small needles and local anesthetic ( lidocaine) to mechanically break up the muscle “knots”. The procedure takes less than 5 minutes. Side effects may include mild soreness during the first 24 hours, followed by a sense of openness and looseness in the muscle group. Possible side effects of any injection include a risk for bleeding or infection. Lidocaine is an anesthetic which can stop cardiac arrhythmias, but can also cause them if injected intravenously. Because the injection site is the muscle and the syringe is pulled back to make sure we are not in a blood vessel the risk is extremely low. Lidocaine is metabolized in the liver. Lidocaine leaves the body within 4-6 hours. Aside from lidocaine, traumeel, a blend of several herbal medications, can be injected into the trigger points.
Contraindications to trigger point injections:
People who should not get trigger point injections include pregnant or nursing women. Anyone on blood thinners (325mg of aspirin, coumadin, plavix or someone who has a problem with clotting). Anyone with a rash or skin infection, or anyone who has an allergy to lidocaine.
Dry needling:
For those with an allergy to lidocaine or those who prefer not to inject any medications, trigger point injections can be done with out lidocaine. This is referred to as “dry needling.” Dry needling can also cause release of trigger points and the sensation of openness, but may be accompanied with more soreness than when lidocaine is injected.
Medications:
Sometimes medications can be prescribed, such as anti-inflammatories or muscle relaxants. These are not without their side effects and risks. Anti-inflammatories can erode gastric lining, impair renal function, and alter clotting mechanisms. Muscle relaxants can cause sedation, grogginess, and decreased ability to focus. Other medications may also be used. Alternatively, an anti-inflammatory diet can be incorporated to help decrease inflammation in the body.
Recognition of this syndrome is difficult and requires the physician to have a precise understanding of the body’s anatomy. Trigger points can be identified by pain produced upon digital palpation (applying pressure with one to three fingers and the thumb). In diagnosing myofascial pain syndrome, four types of trigger points can be distinguished:
active trigger point — an area of exquisite tenderness that is usually located in a skeletal muscle and is associated with local or regional pain;
latent trigger point — a dormant area that can potentially behave like an active trigger point;
secondary trigger point — a hyperirritable spot in a muscle that becomes active as a result of a trigger point and muscular overload in another muscle;
satellite myofascial point — a hyperirritable spot in a muscle that becomes active because the muscle is located within the region of another trigger point.
The best treatments for myofascial pain syndrome are active and passive physical therapy methods. There is also the “stretch and spray” technique, in which the muscle with the trigger point is sprayed along its length with a coolant such as fluorimethane, and then stretched slowly.
Trigger point injection, whereby local anesthesia is injected directly into the trigger point, also is used. At times, corticosteroids and botulinum toxin can be injected. Massage therapy also can be of significant benefit in some patients. Often a combination of physical therapy, trigger point injections and massage are needed in refractory chronic cases.
Myofascial pain (MP) is a common, painful disorder that is responsible for many pain clinic visits. MP can affect any skeletal muscles in the body. Skeletal muscle accounts for approximately 50% of body weight, and approximately 400 muscles make up the body. MP is responsible for many cases of chronic musculoskeletal pain.
MP can cause local or referred pain, tightness, tenderness, popping and clicking, stiffness and limitation of movement, autonomic phenomena, local twitch response (LTR) in the affected muscle, and muscle weakness without atrophy. Trigger points (TrPs), which cause referred pain in characteristic areas for specific muscles, restricted range of motion (ROM), and a visible or palpable LTR to local stimulation, are classic signs of MP. Over 70% of TrPs correspond to acupuncture points used to treat pain.
An active TrP is an area that refers pain to a remote area in a defined pattern when local stimulation is applied. Satellite TrPs appear in response to a primary, active TrP and usually disappear after the primary TrP has been inactivated. Latent TrPs cause stiffness and limitation of ROM but no pain. Frequently, they are found in asymptomatic individuals.
Although MP and fibromyalgia have some overlapping features, they are separate entities; fibromyalgia is a widespread pain problem, not a regional condition caused by specific TrPs.
Pathophysiology
A taut band in a muscle may be necessary as a precursor to the development of a trigger point (TrP). Taut bands are common in asymptomatic individuals, but patients with them are more likely to develop a TrP. A latent TrP can develop into an active TrP for a number of reasons. Psychological stress, muscle tension, and physical factors, such as poor posture, can cause a latent TrP to become active.
The pathophysiology of myofascial pain is not well understood. Current research supports sensitization of low-threshold, mechanosensitive afferents associated with dysfunctional motor endplates in the area of the TrPs projecting to sensitized dorsal horeurons in the spinal cord. Pain referred from TrPs, as well as LTRs, may be mediated through the spinal cord after stimulation of a sensitive locus.
Possible factors that lead to myofascial pain syndromes.
Tendonitis presents as local pain, inflammation, dysfunction, and degeneration. It can be associated with overuse, infection, systemic rheumatic disease, or metabolic disturbance such as calcium apatite or pyrophosphate deposition. Fluoroquinolone antibiotic use can be associated with tendonitis and rupture. Inflammation can cause “triggering,” in which the digit locks and a snapping sensation is felt upon release.
The spectrum of nonarticular myofascial pain syndromes.
Bursitis presents as local pain and inflammation of the synovial fluid filled saclike structures that protect soft tissues from underlying bone. Overuse, infection, systemic rheumatic disease, and metabolic disturbance such as calcium apatite and pyrophosphate deposition can also cause bursitis. Gout often causes olecranon bursitis and prepatellar bursitis.
Structural disorders such as scoliosis, lateral patellar subluxation, and flatfoot can cause local pain but are not always a source of pain or dysfunction. The hypermobility syndrome presents with arthralgias due to increased joint laxity in the face of muscle disuse.
Neurovascular entrapment can occur centrally (eg, in spinal stenosis), in deep tissues (eg, thoracic outlet syndrome), or peripherally (eg, carpal or tarsal tunnel syndromes). Bone enlargement due to osteophytes, muscular tension, and inflammation can contribute to narrowing of a neurovascular passage. Pain and paresthesia usually occur distal to the site of entrapment.
Regional myofascial pain syndromes, such as temporomandibular joint syndrome, may represent a pain-spasm pain cycle triggered by mechanical injury, such as strain or overuse.
Multiple bursitis and tendonitis syndrome present with anatomically localized areas of pain and dysfunction. Pain can be widespread, but the muscle tender points observed in fibromyalgia are absent. Usually, much less fatigue occurs, and responses to local therapies are better than in fibromyalgia.
Fibromyalgia, in many cases, presents as a form of allodynia, in which usually painless stimuli are perceived as painful, and hyperalgesia, in which normally painful stimuli is amplified. Cerebrospinal fluid levels of substance P are elevated, and additional abnormalities in the serotonin system and in the regulation of cortisol exist. Fibromyalgia can also coexist with various autoimmune diseases and often presents after a severe flulike syndrome, a defined infection (eg, Lyme disease), or trauma. Sleep is often disturbed, and nonrestorative sleep is associated with increased pain. The increased prevalence in females may point to a hormonal influence. Few abnormalities occur in the peripheral musculature. Studies that show abnormalities of cerebral blood flow in the thalamus and caudate nucleus help support the likelihood that pain processing in the central nervous system behaves abnormally.
A recent study found that patients with fibromyalgia have an increased expression of sensory, adrenergic, and immune genes during moderate exercise.5 Abnormalities of the neuroendocrine immune system are well documented, but none has yet been proven to be sensitive and specific enough to be used as a criterion for diagnosis.
Psychological, personality, and social factors may play important roles in many chronic cases of local and generalized pain syndromes. The image below depicts possible factors that contribute to the generation of these syndromes.
Clinical
History
Patients with myofascial pain usually report regionalized aching and poorly localized pain in the muscles and joints. They also may report sensory disturbances, such as numbness in a characteristic of distribution. The type of pain felt is characteristic of the muscle involved. An acute onset may occur after a specific event or trauma (eg, moving quickly in an awkward position), while chronic pain may result from poor posture or overuse.4 Patients may note disturbed sleep. Persons with cervical and periscapular myofascial pain may have difficulty finding a comfortable sleeping position. They may or may not be aware of muscle weakness in the affected muscles and may have a tendency to drop things.
Physical
A skilled examiner can provide accurate diagnosis of myofascial pain (MP). Unfortunately, most medical school and residency training programs do not adequately cover this common condition. Locating trigger points (TrPs) is the most important part of the physical examination. TrPs tend to occur in characteristic locations in individual muscles. The book Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual is considered the criterion standard reference on locating and treating TrPs.
When the TrP is located, the patient typically has a positive jump sign when local pressure is applied over the area; the jump sign should not be confused with an LTR. The jump sign simply means that the patient jumps from pain or discomfort in the area that has been palpated. Apply a consistent amount of pressure to the area, because applying too much pressure can elicit pain iearly all individuals. A pressure algometer (ie, pressure threshold meter) or palpatometer can be used to standardize the amount of pressure applied.
A taut band is found in the muscle, either by palpation or by needle penetration. It can be distinguished by palpating or by dragging the fingers perpendicular to the muscle fibers. A localized knot or a tight, ropy area is noted. Patients report that the area is extremely tender when palpated. A localized flinching in the area of the muscle being palpated or an LTR may be noted in active TrPs, as well as in latent ones. Palpation or insertion of a needle into the TrP causes reproduction of the patient’s pain and, frequently, sensory complaints. Palpation of either an active or a latent TrP causes referred pain in a characteristic area for each muscle, a phenomenon described in the above-mentioned TrP manual. Sensory disturbance (eg, paresthesias, dysesthesias, localized skin tenderness) may be noted in the same area where pain may be referred. Autonomic phenomena also may be elicited (eg, sweating, piloerection, temperature changes).
Essential criteria for identifying an active or latent TrP include the following:
Palpable taut band if the muscle is accessible
Exquisite spot tenderness of a nodule in a taut band
Patient’s recognition of current pain complaint by pressure on the tender nodule
Painful limit to full ROM stretch of the involved muscle
Confirmatory observations include the following:
Visual or tactile identification of an LTR
Imaging of an LTR induced by needle penetration of a tender nodule
Pain or altered sensation on compression of a tender nodule, in the distribution expected from a TrP in that muscle
Electromyographic demonstration of spontaneous electrical activity (SEA) that is characteristic of active loci in the tender nodule of a taut band
Lowered skin resistance to electrical current – This has been found over active TrPs when compared with surrounding tissue and may be useful in localizing TrPs. Skin resistance normalizes after the treatment of TrPs.
Causes
Several factors contribute to myofascial pain (MP). Abnormal stresses on the muscles from sudden stress on shortened muscles, leg-length discrepancies, or skeletal asymmetry are thought to be common causes of MP. Poor posture also may cause MP. In addition, the assumption of a static position for a prolonged period of time has been implicated in the condition. Anemia and low levels of calcium, potassium, iron, and vitamins C, B-1, B-6, and B-12 are believed to play a role. Chronic infections and sleep deprivation have been cited as causative factors, as have radiculopathy, visceral diseases, and depression. Hypothyroidism, hyperuricemia, and hypoglycemia also have been implicated in MP. The pathogenesis likely has a central mechanism, with peripheral clinical manifestations.
Other Problems to Be Considered
Articular dysfunction requiring manual mobilization
Nonmyofascial trigger points
Radiculopathy
Workup
Laboratory Studies
No specific lab tests confirm a diagnosis of myofascial pain (MP), but lab tests can be helpful in looking for predisposing conditions, such as hypothyroidism, hypoglycemia, and vitamin deficiencies. Specific tests that may be helpful include complete blood count (CBC), chemistry profile, erythrocyte sedimentation rate (ESR), and levels of vitamins C, B-1, B-6, B-12, and folic acid. A thyrotropin level may be helpful if clinical features of thyroid disease are present.
Imaging Studies
Infrared or liquid crystal thermography can show increased blood flow, which is sometimes noted at trigger points. Other imaging studies are useful only to rule out other sources of pain generation.
Other Tests
Needle electromyography (EMG) examination of trigger points (TrPs) in humans and rabbits has shown high-voltage spike activity and spontaneous, low-voltage endplate noise, which is considered characteristic but not pathognomonic. Surface EMG has been used in experiment protocols to monitor muscle activity in TrPs. Ultrasonography has been used to visualize the LTR elicited by needle penetration.
Procedures
Trigger point (TrP) injections sometimes are performed with bupivacaine, etidocaine, lidocaine, saline, or sterile water. Dry needling is occasionally performed, without the injection of any substance.
Steroids may be used in areas possibly associated with inflammation, as in frozen shoulder. Botulinum toxin shows promise as a substance that can provide long-lasting relief. Its mechanism of action may be related to the blocking of acetylcholine release at the neuromuscular junction of the dysfunctional motor endplates.
A report by Affaitati et al indicated that a topical anesthetic patch can also relieve myofascial pain, without the discomfort that can result from TrP injections. Patients in the study were separated into groups of 20, one of which was treated for 4 days with a lidocaine patch applied to each patient’s trigger point (with patients receiving a total daily dose of 350 mg). The second group received a placebo patch, and the third group was treated with injections of 0.5% bupivacaine hydrochloride.
In members of the lidocaine patch and bupivacaine injection groups, the investigators found significant decreases and increases in, respectively, subjective symptoms and pain thresholds. Although the effects at muscle TrPs and target areas were more pronounced in the injected patients, the lidocaine patients experienced less therapy-related discomfort. Subjective symptoms and pain thresholds did not improve in the placebo group.
Treatment
Rehabilitation Program
Physical Therapy
Physical therapy for patients with myofascial pain focuses on correction of muscle shortening by targeted stretching, strengthening of affected muscles, and correction of aggravating postural and biomechanical factors. Modalities can be useful in decreasing pain, allowing the patient to participate in an active exercise program.
Corrections of leg-length discrepancies with a heel lift or the use of dynamic insoles also may be helpful. Various other techniques and procedures, including the following, have been demonstrated to be effective in some patients:
Indomethacin phonophoresis
Massage and exercise
Stretching
Electrical muscle stimulation (
Deep Muscle Stimulator
Ultrasonography
EMG biofeedback
Occupational Therapy
Occupational therapy can be helpful in assessing and setting up ergonomically correct workstations for patients with myofascial pain. Properly set up work sites can help to decrease aggravating postural factors.
Medical Issues/Complications
Trigger points (TrPs) can result from noxious stimuli, such as a herniated disc. Inquire about such precipitating factors in the patient’s environment.
The treatment of TrPs can provide temporary relief of visceral pain referred from other organs and can mask the pain of serious conditions (eg, appendicitis, myocardial infarction).
Complications of TrP injections are rare and depend on the area being injected. They include local pain, bleeding, bruising, intramuscular hematoma formation, infection, and, more rarely, neural or vascular injury, or penetration of an underlying organ (which could lead to pneumothorax).
Consultations
Consultation with a specialist in physical medicine and rehabilitation may be indicated and should be arranged as needed.
Other Treatment
Acupuncture may be helpful.
Osteopathic manipulation techniques may include integrated neuromusculoskeletal release, myofascial release, strain-counterstrain, muscle energy, and high-velocity/low-amplitude manipulation.
Medication
Muscle relaxant medications23 and nonsteroidal anti-inflammatory drugs (NSAIDs) can at times be a useful adjunct to active, exercise-based treatment for myofascial pain, but they are helpful only rarely on their own. Medications such as low-dose amitriptyline may help to improve the patient’s sleep cycle. Botulinum toxin type A injected into trigger points can reduce muscular contractions through the inhibition of acetylcholine release at the neuromuscular junction and appears to have an antinociceptive effect. Current research suggests that peripheral sensitization is blocked, which indirectly reduces central sensitization.
Myofascial pain syndrome. Manual methods of muscle correction
INTRODUCTION
The first description of myofascail pain syndrome was published in the german literature in 1843.
Myofascial pain is probably the most common cause of musculoskeletal pain in medical practice (Imamura, Fischer, Imamura et al.1997).
Myofascial pain is caused by hyper- irritable spots called trigger points that develop in skeletal muscle or its surrounding fascia.
Despite the fact that an estimated 44 million Americans struggle with the condition, myofascial pain is arguably one of the better kept Secrets of modern medicine. Relatively little is known about it in the medical community which makes it difficult for medical professionals to distinguish it from other forms of soft tissue disorders Or to understand how it can undermine for interact with other illnesses. Also unfortunate is that the practical experience required to accurately diagnose myofascial pain are simply not available in many medical schools.
It is not difficult, however, to realize potential the devastation caused by myofascial pain once one realizes how prevalent it can be in the human body.
In 1987, David Simons, MD, a pioneer in the field of myofascial pain, wrote skeletal muscle is the largest organ of the body makes up nearly half of body weight. Muscles are the motors of the body. They work with and against the ubiquitous spring of gravity together with cartilage, ligaments, and intervertebral discs as the bodies mechanical shock absorbers. Each of the approximately 500 skeletal muscles subject to acute and chronic strain. Each muscle can develop myofascial trigger points and has its own characteristic pattern of referred pain.
An
WHEN FASCIA IS INJURED
Because fascia permeates all regions of the body and is all interconnected, when it scars and hardens in one area (following injury, inflammation, disease, surgery, etc.), it can put tension on adjacent pain-sensitive structures as well as on structures in far-away areas. Some patients have bizarre pain symptoms that appear to be unrelated to the original or primary complaint. These bizarre symptoms caow often be understood in relationship to our understanding of the fascial system.
UNDERSTANDING FASCIA SYSTEM
Fascia is a three dimensional web of connective tissue which runs continuously throughout the body from head to foot and superficial to deep without interruption. It does not have origins or insertions, as do muscles. Rather it runs continuously throughout the body lending support and separation to all systems.
Fascia is composed of an elastocollagenous complex with elastin fibers which lend elasticity and tissue memory), and collagen fibers (which lend strength), embedded in a gelatinous ground substance which allows fiber mobility, as well as cellular circulation.
Muscles do not exist in isolation. Muscles are actually groups of myofibrils/myofibers/myofascicles which are bound together by fascial envelopes. The muscular fascia (perimysium) runs continuously into the osseous fascia (periosteum) which joins the periarticular tissue as well.
The vertebral column is supported in space by the myofascial system, just as a tent pole is supported by the guide wires. The system was designed to work in a balanced, symmetrical position. When using myofascial release techniques, a primary goal is to improve structural alignment and reduce abnormal pressure on pain sensitive structures that may be producing the symptoms of pain, spasm or abnormal tone.
Fascia reorganizes itself along the lines of tension imposed upon it in order to support the structure. Where there is excess stress, fascia will thicken to add strength and support. Although connective tissue functions to support our posture and motion, it does not evaluate how we can equally reinforce poor posture and motion, as it does efficient movement the body fascia may be regarded as a continuous laminated sheet of connective tissue that extends without interruption from the top of the head to the tip of the toes. It surrounds and invades every other tissue and organ of the body, including nerves, vessels, muscle and bone. Fascia is more dense in some areas than others. Dense fascia is easily recognizable (for example, the tough white membrane that we often find surrounding butchered meat).
Myofascial restrictions:
A small change in the myofascia can cause great stress to the body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40 %; (Greenman, 1996). If two major joints are restricted in the same extremity, it can increase by as much as 300 %;. Multiple minor restrictions of movement, particularly in the maintenance of normal gait, can also have a detrimental effect upon total body function.
In “Principles of Manual Medicine” (ibid), the author finds it convenient to separate fascia into three layers, but it is continuous and three dimensional, so please visualize it as such.
Superficial fascia is attached to the underside of the skin. Capillary channels and lymph vessels run through this layer, as do many nerves, and subcutaneous fat is attached to it. If the superficial fascia is healthy, skin moves easily over the surface of the muscles. In FMS and CMP, it can get stuck. There is also a great potential to store excess fluid and metabolites in the superficial fascia. This fascia is often the easiest to palpate, but palpation may be hampered by the presence of excess fluid. The presence of this fluid is a clue that there is something wrong and may also give clues as to the location of the problem.
Deep fascia is tougher and denser, and is used to separate large sections of the body. It covers some areas like huge sheets, protecting them and giving them shape, and separates muscles and organs. The pericardium, the pleura and the perineum are all made up of specialized deep fascia. The dural tube is also fascial, and this fascia is connected to the membranes surrounding the brain. Together, they hold and protect the craniosacral system, and changes in the craniosacral fascia can affect what it contains. Sheets of fibrous myofascial adhesion can form anywhere along nerves and block normal healthy function.
The subserous fascia is loose tissue covering the internal organs and holding the network of blood and lymph vessels that keep them moist.
Myofascia is fascia related to muscle tissue. Healthy myofascia allows for compression and tension, as well as relaxation. It is the fascia that forms adhesions and scar tissue. Healthy ground substance making up part of the myofascia has a gelatinous consistency so that it can better absorb the forces that are created during movement. Ground substance maintains the distance between connective tissue fibers. This prevents microadhesions from forming and keeps tissues supple and elastic. When the critical distance is not maintained, the fibers become cross-linked by newly synthesized collagen fibers, which are also part of the fascia. Collagen crosslinks are arranged haphazardly, unlike healthy linkages, and are harder and more painful to break up. The state of the ground substance can profoundly affect the state of health. Muscles and tendons join bones and ligaments and come together at attachment areas. The cellular membranes in these areas can become extremely convoluted, which increases the surface area and changes the angle of force. This increases the potential for tissues to stick together and causes tissues near attachment areas to become more easily torn (Simons, Travell and Simons, 1999). Attachment TrPs can become fibrotic or calcified with time. The sooner they are appropriately treated, the easier it will be to return the myofascia to a healthy state. Chronicity can often be prevented by prompt and through acute care.
PHYSICAL FINDINGS AND CHARACTERISTICS
Any muscle with a painfully restricted range of motion and a tender spot that reproduces the patient’s pain when compressed likely has a myofascial trigger point.
A number of important physical findings have been reported in muscle that pl plays host to trigger points for example, the is usually limited range of motion in the muscle which is caused by pain. Loss of strengths and stamina frequently of course as well. During clinical examination, the actual trigger point can be recognized as a localised spot of tenderness which occurs in a nodule or a palpable taught band. Of muscle fibres. These changes can be caused by a massive increase of the neurotransmitter acetylcholine.
Gently rubbing across the direction of the muscle fibres of superficial muscle, the examiner can feel a nodule at the trigger point and a rope like induration that extends from this nodule to the attachment at each end of the involved muscle fibres. The taut band can be snapped or rolled under the finger in accessible muscles. snapping palpation Of the trigger point frequently evokes a transient twitch response of the taut band fibers. This is often referred to as a local twitch responce or LTR.
In 1981, One hypothesis explained how the taut band muscle fibers contracted in the absence of propagated electrical activity, and why stretching the muscle could produce rapid resolution of the tenderness of the nodule and the tautness of the band. The hypothesis focused on excessive calcium release from the sarcoplasmic reticulum as a cause of local muscle fiber contracture. The contracture, in turn, causes local ischemia that limits energy replacement and consumes more adenosine triphosphate (ATP), depleting the energy source. These events leave insufficient ATP for adequate return of calcium from the contractile elements to the sarcoplasmic reticulum by the calcium pump. Stretching the muscle reduces the overlap between actin and myosin, thereby reducing energy demand and breaking the cycle.
TISSUES SUSCEPTIBLE TO REPETITIVE STRAIN INJURIES
Chronic myofascial pain is a neuromusculoskeletal condition. It is nonprogressive, nondegenerative, and noninflammatory. It is composed of myofascial trigger points (TrPs) which refer pain and other symptoms in very precise patterns in specific regions of the body. It seems progressive because each TrP can develop satellite and secondary TrPs, which can form secondaries and satellites of their own. With treatment of TrPs and the underlying perpetuating factors, however, the TrPs can be “reversed” and minimized or eliminated. A small change in the myofascia can cause great stress to other parts of your body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40%, and, if two major joints are restricted in the same extremity, it can increase by as much as 300% (Greenman 1996). Multiple minor restrictions of movement, particularly in the maintenance of normal gait, can also have a detrimental effect upon total body function. A myofascial TrP is always found in a taut band, which is structurally related to contraction knots caused by a thousand-fold increase in the release of acetylcholine, an important neurotransmitter. This action takes place in an area of the muscle where nerves end, which is called a motor endplate (Gerwin 1999). The cause of TrPs appears to involve serious disturbances of the nerve ending, and dysfunction of the contractile mechanism of the muscles.
One of the most common perpetuating factors of myofascial trigger points is inappropriate therapy. You cannot strengthen a muscle with a TrP because it is already physiologically contractured. The TrP must be gone before the muscle can be strengthened. The patient usually presents with complaints from the most recently activated TrP. When this is eliminated, the pain pattern may shift to an earlier TrP, which also must be inactivated. Trigger points are directly activated by acute overload, overwork fatigue, direct trauma, and chilling. They are also activated indirectly by other TrPs, visceral disease, arthritic joints, and emotional distress. Active TrPs vary from hour to hour and day to day. The signs and symptoms of TrP activity long outlast the precipitating event.
Inflammation
It is important to keep in mind that neither FMS nor CMP is inflammatory, although secondary inflammation of the joints may sometimes occur in long-standing untreated TrPs. This occurs because contracted muscles harboring trigger points (TrPs) can pull bones slightly out of alignment. “Inactivating the related myofascial TrPs and the elimination of their perpetuating factors appear to be important parts of early therapy to delay or abort the progression of some kinds of osteoarthritis
Change in the Fascia
A muscle with active trigger points cannot be strengthened. The TrPs must be deactivated first. This can be accomplished by careful galvanic electrical stimulation, spray and stretch techniques, trigger point therapy, Myofascial therapy and other modalities. These therapies often work well in concert. Work hardening and weight training will do nothing but create more pain and disability.
Perpetuating Factors of Myofascial Trigger Points
Common MTrP perpetuating factors are:
• skeletal asymmetry and disproportion
• nutritional inadequacies
• reactive hypoglycemia or insulin resistance
• paradoxical breathing
• pain
• impaired sleep
• conditions impairing muscle metabolism
• head-forward posture
• chronic infections
• bad habits such as chronic gum chewing
• other TrPs
• visceral disease
• arthritic joints
• FMS and other chronic illnesses
• vitamin and mineral insufficiency
• adhesions
• previous surgeries
• previous traumas
• allergies
• poor posture
• poor body mechanics
• poor coping behaviors
• lifestyle
• smoking
• alcohol consumption
• stress
• Morton’s foot
• thyroid resistance
• short upper arms
• short lower legs
• unequal leg length
• hypothyroid
• psychological stress
• ill-fitting shoes
• ill-fitting furniture and car seats
• hypermobility
• repetitious exercise and work
• overwork
• immobility
Autonomic Reactions and TrPs
Some trigger points may produce autonomic reactions, such as sweating, blanching, dizziness, and nausea. These autonomic responses may be relieved by treating the trigger point. Many muscles have multiple TrP locations. The major factor in TrP pain is always mechanical, even if it was triggered by stress.
Myofascial Trigger Points (MTrPs)
Trigger points are extremely sore points occurring in ropy bands throughout the body. To more easily palpate TrPs in the arm or leg muscles, stretch the involved muscle about 2/3 of the way out. If there is pain at the end of a restricted range of motion, there is probably a TrP involved. TrPs cause muscle weakness and other dysfunction before they cause pain. Much of the restricted range of motion and dysfunction often attributed to old age may be due to myofascial TrPs and thus can be successfully treated. Travell and Simons have carefully documented and detailed the maps and common associated proprioceptive and autonomic concomitants.
Myofascial Trigger Points
A latent MTrP doesn’t hurt unless you press it. Your patient might not even know it’s there, but his or her body does. It weakens the affected muscle, restricting movement and preventing its full lengthening. If you press on the TrP it refers pain in its characteristic pattern. Latent TrPs may be activated by overstretching, overuse, or chilling the muscle. People who get little exercise have a greater chance of developing latent TrPs. Some people believe that by restricting their range of motion they are getting rid of their TrPs. Nothing can be farther from the truth. When someone with multiple latent TrPs falls, develops an infection, or is affected by any other stressor, all of the latent TrPs can activate simultaneously. Physical stress isn’t the only thing that can cause TrPs. Tension TrPs can occur. These are not the psychological result of tension, but they are physiological biological effects of long-term emotional abuse, mental trauma or other stressor. Constantly holding muscles tight in a “fight-or-flight” stress response changes biomechanics. It will take both patient and care provider effort, time and persistence to change them back. Bodywork and exercise can activate TrPs, and so can a TrP examination.
An active TrP not only hurts when it is pressed, like an FMS tender point, but it “triggers” a referred pain pattern somewhere else in the body. This pain pattern is similar from patient to patient and may include spillover pain areas. These TrPs often produce symptoms other than pain. Active TrPs hurt when the muscle is in use. When the TrP becomes very active, pain and other symptoms occur even when the muscle is resting. The fact that these pain patterns are very much similar from patient to patient helps if the diagnostician is familiar with the patterns so well described by Travell and Simons. A comprehensive history will tell you where to look for TrPs and may help prevent needless pain. If your patient has a stiff neck, for example, you can check for TrPs in the levator scapulae, and if there is a problem with incontinence, there are TrPs that can affect that too. Some other TrP associated symptoms include localized sweating, tearing, poor balance, nausea, tinnitus, goosebumps, runny nose, buckling knees, weak ankles, illegible handwriting, headaches, and muscle cramps.
Myofascial Trigger Point Therapy (MTPT) is a unique treatment protocol for the treatment of myofascial pain and dysfunction.
The protocol is based on the seminal works of Janet G. Travell, MD and David G. Simons, MD and integrates current scientific concepts and research. This protocol includes the following: differential diagnosis, comprehensive patient history, pain mapping, range of motion evaluation, postural analysis, identification of perpetuating factors, correction of perpetuating factors by working with an interdisciplinary team, manual techniques like Advanced Myofascial release to treat myofascial pain and dysfunction, personalized patient stretch and exercise rehabilitation program, patient education.
STAGES OF REHABILITATION PROCESS
Stage 1 -Recovery
Stage 2- Stabilization
Stage 3-Follow up, To enhance recovery and reduce risk of relapse.
TREATMENT METHODS
Neuro-Myofascial system
Myofascial therapy
Manual trigger point therapy
Neuromuscular techniques
Muscle release techniques
Muscle energy techniques
spray and stretch therapy
MTP injections with stretching (dry needling)
Galvanic stimulation
Joints, ligaments and tendons
orthopedic medicine
Transverse frictions
Injections
Mobilizations ( Muscular, soft tissue, nervous and articular )
Manipulation of the Soft tissues and Joints.
Advanced and Specific Exercise Program.
Functional Restoration
Relaxation techniques
Clinical ergonomics
Postural advice and correction (using adhesive Tapes Etc.)
Nutrition – health diet
Nutritional supplements.
Managing psychosocial risk factors.
Manual therapy (chiropractic).
Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system. Chiropractic is controversial, and it is generally considered to be complementary and alternative medicine, a characterization that many chiropractors reject. The main treatment involves manual therapy, including manipulation of the spine, other joints, and soft tissues; treatment also includes exercises and health and lifestyle counseling. Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body’s function and its innate intelligence, a notion that brings ridicule from mainstream science and medicine.
D.D. Palmer founded chiropractic in the 1890s and his son B.J. Palmer helped to expand it in the early 20th century. It has two main groups: “straights”, now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider subluxations to be the leading cause of all disease; “mixers” are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture. Chiropractic is well established in the
For most of its existence, chiropractic has battled with mainstream medicine, sustained by ideas such as subluxation that are not based on solid science. Vaccination remains controversial among chiropractors. The American Medical Association called chiropractic an “unscientific cult” and boycotted it until losing a 1987 antitrust case. Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical physicians and health plans in the
Treatment techniques
Picture 1. Doctor applies a caudad pressure to the dorsum of the hand bilaterally. Normally, the patient maintains strong wrist extension. A hidden cervical disc may be present when the patient exhibits a weakness with wrist extension.
Picture 2: Doctor applies anterior-superior pressure to the transverse processes of the cervical spine, to detect the level of involvement.
Picture 3: When the vertebra above the level of the disc involvement is challenged, the wrist extensor muscle will test weak.
Picture 4: Supine correction for a hidden cervical disc is displayed. Note that the Index Finger DIP contact is on the spinous process inferior to the involved disc level. (This is the segment below the challenged vertebra that produced weakness in the extensor muscle test.)
Spinal manipulation, which chiropractors call “spinal adjustment” or “chiropractic adjustment”, is the most common treatment used in chiropractic care; in the
There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 10% of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation, employing various techniques), extremity adjusting, Activator technique (which uses a spring loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), Gonstead (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes chiropractic with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, Applied Kinesiology (which emphasises “muscle testing” as a diagnostic tool), and cranial. Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.
Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than 1/3 of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice.
Principles of modern reflexology
1. Consistency – methods punkturnoyi refleksooterapiyi be appointed on the basis of previous treatment.
2. Early use – justified the appointment of private medical factors in the early stages of pathological process significantly improves results and reduces the time complex therapy.
3. Adequacy of influence – the choice of physical factors, methods of procedure should adaptive capacities of the patient or organ system.
4. Optimal dose – should try to pursue the best treatment options physical factors.
5. Specificity of action – the choice and differential use of physical factors is to maximize the use of features of their mechanism of action and relevance of the pathogenesis of specific diseases.
6. Dynamism of use – during the course of treatment should be messing with the recipe physiotherapy procedures, depending on the reaction of the patient to avoid habituation to the effects.
7. Complexity and systematic physical therapy – medical complex should consist of methods of influence on different body systems, provide basic treatment and concomitant diseases.
8. Individual approach – the appointment of physiotherapeutic procedures should take into account biological rhythms, sex and age characteristics.
