Browsing articles tagged with " Acupuncture"

26. Acupuncture and Carpal Tunnel Syndrome

Feb 17, 2011   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 3 (1), February, 2011, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Carpal Tunnel Syndrome

www.0831120.com

Jessica is a 35 year old computer programmer, who for the last 15 years, works roughly 10 hours a day at the computer.   For last 2 years, she started to feel right hand numbness and tingling sensation along her thumb, index and middle fingers. This sensation often occurs while holding a steering wheel, phone, newspaper or upon awakening. She very often “shakes out” her right hand to try to relieve symptoms, especially when the pain interferes with sleep waking her up. As the disorder progresses, the numb feeling becomes constant. She sometimes also feels right wrist pain radiating up to arm and shoulder, and also down to palm, especially at end of the day after spending a long time typing. She has difficulty holding a book or cup and very often drops her book or other objects. She tried to massage her hand and wrist, however, she felt no improvement. She then came to me for evaluation and treatment.

I performed a physical examination, finding out while I squeezed her right palm together and held for 2 mins, she started to feel numbness and tingling sensation at thumb, index and middle fingers. By comparison, her muscles of  right thumb and lateral palm are slightly atrophy and the sensation is decreased by using pinpoint.  Suspecting this patient had carpel tunnel syndrome, I also performed the following two tests:

1. Tinel’s sign. I used my hammer to tap lightly at the middle line of the wrist above the carpal tunnel, so the patient felt the sensation of tingling or pins and needles following to the first three fingers.

Fig 2.1

www.flickr.com

2. Phalen’s maneuver.  I asked the  patient to flex the wrist about 60-80 degrees, then waited for one minute, which caused her to feel numbness and tingling following along the median nerve distribution.

Fig.2.2

www.flickr.com

Jessica most likely suffered from carpal tunnel syndrome. Carpal tunnel is a tunnel located at the midline of palm adjacent to the wrist, median nerve lies inside the tunnel.  The median nerve is a mixed nerve, meaning it has a sensory function and also provides nerve signals to move your muscles (motor function). The median nerve provides sensation to your thumb, index finger, middle finger and the middle-finger side of the ring finger.

Fig. 2.3

www.thepainsource.com

Pressure on the nerve can stem from anything that reduces the space for it in the carpal tunnel.

There are several causes of carpel tunnel syndrome:

1.      Most are idiopathic (not knowing the cause)

2.      Genetic predisposition.  Many families have this tendency toward carpel tunnel syndrome.  About 50% of those who develop the condition are women, where this complaint runs in the family. It may be that your carpal tunnel is more narrow than average.

3.      Professionally related.  Though there is some controversy over this, certain professions such as data entry technicians, secretaries, construction workers etc. have high liability toward carpel tunnel syndrome.  Repetitive flexing and extending of the tendons in the hands and wrists, particularly when done forcefully and for prolonged periods without rest, can increase pressure within the carpal tunnel. Injury to your wrist can cause swelling that exerts pressure on the median nerve.

4.      Diseases related conditions such as trauma, pregnancy, multiple myeloma, amyloid, rheumatoid arthritis, acromegaly, mucopolysaccharidosis or hypothyroidsm compress the median nerve, and all can cause the symptoms of carpel tunnel syndrome.  If the cause of the disease is treated, then carpel tunnel syndrome will gradually disappear.

How is carpal tunnel syndrome diagnosed?

1.      Most important: Your symptoms.  As mentioned above, if  you have numbness and tingling sensation at thumb, index, middle and half of the ring fingers, if you wake up and shake your hand try to relieve hand pain and numbness, if  you very often drop off the object, such as books, cup, pen, etc., the diagnosis of carpal tunnel syndrome is suspected.

2.       By physical examination:  Sometimes tapping the front of the wrist can reproduce tingling of the hand, and is referred to as Tinel’s sign and Phalen’s sign of carpal tunnel syndrome. Symptoms can also at times be reproduced by the examiner by bending the wrist forward (referred to as Phalen’s maneuver).

3.      Nerve Conduction Velocity test (NCV)and Electromyogram (EMG) :

The golden standard for the diagnosis of carpel tunnel syndrome is electrophysiological testing, i.e. nerve conduction and electromyography.  Usually a physical examination, coupled with the patient’s complaints on her condition, are sufficient to make an accurate diagnosis.  However, the final diagnosis depends on the electrophysiological testing. The test not only will tell you the diagnosis, but also the types of treatment and prognosis, if your condition needs physical therapy, acupuncture, brace, steroid injection, or surgery, etc. if your condition is reversible or non-reversible, etc.

There are two parts of electrophysiological tests, i.e. Nerve Conduction Velocity Study (NCV) and Electromyography (EMG). It usually is performed by Physiatrists, i.e. Physical Medicine and Rehabilitation Doctor, or Neurologists with special training on the test.

NCV involves with mild to moderate electrical current stimulation at patient’s median nerves at the elbows and wrists of both side, then a computer will record the responses of the nerves and compare the velocity, amplitude and latency. By comparing with normal standard, also the patient’s left side median nerve with right side, your physician will identify injury at the median nerves if you have any.

EMG test applies a very fine needle into your muscles at the palm, arm and neck. The needle contains a microscopic electrode, which picks up both normal and abnormal electrical signals given off by a muscle. If there is nerve damage, the muscles supplied by the nerve will send out abnormal signals. Because median nerve originates from cervical spine, i.e. on the neck and go through entire arm and  lateral palm, therefore, some muscles will be examed with the needles.

The test usually will take about 30 min to one hour depending on how severe your condition and how extensive of a study your physician would choice. You may feel mild discomfort with the test, however, 99.9% of my patients easily take the test from my hand.

4. Blood tests may be performed to identify medical conditions associated with carpal tunnel syndrome. These tests include thyroid hormone levels, complete blood counts, and blood sugar and protein analysis. X-ray tests of the wrist and hand might also be helpful to identify abnormalities of the bones and joints of the wrist.

How is carpal tunnel syndrome treated?

Carpal tunnel syndrome can be classified as three types: mild, moderate and severe, depends on their symptoms and electrophysiological testing.

For mild and moderate cases, the following treatments are recommended:

1.      Immobilizing braces.  A wrist splint can help limit numbness by preventing wrist flexion, which might compress the median nerve.  The patient should wear a night splint, usually called a cock-up splint and the wrist should be hyperextended above 30 degrees.  Worn overnight for 7-8 hours, the nerves are rested and, in the morning, the patient feels much relieved and the symptoms will gradually improve.

Fig. 2.4

www.healthwise-everythinghealth.blogspot.com

2.      Physical Therapy

It is very important to improve mobility in the wrist flexors by means of stretching to rid of any restrictions and inflammation being placed through the carpal tunnel where the tendons of the wrist flexors and median nerve pass through.  To perform this stretch pull the fingers and thumb back to you with your palm facing away from the body.  This stretch for the wrist flexors can be progressed to placing the hand on a wall or a table.  A strong but comfortable stretch should be performed 2-3 times a day and held for 30-60 seconds.

Fig. 2.5

http://www.revolutionhealth.com/articles/stretches-to-ease-wrist-and-arm-fatigue/zm2290

In addition to stretching the wrist flexors, great research on Nerve Gliding has shown quicker decreases in levels of pain, increased grip strength, improved function, while decreasing need for surgery.  Patients performing Nerve Gliding Exercises underwent surgery over 30% less then those not performing the technique (Rozmaryn LM, Dovelle S. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J Hand Ther. 1998 Jul-Sep;11(3):171-9).

Fig. 2.6

http://daiseypt.com/articles/cts_conservative.htm

Modalities that have evidence behind them to effectively treat carpal tunnel are Ultrasound, Iontophoresis and Low Level Laser Therapy.  The American Academy of Orthopedic Surgeons recommends Ultrasound as a treatment option to assist with short and medium term benefits of carpal tunnel.  Iontophoresis with Hydrocortisone was very effective in mild and moderate stages of carpal tunnel.  Low Level Laser Therapy study results include decreased pain, numbness and tingling and improved function, grip strength, EMG results and patient satisfaction.

Fig. 2.7

http://ericksonchiropractic.com

Fig. 2.8

http://www.riversidechirorehab.com

Carpal Mobilizations have been shown to improve symptoms related to carpal tunnel.  A qualified physical therapist can perform such mobilizations to improve joint mobility and remove compressive joint forces off the median nerve at the thumb, wrist and elbow.

Fig. 2.9

 

http://www.rumsua.org/Upcoming_Book_.php

Other manual techniques with great research behind them in their effectiveness to treat carpal tunnel are categorized as bodywork or soft-tissue treatments.  Active Release Technique (ART) and Graston Technique are two such techniques fitting into this category.  Both ART and Graston showed improvements in mobility, strength and nerve conduction latencies at the wrist by working to remove restrictions and adhesions in the muscles and tendons of the wrist flexors. (Burke, Buchberger, et al. A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome. 2006.)

Fig. 2.10

http://www.sportfitrehab.com/ActiveReleaseTechnique/tabid/1356/Default.aspx

Fig. 2.11

http://www.therapytimes.com/content=0802J84C48768694404040441

Eighty-one percent of CTS patients in a private study attained

80 to 100% of decreased pain and increased function goals

in 10 treatments with the Graston Technique®.”

AOTA Annual Conference and Exposition [carpal tunnel syndrome poster presentation]. 2000 Apr. http://www.grastontechnique.com/Findings.html

Strength of the forearm muscles is important to assess.  With carpal tunnel there is an imbalance with the wrist flexors being predominantly stronger then the wrist extensors.  The wrist extensors must be strengthened to maintain balance to the forearm and wrist.  This will be accomplished by performing 2-3 sets of 10 repetitions with increasing levels of resistance bands or dumbbells.

Fig. 2.12

http://www.physioadvisor.com.au/8122850/wrist-strengthening-exercises-wrist-rehabilitati.htm

There is also great research showing the positive effect of Eccentric Strengthening Exercise to the Wrist Flexors to improve both Strength and Length of the muscle.  Eccentric Muscle Contraction is when the muscle is being activated while lengthening.  This would be performed by slowly lowering the wrist to the starting position over a period of 5 seconds for 2 sets of 10 repetitions.

Fig. 2.13

http://www.emedx.com/apex/apex_exercises/apex_wrist_flexor_strengthening.htm

It is also important to assess posture overall.  Many symptoms of carpal tunnel syndrome can be the result of improper posture at the shoulders and neck.  A few simple exercises to help correct any imbalances at the shoulders and neck should be part of the carpal tunnel program such as Shoulder External Rotation and Upper Traps Stretch.

Fig. 2.14

http://www.sportsinjuryclinic.net/

Fig. 2.15

http://www.wholistichealthworks.com/dealing_with_a_pain_in_the_neck.htm

Even with all the treatment approaches listed previously, if the underlying problem, such as inappropriate stresses placed to the body while at work, are not corrected the problem will resurface.  Physical Therapist also play an important part in educating the patient on proper ergonomics and even visit work sites to properly set up office spaces to ensure proper arm and wrist position.

Fig. 2.16

http://blog.scad.edu/bcasam20/2011/02/01/

Fig. 2.17

http://chirohealthwellness.com/custom_content/c_97882_sitting_survival_workshop_for_your_emplo.html

3.      Western medicine also uses nonsteroid  anti-inflammatory drugs such as Aleve and naproxen, or even some steroid drugs taken orally.

4.      Localized steroid injections.  Steroid injections can be used for mild and moderate forms of this syndrome, and are very effective for temporary relief. However, these injections are not recommended for severe carpel tunnel syndrome.

Fig. 2.18

www.aafp.org

5.      Acupuncture.  Acupuncture is also very effective for mild to moderate forms of this syndrome.  The points used are PC 7 Da Ling and PC 6 Nei Guang Usually after inserting the needles at these two points, it is effective to introduce electrical stimulation whose direction should be toward the fingertip.  The patient should feel the needle sensation radiating to the tips of the fingers and sometimes feels swelling and sore and experiences electrical shock to the fingertip.  This treatment is most effective three times a week for a month, while during the nighttime she should wear a cock-up splint for sleep.  Many patients get excellent results from the combination of these two treatments.

Table 2-1

Points Meridan/Number Location Function/Indication
1 Da Ling Pericardium 7 In the middle of the transverse crease of the wrist, between the tendons of palmaris longus and flexor carpi radialis Cardiac pain, palpitation, stomach ache, vomiting, mental disorders, epilepsy, stuffy chest pain in the hypochondriac region, convulsion, insomnia, irritability, foul breath, pain of the elbow, arm and hand.
2 Nei Guang Pericardium 6 2 inch above the transverse crease of the wrist, between the tendons of palmaris longus and flexor radialis Cardiac pain, palpitation, stuffy chest, pain in the hypochondriac region, stomach ache, nausea, vomting, hiccup, mental disorders, epilepsy, insomnia, febrile diseases, irritability, malaria, contracture and  pain of the elbow, arm and hand.
3 Qu Ze Pericardium 3 On the transverse cubital crease, at the ulnar side of the tendon of biceps brachii Cardiac pain, palpitation, febrile diseases, irritability, stomach ache, vomiting, pain in the elbow, arm and hand, tremor of the hand and arm.

Fig. 2.19

For severe carpel tunnel syndrome, surgery is the best option.  There are  two major type surgeries, i.e. open hand surgery and endoscopic surgery.
In carpal tunnel release, your surgeon cuts the tissue that holds joints together (carpal ligament) to relieve the pressure on your median nerve. You’ll have local or regional anesthesia, and you’ll usually go home soon after your surgery. Surgery usually results in significant improvement in your symptoms, but you still may experience some residual numbness, pain or weakness.

In endoscopic surgery, your surgeon performs carpal tunnel release through one or two small incisions in your hand or wrist using a device with a tiny camera attached to it (endoscope) to see inside the carpal tunnel.

Jessica underwent my treatment for a total of 12 visits and used a cock-up splint at night and rested her hand for one month without typing.  Gradually her symptoms lessened and she felt much less numbness and tingling sensation; her hands recovered their strength as well.

Tips for both acupuncturists and patients:

1.                              A clear diagnosis is necessary.  Some patients feel numbness and tingling in their fingers and hands without having carpel tunnel syndrome.  These sensations might be due to rheumatoid arthritis, osteoarthritis and other causes and if the diagnosis is not correct, the acupuncture and a cock-up splint cannot help.

2.                              The insertion of the acupuncture needles for the two points PC7 and PC 6 should not be too deep, about ½ inch, however, the electrical stimulation should be as strong as possible and as tolerable so it will bring enough energy to flow through the carpal tunnel and decrease the swelling of the hand.

3.                              I usually encourage the patient to wear the cock-up splint not only at night, but as much as is practicable during the day, while driving, doing housework, etc. which will greatly improve the patient’s rest on the median nerve and the carpal tunnel.

25. Acupuncture and Low Back Pain-Spine Compression Fracture-Collapse of the spine bone

Jan 7, 2011   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  4 Comments

News Letter, Vol. 3 (1), January, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Low back pain-spine compression fracture

Collapse of the bone in the spine

www.yanduguke.com

Linda S. is a 70 year old female, who complains of low back pain the day after she bent down to pick up her 1 year old granddaughter. She felt sudden onset low back pain; she had no history of low back pain before. She immediately felt entire low back spasm and was unable to bend forward and move her back. She had difficulty sitting and standing, the only position she felt comfortable was lying on the bed. She called her daughter right away; she was put on bed rest, she thought she might have low back sprain, she would get better after rest on the bed overnight. However, at the second day, she still felt the pain was sharp and stabbing, she could not move. Therefore, she was brought to me for evaluation and treatment.

By inquiry of her pain, she reported her pain was constant, and the pain also felt at the right hip, accompanied with stomach ache, slightly shortness of breath. But there were neither pain radiating down to legs nor urinary nor bowel incontinency; she denied any numbness or tingling sensation. The patient had history osteoporosis for 20 years, she was advised to take vitamin D 400 units and calcium 800 mg per day, forgetting many times to take them. Her daily exercise is swim and stationary bike one or two times per week.

I examed her, she had curved back to the right side of spine, i.e. kyphosis by medical term,  her muscles on the right side of back were very spasmodic, however,  the muscles on the left side of the back were looser, she looks like to have a hunchback. I was not able to identify a specific spot of her back pain, only at the vague area of  entire low back. Also her muscle strength was unable to be checked because of pain. She did not have any abnormal sensation at either leg.

The above signs and symptoms indicated that she might have diagnosis of Spinal  Compression Fracture. I immediately ordered CT-scan of her spine, which showed the following,

www.haodf.com

The CT-Scan depicted the wedge shaped vertebra, and confirmed my diagnosis of low back spinal compression fracture.

The Causes of Spine Compression Fracture:

The underline pathophysiology spinal compression fracture is osteoporosis, i.e. the vertebral bones lost their bone substance, the shape of the bones is existed, but the bones can not hold certain weight added to their body. The sponge liked bone at the low back spine can not sustain any acute stress, such as sudden bending forward to tie shoe lace, pick up something from the floor, etc.  The reasons for osteoporosis are as following,

1.      For women, the leading risk factors are menopause, or estrogen deficiency, cigarette smoking, physical inactivity, use of prednisone and poor nutrition. For men, except all the above nonhormonal factors, low testosterone levels also may be associated with osteoporosis.

2.      Renal failure and liver failure, which would make nutritional deficiencies, leading to decreased bone remodeling and increased osteopenia.

3.      Genetics, osteoporosis can be observed in closely related family members.

4.      Malignance, i.e. malignant tumors, might metastasize to the spine, such as myeloma, lymphoma, renal cell, prostate, breast, lung cancers.

5.      Infections: chronic osteomyelitis may result in spinal compression fracture.

The following are the major symptoms of spinal compression fracture:

  • Sudden, severe back pain.
  • Worsening of pain when standing or walking.
  • Loss of height.
  • Deformity of the spine – the curved, “hunchback” shape.
  • Some pain relief when lying down.
  • Difficulty and pain when bending or twisting.
  • Neurologic problems may manifest in many ways:
    • Reduced leg strength (paresis) or complete weakness (paralysis) is an obvious problem.
    • Loss of sensation in the lower extremities and in the perianal area (saddle anesthesia) can be just as important.
    • Urinary retention and urinary and fecal incontinence are very important signs that indicate the need for emergency surgery.

Most patients only had the following slight activities, and then the pain starts:

  • Slipping on a rug or making a misstep.
  • Lifting a suitcase out of the trunk of a car.
  • Lifting a bag of groceries.
  • Getting up from sitting position
  • Bending to the floor to pick something up.
  • Lifting the corner of a mattress when changing bed linens.
  • Getting in or out of car

Signs of Multiple Spinal Compression Fractures

Some patients might have multiple spinal compression fractures without notices. However, by careful examination, you may find the following,

  • Kyphosis (curved back, or hunchback): These fractures often create wedge-shaped vertebral bones, which makes the spine bend forward (Kyphosis). Sometimes, your body might twist the spine to the side leading to Scoliosis.  Eventually, neck and back pain may develop as your body tries to adapt the posture changes of the dynamic train of  entire spine.
  • Height loss: With each fracture of a spinal bone, the spine loses some of its height. Eventually, after several collapsed vertebrae, the person’s shorter stature will be noticeable.
  • Hip pain: The shorter spine brings the rib cage closer to the hip bones. If rib and hip bones are rubbing against each other, there will be discomfort and pain.
  • Breathing problems: If the spine becomes severely compressed, lungs may not function properly and breathing can be seriously affected, such as shortness of breath, sometimes the poor spine position may make people prone to infection, such as pneumonia or bronchitis.
  • Stomach complaints: A shorter spine can compress the stomach, causing a bulging stomach and digestive problems like constipation, poor appetite, acid reflexes, and weight loss.

Treatment of Spinal Compression Fractures

1. The best treatment is prevention. This is best accomplished by treating osteoporosis with exercise, calcium, and medications.

1).        Medications for osteoporosis
Calcium 1000 mg per day should be taken for women before menopause and a 1200 mg per day for women who are postmenopausal.
Vitamin D 800 IU for women before menopause and 1000 IU vitamin D for postmenopausal women.  Men up to age of 50  should increase vitamin D and calcium intake to 800 IU of vitamin D and 1000 mg of calcium per day.

Bisphosphonates, such as alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Reclast), which slow the rate of bone thinning and can lead to increased bone density. These medicines may be used in men and women.

2).        Regular weight bearing exercise. Increased walking, jogging, tai chi, stair climbing, dancing, and tennis. Muscle strengthening exercises include weight training and other resistive exercise.  Weight bearing exercise programs not only increase bone density but also improve both heart and lung functional ability and muscle strength. You may walk with a one to three pound of sand bag tied on your each calf for 2 to 3 miles a day, it will greatly improve your bone density if you stick to the program longer enough.

3).        For prevention, you should take all preventative procedures such as checking and correcting vision and hearing, evaluating any neurological problems, reviewing any prescription medications for side effects that may affect balance, and providing a check list for improving safety at home.  Wearing undergarments with hip pad protectors may protect an individual from injuring the hip in the event of a fall.  Hip protectors may be considered for patients who have significant risk factors for falling or for patients who have a previously fractured hip.

4).        Avoidance of tobacco use and excessive alcohol intake.  Alcohol and cigarettes inhibit osteoblast cell activities and improve osteoclast cell functioning.  Osteoclast cells usually destroy the bone density and osteoblast cell build up the bone density.

2. Alleviating the pain: Usually, treatment is aimed at alleviating the pain, and preventing injuries in the future, we use physical therapy, acupuncture, medications, etc.

1). Physical Therapy

Recent research has shown many benefits of using Whole-Body Vibration (WBV) to increase strength and decrease bone mineral density losses from astronauts, athletes to those recovering from injury.  Holding a quarter squat position for 30 seconds on a WBV machine set at 50 Hz would be equivalent to performing 1,500 squats without the stress on the joints.  WBV is very effective to increase BMD in post-menopausal women even in comparison to a walking regimen (http://www.biomedcentral.com/1471-2474/7/92/, http://www.ncbi.nlm.nih.gov/pubmed/15040822?dopt=AbstractPlus)

http://www.powerplate.com/resources/htm/research/research-cards/research-health-whole-body-vibration-proves-effective-for-the-elderly.htm

http://search.barnesandnoble.com/Using-Whole-Body-Vibration-in-Physical-Therapy-and-Sport/Alfio-Albasini/e/9780702031731/?itm=1&USRI=whole+body+vibration

Wearing a back brace is a very effective means to prevent unwarranted motions of the spine during early healing.  Be cautious of keeping a patient in a brace for an extended period of time typically over 6-8 weeks to avoid secondary complications of immobilization.  Maintaining a neutral spine is very important and must be taught how to properly perform functional activities such as getting in and out of bed while keeping the spine straight by using a technique called the “log roll” to go from lying on ones back with knees bent to log rolling to their side then pushing with their upper arm to a seated position and finally to standing.

http://www.pvhs.org/documents/Orthopedics/ThorasicSpineSurgery.pdf

In addition to learning how to properly perform activities of daily living such as getting in and out of bed it is very important to work on core stabilizing with exercises such described in the previous newsletter dealing with low back pain with failed back surgery syndrome with link at http://drxuacupuncture.co/2010/12/19/low-back-pain-again-after-back-surgery/

Performing a balance test such as the Berg Balance Test or Tinetti Test will give objective measurement of current balance level and risk of falls.  Preventing the risk of falls is very crucial as fractures are more likely with low bone mineral density levels.

There are many ways to improve balance and progressions to do so.  A basic progression would be standing with feet at shoulder width in front of a counter or couch so that you can use your hands to catch yourself if you experience a loss of balance or better yet, have a spotter.  Once able to hold that shoulder width stance without loss of balance, take a narrow width stance progressing to your feet being right next to each other for 1 min.  Taking a smaller base of support, such as bringing the feet closer, makes the exercise more challenging.  From there you can balance on a single leg taking turns between the left and right foot.  Next you are ready to try the shoulder width stance with your eyes closed working again to the narrow width stance with eyes closed.

http://www.diabetesmonitor.com/diet-and-lifestyle/exercise/national-institute-of-aging-guidelines/chapter4_balance_plantar.htm

Next, assume a stance where one foot is in front of the other such as a walking stride and again work balance with eyes open then narrowing the stance till one foot is directly in front of the other in a heel to toe fashion called tandem stance.  Once able to accomplish tandem stance with eyes open go back to walking stride stance and work to tandem stance with eyes closed.

http://www.exercise-to-a-healthier-life.com/tandem-stands.html

Another way to progress with balance exercises is to go from a flat stable surface such as the ground to an unstable surface such as a balance board or foam pad.  An unstable surface will increase muscle activity in the ankles, knees, hips and core making the exercise more challenging.

http://www.physicalcompany.co.uk/products/product_detail.asp?productId=ABPE

In addition to performing core and balance exercises, it is important to increase the strength in the upper spine and shoulders.  Using a theraband is easy but more importantly effective for increasing muscle strength.  A series of Lat Rows, Lat Pulls, and Shoulder External Rotations are three effective exercises to be performed 3-4 x week for 3 sets of 10, progressing to 2 sets of 15 and finally 1 set of 30 in a row.  Start off with a lighter theraband and work you way up to a higher resistance theraband such as progressing through yellow, red, green, blue to black.

http://www.thera-band.com/store/products.php?ProductID=28Standing Row with Theraband http://www.health24.com/fitness/Exercises/16-1339-1344,33165.asp

Standing Lat Pulls with Theraband    http://www.sbortho.com/educational_resources/strength_exercises.html

External Rotation with Theraband    http://www.health.com/health/library/mdp/0,,zm2387,00.html

2). Acupuncture

Hua Tuo Jia Ji points are sets of specially designed points used to treat spine disease. By palpation, you should feel the tender points around the  spinal process, then insert the needles into the disc about 0.5 inch deep and one up and one lower levels of the spinal process, plus 0.5 inch of the lateral sides of the three levels,  i.e. total 9 needles inserted into the tender points around the spine and adjacent area.

I also selected the following points: Sheng Shu, Qi Hai Shu, Chi Bian, Huan Tiao, Yang Ling Quan, Fei Yang, Ju Liao, Jue Gu, and Cheng Fu.

Table 25-1

Points Meridan/No. Location Function/Indication
1 Hua Tuo Jia Ji ExperiencedPoints Along the spine, use the most painful vertebral spinal as midpoint, then locate the upper and lower spinal process and 0.5 inch on the either side, you may choose two spinal process as the starting points. See Pic 4-1 Specifically treat for local neck and low back pain, and pain along the spine.
2 Sheng Shu UB 23 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the second lumbar vertebrta Nocturnal emission, impotence, enuresis, irregular menstruation, leucorrhea, low back pain, weakness of the knee, blurring of vision, dizziness, tinnitus, deafness, edema, asthma, diarrhea
3 Qi Hai Shu UB 24 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the third lumbar vertebra Low back pain, irregular menstruation, dysmenorrheal, asthma
4 Zhi Bian UB 54 Lateral to the hiatus of the sacrum, 3 inch lateral to the midline of spine Pain in the lumbosacral region, muscular atrophy, motor impairment of the lower extremities, dysuria, swelling around external genitalia, hemorrhoids, constipation
5 Huan Tiao GB 30 At the junction of the lateral 1/3 between the great trochanter and the hiatus of the sacrum. Pain of h elumbar regiin and the thigh, muscular atrophy of the lower limbs, hemiplegia
6 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
7 Jue Gu( Xuan Zhong) GB 39 3 inch above the tip of the external malleolus, in the depression between the posterior border of the fibula and the tendons of peronaeus longus and brevis Apoplexy, hemiplegia, pain of the neck, abdominal distension, pain in the hypochondriac region, muscular arophy of the lower limbs, spastic pain fo the leg, beriberi
8 Cheng Fu UB 36 In the middle of the transverse gluteal fold Pain in the lower back and gluteal regioin, constipation, muscular atrophy, pain, numbness and motor impairment of the lower extremities

3). Pain Medicines

Pain medications. A carefully prescribed “cocktail” of pain medications can relieve bone-on-bone, muscle, and nerve pain, explains F. Todd Wetzel, MD, professor of orthopaedics and neurosurgery at Temple University School of Medicine in Philadelphia. “If it’s prescribed correctly, you can reduce doses of the individual drugs in the cocktail.”

Over-the-counter pain medications are often sufficient in relieving pain. Two types of non-prescription medications — acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) — are recommended. Narcotic pain medications and muscle relaxants are often prescribed for short periods of time, since there is risk of addiction. Antidepressants can also help relieve nerve-related pain.

If the pain is severe, and collapse is becoming problematic, procedures called vertebroplasty or kyphoplasty may be considered. In these procedures an interventional radiologist restores the height of the bone and injects cement into the vertebra to stabilize the fracture and prevent further collapse.

Surgical Treatment for Spinal Compression Fractures

When chronic pain from a spinal compression fracture persists despite rest, activity modification, back bracing, and pain medication, surgery is the next step. Surgical procedures used to treat spinal fractures are:

  • Vertebroplasty

Figure 25.16

From: https://www.healthbase.com

After general anesthesia, or simply under sedation, a special bone needle will be inserted into the soft tissues of the back guided by x-ray, along with a small amount of x-ray dye, which will allow the position of the needle to be seen at all times. Then, a small amount of orthopedic cement, called polymethylmethacrylate (PMMA) will be pushed through the needle into the vertebral body, then the cement will be solid after a few mins. The cement will be filled in the fractured vertebrae, and sustained the body weight over night. Each vertebral body is injected on both the right and left sides, just off the midline of the back.

The cement is sometimes mixed with an antibiotic to reduce the risk of infection, and a powder containing barium or tantalum, which allows it to be seen on the x-ray.

Within a few hours, patients are up and moving around. Most go home the same day.

  • Kyphoplasty

From: www. sarasotaspine.com

Similar to vertebroplasty, Kyphoplasty is performed under local or general anesthesia. Using image guidance x-rays, two small incisions are made and a probe is placed into the vertebral space where the fracture is located. The bone is drilled and a balloon, called a bone tamp, is inserted on each side. These balloons are then inflated with contrast medium (to be seen using image guidance x-rays) until they expand to the desired height and removed. The balloon does not remain in the patient.   It simply creates a cavity for the cement and also helps expand the compressed bone.

The spaces created by the balloons are then filled with PMMA, the same orthopaedic cement used in vertebroplasty, binding the fracture. The cement hardens quickly, providing strength and stability to the vertebra, restoring height, and relieving pain.

The above procedures provide new options for compression fractures and are designed to relieve pain, reduce and stabilize fractures, reduce spinal deformity, and stop the “downward spiral” of untreated osteoporosis. In my experience, many patients reported miracle results after the procedures.

  • Spinal fusion surgery

From: http://www.neurosurgery.ufl.edu/

This procedure is used primarily to fuse or immobilize two or more vertebrae and to eliminate the pain caused by abnormal motion of the vertebrae.  Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction with the body’s natural bone growth (osteoblastic) processes to fuse the vertebrae.

The above procedures may help you a lot with a decrease of pain, and improve  your  spine stability and flexibility. However, the procedures may not solve all your problems. Sometimes, you may feel very much pain after the procedures. Therefore, it is necessary to have acupuncture treatment in order to reduce the pain.

TREATMENT OF LINDA

Linda first underwent physical therapy 2x  per week for 4 weeks in another physical therapy facility, she underwent many trunk forward bending and backward extension exercises, however, she felt more pain on the low back after her physical therapy. I did CT scan again, I found out her low back compression fracture was worse than the first CT scan. I immediately informed her stop doing the forward bending exercise, because this exercise causes the further compression fracture.

She was referred to interventional radiology for veterbroplasty treatment. She felt much better after the surgery. However, after 2 months of the surgery, she complained  of low back pain again. She came to me for treatment again.

I then started her with physical therapy 2x per week for another 4 weeks and in the mean time, acupuncture treatment 2x  per week for 4 weeks, Fosamax also was prescribed for her long term use. After about 6 weeks treatment, her pain is much subsided and she is more flexible.

Tips for the patients:

      1. You must give up the bending forward exercise of low back, and try to avoid bending forward postures, for example, do not pick up heavy object from floor, tight your shoes, etc.
      2. You must check your BMD (Bone Mineral Density) measurements at spine, hip, or forearm by DXA devices.
      3. Please read my news letter article no. 4, which will give you the information about how to take care of osteoporosis, please see the attached link: http://drxuacupuncture.co/2009/04/27/case-discussion-4/.

Tips for the acupuncture practitioners :

1.      Acupuncture could decrease the pain, but it can not change the shape of the compression fractured spinal spine.

2.      Do not advise the patients not go to the surgery, because the surgery might be the necessity for the treatment of long run.

3.      Teach the patients that do not bend their low back forward, which will worse the low back compression fracture. The patient should avoid the bending forward exercise.

4.      The patients should be advised to wear lumbar sacral  brace to protect the low back during acute stage of the low back pain.

5.      Acupuncture is not  the only treatment for spinal compression fracture, an integrated treatment might get better results.

24. Acupuncture and Low back pain again after back surgery

Dec 19, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 2 (12), December, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

 

 

Dear Friends and Patients:

Happy Holidays!

This is the last newsletter for 2010. We are very happy to introduce Dr. Robert Blizzard, who recently joined in our practice. Dr. Blizzard graduated from the University of Connecticut with a Bachelor’s Degree in Exercise Science, and continued on to receive his Doctoral of Physical Therapy at Franklin Pearce University. He is a full time licensed physical therapist in RMAC. We believe his knowledge and experience will help you to fulfill your goal to be completely recovered from your injury. Dr. Blizzard joined us to write this newsletter too.

From now on, we will leave our comment space on under the news letter at our website, www.DrXuAcupuncture.com.  you are welcome to leave  your questions or comments .  We will try our best to answer your questions.

We wish you happy holidays!

Jun Xu, M.D.

Hong Su, C. M. D.

Robert Blizzard III, D.P.T.

Low back pain with failed back surgery syndrome (FBSS)


 

 

From: www.yorkshirehighlanders.co.uk

Peter is a 56-year-old male who complains of low back pain for three years.  The pain started from the low back and radiated down to the right leg, which made it difficult sitting, walking, and standing.  The pain also interferes with his sleep, especially while he changes positions in the bed, and therefore he went to his primary care physician. He was referred to physical therapy for about three months of treatment.  However, the pain was not getting better and still he felt pain is sharp and stabbing, and that radiated down to the right lateral thigh and the lower leg.  The pain was constant.  In the meanwhile, he gradually felt his leg was weak and he had difficulty standing from the sitting and driving position.

Then one day he realized his underwear was wet because he had difficultly controlling his urinary bladder and he had decreased sensation at right lateral lower leg.  Therefore, his primary care physician referred him to a neurosurgeon.  An MRI was done, which showed two large right L4/L5 and L5/S1 herniated disc with impingement of right L5, S1 nerve roots.  He was advised to have surgery, L5/S1discectomy.

However, he was afraid of the surgery, then he consulted another neurosurgeon, who suggested to have laminectomy because the MRI, which showed two levels, L5 and S1, with  severe right foraminal L5-S1 nerve impingement and  degenerative changes between L5 and S1 and S1 and S2, which are the reasons for urinary incontinence.

He was thinking, however, he would like to wait a few more months to see if this would be getting better.  He restarted physical therapy again, and also he had epidural injection at those two levels and his pain seemed  better slightly.  However, he felt the right leg is weaker, he sometimes loses control of his urine.  Therefore, he decided to have surgery.

Laminectomy was performed one year ago.  After the surgery within one month, he had immediate pain relief and also he could control his urine and the bowel movement.  The patient was very happy about the surgery.

However, after six months, he started to feel low back pain again and this time he felt the pain is a gradual onset, dull and achy without any radiating down to the leg and he had no bowel or bladder abnormalities, but he still feels some weakness and mild numbness and tingling sensation on the right lateral leg. He visited his neurosurgeon, who told him this pain sometimes occurred after surgery about 6 months, and if he continued to do the physical therapy, the pain should be getting better.

The patient started to do physical therapy again after six months and he did muscle strengthening and stretching on the low back.  However, one day, he felt the pain suddenly getting worse after waking up and the pain is like stabbing with burning sensation around the L3-L4, L5-S1 middle spine and paraspine, and since then, he has had difficulty bending forward and backward, sitting to standing, and driving.  The patient then revisited his surgeon and he was prescribed Tylenol with Codeine.  After he took this pain medication, he felt better.  However, he started to feel drowsy and he had difficulty driving and concentrating on his work, and gradually he also started craving for this drug.  If he did not take for one day, he felt uncomfortable not only in the low back but the entire body and also he felt depressed and low energy.  Therefore, he came to me for evaluation and treatment.

I performed  physical examination, I saw the scars on the both sides of the L4, L5, and S1 para-spine, by palpation,  there was tenderness around L3-L4 and L5-S1 para-spine.  There was no palpation pain at bilateral sciatic areas.  He can bend his low back forward only about 40 degrees and bend his back backward only about 10 degrees.  He had no problem to walk on tippy toes and heels.  He had no decreased sensation at both legs.  I compared the MRI of presurgery and postsurgery,  There was no impingement of the nerve roots anymore.  Based on all the above information, I thought the patient was suffering with post-lumbosacral laminectomy syndrome, also called “failed back surgery syndrome” (FBSS), refers to chronic back and/or leg pain that occurs after back (spinal) surgery.

Before I introduce the Failed Back Surgery Syndrome, I would like to let you understand the basic knowledge of low back surgery;

There are seven types of low back surgery.

1.      Discectomy.

2.      Foraminotomy.

3.      Intradiscal electrothermal therapy.

4.      Nucleoplasty.

5.      Radiofrequency lesioning.

6.      Spinal fusion

7.      Spinal laminectomy, etc.

Discectomy
This is a procedure done to relieve pressure on a nerve root that’s being compressed by a bulging disc or bone spur. In order to relieve this pressure, the surgeon removes a small piece of the lamina (the bony roof of the spinal canal) from above the obstruction.

Figure 24.1

http://indiahealthtour.com/treatments/spine-surgery/endoscopic-micro-discectomy-surgery.html

Foraminotomy
This is type of surgery is undertaken to enlarge the foramen (the bony hole) where a nerve root branches out from the spinal canal. Joints thickened with age, or bulging discs, may cause the foramen to narrow, thereby pressing on the nerve. This pressure can cause pain, numbness or weakness in the extremities. In order to relieve the pressure, the surgeon removes small pieces of bone over the nerve through a small slit, which allows her to cut away the blockage.

Figure 24.2

From: http://www.laser-spine.com/spinehealth/treatments/endoscopic_foraminotomy/

IntraDiscal Electrothermal Therapy (IDET)
IDET is used to treat pain caused by a cracked or bulging spinal disc. This therapy involves inserting a special needle into the disc via a catheter. Once inserted, the needle is heated to a high temperature for approximately twenty minutes, effectively thickening and sealing the disc wall. This procedure reduces inner disc bulge and spinal nerve irritation.

Figure 24.3

From: http://www.advanced-pain-care.com/Intradiscal.htm

Nucleoplasty
Nucleoplasty is used to treat lower back pain resulting from mildly herniated or contained discs. During this procedure, a wand-like instrument is guided by x-ray imaging and inserted through a needle into the disc in order to create a channel. This facilitates the removal of inner disc material. Several channels may be made, depending on the amount of material needing to be removed. After removal, the wand heats and shrinks the tissue of the disc wall in order to seal it.

Figure 24.4

From: http://www.kcpain.com/kcp_help5c.php

Radiofrequency (RF) Lesioning
This procedure is used to interrupt of nerve conduction and the transfer of pain signals. Electrical impulses are used in order to destroy the nerves located in the affected area. A special needle is inserted into the localized nerve tissue, with the guidance of an x-ray. This area is then heated for 90 to 120 seconds, destroying the nerve tissue. This may result in cessation of pain for 6-12 months.

Figure 24.5

From: bnsmedical.com

Spinal fusion
Spinal fusion is a procedure which is done in order to support a weak spine and/or to prevent painful movements. However, spinal fusion requires a long recovery period, and may result in a permanent loss of spinal flexibility. The procedure involves the removal of the spinal disc between two vertebrae, and the subsequent fusion of those vertebrae. Methods of fusion include either bone grafting and/or using metal devices secured by screws.

Figure 24.6


From: http://skillbuilders.patientsites.com/Injuries-Conditions/Lower-Back/Lower-Back-Issues/Lumbar-Spinal-Stenosis/a~51/article.html
Spinal Laminectomy
This procedure is used to relieve pressure on the spinal cord and nerve roots. Also known as spinal decompression, this type of surgery involves the removal of the lamina to increase the size of the spinal canal.

Figure 24.7

http://www.eorthopod.com/content/lumbar-laminectomy

Treatments for Faild Back Surgery Syndrome (FBSS)

In 1992, Turner et al. published a survey of 74 journal articles which reported the results after decompression for spinal stenosis. Good to excellent results were on average reported by 64% of the patients. (Turner, J., et al., Spine 1992; 17:1-8 ) Therefore, there are about 36% of the post back surgical patients, who might suffer some degrees of back pain, usually after 6 months of surgery.  For some patients, the pain might achieve the peak intensity as pre-operation after two-year surgery.

Failed back surgery syndrome (FBSS),  is characterized by intractable diffuse, dull and aching pain or sharp, pricking, and stabbing pain in the back and/or legs accompanied with varying degrees of functional incapacitation.  Recurrent herniated disc and symptomatic hypertrophic scar can produce similar low back symptoms and radiculopathy as before the surgery. Gradually increasing symptoms beginning a year or more after discectomy are considered more likely a result of scar radiculopathy, while a more abrupt onset at any interval after surgery is more likely due to recurrent herniated disc. Multiple factors can contribute to the onset or development of FBS, such as residual or recurrent disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness and spinal muscular deconditioning.

The treatments of Failed back surgery syndrome (FBSS),  include physical therapy, acupuncture, minor nerve blocks, transcutaneous electrical nerve stimulation (TENS), behavioral medicine, non-steroidal anti-inflammatory (NSAID) medications, membrane stabilizers, antidepressants, and intrathecal morphine pump. Use of epidural steroid injections may be minimally helpful in some cases. Here, we will mainly introduce physical therapy, pain medications and acupuncture treatment.

1. Physical therapy:

Spine surgery changes the anatomy of the spine but does nothing to improve activation of deep core stabilizing muscles.  That is one of the benefits of physical therapy for re-training the body to properly activate the deep core muscles that stabilize the spine.  The two deep co-stabilizing muscles of the spine are the Transverse Abdominis (TrA) and Multifidus

Spinal braces are an option to wear especially immediately following surgery to improve recovery. A corset helps to brace the lumbar spine by increasing the pressure in the abdomen, and thus reducing the amount of weight placed through the spine.

Figure 24.8The Transverse Abdominis is often called the “human corset” as it is the only abdominal muscle attaching to the posterior spine and runs transverse around the body.

Figure 24.9

http://www.unm.edu/~lkravitz/Media/transverse.gif http://www.exerciseyourpainaway.co.uk/muscles.htm

Draw-Ins

These exercises can be performed in any position and progressed once the very important concept of TrA activation is achieved. The two starting positions are quadruped and supine.  Stabilizing the spine by activating TrA and Multifidus occurs without rotating the hips, tensing the shoulders or holding ones breath but from slowly drawing-in the deep core muscles of the abdominal wall.

Figure 24.10http://www.strattonpt.com/images/uploads/images.3.jpg

Figure 24.11

http://staceyspt.com/Exercise/LowerBack.htm

Figure 24.12http://www.sportstek.net/pressure_biofeedback.htm

Draw-Ins with Alternating Upper Extremity/Lower Extremity Movement

These movements build upon a solid foundation of spinal stabilization from the previous exercises.  Start off first by performing a Draw-In and holding that contraction while moving the Upper Extremities (UE) only, then work on the Lower Extremities (LE) finally moving on to simultaneous movement of both UE/LE.  Quadruped Alternating UE/LE Movement is also called “Bird-Dog” while “Dead-Bug” is the name of Supine Alternating UE/LE Movement.  It is important to maintain a neutral spine from hips to shoulders and for the core to take in the force when an extremity is lifted and not involve a rotation component to the opposite hand or knee.  This will occur if done improperly or rushed to without developing strength and control through the previous mentioned exercises.  Both the Bird-Dog and Dead-Bug can be progressed from a solid stable surface such as the ground or exercise mat to an unstable surface such as foam dyna-discs or a foam roller to increase the activation of core stabilizing muscles thus making the exercise more challenging and effective.

Figure 24.13 Bird-DogFigure 24.14  Dead-Bughttp://michaelwoodspg.blogspot.com/ http://www.canada.com/health/3390881.bin

Kneeling and Standing Chops/Lifts

Once properly able to stabilize the spine with Alternating UE/LE Movements, progression to more functional activities is deemed ready.  Theses moves involve working through all planes of movement while stabilizing the spine.

A resistance cable is used with the hands at arms length from the body starting over one shoulder and working diagonally across the body to the opposite knee, engaging the TrA and keeping from rounding the back forward.  In a Cable Lift the hands start at the knee and work diagonally up to the opposite shoulder.

Cable Chops

Figure 24.15

http://www.menshealth.com.sg/fitness/best-exercises-your-core

Figure 24.16

http://fms.riaguy.com/articles/fitness/2010-03-15_balanced_body_series.introduction_to_the_chop_and_lift

Cable Lifts from Kneeling and Standing

Figure 24.17

http://eas.com/training/strength/rotational-lift–split-squat-cable http://www.whatsupusana.com/2009/04/pregnancy-and-exercise.html

Soft-Tissue Mobilization

Adhesions and scar tissue development are very common following any surgery.  Development of these adhesions can lead to decreased mobility and compression on nerve roots causing increased stiffness and pain. A few simple techniques to rid adhesions/trigger points/scar tissue and improve recovery along the spine are from using a foam roller or having manual work specific to your individual needs.

Figure 24.18 Figure 24.19

http://www.foamroller.co.uk/ http://www.boulderbodyworks.com/physical-therapy.html

2.   Medications:

A. Acetaminoph: (one brand name: Tylenol) helps many kinds of chronic pain.

B. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Examples include aspirin, ibuprofen (two brand names: Motrin, Advil) and naproxen (one brand name: Aleve). NSAIDs come in both over-the-counter and prescription forms. These medicines can be taken just when you need them, or they can be taken every day. When these medicines are taken regularly, they build up in the blood to levels that fight the pain of inflammation (swelling) and also give general pain relief. Please remember that you always take it with food or milk because the most common side effects are related to the stomach.

C. Narcotics: Narcotics can be addictive. For many people who have severe chronic pain, these drugs are an important part of their therapy. If your doctor prescribes narcotics for your pain, be sure to carefully follow his or her directions. Tell your doctor if you are uncomfortable with the changes that may go along with taking these medicines, such as the inability to concentrate or think clearly. Do not drive or operate heavy machinery when taking these medicines.

When you’re taking narcotics, it’s important to remember that there is a difference between “physical dependence” and “psychological addiction.”

Physical dependence on a medicine means that your body gets used to that medicine and needs it in order to work properly.
Psychological addiction is the desire to use a drug whether or not it’s needed to relieve pain. Narcotic drugs often cause constipation (difficulty having bowel movements). If you are taking a narcotic medicine, it’s important to drink at least 6 to 8 glasses of water every day. Try to eat 2 to 4 servings of fresh fruits and 3 to 5 servings of vegetables every day.

C. Other medicines

Many drugs that are used to treat other illnesses can also treat pain. For example, carbamazepine ( Neurotin )is a seizure medicine that can also treat some kinds of pain. Amitriptyline is an antidepressant that can also help with chronic pain. It can take several weeks before these medicines begin to work well.

 

3. Acupuncture Treatment:

There are three types of Failed back surgery syndrome (FBSS) according to Traditional Chinese Medicine.

Figure 24.20

Figure 24.21

Figure 24.22

Figure 24.23

Figure 24.24

Figure 24.25

Type 1: Coldness and Wetness of FBSS:

Patients feel cold, heavy, and  pain at entire low back, difficulty turning over on the bed or standing up from sitting position, getting worse during the cold weather, stiffness at low back, hip and knee joints.

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun, plus Du 26 Ren Zhong, GB 34 Yang Ling Quan, and UB 58 Fei Yang.

Table 24.1

Points Meridan/No. Location Function/Indication
1. Da ChangShu UB 25 1.5 inch lateral to midline of the body on the back, at the level of the spinous process of the fourth lumbar vertebraFigure 24.20 Low back pain, abdominal distension, diarrhea, constipation, muscular atrophy, pain, numbness and weakness at legs, sciatica
2. Huan Tiao GB30 At the junction of the lateral 1/3 and medial 2/3 of the distance between the great trochanter and the hiatus of the sacrum.Figure 24.23 Low back  pain, thigh pain, muscular atrophy of the lower limbs, hemiplegia
3 Wei Zhong UB 40 Mid point of the transverse crease of the popliteal fossa, between the tendons of biceps femoris and semitendinosius musclesFigure 24.23 Low back pain, motor impairment of t he hip joint, contracture of the tendons in the popliteal fossa, muscular atrophy, pain, numbness and motor impairment of the lower extremities, hemiplegia, abdominal pain,k vomiting, diarrhea, erysipelas.
4 Kun Lun UB 60 In the depression between the external malleolus and calcaneus tendonFigure 24.23 Headache, blurring of vision, neck rigidity, epistaxis, pain in the shoulder, back and arm, swelling and pain of the heel, difficult labor, epilepsy.
5 Ren Zhong Du 26 A little above the midpoint of the philtrum, near the nostrilsFigure 24.24 Mental disorders, epilepsy, hysteria, infantile convulsion, coma, apoplexy-faint, trismus, deviation of the mouth and eyes, puffiness of the face,  low back pain and stiffness
6 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibulaFigure 24.22 Hemiplegia, weakness, numbness and pain of the lower extremities, swelling and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile convulsion
7 Fei Yang UB 58 7 inch directly above Kun Lun on the posterior border of fibula, about 1 inch inferior and lateral to Cheng Shan (UB 57)Figure 24.23 Headache, blurring of vision, nasal obstruction, epistaxis, back pain, hemorrhoids, leg weakness

Type 2: Kidney Deficiency of FBSS:

Patients’ pain demonstrate weakness,  and pain at nonspecific-pointed area, difficulty standing, feel better while lying on the bed, the pain is dull and achy, cold in four extremities

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun plus St 36 Zu San Li, Sp 6 San Yin Jiao, and Ki 3 Tai Xi. ( Please see tables 24.1, and 24.2)

Table 24.2

Points Meridian/No. Location Function/Indication
1. Zu San Li St 36 On finger-breadth from the anterior crest of the tibia in tibialis anterior muscleFigure 24.22 Gastric pain, vomiting, hiccup, abdominal distension, diarrhea, dysentery, constipation, mastitis, enteritis, knee joint and leg pain, edema, cough, asthma, waste syndrome, poor digestion, hemiplegia, dizziness, insomnia, mania
2. San Yin Jiao Sp 6 3 inches directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibiaFigure 24.22 Abdominal pain, distension, diarrhea, dysmenorrheal, irregular menstruation, uterine bleeding, morbid leucorrhea, prolapse of the  uterus, sterility, delayed labor, night bed wet, impotence, enuresis, dysuria, edema, hernia, pain in the external genitalia, muscular atrophy, motor impairment, paralysis and leg pain, headache, dizziness and vertigo, insomnia
9 Tai Xi Ki 3 In the depression between the medial malleolus and tendo calcaneus, at the level of the tip of the medial malleous.Figure 24.21 Sore throat, toothache, deafness, tinnitus, dizziness, spitting of the blood, asthma, thirst, irregular menstruation, insomnia, nocturnal emission, impotence, frequency of micturition, low back pain.

Type 3: Blood Stagnation of FBSS:

There is sharp, stabbing pain at specific area in the low back and buttock. The pain is very severe, so that nobody could touch the tender area, difficulty bending, sitting and standing, and turning over in the bed.

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun plus Sp 10 Xue Hai, UB 17 Ge Shu, LI 4 He Gu, UB 57 Cheng Shan.

(Please refer to tables 24.1, 24.3)

Table 24.3

Points Meridian/No. Location Function/Indication
1 Xue Hai Sp 10 2 inch above the mediosuperior border of the patella (Knee Cap)Figure 24.21 Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
2 Ge Shu UB 17 1.5 inch lateral to the middle line of the body on the back, at the level of the lower border of the spinous process of the 7ththoracic vertebraFigure 24.20 Vomiting, hiccup,belching,difficulty in swallowing, asthma, cough, spitting of blood, afternoon fever, night sweating, measles
3 He Gu LI 4 On the dorsum of the hand between th e1st and 2nd metacarpal bones, approximately in the middle of the 2ndmetacarpal bone on the radial side.Figure 24.25

 

Headache, pain in the neck, redness swelling and pain of the eye, epistaxis, nasal obstruction , rhinorrhea, toothache, deafness, swelling of the face, sore throat, arotitis, trismus, facial paralysis, febrile dieseases with anhidrosis, hidrosis, abdominal pain, dysentery, constipation, amenorrhea, delayed labour, infantile convulsion, pain, weakness and motor impairment of the upper limbs.
4 Cheng Shan UB57 Directly below the belly of gastrocnemius muscle, on the line joining Wei Zhong UB40 and calcaneus tendon, about 8 inch below Wei Zhong UB40Figure 24.23 Low back pain, spasm of the gastrocnemius, hemorrhoids, constipation, beriberi.
  1. Transcutaneous Electrical Nerve Stimulation (TENS):

TENS is thought to disrupt the   pain transmitting to the brain delivering a different, non-painful sensation to the skin around the pain site. In essence, it modulates the way we process the pain sensations from that area, i.e. it closes the pain gate to the brain. It can also trigger the brain to release endorphins. Endorphins act as natural painkillers, and help promote a feeling of well-being.

Figure 24.26

http://www.sodahead.com

5. Local Nerve Block

An epidural nerve block is the injection of corticosteroid medication into the epidural space of the spinal column. This space is located between the dura (a membrane surrounding the nerve roots) and the interior surface of the spinal canal formed by the vertebrae.

After a local skin anesthetic is applied to numb the injection site, a spinal needle is inserted into the epidural space under fluoroscopic (x-ray) guidance, using a contrast agent to confirm needle placement. Local anesthetic and corticosteroid anti-inflammatory medication are delivered into the epidural space to shrink the swelling around nerve roots, relieving pressure and pain.

Figure 24.27

http://www.treatingpain.com

6. Intrathecal Morphine Pump

Pain pump delivery of narcotic drugs is a rather new option available to persons with cancer and non-cancer pain. It is also called intraspinal (within the spine) or intrathecal (within the spinal canal) delivery. It was first used in 1979 after the discovery of narcotic receptors in the spinal cord. The use of an implant device to deliver medications directly in the area of the spinal cord was first used in 1981 for cancer pain. Since then, the pain pump has been used for chronic non-cancer pain such as failed low back surgery syndrome and spasticity from neurological conditions like multiple sclerosis, spinal cord injury, and cerebral palsy.

Figure 24.28

http://www.eorthopod.com

 

About Peter’s Treatment:

Peter underwent our treatment with both acupuncture and physical therapy. The typical protocol was as following,

  1. Peter was first put in the bed with heating pad on the low back for about 10 to 15 mins, his low back muscles were gradually loosening, then massage was given to further relax his low back muscles.
  2. After massage, acupuncture treatment was given, the most important points were selected based on the above principal. He was given needles with electrical stimulation for 20 to 30 min, his energy flow,  therefore,  is activated and the pain is gradually decreased.
  3. He then was transferred to physical therapy area, started to strengthen his abdominal and low back muscles with the above guidance.
  4. He was given the above treatment for about 20 sessions, he felt greatly improvement after the treatment. He has had more flexibility and much less pain. His pain scale decreased to 2/10 from 10/10. He was pain free for one year, and he sometimes returns to my office for tuning.

Tips for patients who had low back surgery, but still feel a lot of pain on the low back:

  1. MRI of low back spine is necessary to check any new injuries, such as new herniated disc, degenerative changes of other levels, any loosening of the screws, and spinal stenosis.
  2. Be very cautious for the subsequent low back surgery. Sometimes, you may be advised to have the second surgery for your low back. From my personal experience, I did not see many successful cases after the secondary even third low back surgery.
  3. Try to find a physiatrist MD, who also practices acupuncture. Physiatrist MDs are trained in US for Musculoskeleton Medicine. They not only understand your problem but also more specifically treat you with acupuncture. They also could guide your physical therapist for the treatment.
  4. The combination of physical therapy, massage and acupuncture treatments are very important, because these combined treatments could not only relax your muscles but also maximize your abilities to perform core body strengthen.
  5. Different patients like different sequence  of the treatment, it is not absolutely necessary to have massage, acupuncture, then physical therapy, because everybody is different. It depends on your personal preference. The most important is that you have to have the combined treatment to benefit the most.
  6. If you drive a distance for longer than 30 min, it is wise to have the lumbosacral corset, i.e. low back brace on,  the brace will protect your low back and prevent further injuries.

Tips for acupuncturists:

  1. You must clearly understand the patient’s pathological mechanism. Some patients are not allowed to have flexion exercise, some patients not for extension exercise.
  2. Heating pad and massage are very important to induce energy and relax low back muscles.
  3. LI 4 is a very important point to increase the secretion of endorphin and inhibit the up going reticular formation to send the pain signal to the brain.
  4. Electrical stimulation on the back points is a must.

23. Acupuncture and Chronic Low Back Pain-Herniated Disks and Pinch Nerves

Nov 14, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol.2 (11), November, 2010, (C) Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

 

Chronic Low Back Pain-Herniated Disks and Pinch Nerves

Jason W is a 46-year-old male who has suffered low back pain, on and-off, for about six months.  He is a teacher for special education who caught a student when the student was falling and about to hit the corner of a desk, at which moment he felt sudden onset low back pain.  The pain was so severe he was unable to stand, and felt weakness with the pain radiating to his left leg and causing a tingling and numbness sensation there.  When he was brought to my office, he was unable to stand but had to talk to me from a prone position on an examining table.

About one year ago Jason had a similar experience with a student and, at that time, felt the same sensations of low back pain, which radiated to his left leg, and accompanied with tingling, tenderness, numbness and heaviness of his left leg.  He consulted his primary care physician who diagnosed acute low back sprain, and prescribed anti-inflammatory medication and bed rest.  After two days he felt a little better however, since then, he has experienced pain off and on and also feels his lower back is weak.

At present, he finds it difficult to hold his low back, and his left leg is heavy and he has difficulty raising it, he cannot bend forward with any ease and has trouble donning his pants.  He also has difficulty picking up objects such as a pen from the floor and is experiencing a bit of urinary incontinence.

The patient is moderately obese and has a somewhat large abdomen, so I asked him to stand straight then bend forward.  He was unable to  perform this maneuver and immediately felt back weakness, and had difficulty bending forward more than 40 degrees.  When I asked him to walk on his tiptoes and heels, he was unable to do so, and he reported when he walks on his heels he feels low back pain radiating down the left leg, especially around the lateral of the knee and lateral to lower leg.  I also performed a straight leg raising test.  On the right side the patient could do straight leg raising by about 80 degrees, however, only 50 degrees on the left side, at which point he feels the pain radiating again down to the leg and knee.  I used a pinprick to check the patient’s response to sharpness and cotton ball to check his light touch sensation. Both tests showed decreased sensation along the left lateral thigh and leg.  I also checked his deep tendon reflexes, which showed the left knee jerk and left ankle jerk to be about 1+.  By examining the strength of his left leg, his ankle dorsal flexors are 3/5 and the ankle plantar flexors are 4/5, the knee flexors and extensors are 3/5, The rest are 5/5.

Because of the severity of his condition, I ordered a lumbar sacral MRI which showed severe L4/L5 herniated disc with a left protrusion.

Pic 17-1

Pic 17-2

From that above MRI pictures, you may see the arrows indicate the herniated disc from Jason’s Lumbar spine.

Jason appeared to have left L5 radiculopathy.  Because the above image showed severe herniated disc between L4/L5, he was immediately referred to a neurosurgeon.

After careful examination by a neurosurgeon, he was advised to have emergency surgery for discectomy, i.e. a small incision to cut off part of his herniated disc,  based on his emergency symptom, such as, severe low back pain radiating to left leg with numbness and tingling sensation, and slightly urinary incontinency.  Jason agreed the surgery.

However, the insurance companies’ argument prevented him from immediate surgery. He went through two similar episode of the low back injury during work as I described above, the second worker’s compensation company requested the first worker’s compensation company to pay the medical expenses, they believed the second injury was the consequence of first injury. But the first worker’s compensation company refused the request. Therefore, Nobody would like to pay the expenses, and Jason was so painful, he could not wait for  the final decision between the two worker’s compensation companies, Jason thought it would take months to solve the problem. The patient then called me and said, “ I am stuck here, nobody would like to pay for the expenses, I can not have surgery right now, could you please help me with acupuncture, I might avoid the surgery if it is possible?” I decided to accept the challenge then and I started to treat him right away.

Low back pain is the secondary most common injury to cause workforce loss in the US and almost everyone has experienced this kind of pain sometime in lifetime.

Low back pain has many different manifestations, the causes of which follow:

1.     Myofascial or tendon ligament sprain.  This is acute pain in the muscles that can come from poor posture, tendon ligament injury, or from overuse or overstretching.

2.     Radiculopathy which is a pinched nerve, usually originated from a herniated or slipped disc pinching one of the lumbar sacral roots as indicated from above MRI pictures.

3.     Spinal stenosis and narrowing of the nerve opening either around the spinal cord or nerve roots that cause symptoms similar to pinched nerve.

4.     Overuse and overstretch of ligaments of facet and sacroiliac joints.

5.     Fracture of the vertebrae caused by significant force such as an automobile or a bicycle accident, or a fall.

6.     Scoliosis or kyphosis, i.e. the spine curves changed in a wrong way.

7.     Compression fracture, which is common among postmenopausal women with osteoporosis.

There are also some less common spinal conditions capable of causing low back pain, including:

1.     Ankylosing spondylitis, which is a severe bony fusion of lumbar sacral spine and pelvic bone with unknown reasons, the patients have difficulty straight their back, and sometimes, are unable to look at sky.

2.     Bacteria infection such as osteomyelitis, etc.

3.     Spinal tumors.

4.     Paget disease: a bone disease in which the bone is unable to keep the balance of remodeling process, i.e. to lay down new bone and take up old bone for the purpose of rebuilding the bone. As a result, the bone  formation is abnormal with loose bone structure, and enlarged and low density bone, which are brittle and prone to fracture.

5.     Scheurmann’s disease, in which bones of the spinal vertebrae develop wedge-shaped deformities, i.e. the vertebrae grow unevenly, that is, the anterior angle is often greater than the posterior, results in the wedging shape of the vertegbrae and kyphosis.

Diagnosis:  The symptoms and physical exam usually give a good idea as to the correct diagnosis.  However, it is important to also have the following tests performed:

1.     X-rays will give evidence of the lumbosacral osteoarthritis and sacroiliac osteoarthritis and any degenerative changes of the disc.

2.     MRI will indicate the hernia disc and nerve impingement, facet joint osteoarthritis and also give a clear view of degenerative changes of the disc.

3.     Electromyograph (EMG) which is divided into two parts.  The first is nerve conduction study in which electrical stimulation is used to stimulate the nerves in one extremity.  The machine then checks the velocity of the nerve travel and the amplitude of each individual nerve, which is then compared to the opposite or paired extremity.  If there is any difference in the velocity and amplitude, as well as the latency, it is possible to differentiate among the nerves and determine which are injured  The second part consists of an electromyography, during which a small needle is inserted into certain muscles of the spine and extremities, if the muscle is injured, it will show up on the screen, which will pinpoint which nerve roots are injured.

4.     Lumbar myography.  This is radiographic examination of the lumbar spinal canal with  intrathecal injection of contrast medium.  After injection, X-rays are taken and show if any nerve roots are impinged.

Based on the clinical symptoms and physical examination plus one or all of the above tests, a clear diagnosis of lower back pain can be made.

Treatment by western medicine:

Generally speaking, lower back pain is categorized into two major types:

1.     Nonsurgical.  Most physicians recommend non-surgical treatment before resorting to surgery.  The following are usually recommended:

a.     Anti-inflammatory medications such as acetaminophenm Advil, naproxen, etc. and muscle relaxants such as Valium, Skelaxin, etc. which probably help relax lower back muscles.

b.     For a more severe condition, a lumbosacral brace or binder is usually recommended, which gives the patient support in the lower back.  However, continued use of the brace can lead to muscle weakness of the lower back and should therefore only be used for such activities as driving, lifting the baby or some heavy object, etc.

c.      Traction.  If the patient is diagnosed with a herniated disc, the usual treatment would be traction.  The patient is placed on a folding bed, then the an attempt is made to slightly pull apart the patient’s vertebral body.  It is possible for the herniated disc to return to its original position. The traction is not indicated for other lower back pain such as myofascial sprain, spinal stenosis, or spondylolithesis, and the traction must be guided by a physician.

d.     Physical therapy, which helps the patient strengthen the abdominal and leg muscles, which will alleviate the back pain; a strong abdominal muscle helps in holding the entire trunk.

Treatment by acupuncture:

All the acupuncture points are chosen along the nerve distribution and it is typical to stimulate these points with electrical stimulation and combine this with Moxibustion and massage, all of which greatly helps the patient.

Hua Tuo Jia Ji points are sets of specially designed points used to treat disc disease. By palpation, you should feel the herniated disc spinal process, then insert the needles into the disc about 0.5 inch deep and one up and one lower levels of the herniated disc, plus 0.5 inch of the lateral sides of the three levels,  i.e. total 9 needles inserted into the herniated disc and adjacent area. For Jason’ treatment, I inserted the needles to L4, also extended this Hua Tuo Jia Ji to L3 and L5 levels.

I also selected the following points: Sheng Shu, Qi Hai Shu, Chi Bian, Huan Tiao, Yang Ling Quan, Fei Yang, Jue Gu, and Cheng Fu.

Pic 11-3

Pic 11-4

Table 4-1

Points Meridan/No. Location Function/Indication
1 Hua Tuo Jia Ji ExperiencedPoints Along the spine, use the most painful vertebral spinal as midpoint, then locate the upper and lower spinal process and 0.5 inch on the either side, you may choose two spinal process as the starting points. See Pic 4-1 Specifically treat for local neck and low back pain, and pain along the spine.
2 Sheng Shu UB 23 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the second lumbar vertebrta Nocturnal emission, impotence, enuresis, irregular menstruation, leucorrhea, low back pain, weakness of the knee, blurring of vision, dizziness, tinnitus, deafness, edema, asthma, diarrhea
3 Qi Hai Shu UB 24 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the third lumbar vertebra Low back pain, irregular menstruation, dysmenorrheal, asthma
4 Zhi Bian UB 54 Lateral to the hiatus of the sacrum, 3 inch lateral to the midline of spine Pain in the lumbosacral region, muscular atrophy, motor impairment of the lower extremities, dysuria, swelling around external genitalia, hemorrhoids, constipation
5 Huan Tiao GB 30 At the junction of the lateral 1/3 between the great trochanter and the hiatus of the sacrum. Pain of h elumbar regiin and the thigh, muscular atrophy of the lower limbs, hemiplegia
6 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
7 Jue Gu( Xuan Zhong) GB 39 3 inch above the tip of the external malleolus, in the depression between the posterior border of the fibula and the tendons of peronaeus longus and brevis Apoplexy, hemiplegia, pain of the neck, abdominal distension, pain in the hypochondriac region, muscular arophy of the lower limbs, spastic pain fo the leg, beriberi
8 Cheng Fu UB 36 In the middle of the transverse gluteal fold Pain in the lower back and gluteal regioin, constipation, muscular atrophy, pain, numbness and motor impairment of the lower extremities


 

If the above noninvasive treatment does not help the patient, then epidural injections are indicated.  Epidural injections under fluoroscope and X-ray guided injections inject steroid and lidocaine into the facet joint or nerve root in order do decrease the nerve root inflammation as well as decrease the pain.

Surgical treatment:

Surgery is the last resort and there are several surgical options.

1.     Discoctomy surgically cuts into the herniated disc to decrease the compression of the nerve root.

2.     Laminectomy is used if the discetomy is not successful; in this surgery a piece of the bone is out to release the impinged nerve root.

3.     Fusion. If the vertebral body is unsteady, and cannot hold together, it is necessary to use a rod or bone chip to fuse the vertebrae which protects the nerve from further impingement.

Jason was diagnosed with left L5 radiculopathy. He was treated with me with the combination of both western and Chinese medicines. I first used Hua Tuo Jia Ji with 9 needles and other adjunct points as above, I also used heating pad, massage, traction machine for 90 lbs 20 min, for stabilizing his low back, I prescribed customized lumbosacral corset, i.e. back brace. He was treated with me three times per week for 8 weeks.

Gradually the pain subsided, Jason felt less weakness on the leg and the burning and tingling sensations went away and eventually he returned to work but continued his visits with me for maintenance once every two weeks or once a month.  After 6 months, he then consulted the neurosurgeon again who felt surgery was no longer indicated, based on the low intensity of his lower back pain.

Tips for acupuncturist:

1.     It is absolutely necessary to make a clear diagnosis, Differentiate acute and chronic lower back pain, differentiate muscle sprain from herniated disc and spinal stenosis and radiculopathy, because only in this way can the prognosis be predicted.  For example, if the diagnosis is muscle spasm, acupuncture can make the patient experience a quick recovery and greatly lessen the pain, and he/she can  most probably return to work after only one or two days.  However, if the patient has a herniated disc or spinal stenosis, acupuncture probably will help, but it will be a long recovery, probably two or three months.

2.     Treatment:  Most patients opt for non-surgical treatment first.  However, if the pain radiates down the leg, with numbness, tingling down the leg, combined with urinary incontinence, it is very important to have an MRI and CT scan or X-ray to make sure there is no significant herniated disc or spondylolisthesis or spinal stenosis.  If a severe medical condition is confirmed, then it is best to refer the patient to a neurosurgeon.

3.     Acupuncture can treat a herniated disc, especially if combined with traction and massage.

4.     A lumbosacral corset is also a great tool to help a patient move around with less pain.

Tips for patients:

1.     Identifying the symptom, if you feel your low back pain radiating down to the leg with numbness, tingling sensation and weakness, sometimes accompanied with slightly urinary incontinency, you have to make your doctor to order MRI to make a clear diagnosis.

2.     If it is acute or chronic low back sprain, you may need a few acupuncture treatments with massage and heating pad, if it is low back pinch nerves or herniated disks with above symptom, you have to ask your acupuncturist to use Hua Tuo Jia Ji points accompanied with massage, heating pad, even traction machine, if they are legally allowed to do so.

3.     Low back brace always helps  you to reduce your pain, however, you can not use it for 24 hours a day, you should be aware that the brace has side effects, which may weak your low back and abdomen muscles if you use it too long time. You only can use it intermittently. While you are at home, do not use it.

22. Acupuncture and Acute Low Back Pain – Low Back Sprain

Oct 23, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  1 Comment

News Letter, Vol. 2 (10), October, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Acute Lower Back Sprain


Frank M., a 35-year-old male, experienced sudden-onset lower back pain for two days.  He was moving a large piece of furniture for his girlfriend when he suddenly felt pain in his lower back.  The pain was constant, making it impossible for him to move his back; it was so severe that it caused his entire back to spasm.  The pain occurred from his lower back down to his buttocks, though it did not radiate down his legs, nor did he experience tingling or numbness.  All the above symptoms made it extremely difficult for him to put on his socks and pants.  He did not experience any urinary incontinence or bowel or bladder abnormalities.

Frank’s girlfriend took him to the emergency room, where he was given an MRI that came back negative, showing that he did not have a herniated disc.  He also had an X-ray which did not reveal a fracture.  He was given pain medication and sent home and assigned bed-rest for two days.  Massages and heating pads did not help the pain. After two days, the pain had not abated and Frank could not sleep in his bed (he had to lie on the floor, instead), nor was he able to go to work.  At this point, he came to me for a consultation.

My examination showed that Frank could only move his back forward about 30 degrees and could not bend backwards or extend his back.  When I touched his back, his entire back muscle went into spasm, and his cervical, thoracic and lumber spine areas were slightly twisted.  Using a manual muscle test, I concluded that he had no weakness in either leg. A sensibility test showed intact sensation in bilateral legs. There were no signs of a herniated disc or nerve impingement, no spinal fracture, no pain radiating to the legs, and no numbness or tingling sensations.  Based on my examination, I concluded that Frank had acute lower back sprain.

Lumber muscle strains and sprains are the most common causes of lower back pain and occur when the muscles or fibers are abnormally stretched or torn.  Lumber sprain occurs when the ligaments are torn from their attachments. There are usually no positive MRI and X-Ray findings. Because it is often difficult to differentiate between a sprain and a strain, the diagnosis of these two conditions is often confused.

The most important differentiations for acute lower back pain as opposed to other severe herniated discs or lower back nerve impingements, are that the latter two conditions involve the following:

1.     Loss of control of the bladder or bowels

2.     Numbness and tingling sensation in one or both legs

3.     Progressive lower extremity weakness

4.     Lower back pain radiating down one or both legs

If the acute lower back pain is accompanied by the above four symptoms, it is likely that the patient has a herniated disc or that the lumbar sacral nerves are impinged.  If there is only acute lower back pain without these four symptoms, the patient probably suffers from lower back sprain or strain.

The treatments used for lower back sprain and herniated disc are completely different.  For acute lower back sprain, the following method is utilized:

1.     According to Western Medicine techniques, the patient is usually prescribed bed rest for a few days up to one week. Doctors expect that the patients will feel better after bed rest and will be able to return to work and daily functions. However, this treatment is usually not very successful.

2.     Western medicine also employs anti-inflammatory medications,  such as Naproxen, Advil, etc,  or muscle relaxants, such as Skelexin, Valium, etc.  though usually this treatment, too, is not very successful in alleviating acute lower back pain.

3.     Sometimes the patient is fitted with a brace—a lumboscarcal corset that helps support the back—but there are negative side effects of using this because a corset weakens the muscles and ligaments of the lower back.

Traditional Chinese medicine treats this condition as follows:

We utilize the acupuncture points Zan Zhu UB2, Sheng Shu UB23, Da Chang Shu UB 25, Huang Tiao, GB 30, Wei Zhong UB40, Cheng Shan UB57, Kun Lun UB60, and the Arshi points (the tender points along the lower back).

Points Meridian/No. Location Function/Indication
1 Zan Zhu UB 2 On the medial extremity of the eyebrow, or on the supraorbital notch Headache, blurring and failing of vision, pain in the supraorbital region, lacrimation, redness, swelling and pain of the eye, twitching of eyelids, glaucoma, acute lower back pain
2. Sheng Shu UB 23 1.5 inch lateral to Mingmen (DU 4), at the level of the lower border of the spinous process of the second lumbar vertebra Nocturnal emission, impotence, enuresis, irregular menstruation, leucorrhea, low back pain, weakness of the knee, blurring of vision, dizziness, tinnitus, deafness, edema, asthma, diarrhea
3. Da ChangShu UB 25 1.5 inch lateral to Yao Yang Guan(Du 3), at the level of the lower border of the spinous process of the 4th lumbar vertebra Low back pain, borboryggmus, abdominal distension, diarrhea, constipation, muscular atrophy, pain, numbness and motor impairment of the lower extremities, sciatica
4. Huan Tiao GB 30 At the junction of the lateral 1/3 and medial 2/3 of the distance between the great trochanter and the hiatus of the sacrum (Yaoshu, Du2). When locating the point, put he patient in lateral recumbent position with the thigh flexed. Pain of the lumbar region and thigh, muscular atrophy of the lower limbs, hemiplegia
5. Wei Zhong UB 40 Mid-point of the transverse crease of the popliteal fossa, between the tendons of the biceps femoris and semitendinosius muscles Lower back pain, motor impairment of the hip joint, contracture of the tendons in the popliteal fossa, muscular atrophy, pain, numbness and motor impairment of the lower extremities, hemiplegia, abdominal pain, vomiting, diarrhea, erysipelas
6. Cheng Shan UB57 Directly below the belly of the gastrocnemius muscle, on the line joining Wei Zhong UB40 and the calcaneus tendon, about 8 inches below Wei Zhong UB40 Lower back pain, spasm of the gastrocnemius, hemorrhoids, constipation, beriberi
7. Kun Lun UB 60 In the depression between the external malleolus and calcaneus tendon Headache, blurring of vision, neck rigidity, epistaxis, pain in the shoulder, back and arm, swelling and pain of the heel, difficult labor, epilepsy.

Fig 16-1

Pic 16-2

Pic 16 -3

All the above points belong to the urinary bladder meridian except the GB 30.  I usually start treatment by inserting the needles into the Zan Zhu UB2 and ask the patient to stand up.  Then I insert the needles deeply along the Zan Zhu and apply a strong stimulation, either by manipulating the needles by hand or via an electrical stimulation.  The energy of the stimulation should transmit from the needles and travel upwards along the meridian of the bladder to the scalp, forehead, and back of the neck, then down along the upper back and into the lower back and legs. I then ask the patient to gradually move his/her back forward and backward and then to turn around.  Many patients are afraid to do so because they think these movements will exacerbate the pain.  However, the energy flow stimulation should relax the lower back muscles and make movement easier for the patient.

Usually, acute stimulation of the needles for 15 to 20 minutes greatly improves the movement of the lower back and alleviates the pain, making the patient’s range of motion in this area much better.  After the range of motion improves, the patient is asked to lie face down on the table.  I then insert the needle into the local Arshi points (around the spasmodic muscles) and into UB40, UB57 and UB60, and apply a strong electrical stimulation for 30 minutes.  This should stimulate the entire bladder meridian and gradually relax the lower back muscles.

After the acupuncture treatment, Frank immediately felt a decrease in the intensity of the muscle spasms, was able to move his back, and bend forward and backward by 50 degrees to a regular position.  He went home, applied a heating pad to the affected area, and returned the following day for the same treatment, which decreased the pain by almost 100%.  At this point, I prescribed a regimen of exercises and stretches that completely relieved the pain.  This is an effective treatment for both acute lower back strain and sprain.

Tips for Acupuncturists:

1.     You should always encourage your patients to move their backs during the stimulation of the Zan Zhu UB2, even if they are afraid to do so.

2.     The stimulation should be strong (stronger than the pain that the patient feels in the lower back).

3.     If you use a combined treatment of massage, acupuncture, and heating pads, you will have better results.

4.     Points in UB meridian are  the most important points to treat acute low back pain.

Tips for Patients:

1.     If you feel the pain radiating to the legs, experience numbness or a tingling sensation, or weakness in the legs, you may have a herniated lumbar sacral disc instead of acute lower back sprain.

2.     If you experience urinary incontinency, this is an indication that your herniated disc is affecting the nerves controlling your urinary system.

3.     If you have the above symptoms, you must consult a physician and ask for an MRI to make a clear diagnosis.

4.     If you lift heavy objects, please keep your objects close to your body’s center of gravity, the closer, the better.

5.     If you upload something in your car, please put one of your foot on your car’s bump or step, your leg will support your back in this way.

6.     If you have low back pain, but you have to drive for long distance, please use low back brace, which will protect your back, you will feel less pain on the back. However, you only can use the brace for short period, otherwise, your low back muscle will become weak if you use it for a long time.

21. Acupuncture and Trigger Finger-Dont’ Text Message Too Much

Sep 26, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  1 Comment

News Letter, Vol. 2 (9), September, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720


TRIGGER FINGER

You may text message too much

Martha L., a 16-year-old girl who likes to text-messages her friends, had been experiencing pain in the area of her right first finger joint near the palm (right Metacarpal Phalangeal MCP joint) for about four months.  As a new fassion, she spent two to three hours per day text message to her friends, and constantly opening and closing her hand at the exact point where she experienced the pain, tenderness and redness (at the joint of her right index finger). She ignored the condition for a month, but the pain became worse and she had difficulty extending the index finger, as well as feeling her knuckles keeping her finger from sliding in and out, Her finger would sometimes get locked into a bent condition.

Upon examining her, I discovered that she could bend the knuckle located at the joint of the base of the right index finger, but had difficulty extending her first finger.  When I forced her to extend this finger, she felt extreme pain, though this manipulation did succeed in extending the finger. She reported that in the mornings she could not move the finger at all until she had immersed it in hot water for ten minutes.

Martha suffers from a condition known as trigger finger, which is the snapping of the digits of the hand when opened or closed.  Trigger finger was first noted in soldiers who could not fire their weapons, due to inflammation of the right index finger through repeated use.  This condition is also called stenosing tenosynovitis, and involves the hand’s pulley and tendon system that governs the bending of the fingers.  The pulley at the base of the finger becomes too thick, constricting the tendons, making it difficult for the finger to move freely through the pulley.  Sometimes the tendon develops a knot or swelling at the base of the index finger.  Trigger finger is different from a Dupuytren’s Contracture, which is a condition that causes the thickening and shortening of the connective tissue in the palm of the hand.  Trigger finger, on the other hand, is characterized by inflammation at the pulley system of the finger that prevents the tendon from freely moving in and out of the pulley system (i.e the index finger is unable to flex or extend freely).

Trigger finger most commonly affects the index finger – or thumb, following more and more young generation involving in computer games and text message, more thumb trigger finger cases are showing up – and starts with discomfort felt at the base of the finger or thumb where they join the palm.  The area often feels tender when pressure is applied, and a nodule may sometimes be found in this area.  The patient often thinks there is a problem with the middle or tip knuckle of the digit after a nodule is found in this area.

The risk factors for trigger finger are as follows:

1.     Gender: trigger finger more often affects men than women.

2.     Repetitive grinding and gripping of knuckles such as repeated use of power tools or musical instruments (i.e. bows for violins, cellos, etc.) or now people frequently text massage for an extended period.

3.     Some medical conditions such as rheumatoid arthritis, diabetes, hypothyroidism, amyloidosis, tuberculosis, etc., leave patients more prone to developing trigger finger.

Western medicine treatments of trigger finger are:

1.     Rest.  I always strongly advise the patient to rest the affected finger, with no gripping and no repetitive opening and closing other hand.

2.     Splinting. A splint can help keep the finger in the extended position, which rests the joint and decreases the inflammation.  The brace may have to be worn for as long as six weeks.

3.     Soaking and massage.  The patient is instructed to immerse the afflicted finger in hot water each morning for 15 to 20 minutes, and then gently massage it to help relieve the pain and soften the nodule.

4.     NSAID (Non Steroid Anti-Inflammation Drug), such as ibuprofen, Advil, and Motrin can decrease the swelling and inflammation of the trigger finger.

5.     Steroid injection.  Injections of steroids near or into the tendon sheaths usually reduce the inflammation of the cyst dramatically; this treatment is extremely effective.

6.     Surgery.  If none of the treatments above are successful, it is necessary to find a hand surgeon to perform a surgical release of the tendon.

Traditional Chinese Medicine:

Acupuncture is also an effective treatment for trigger finger.  The needle should be inserted directly along the nodule (the Archi Point), electrical stimulation should be applied, and ultrasound employed.  Acupuncture softens the nodule, after which the needle should be inserted directly into the nodule, and electrical stimulation should be applied to the needle for 30 minutes. The ultrasound that follows can increase the blood flow around the nodule, and these three methods, used together, can greatly decrease the inflammation of the nodule to such a degree that the patient may need no other treatment.

Pic 14-1

Martha underwent the traditional Chinese medicine treatment for 10 visits.  Her condition improved so much that she was able to return to work and experienced no more pain.

Tips for patients:

My experience with this condition shows that rest is most important for trigger finger, and the patient must take care not to do any repetitive gripping during this period.  In the mean time, you have to immerge your hand into hot water for 10 to 15 min, then massage the joint with massage oil for about 10 min, then after, put ice on the joint about 10 min. The secret is you have to put ice on the joint for 10 min after your massage.

 

Tips for Acupuncturists:

Early treatment with acupuncture, electrical stimulation and ultrasound can be used effectively for mild to moderate trigger finger.  Surgery, if called for, should only be utilized as a last resort.

20. Acupuncture and Wrist Pain

Aug 22, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 2 (8), August, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Wrist Pain




Margaret D., a 45-year old pianist and professor at a music school in New York, had been preparing for a European concert for a year and was thus practicing more than usual.  A month before she was due to depart for Europe, she began experiencing a constant and severe pain in her left wrist. The pain, which was sharp, originated near the base of her thumb and gradually spread farther back into her forearm.  When she played the piano or tried to grasp or pinch an object, she felt a sharp pain in her wrist.  She also felt some numbness at the back of her thumb and index finger, and found a fluid-filled cyst on her left wrist.  Overall, she had difficulty moving that thumb and wrist.  She was extremely nervous and upset when she consulted me, fearing she might have to cancel her European concert.

Upon examining her, I found that her left wrist was swollen and extremely tender, especially at the base of the thumb.  Margaret was unable to bend her wrist or grasp a book or a cup.  Believing that she had de Quervain tenosynovitis, I performed the ‘Finkelstein test’ to determine the source of Margaret’s pain.  I asked her to hold her thumb in the palm of her hand and bend her wrist toward the little finger.  Margaret felt immediate exacerbation of the pain, which confirmed my diagnosis of de Quervain tenosynovitis.

De Quervain tenosynovitis affects two tendons: the extensor pollicis brevis and the abductor pollicis longus, which are located on the lateral side of the wrist.  These run parallel to each other and pass through the wrist in the synovial sheath.  This sheath enables the tendons to exercise their function: i.e. flexing and extending the thumb, like when you make a fist.

Some doctors believe the cause of de Quervain tenosynovitis is unknown.  Others believe that it can be caused by repetitive exercise such as playing piano, like in Margaret’s case.  Overuse of the two tendons can cause wrist pain, swelling, numbness or a tingling sensation when the nerve is pinched.  The differential diagnosis also includes osteoarthritis of the first scarpometacarpal joint: i.e. the osteoarthritis at the base of the thumb.

There are various ways of treating this condition:

  1. Western medicine:
    1. Non-steroid anti-inflammatory drugs such as ibuprofen, naproxen, Aleve, etc.
    2. Steroid injections, which are often extremely effective, however, the side effect is that steroid might cause the tendon become fragile and easily reinjuried.
    3. Natural treatment:
      1. Immobilization of the thumb by using a spica splint, which fixes the thumb in place, promotes total rest, and avoids any thumb movements. 2. Hot/cold compresses can be effective.  First apply a heating pad to the affected area to induce blood flow to the                  affected thumb and wrist, which will flush away the inflammatory factors.  Next, apply ice packs to drive away the                  inflammatory fluids.

2.Acupuncture.  The three most important points to utilize in this treatment are

  1. Large Intestine 4 He Gu, which serves to increase the endorphin secretion in the brain. It can thus synchronize with local points to decrease the pain signals from the brain.
  2. Large Intestine 5 Yang Xi and San Jiao 4 Yang Chi.  LI 5 is the point located exactly in-between the tendons of the extensor pollicis brevis and the abductor pollicis longus of the distal insertion.  SJ 4 is adjacent to the LI 5, and will help the healing effects of LI5. Heating this area will increase the amount of blood flow and wash away the inflammation.  Electrically stimulating the two needles will continually increase the energy flow to the area to decrease the feeling of pain.
  3. Large intestine 11 Qu Chi. LI 11 is the point along the same meridian of LI5 and helps decrease the pain by activating energy from the distal meridian.
Points Meridian/No. Location Function/Indication
1 He Gu LI 4 See table 3-1/Pic 3-4 See table 3-1
2 Yang Xi LI 5 On the radial side of the wrist, when the thumb is tilted upwards, it is in the depression between the tendons of m. extensor pollicis longus and brevis Headache, redness, pain and swelling of the eye, toothache, sore throat, pain of the wrist
3 Yang Chi SJ 4 On the transverse crease of the dorsum of wrist, in the depression lateral to the tendon of m. extensor digitiorum communis. See Pic 11-1. Pain in the arm, shoulder and wrist, malaria, deafness, thirst.
4 Qu Chi LI 11 See table 4-1/Pic 4-2 See table 4-1

Pic 8-3

Margaret received acupuncture treatment three times a week for four weeks then came in twice a week for an additional six visits with the electrical stimulation and heated needle treatments.  She also wore the spica splint and used an ice massage treatment immediately after practicing piano.  Her pain decreased significantly and she went to Europe for her piano tour.  As a reward to me, she brought her CDs recorded in her Europe trip to me. She had very successful performance.

Tips for acupuncturists:

  1. In addition to the above points, you may add a few Arshi points along the insertional tendons of extensor pollicis brevis and abductor pollicis longus. Note that the distal tendons are located in the lateral wrists, and are also called the “snuff box”.
  2. Recommend that the patient wear the spica splint, which will immobilize the patient’s wrist and accelerate the healing process.

Tips for patients:

  1. The sooner treatment is commenced, the better chance you have of recovering; you should not wait to consult the doctor.
  2. Resting and immobilization are necessary.  Many physicians think the cause of this condition is idiopathic (unknown), but my observation is that mechanical repetitions of the thumb cause this condition.
  3. After acupuncture and heating and electrical stimulation, it is best to apply ice to the wrist, which in turn helps decrease the inflammation.

19. Acupuncture and Elbow Pain

Jul 25, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

 

News Letter, Vol. 2 (7), July, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.rmac.yourmd.com; www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Both Side Elbow Pain


Christina W. is a 25-year-old violinist who recently graduated from music school.  With a large tuition loan to repay, Christina teaches 30-40 students a day via group lessons.  During the few months prior to consulting with me, Christina began to feel pain in her left lateral and medial elbow.  The pain was constant, and whenever she played her violin, she experienced elbow pain, which radiated from the inside of the elbow into the forearm and wrist.  When she flexed her wrist, the pain worsened and she also experienced weakness in her forearm.  When she held an object such as a book or coffee cup, shook hands, or turned a doorknob, the pain became unbearable.  She had no numbness or tingling sensation, but was unable to play tennis or golf.  Her doctor told her to take Tylenol or Advil, but because her symptoms did not improve, she decided to consult me.

I noted that Christina experienced severe tenderness at the lateral and medial portions of her elbow.  The pain increased significantly when I asked her to flex or extend her wrist.  I concluded that Christina was suffering from both tennis elbow (lateral epicondylitis) and golf elbow (medial epicondylitis).  The causes of these conditions are as follows:

  1. Recreational sports such as tennis ground stroke, racquetball, squash and fencing, etc.
  2. Occupational tasks associated with playing musical instruments, painting, plumbing, weaving, raking and the like.

Tennis elbow and golf elbow are not always the result of playing sports, and are simply caused by repetitive wrist extension and wrist flexing which leads to inflammation of the medial and lateral epicondyles.  The diagnosis of both these conditions is routine—the doctor should take the patient’s history and perform a physical examination. X-rays are not necessary.  Occasionally, however, an MRI may be used to show the changes in the tendon at the site of the attachment to the bone.

Tennis and golf elbow can be treated non-surgically or surgically; in Christina’s case surgery was not called for, and she instead underwent these treatments:

  1. Rest, and cessation of any activity that may have caused the condition.
  2. Ice packs applied to the outside and inside parts of the elbow.
  3. Ingestion of acetaminophen or other anti-inflammatory medications for pain relief.
  4. Orthotics to diminish the symptoms. The orthotics (i.e. an elbow splint) should be tightly attached to the elbow in order to prevent the stretching of either the lateral epicondyle tendons (such as extensor carpi radialis longus, extensor carpi radialis brevis and extensor carpi ulnaris, etc.) or the medial epicondyle tendons (such as Flexor carpi radialis, flexor carpi ulnaris and flexor digitorum superificialis, etc.). See Pic 7-1 below:Acupuncture, which is very effective if started early, and at the correct acupuncture points.

To treat Christina’s lateral epicondylitis, I used the following acupuncture points: LI 10 Shou San Li, LI 11 Qu Chi, LI 12 Zhou Liao, and Arshi points.  The Arshi points should be selected in this manner:

Feel the tendons of the lateral epicondyle attached to the radial head, then insert the needles between the bone and tendon in order to separate the bone and the tendon.  Usually, two to four Arshi points are used, followed by an electrical stimulation that should be applied with as high an intensity as tolerable for 23-30 minutes. (See Pic 10-2)

The process is similar for treating medial epicondylitis.  The acupuncturist should use Heart 3 Xiao Hai and three to four Arshi points.  The Arshi points will allow the doctor to follow the tendon of the wrist to the site where the tendon is attached to the bone.  Three to four needles should be vertically inserted along this tendon attachment.  A high level of electrical stimulation should then be applied for about 25 to 30 minutes. (See Pic 7-2)

Points Meridian/No. Location Function/Indication
1 Shou San Li LI 10 On the line between LI 5 and Li 11, 2 inches below LI 11 Abdominal pain, diarrhea, toothache, swelling of the cheek, motor impairment of the upper limbs, pain in the shoulder and back
2 Qu Chi LI 11 See table 4-1/Pic 4-2 See table 4-1
3 Zhou Liao LI 12 When the elbow is flexed, the point is superior to the lateral epicondyle of the humerus, about 1 inch superlateral to LI 11, on the medial border of the huerus Pain, numbness, and contracture of the elbow and arm
4 Xiao Hai Heart 3 When the elbow is flexed into a right angle, the point is in the depression between the medial end of the transverse crease of the wrist Chest pain, spasmodic pain of the elbow and arm, sudden loss of voice

Table 7-1

 

The acupuncture-points stimulation should be followed by an acupressure massage.  This friction massage should help to loosen the attachment of the inflamed tendon to the bone, and subsequently decrease the symptoms associated with tennis and golf elbow.

Other options for tennis and golf elbows are steroid injections and surgery, but neither was necessary in Christina’s case.  After three weeks of a combination of acupuncture, acupressure, and massage treatments, during which she was advised not to play her violin, her pain had decreased significantly.

Tips for acupuncturists:

  1. Correct direction of the needle insertion: the needles should be inserted between the bone and the tendons for the purpose of trying to separate the adhesion of the inflamed tendon and bone.
  2. Use friction massage: by moving your fingertips over the tendon head, you may detach the adhesion between the inflamed tendon and bone.

Tips for patients:

  1. You should put ice on the tender points and then perform the friction massage 15 minutes, two times a day.
  2. Stop playing sports, such as tennis, golf and other upper-extremity activities for at least one month or more, depending on the severity of the condition.

18. Acupuncture and Rotator Cuff Tear-Shoulder Pain 2

Jun 27, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  1 Comment

 

News Letter, Vol. 2 (6), June, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.rmac.yourmd.com; www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

ROTATOR CUFF TEAR

Matthew P., a 45-year-old man, injured himself after pitching a few baseballs to his son.   He felt a sudden onset of right shoulder pain, which was so severe that he could not raise his arm, and this considerably interfered with his daily activities.

When I questioned him, Matthew told me he had experienced this pain on and off for more than six months, but it was mild enough that he did not feel it was necessary to see a doctor.  This pain was present both during daily activities and at night, radiating from the front of the shoulder to the side of the arm.  It had been steadily worsening, and the injury was exacerbated by the fact that his son had just returned from boarding school two weeks before and they began playing baseball together again.  Within those couple of weeks, Matthew’s condition had worsened and he was no longer able to raise his arm to a 90-degree angle.

When I performed the physical examination, I found that his right shoulder was moderately swollen and very tender to the touch at the front and back of the deltoid area.  He also had a painful arc of movement between 60 and 120 degrees.  I had to help him raise his arm from 60 to 90 degrees, which caused him pain, but once he got it past the 120 degree mark he could do it himself and the pain subsided.  I also tried a drop arm test—I lifted his right arm passively up to 90 degrees, then let go—and he had difficulty maintaining the arm at this position on his own.

Based on the above observations, I concluded that Matthew had most likely torn his rotator cuff.  This condition has different names: rotator cuff tendonitis, rotator cuff inflammation, shoulder impingement syndrome, rotator cuff bursitis, etc.  The most common symptom is that patients experience gradual onset of shoulder pain with difficulty in raising the arms up to 120 degrees.  The impingement of the rotator cuff tendons is the most common cause of shoulder pain.

The rotator cuff is a group of tendons composed of four muscles: the supraspinatus, infrapinatus, subscapularis and teres minor.  These muscles cover the head of the humerus, and combined with the deltoid muscle, they form the bow of the shoulder.   The muscles’ function is to rotate and lift the shoulder.

http://www.achesandjoints.com/images/anj4/RotatorCuff-s.jpg

The acromion is the front edge of the shoulder.  It normally sits over and in front of the humeral head when the arm is lifted and in most cases will not rub the tendons of the rotator cuff.  However, in some cases, the acromion might wrap or impinge on the surface of the rotator cuff, which causes pain and limits the shoulder movement; this is called impingement syndrome.  There are three stages of rotator cuff impingement syndrome:

  1. Stage one: edema or hemorrhage stage. This usually occurs when a patient is under 25 years old. The shoulder shows acute pain, edema or hemorrhage with signs of inflammation. This stage is reversible and surgery is rarely used to treat the condition.
  2. Stage two: fibrosis and tendonitis stage.  The inflamed rotator cuff tendons continue to get worse, and develop to fibrosis and tendonitis.  This most often occurs between age 25 and 40. Conservative treatment and surgery should both be considered, depending on the severity of the patient’s condition.
  3. Stage three: arcomioclavicular spur and rotator cuff tear.  This stage occurs because of continuous mechanical disruption of the rotator cuff tendon between the arcomioclavicular and humoral head. Surgical anterior acromioplasty and rotator cuff repair is usually required.

Matthew appeared to have stage two (rotator cuff tear). In order to make a clear diagnosis of the disease, I ordered X-rays.  They showed a  anterior spur, which caused the impingement of the rotator cuff and the pain.

When Matthew played ball with his son, he had traumatized his shoulder, causing the rotator cuff to partially tear.

Treatment:

Western medicine is usually administered in four stages:

  1. Nonsurgical treatment: the patient takes a course of oral prednosone or some form of non-steroid, anti-inflammatory medication.
  2. The patient avoids strenuous activity and puts an ice pack on the injured shoulder.
  3. Injection of a local steroid into the affected area.
  4. Physical therapy: this can take from several weeks to a number of months.  Many patients experience gradual improvement and a return to normal function.

Surgical treatment is usually indicated for full thickness or partial tears that failed to improve with conservative treatment.  There are two kinds of surgical techniques.

  1. Arthrosopic technique: two or three small puncture wounds are made and a small instrument is inserted to remove the surface of the arcomion and clean out the injured tissue of the rotator cuff.
  2. Open technique: open surgery that cuts into the shoulder and allows direct visualization into the acromion and rotator cuff.

Matthew was offered all these options, but because of his work, he could not afford to take off time, and thus opted for a conservative treatment.

I first combined physical therapy with acupuncture, and advised him to put an ice pack on his shoulder immediately, and rest his arm as much as possible, strictly avoiding any activities that might aggravate the symptoms.

I then introduced acupuncture to decrease the pain.  I used  “the three famous shoulder needles” technique: Jian Qian, Jian Yu, and Jian Zhen.  All of these must be inserted 2-3 inches deep into the respective anatomic points: the rotator cuff including bicepital, supraspinator tendons, and acromial bursa etc.  Then, a strong electrical stimulation should be used to bring a large amount of blood flow to the shoulder and wash away the inflammation to gradually diminish the sensation of pain and improve the range of shoulder motion.

The ancillary points include LI 14 Bi Nao, SJ 5 Wai Guan, LI 4 He Gu and LI 11 Qu Chi.  The patient was treated for about three months and, after passing through the acute stage, I gradually strengthened his rotator cuff muscle and after six months his shoulder had returned to normal.  His range of motion also returned to normal, and there was no need for surgery.

Table 8-1

Points Meridian/No. Location Function/Indication
1 Jian Qian Extra 23 Midway between the end of the anterior axillary fold and LI 15, Jian Yu Pain in the shoulder and arm, paralysis of the upper extremities
2 Jian Yu LI 15 Antero-inferior to the acromion, on the upper portion of m. deltoideus. When the arm is in full abduction, the point is in the depression appearing at the anterior border of the acromioclavicular joint Pain in the shoulder and arm, motor impairment of the upper extremities, rubella, scrofula
3 Jian Zhen SI 9 Posterior and inferior to the shoulder joint. When the arm is adducted, the point is 1 inch above the posterior end of the axillary fold Pain in the scapular region, motor impairment of the hand and arm
4 Bi Nao LI 14 On the line joining Qu Chi (LI 11) and Jian Yu (LI 15), 7 inches above Qu Chi (LI 11), on the radial side of the humerus, superior to the lower end of the m. deltoideus Pain in the shoulder and arm, rigidity of the neck, scrofula.
5 Wai Guan SJ 5 See table 5-1/Pic 5-3 See table 5-1
6 He Gu LI 4 See table 3-1/Pic 3-4 See table 3-1
7 Qu Chi LI11 See table 4-1/Pic 4-2 See table 4-1

Pic 8-1

Tips for both acupuncturists and patients:

1.   If the patient has rotator cuff tendonitis or impingement, and is less than 25 years old and in the acute stage, an ice pack on the shoulder to decrease both the edema and inflammation, followed by acupuncture, is usually a sufficient cure.

2.   If the patient has stage two fibrosis and tendonitis, and is between the ages of 25 and 40, acupuncture should start as soon as possible, as described above.  This is usually sufficient treatment at this stage.

3.   If the patient has stage three acromioclavicular spur and rotator cuff tear, and is over the age of 40, doctors should cautiously examine treatment options.  The patient should have an X-ray and MRI without contrast to discover if the patient has a partial or complete tear, and he should consult an orthopedic surgeon to see if surgery is necessary.  If the patient is young and the injury is related to sports, the torn rotator cuff should be sutured as soon as possible in order to accelerate a complete recovery.

17. Acupuncture and Frozen Shoulder-Shoulder Pain 1

May 26, 2010   //   by drxuacupuncture   //   Blog, Case Discussions, Uncategorized  //  No Comments

News Letter, Vol. 2 (5), May, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.rmac.yourmd.com; www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Frozen Shoulder-Shoulder Pain 1



 

The above photo is coming from: www.1thing.info/50kata/gojukata1.gif

Martha T. is a 50-year-old woman with a long history of diabetes.  Approximately two months before consulting me, she felt a slight pain in her right shoulder when she tried to lift a heavy object.  Though the pain was not severe for the first few weeks, she gradually noticed a decrease in the mobility and function of that shoulder, coupled with more severe pain.  After the incident, she had trouble lifting her arms for tasks such as combing her hair and dressing with ease, especially when putting clothes on her right arm or fastening her brassiere.  Hoping the pain would go away, she did not consult a doctor.

When the pain became too severe, she came to me.  By physical examination, I noted that there was moderate tenderness at the right frontal and posterior shoulder.  Through palpation, I noted tenderness in her upper arm and lateral elbow.  She had difficulty raising her right shoulder up to her head and with movements that crossed the body’s middle line.  The pain was constant and she was unable to sleep on the right side of her body. Her right arm was weak due to the pain. There was no numbness or a tingling sensation.

Martha suffers from a “frozen shoulder,” or, in medical terminology, adhesive capsulitis.  This usually occurs after the age of 40, and about 20% of patients who suffer from this disorder have a history of diabetes and most of them have also been involved in some form of accident.  When these patients begin to feel shoulder pain, they try to compensate by limiting the normal range of motion in the injured shoulder.  Unfortunately, this makes some normal tasks such as brushing the hair, dressing, reaching for objects above the head, etc., more difficult.  By this stage, the patient usually realizes it is necessary to seek medical treatment for the condition.

Frozen shoulder is usually exhibited in three stages:

  1. Painful stage: A gradual onset associated with a vague pain. Unknown specific date of onset.  Lasts roughly 8 months.
  2. Frozen stage: The pain may begin to diminish during this stage. However, the shoulder becomes stiffer and the range of motion decreases noticeably, which causes the patient to avoid extreme movements that exacerbate the pain during this phase.  Usually lasts from six weeks to nine months.
  3. Thawing stage: The shoulder movement gradually returns to normal and the pain lessens.  Lasts from five months to two years.

Though the causes of frozen shoulder are still unclear, these are some noted possibilities:

  1. Injury resulting from surgery or any traumatic accident.  Most patients have a history of an injury that causes pain and causes the patient to decrease his/her range of movements.
  2. Diabetic patients have a tendency to have frozen shoulder. In those patients who are diabetic (about 20%), this condition worsens the symptoms.
  3. Autoimmune, inflammatory, and any procedures that immobilize the shoulder will increase the chances of frozen shoulder.

Western medicine treatments:

  1. Anti-inflammatory medications: The use of anti-inflammatory medications such as ibuprofen, naproxen, etc. However, these oral medications are not a very effective treatment.
  2. Corticosteroid injection: Using a corticosteroid (i.e. 40 mg of Kenalog and 5 cc of 1% lidocaine injected directly into the shoulder bursa) will greatly decrease the intensity of the pain. However, there are some side effects of corticosteroid injections such as blood sugar elevation, fragile shoulder tendons, osteoporosis, etc. I usually do not recommend using corticosteroid injections unless it is absolutely necessary (i.e. when there is severe pain, largely decreased range of motion, and handicapped daily activities).
  3. Physical therapy: Using heating pads, stretching, performing wheel range of motion exercises, muscle strengthening, electrical stimulation, ultrasound, electrophoresis, etc.  The dual treatment of corticosteroid injection and physical therapy can be very effective.

In some cases, surgery may be necessary.  There are two common types of surgery used to treat frozen shoulder:

  1. Manipulation under general anesthesia: forces the shoulder to move.  This process can unfortunately cause the capsule to stretch or tear.
  2. Shoulder arthroscopy: The doctor makes several small incisions around the shoulder capsule.  A minute camera and instrument are inserted through the incision and the instrument is used to cut through the tight portion of the joint capsule.  Often, manipulation and arthroscopic surgeries are used together and many patients have good results form this type surgery.

Traditional Chinese Medicine Treatment:

 

The following points were selected:

LI 15 Jian Yu, SI 9 Jian Zhen, SJ 14 Jian Liao, SI 10 Nao Shu, SI 11 Tian Zhong, LI 16 Ju Gu, St 38 Tiao Kou penetrating to UB 57 Cheng Shan, SJ 5 Wai Guan and LI 4 He Gu, LI 11 Qu Chi.

Table 7-1

Points Meridian/No. Location Function/Indication
1 Jian Qian Extrapoints 23

Midway between the end of the anterior axillary fold and LI 15, Jian Yu

Pain in the shoulder and arm, paralysis of the upper extremities
2 Jian Yu LI 15 See table 5-1/Pic 5-1 See table 5-1
3 Jian Zhen SI 9 Posterior and inferior to the shoulder joint. When the arm is adducted, the point is 1 inch above the posterior end of the axillary fold Pain in the scapular region, motor impairment of the hand and arm
4 Jian Liao SJ 14 Posterior and inferior to the acromion, in the depression about 1 inch posterior to LI 15 Jian Yu, when the arm is abducted. Pain and motor impairment of the shoulder and upper arm
5 Nao Shu SI 10 When the arm is adducted, the point is directly above SI 9 Jian Zhen, in the depression inferior to the scapular spine Swelling of the shoulder, aching and weakness of the shoulder and arm
6 Tian Zhong SI 11 See table 5-1/Pic 5-2 See table 5-1
7 Ju Gu LI 16 In the upper aspect of the shoulder, in the depression between the acromial extremity of the clavicle and the scapular spine Pain and motor impairment of the upper extremities, pain in the shoulder and back
8 Tiao Kou St 38 2 inches below St 37 Shang Ju Xu, midway between St 35 Du Bi and St 41 Jie Xi. Numbness, soreness and pain of the knee and leg, weakness and motor impairment of the foot, pain and motor impairment of the shoulder, abdominal pain
9 Cheng Shan UB 57 Directly below the belly of m. gastrocnemius, on the line joining UB 40 Wei Zhong and tendo calcaneus. About 8 inches below UB 40. Low back pain, spasm of the gastrocnemius, hemorrhoids, constipation, beriberi
10 Wai Guan SJ 5 See table 5-1/Pic 5-3 See table 5-1
11 He Gu LI 4 See table 3-1/Pic 3-4 See table 3-1
12 Qu Chi LI 11 See table 4-1/Pic 4-2 See table 4-1

Pic 7-1

Pic 7-2

Pic 7-3

Pic 7-4

To treat Martha, I applied the heating pad to her right shoulder for approximately 20 minutes.  This increased the flexibility of the tendon underneath. Then, I inserted the needles into the above acupuncture points. After 30 minutes of acupuncture treatment, I gave her a deep massage, and she was told to raise her shoulder and perform other range of motion exercises. The patient underwent my treatment for a total of 10 visits.  Afterwards, she reported that her right shoulder pain and range of motion had improved greatly.

Tips for acupuncturists:

  1. Instruct the patient to sit down and relax.  First, insert the needle into the Qu Chi tips toward to the shoulder about 1.5 inches deep, causing the energy to transmit up to the shoulder.  Then insert the needles into the points of Jian Yu, Jian Zhen, Jian Liao, and Tian Zhong. Insert the needle into Tiao Kou so that it penetrates to Cheng Shan.  During the treatment, scratch the handles of needles, and make sure the patient feels this energy sensation from the needle tips spreading to the shoulder.
  2. Tell the patient to slowly raise his/her arm up to the head, and move the arm around. Usually, the patient will feel instant relief from the pain.

Tips for patients:

  1. Do range of motion exercises for 20 minutes every morning taking a hot bath or shower. The hot water increases the blood circulation and energy flow and will allow for the best range of motion and the least pain when doing these exercises.
  2. Purchase a heating pad and apply it to the shoulder for 20 minutes. Do the range of motion exercises again.
  3. The main goal is to increase the range of motion of the shoulder.  The second goal is to decrease the pain in the shoulder.
  4. Try to get an acupuncture treatment as soon as possible; do not wait.  Without treatment, it may take a few years for natural recovery, and in some cases range of motion will never fully return.
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