Repetitive strain injury

Repetitive strain injuries such as carpal tunnel syndrome and hand, wrist, forearm tendinitis represent 56% of all workers compensation claims in the US at this time. (1) In many acupuncture clinics, hand, wrist, and forearm pain and numbness is a common pain pattern that is seen on a regular basis. It is most often related to the type of work that a patient does and is twice as common in women as in men. Hairdressers, musicians, aestheticians, massage therapists, manicurists, and anyone who works for extended hours on a computer seem to be particularly prone to this type of overuse injury. And since it threatens their livelihood, such people often find these injuries as frightening as they are physically painful. Unfortunately, it may be true that a patient with a severe case of hand/wrist tendinitis or full-blown carpal tunnel syndrome may have to stop the work that aggravates the condition at least for a while. Less severe cases can be treated quite successfully with acumoxa therapy for a very reasonable cost and kept from becoming debilitating and, therefore, threatening to someone's livelihood.

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Western medical etiological factors

In Western medicine, the continuum leading to full blown carpal tunnel syndrome starts with any repetitive, complex set of motions placing very specialized demands on this specific region of the upper extremities. Further, because of the tremendous variability of their movement, the great number of articulations and intrinsic and extrinsic muscles, and their use as a major sensory as well as a motor organ, the hand and wrist are particularly vulnerable to injury and difficult to treat successfully. According to Western medical theory, tendinitis in the hand and wrist is a process, which begins with tendinomuscular fatigue leading to micro-tears which becomes chronic inflammation as they are aggravated over and over again without adequate rest. Without rest, muscles do not receive enough oxygen and other nutrients from the blood and are unable to flush lactic acid and other metabolic wastes. When the nervous system becomes involved, the muscle tendon bundles remain hypertonic and pain reflexes in the area are activated. This becomes a chronic inflammatory/pain cycle and is the same for any part of the body.

Chinese medical etiological factors

The causes of muscle and sinew pain have been well described in many Chinese medical texts, as early as the "The Treatise on Bi" in the Nei Jing Su Wen. In Huang-fu Mi's Systematic Classic of Acupuncture & Moxibustion, there are several chapters devoted specifically to these types of problems. (2) In more modern books such as Bi Syndromes by Vangermeersch and Sun, theories about muscle/sinew pain have been synthesized into a format that is quite accessible for Western students and practitioners.

1. Bi

Classically, many types of muscle or sinew pain may be classified as bi or blockage pattern. According to Drs. Vangermeersch and Sun, "In TCM, the term bi is specifically used to indicate obstruction of qi and blood in the channels and collaterals due to several kinds of pathogenic factors, such as wind, coldness, dampness, etc ... and leading mainly to pain, numbness, and impairment of movement." (3) In the same book, the authors state that in order for external pathogenic qi to invade the tissue, correct or righteous qi must be weak, as is often the case in elderly or weakened patients. (4)

While blockage patterns are definitely a co-factor to be considered when confronted with a patient presenting pain in the forearm, wrist, and hand, (or anywhere else in the musculoskeletal system), it is my experience that there are usually other factors of equal importance involved. These may include vacuity of qi and blood, weakness or one or another organ, and possibly blood stasis.

2. Qi and blood vacuity due to spleen qi vacuity

Chinese medicine says that the spleen rules the muscles and flesh and the four limbs. If a patient with wrist, hand, and/or arm pain has other signs and symptoms indicating spleen qi vacuity as well, this will definitely have an impact on their dysfunction. If the patient has numbness as well as pain, spleen vacuity may be participating in this problem as well. We know this because Chinese medicine says that the spleen is the organ of transformation of qi and blood. (5) A weak spleen may not be able to transform enough qi and blood to circulate the extremities adequately.

Further, qi is required to transform dampness. If the spleen is unable to generate enough qi to transform and transport fluids, they congeal in the tissues and hinder the normal flow of qi. The patient will describe this as pain that feels heavy or worsens in damp weather. Also, since dampness is one of the three factors in bi patterns, this is another example of how qi vacuity can contribute to a bi or blockage pattern.

As a person gets older, the spleen function weakens and less qi and blood is created to circulate to the extremities. This inadequate flow of qi and blood makes older people more prone to pain, weakness, and/or numbness. Also, as stated by Vangermeersch and Sun above, an elderly person whose qi and blood are weak is also made more vulnerable to invasion of external evils. (6)

It is important to remember that for most people who present with hand/wrist/arm pain and numbness, overwork or repetitive work is a major contributor to their problem. Overwork depletes the qi and blood and therefore complicates any situation in which there is pain due to pre-existing qi and blood vacuity.

3. Blood stasis

In his book on aging and blood stasis, Zhong Guo Li Dai Zhong Yi Kang Shuai Lao Mi Yao, Yan De-xin describes in great detail how blood stasis may participate in a variety of geriatric diseases, including muscle and skin numbness, limb and body aching and pain. He quotes "The Treatise on Bi" from the Nei Jing Su Wen, "If there is bi in the vessels, blood will congeal and does not flow." Thus we can see that blood stasis can complicate muscle or sinew pain anywhere in the body or be a secondary factor in a bi pattern. Of course, pain due to blood stasis will usually be fixed and stabbing in nature. This quality of pain may alternate with other qualities, depending upon what other factors are involved in a particular patient's case.

4. Liver depression qi stagnation

In my experience, most of the patients who present with this problem are under stress in connection with their work. It is my feeling that the stress plays a role in their pain and dysfunction. This is because emotional stress can cause liver depression qi stagnation. When this happens, the liver cannot properly perform its function of coursing and discharging. This may exacerbate local qi stagnation anywhere in the body. Another Chinese medical statement of fact about the liver is that it governs the sinews and movement, and that when the liver receives blood, the sinews stretch. (7) If the liver's functions are negatively impacted by emotional stress, both qi stagnation and impairment of the sinews may affect hand/wrist/arm pain and dysfunction.

5. Combined factors

Most cases of hand/wrist tendinitis or carpal tunnel syndrome that I have seen are a combination of local qi stagnation, internally or externally generated dampness and/or cold, possible blood stasis, and blood and/or qi vacuity manifesting as pain, numbness, and weakness. Patients may also manifest signs and symptoms of spleen qi vacuity, kidney qi vacuity, or liver depression qi stagnation. These patterns may complicate the successful treatment of the problem if not taken into consideration. In such cases, proper herbal therapy may also be necessary to ensure success and diet and lifestyle suggestions must be part of the treatment plan as well.

Questions to ask

I have developed a list of questions that I always ask a patient who presents with this type of dysfunction. It will give me as much information as possible about the causes and progression of the problem, and what possible methods of treatment may be helpful.

1. Exactly where is the pain (weakness, numbness) located? (Determine channels involved.)

2. Is there numbness or tingling (a sign of blood vacuity or blood stasis, at least locally)?

3. What makes it better, worse? (any particular weather, cold, heat, dampness) (Worse with cold or dampness, use moxa and massage; worse with heat, use needles, liniments, very little or no massage)

4. What other treatments have you tried?

5. Does the pain move around or remain in one place?

6. Does movement improve or worsen the pain?

7. Can you/have you rested the arm from work?

8. Does massage make it better or worse?

9. Regular "10 Questions" of Chinese medical diagnosis. These help to determine constitutional weakness, organ/bowel dysfunction, or other factors that may play a role in the patient's pain or loss of function.

Basic Treatment Plan for Hand, Wrist, Arm Pain

Root Treatment

If you determine that there is spleen vacuity, kidney vacuity, liver blood vacuity, liver depression qi stagnation, or any other organ/bowel involvement complicating the problem, choose the supplementation point, source point, and/or back shu point as a root treatment to support what you are doing as a branch treatment. In addition to a better long-term effect on the specific problem for which the patient requests help, other, less troubling symptoms may improve as well.

For example: If the guan position on the right hand is weakest pulse position (soft, fine, deep, soggy, or weak) and there are other symptoms to corroborate a root diagnosis of spleen vacuity such as a tendency to fatigue, loose stools, insomnia, etc.), one should palpate spleen channel points #2,3, and 6 for tenderness or spleen-related areas of the abdomen to confirm using points on this channel as part of the root treatment in this case. In this case, my first choice would be to supplement Sp 2 (mother point) or Sp 3 (horary point) with a 38 or 40 gauge needle (the finer the gauge the better). The needle technique should be very shallow, and the intent is to just contact the qi without causing any pain at all.

Choose one pair of extraordinary channel points if they seen appropriate and based on the location of the pain and numbness. For example, if the problem is on the:

* jue yin, you may add very shallow needles with IP cords at Per 6 (Nei Guan) and Sp 4 (Gong Sun).

* shao yang, you may add TH 5 (Wai Guan) and GB 41 (Zu Lin Qi), same tx

* tai yin and yang ming add Lu 7 (Lie Que) and Ki 6 (Shao Hai), same tx

* tai yang add SI 3 (Hou Xi) and Bl 62 (Shen Mai), same tx.

These are especially appropriate if there is tenderness and/or pain on at least one of the paired points.

Choose any point that decreases pressure-pain in the abdomen. For example, if there is pressure-pain on the part of the abdomen corresponding to the kidneys (around the navel in some systems, 3-4 cun below the navel in another system), one may palpate Ki points #3 (source point), 6, and 7 (mother point) to see if these reduce the sensitivity of the abdominal area. If they do, again needle to supplement the point with a very fine gauge needle, shallow insertion. Check again to see if the abdominal sensitivity changes. These root treatments should be the first part of your protocol.

Branch Treatment

1. Palpate entire length of affected channels looking for tender points.

Treat tender points with very gentle needling to release if stagnation/stasis is main problem. Use thread moxibustion on these points (3-5 threads) if vacuity is the main issue. A combination of needles and moxibustion can be used where there is both stagnation/stasis and vacuity.

2. Apply needles at main points for the affected channel. This may be on the affected or the unaffected side depending on various factors that we will discuss later in this article:

* Per 7 (Da Ling) = jue yin This point is especially important and seems often to make the difference in effective treatment. It is mandatory to needle it if there has been carpal tunnel surgery since the surgery can hinder the normal flow of qi and blood in the area. My experience with this point is interesting in that it can have a positive effect on wrist and hand numbness no matter which of the channels are involved according to the patient's subjective experience. This seems to be a sort of "master point" for wrist/hand pain and numbness.

* LI 4 (He Gu), 10 (San Li), or 11 (Qu Chi) = yang ming

* Ba Xie points = numbness in the fingers and hand

* SI 3 (Hou Xi) and SI 8 (Xiao Hai) = tai yang

* Lu 5 (Chi Ze) or Lu 9 (Tai Yuan) = tai yin

I have found that LI 10 (Shou San Li) is almost always tender no matter what other channels are involved. I almost always needle it on the unaffected side and often use moxa on the needle.

3. If the pain is on either the tai yang, shao yang, or yang ming, palpate up into the neck and shoulder regions following the channel. Look for tender points at TH 16, 17, LI 18, SI 9, 10, 13, and ah si points in these areas. Use thread moxa or needles to relax tenderness.

4. If the pain improves or relaxes with warmth, or if the pain is worse at night or if the arm and hand become numb at night, add the use of indirect moxa with a liniment. The moxa encourages the liniment to penetrate and increases any pain-relieving effect. This treatment can be administered every day by the patient as homework in some cases to strengthen what you are doing during treatments.

5. If there has been surgery on the medial wrist, use a deep needle into Per 7 plus seven star hammer of the entire wrist area.

6. If there is no inflammation (heat, swelling, redness, sensitivity to massage) end the treatment with massage: tuina, mild kneading and squeezing. It is my experience that it is important not to forget the healing power of touch when treating patients for almost any type of problem.

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7. Suggest series of 4-6 treatments over a 2-3 week period. If that many treatments do not help, it is time to refer the patient as acumoxa therapy may not be helpful to them or you may not be the right practitioner.

You may be unable do all these things in each patient visit. Pick and choose the ones that seem most appropriate for each case. However, I strongly suggest that you not forget the use of moxibustion in treating musculoskeletal pain of any kind. For me, it is a vital part of my protocol and I'm sure that it increases good results.

Using the affected or unaffected side

One of my teachers, Dr. Miriam Lee, quotes an old Chinese medical saying, "If a child is hurt, don't punish it." This means not to needle right on top of the area of pain. Dr. Lee frequently does not even needle on the same side as where the pain exists. While I consider Dr. Lee's saying carefully with each patient, I sometimes treat on the same side as hand pain and numbness appear and sometimes on the opposite side. While it is somewhat difficult to describe how I make this choice, I will try to give some general guidelines.

If there is numbness, I mostly treat the affected side with both needles and moxa. Whereas the use of needles can manipulate existing qi and blood, it cannot directly create fresh qi and blood where none exists. Only with internal herbal medicine or the use of moxibustion can something be added to the body. (8) Since numbness may often involve at least local blood vacuity, I like to use moxibustion directly on the numb areas to add qi and encourage the infusion of blood into the area. Needling of numb areas encourages the increased flow of qi to them.

If there is no numbness but the pain is chronic, my usual procedure is to use thread moxa in the local area and needle either the exact area of pain on the opposite arm and/or choose a point on the corresponding channel on the contralateral leg. For example, if the pain is on the yang ming channel of the left arm, I would needle any tender point below the knee on the foot yang ming channel on the right leg.

Also, how chronic or acute is the problem is and what makes it worse or better affects the decision as to which side to treat. If the pain is worse with movement (local qi stagnation and/or blood stasis) and relatively acute, I am more likely to use needles in the local area. The more chronic and longterm the problem or if it worsens during sleep or rest, the less likely I am to do so. If the problem is definitely adversely affected by cold, indirect moxibustion and local massage seem to give better results than local needles. Beyond these recommendations, each practitioner must experiment and use a combination of intuition and Chinese medical theory to decide how best to treat.

What to try if treatments are unsuccessful

1. Akabane testing/stimulation to balance the channels of the arm/hand will help you confirm your diagnosis of which channels are replete and which ones are vacuous.

2. Ear needles in points for Wrist, Fingers, Pain Master, and Neurogate (Shen Men). You can use mild electrical stimulation if you have it. Use the ear on the affected side.

3. If there are any purple/black veins, if there has been surgery, or if the pain is fixed and stabbing, consider bleeding one or two points, removing one drop of blood at each. If such veins are visible and you do not bleed, you will not get the best possible result.

4. Pay more attention to treating the root. Reexamine the patient's pulse and tongue and go back over what questions you asked to see if you overlooked any factors that may contribute to the condition. Re-examine the abdomen and think through that part of your treatment.

5. Go over self-care techniques with the patient if you have not already done so. Find out if their work habits have changed or if work-related stress levels have worsened. Suggest dietary changes to support your root treatment.

Self-care

There are a variety of things that patients can do to help themselves. Here are a few that I suggest:

1. Wearing a splint at night (many patients will already have one of these) or during work can help maintain proper blood circulation to the area. Rest the affected part as much as possible.

2. Patients may want to take extra doses of B5, B6, and Vitamin C. For inflammatory stage of pain, high doses of bioflavonoids may be helpful.

3. Using indirect moxibustion with liniments at home is a good way to extend the therapy they receive during an acupuncture treatment.

4. A variety of herbal liniments are on the market that can be used to help these patients; it is recommended to use these two-three times per day.

Notes and suggestions

If the patient is also seeing a physical therapist or an orthopedic surgeon, they will often be using regular ice therapy on affected areas and will ask my opinion of this practice. If there is obvious heat, swelling, and redness, or if the patient is in the first 24 hours after a soft tissue injury, ice can be useful therapy. Chinese medicine does not, however, recommend it for everyday, long-term use. Such strong cold therapy can aggravate stagnation and stasis by "freezing" the tissue when what is needed is more circulation through the channels and connecting vessels. My feeling is that long-term use of ice makes things worse rather than better. I give them my opinion and suggest that they try a liniment or a soak instead for one week and see if that works better than ice. If they are obviously very Western medically aligned in their thinking, however, it may be better to approach this issue with caution. One does not want to contradict direct orders from any patient's MD. My way of approaching it is to use the phrase, "If it were my wrist, I would try using this soak or liniment; however, if your doctor has suggested ice and that seems to help you, then fine. You might consider trying the liniment for one week. If it is not as helpful as the ice, then go back to using ice. I want you to do what gives you the most relief." This seems to be non-threatening and gives them the option to choose, while clearly stating your opinion.

As with any health problem, no treatment will work for 100% of patients. Pain due to damp and/or cold with mild vacuity is often easy to treat. Cases with the complication of blood stasis respond well with the addition of mild blood letting therapy. That which is due to damp heat and severe vacuity (of blood, qi, spleen, kidneys, a combination) is the hardest (as in cases of fibromyalgia). Also, it is my experience so far that if a person has already had surgery on their wrists, you may or may not fight battles successfully, but you cannot totally win the war. They will probably require treatment, at least from time to time, for the rest of their life because the tissues have been damaged and the scar tissue aggravates the tendency to stagnation and stasis. Such cases do better with lots of liniment and indirect moxa at home, but even then they can be difficult to treat. It is important to remember that you will never see those people whose surgery has been successful. Therefore, it is impossible to say definitively that the surgery does not work. However, it has been my experience with people who have had surgery and did end up in my office that they are no better off after the surgery than before. If you can help prevent a person with this type of problem from having surgery, you may have done them a great favor.

References

1. Wolkomire, R., "Warning: keyboarding may be dangerous to your health," Smithsonian, June 1994, p. 90

2. The Systematic Classic of Acupuncture & Moxibustion by Huang-fu Mi, Blue Poppy Press, 1994, pp. 581-594

3. Bi Syndromes or Rheumatic Disorders Treated by Traditional Chinese Medicine by L. Vangermeersch & Sun Pei-lin, SATAS, Brussels, Belgium, 1994, p. 1.

4. Ibid., p. 3

5. Statements of Fact in Traditional Chinese Medicine by Bob Flaws, Blue Poppy Press, p. 36-39

6. Vangermeersch & Sun, op. cit., p. 2

7. Flaws, op.cit., p. 29

8. Classical Moxibustion Skills in Contemporary Clinical Practice by Sung Baek, Blue Poppy Press, 1990, pp. 2-3

abstracted & translated by Honora Lee Wolfe, Dipl. Ac., Lic. Ac., FNAAOM

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