Painful Obstruction (Bi) Syndromes - Part One
In Chinese Medicine the word “Bi” has many meanings and may indicate the presence of Pathogenic Factors blocking the limbs, channels, collaterals/network-vessels and/or Organs. The phrase “Bi or Painful Obstructive Syndromes (which has also been translated as: “Obstructive syndromes, “Impediment patterns,” or “Rheumatic patterns”) describes painful disorders including muscular and bony disorders. Painful Obstruction (Bi) syndrome describes biomedical disorders such as: rheumatic diseases, painful local and systemic inflammatory conditions (rheumatoid arthritis, lupus etc.), painful soft tissue disorders, painful metabolic disorders, painful neural disorders, and some traumatic injuries. In general, inflammatory disorders fit most closely the syndromes characterized in TCM as Wind-Damp-Cold (or Heat), while degenerative conditions (osteoarthritis/arthrosis/DJD) more closely fit syndromes of Liver/Kidney-deficiency and Blood-Phlegm-stasis causing degenerative weakness, stiffness, and pain (see note 1).
However, clinically, Painful Obstruction Syndromes are complex and multiple patterns are often the rule. Pathogenic Factors may include: Wind, Cold, Heat, Dampness, Phlegm and Blood-stasis. Other bodily functions such as Qi, Blood, Yin, Yang, Kidney, Liver and Spleen are often affected, and Deficiency-Excess mixed patterns are common as well. There is often general weakness, disharmony of Organs with Pathogenic Factors, and/or generation of Bi-disease from abnormalities of the Defensive and Nutritive-Qi (see note 2).
The Classic of Internal Medicine/Simple Questions devoted an entire chapter to Bi syndromes (Painful Obstruction) and Bi is related in this classic to external Pathogenic Factors, mostly Wind, Cold, and Dampness, with Dampness being at the centre of the complex. Both external and internal Heat and Deficiency syndromes are described. Clinically, endogenous and exogenous factors are often seen at the same time. Painful Obstructive disorders have been further elaborated throughout the history of TCM and were given names such as: moving/Wind-Bi, painful/Cold-Bi, burning/Hot-Bi, fixed/Damp-Bi, inflexible/Liver-Bi, bone/Kidney-Bi, sinew/Liver-Bi, muscle/flesh-Spleen-Bi, blood/vessel/Heart-Bi, skin/Lung-Bi, multiple-Bi, and several Deficient type Bi syndromes. According to Li Gong Zuo, Sinew-Bi is similar to Wind-Bi; Vessel-Bi is equivalent to Heat-Bi; Muscle-Bi is intimately related to Damp-Bi; Skin-Bi may be classified into moving/Wind-Bi and Heat-Bi.
These categories of Bi syndromes describe not only the affected tissues but also a pattern of symptoms. For example, The Systematic Classic of Acupuncture & Moxibustion states:
The Yellow Emperor asked: Circulatory Bi travels around the body upwards and downward, following the [affected] channel up and down. [It attacks] the left and right sides at the corresponding places with no intermission. I would like to learn where this pain lies, in the blood vessels or in the partings of the flesh, and how it comes about in this way. It moves [so swiftly] that there is no time for one to insert the needle, and the time it takes for the pain to build up is [so brief] that it has come to an [abrupt] stop before a treatment is decided upon. What causes it to behave in such a way?
Qi Bo answered: This is multiple Bi rather than circulatory Bi. [The pains] are fixed in location, alternately erupting and then ceasing in succession, with the left responding to the right and the right to the left. However, [the Bi] is incapable of moving, only starting and stopping [in a fixed location]. To needle this, treat the painful place even once then pain there will cease in order to prevent it from recurring...
...Circulatory Bi lies within the blood vessels, following the vessels up and following the vessels down, but it does not travel from left to the right or vice versa, nor does it have a fixed location. For pain travelling from above to below, one must first needle points below to thwart it and then needle points above to eliminate it. As for the pain travelling from below to the above, one must first needle points above to thwart it and then needle points below to eliminate it...
...Bi that lies within the bone causes heaviness. If it lies in the vessels, it causes congestion and failure of Blood flow. If it lies in the sinews, it results in the ability to contract but inability to stretch. If it lies in the flesh, it causes insensitivity. If it lies in the skin, it causes Cold. In the case of any of these five patterns, there is no pain. Any type of Bi may give rise to hypertonicity when coming in contact with Cold, and to slackness when coming in contact with Heat.
In the Classic of Internal Medicine(Simple Questions), Bi syndromes affecting the sinews and bones are also described as difficult to cure, suggesting that Bi syndromes presented a clinical challenge at the time. Characteristically, at the onset, Painful Obstruction (Bi) syndromes manifest as pain, soreness, numbness, and impaired movement. Numb-like sensation is often said to be due to Qi/Blood-deficiency or Cold-Bi, while true numbness (lack of sensation) may be more due to chronicity and deep penetration with Damp-Phlegm and Blood-damage, or stasis, causing malnutrition of the skin, which may also lead to painless numbness. In general, numbness is caused by:
• Congested Pathogenic Factors (especially Phlegm and Blood) which block the network-vessels;
• Righteous-Qi blocked and “hidden” by pathogens;
• Spleen/pancreas-Qi that is Hot and Stomach is Dry damaging Yin-Fluids;
• Defensive and Nutritive aspects that are depleted and cannot flow.
Painful Obstruction and Pathogenic Factors affect Qi and Blood circulation (and Nutritive and Defensive-Qi functions), and with time result in disruption of nourishment to the sinews—numbness and weakness may ensue, and Atrophy/Wilting syndromes may develop. Patients with “rough and coarse” skin and weak muscles are said to have a tendency to contract Bi-diseases. At the onset, Painful Obstruction (Bi) syndromes affect mainly the channels. However, if not treated effectively, Painful Obstruction can affect the Organs and even become fatal. For example, unresolved vessel Bi is said to be capable of affecting the Heart (Heart or chest Bi), and to cause symptoms of irritability with epigastric throbbing (“below the Heart,” Juque-REN 14 or Heart Alarm point), rebellious-Qi (rising of Qi, panting, and pressure in the chest) and fear, as commonly seen with heart disease (see note 3).
The Classic of Internal Medicine says:
The five Yin Organs are related to the five tissues where a chronic disease can settle in. In bone Bi syndrome the pathogenic factor reaches the Kidneys; in sinew Bi syndrome it reaches the Liver; in Blood vessel Bi syndrome it reaches the Heart; in muscle Bi syndrome it reaches the Spleen; and in skin Bi syndrome it reaches the Lungs.
Therefore, any prolonged Bi of an associated tissue will eventually affect the Organ associated with it. Many Organ Bi and polyarthralgia syndromes may correspond to systemic biomedical disorders such as: chronic or acute rheumatic fever, rheumatoid arthritis, psoriatic arthritis, lupus, gout, and lyme disease, among others (see note 4).
Theoretically, Exterior Painful Obstruction (Bi) disorder is mainly caused by exposure to adverse environmental conditions such as dampness, cold or wind. The Pathogenic Factors (Die-Qi, Wind-Cold-Damp) are said to jointly enter the body mostly via the pores, entering the Yang channels and then penetrating the deeper channel and vessel systems. Characteristically, the acute type has a quick and progressive on-set which begins with symptoms associated usually with external Wind, Cold, and Damp (superficial/Exterior syndromes) - or viral and infectious-like disease. Clinically, however, unless the symptoms are clearly inflammatory, patients with arthritic or other pain syndromes (even in acute onset) only occasionally convey such a history. This may be due to lack of awareness (or slower onset) and may be explained by an expansion of the theory of latent pathogenic factor: pathogens enter deeply due to weak antipathogenic-Qi without causing a superficial syndrome. When there is exogenous-Wind attack, if the patient’s anti-Pathogenic Factors are strong, a simple Exterior syndrome should develop and the condition should resolve without development of a Bi syndrome. If, however, there are other complicating factors, pathogens may lurk and Obstruction can develop (see note 5).
In general, Painful Obstructive (Bi) syndromes are said to develop in patients with constitutional weakness or when Defensive-Qi is weak or the surface is open while sweating. Parasitic or Warm-diseases can infect patients regardless of constitution or state of anti-pathogenic forces. Even in Hot-type arthralgias, the majority of traditional discussion was in terms Wind-Damp-Cold disease, which transforms into Heat (Huo-Hua) or into Damp-Heat. Cold, Wind, and Dampness can cause stagnation or slowing of circulation within the channels and network-vessels and may then transform into Heat or Damp-Heat. Or a pre-existing internal-Heat may combine with external or internal Wind-Damp-Cold pathogens to become a mixed Cold and Hot syndrome. Patients with Yang-deficiency constitution are susceptible to the effects of windy, cold, and damp environments and tend to develop Cold-Damp Bi-syndromes. Patients with Yang-fullness or deficient-Yin constitution are susceptible to the effects of windy, damp, dry, and warm environments and tend to develop Damp-Heat Bi-syndromes. Patient with Kidney-Yin-deficiency are especially susceptible to latent/hidden Pathogenic Factors (see note 6).
Retained or lurking Pathogenic Factors are often a result of stressful lifestyles that suppress immunity/anti-pathogenic forces (see note 7).
The magnitude and resolution of pain often reflects the relative strength and struggle between Pathogenic Factors and Righteous-Qi (anti-Pathogenic Factors). In healthy people whose anti-pathogenic-Qi is strong, a “battle” takes place in the Exterior layers between the Pathogenic Factors and the Defensive and Righteous Qi. The pathogens often reach only the outer Tai-Yang, or possibly only the Shao-Yang (intermediate) channels and tend to not affect deeper tissues. The pain will be relatively acute and moderately strong.
In cases where the anti-Pathogenic Factors are weak and/or the patient is feeble or old, the pathogens may enter deeply into the network-vessels, tissues, and Organs. First the muscles and joints will be affected, but with time skin-obstruction will affect the Lungs, vessel-obstruction the Heart, sinew-obstruction the Liver, muscle/flesh-obstruction the Spleen, and bone-obstructionthe Kidneys. Often the pain will be milder and Deficient in character, but chronic. A more complex mix syndrome is then the rule.
Thus, in general, Excess/Full pain in Bi syndromes is associated mostly with Pathogenic Factors and impairment of free-flow of Qi and Blood in the channels and vessels, while Deficient/Empty pain is associated mostly with the malnourishment of sinews, muscles, and bones from insufficiency of Qi and Blood, and is often associated with Kidney and Liver Organ weakness.
Constitutional patterns seen in TCM (usually related to Organ diagnosis) can be developed into a differential diagnosis based on Painful Obstruction (Bi) aetiology and further analysis of key pathologic factors: Wind, Damp, Cold, Heat, and Stasis/Congestion.
• Wind often refers to the sudden onset, mobility, and variability of symptoms. Wind-dominant arthralgia affects first the upper body and corresponds mostly to the early stages of arthritis. Internal-Wind can result in severe pain, tightness, spasms, and headaches, and is not often related to early-stage arthritis. Internal-Wind can be caused by Deficiency (mostly of Yin and Blood) or stirred by extreme-Heat. To treat combined internal and external Wind, herbs that address both may be needed, and, especially in chronic cases, so-called herbs that “track” Wind are used. Stiffness and rigidity caused by Liver-Wind is seen especially in the elderly.
• Dampness refers to the worsening of the symptoms in damp weather, the initiation of the disease, or the worsening of symptoms after exposure to damp environments, and the accumulation of Fluid. Dampness-dominated arthralgia affects most often the lower parts of the body and is said to be characterized by heaviness, swelling; stiffness, and the feeling of being bound up in the joints, limbs, chest, or head. Numbness is said to result from Dampness obstructing Qi and Blood, especially when congealed into Phlegm. Dampness-dominated syndromes are said to correspond often to a middle stage of arthritis; however, external-Dampness can be an etiological factor in early stages as well. Dampness and Phlegm can also refer to the contraction and limitation of the movements of the joint due to an obstructing of the sinews and muscles. It refers to swelling as well (see note 8). While Cold-Dampness is usually thought of as being the most common cause of Painful Obstruction syndromes, Dan-xi said, “Of the six Qi (Pathogenic Factors), disease caused by Damp-Heat amounts to eight or nine out of ten cases” (see note 9).
• Cold often refers to the degree of pain and stiffness, and to the initiation and worsening of symptoms with exposure to cold; improvement by the application of heat; and impaired circulation with feeling cold, or with cold extremities. Cold is associated also with interior-Cold (mostly Kidney-Yang-deficiency) and aging. Cold-dominated arthritis affects the extremities (hands and feet) where circulation is poorest. Interior-Cold is associated often with the lower back and knees (Kidneys), and then is commonly seen in arthrosis (DJD) and back pain.
• Hot-type-arthralgia may be initiated by exposure to a hot environment (especially summer-Heat) and then manifests as pain with redness and Heat of the joints. It can also result from Cold and Dampness transforming into Heat or Damp-Heat. Heat-dominated arthritis may be seen in both early and late stages of arthritis (and can be traumatic as well). Internal-Heat is often due to Empty-Heat from Yin/Blood-deficiency, or from congested/transformative-Heat (depressive-Heat) secondary to stagnation and stasis from Deficiency or Excess. Rapid-onset of Heat dominated arthralgias, usually without Exterior symptoms and signs, may result from lurking pathogens, especially Spring-Wind. It is also important to realize that for example: Blood-stasis, Yin/Blood-deficiency, or severe Yang-deficiency can all result in Heat and feverish symptoms (see note 10).
• Blood is said to become static when the disease is chronic and enduring. Eventually the initiating factors (e.g., Wind or Dampness) become less dominant and mixed Deficiency and Excess (and mixed Blood-stasis and Phlegm) are more dominant. When treating chronic and advanced diseases there may be more emphasis on dispersing static-Blood than when treating an earlier and more variable phase of the disease. Wind-Dampness tends to vary while Blood-stasis is fixed and enduring.
In summary, Painful Obstruction (Bi) syndromes are generally divided into three major stages:
1.Exterior/Superficial stage. Pathogenic Factors affect the channels, and symptoms and signs are moderately acute/new. If the patient is strong, the syndrome will resolve, often on its own.
2.Intermediate stage. There is more involvement of bodily tissues, with symptoms and signs becoming more severe and chronic, or recurrent. The patient’s Righteous-Qi (anti-Pathogenic Factors) is weak, or Pathogenic Factors are strong.
3.Deep stage. Organ and Righteous-Qi in general have been strongly affected; there is gross tissue deformation, and symptoms and signs are chronic, often milder (but may be severe with exacerbations) and usually difficult to resolve. The patient is generally Deficient (although the Deficiency may be difficult to demonstrate and therefore should not be assumed); the Pathogenic Factors stagnate and result in proliferation of tissues and complex syndromes. Atrophy may be setting in.
Treatment of Bi Syndrome
Treatment of Painful Obstruction (Bi) syndromes (musculoskeletal disorders) in TCM generally includes both internal (herbal) and external (acupuncture, heat, and manual) therapies. Treatment is generally aimed at expelling Pathogenic Factors and mobilizing obstructed or stagnant Qi and Blood. Since Deficiency may be at the root, herbal treatments that nourish the Blood, harmonize the Defensive and Nutritive-Qi, warm the Yang, and treat underlying Organic disorders are often integrated.
Manual therapies are important, and, in the text On the Origin and Further Course of Medicine, Hsu writes:
If evil [influences] have entered the sinews, the bones, the muscles or the flesh, then the illness [resulting from this intrusion] is a morphological one, and the [thermo] influences and flavour [influences] of drugs will show no effect. Hence [in such cases] one must apply [therapeutic] methods such as needling and cauterization...As long as they [the illness] flow through the [main] conduits and the network [vessels], as well as through the viscera and bowels, there is no other way to eliminate them except through the intake of drugs.
As we can see, according to Hsu, when disease affects form and structure, herbal medicine may not be sufficient. In the Classic of Internal Medicine, acupuncture is mentioned much more frequently than herbal medicine as treatment of choice for difficult Painful Obstruction. Acupuncture using the Divergent channels and other manual therapies are then important. Hsu also recommends using external ointments, spooning (scraping; Gua Sha), and soaking to treat accumulations, Blood-stasis, and when the illness “assumes” a physical shape. Herbal therapy often involves:
• Expelling Pathogenic Factors: Wind, Cold, Damp, Phlegm, Blood-stasis, Heat, or cooling Hot-Blood.
• Regulating local tissues: relaxing sinews, vitalizing or regulating network-vessels and Blood, softening masses, dispersing entanglements, and moving Qi and Blood to arrest pain.
• Supporting Righteous-Qi and bodily functions: fortifying Spleen/pancreas, moistening Yin and nourishing Blood, warming the Kidneys and assisting Yang, tonifying the Liver and Kidneys and invigorating the sinews and bones.
Alon Marcus received his licensed acupuncturist degree from the American College of Traditional Chinese Medicine in San Francisco, California in 1984, and his Doctor of Oriental Medicine degree from SAMRA University of Oriental Medicine in Los Angeles, California in 1986. He also trained in Japan and China, where he served his internship at the Traditional Chinese Medicine Municipal Hospital in Guangzhou. He trained extensively in Orthopaedic and Osteopathic medicines with several physicians. Dr. Marcus has published numerous articles in both Eastern and Western medical journals and the books Acute Abdominal Syndromes Their Diagnosis & Treatment According to Combined Chinese-Western Medicine; Musculoskeletal Disorders: Healing Methods from Chinese Medicine, Orthopaedic Medicine and Osteopathy; Foundations for Integrative Musculoskeletal Disorders An East-West Approach. In 1995 he became a diplomat of the American Academy of Pain Management. He has lectured internationally and taught courses in complementary orthopaedics for several years. In 1997 he was named Educator of the Year by the American Association of Oriental Medicine. Dr. Marcus is currently in private practice in Oakland and San Ramon, California.
1. Some sources state that in order to qualify as a Bi-syndrome, there must be combined Wind-Damp-Cold pathogens. There may be a predominance of one, but all three must be involved.
2. To treat the Nutritive-Qi in Bi-syndromes, bleeding techniques are often used, while to treat the Defence-Qi, regular needling is used often. Bi-disease in the Nutritive-Qi is characterized by Cold and Heat, diminished Qi, and the disharmonious flow of Blood up and down. Bi-disease generated in the Defence-Qi is characterized by Qi pain that intermittently comes and goes oppression and fullness, and strong borborygmus due to Wind-Cold encroaching upon the Stomach and Intestines (The Systematic Classic of Acupuncture & Moxibustion). Therefore, many of the formulas that have been developed to treat Painful Obstruction (Bi) syndromes are composed of herbs with opposite natures: hot and cold, supporting and attacking, surface resolving and deep penetrating, etc.
3. Careful assessment of symptoms and signs is needed to ascertain which pathogens are primary and which are secondary or tertiary and their relationships.
4. Recently, an infectious and/or inflammatory origin to cardiovascular disease has been suggested by modern biomedicine as well.
5. Polyarthralgia is a variety of conditions that can result in multiple joint pains, swelling, and possibly joint deformity.
6. Recently, infectious agents other than acute bacterial infections have been associated with rheumatoid arthritis (RA), lyme disease, and possibly osteoarthritis. For example, epidemiologic findings support the idea that HTLV-I infection is a risk factor for RA. These findings suggest that approximately 13% of the cases of RA in females living in Nagasaki are associated with HTLV-I infection. Minocycline - an antibiotic - can be effective in about 50% of patients with RA if started early in the course of the Disease. Mycoplasma has been associated with both inflammatory and non-inflammatory arthritis. Of course, lyme, several enterically associated arthritic disorders, viral arthritic disorders (from hepatitis, mononucleosis and rubella) and gonococcal arthritis are infectious.
7. Symptom-less until pathogens surface due to stress or new Exterior syndrome.
8. With retained Pathogenic Factors the patient feels ill for an unusual duration; the Pathogenic Factors as well as the patient are often weak.
9. Joint effusion is often responsible for limited movements in arthritic joints.
10. This statement pertains to Dampness in general, not to Painful Obstruction Syndromes.
11. Many of the author’s patients with Bi syndromes have some type of Heat complicating their patterns. These include Wind-Heat, Damp-Heat, stagnation/depressive-Heat, Blood-stasis- Qi-stagnation-transformative-Heat (or lurking pathogens), and Blood-Heat. Because these can be seen with underlying Cold and Deficiency, care must be taken when designing herbal formulas. If stasis and/or Heat is secondary to a root condition of Deficiency (often Kidney-Yang, Yin and Yang, or Qi) it may be necessary to place emphasis on tonification or neutral formulation. Zhu Liang-chun recommends, in complex syndromes when there is obstinate Painful Obstruction, the use of Yin Yang Huo (Herba Epimedii), 15g, Xian Mao (Rhizoma Curculiginis Orchioidis), 10g, Gou Qi Zi (Fructus Lycii Chinensis), 10g, Zi He Che (Placenta Hominis), 6g, and Gan Cao (Radix Glycyrrhizae), 5g to strengthen the Kidneys (and treat the root disorder) so that Evil and Righteous can be separated (Bi). He states that because the patient is often already Yang-Qi-deficient and debilitated, the disease evils (pathogens) lodge in the channels and network-vessels blocking Qi and Blood. The pathogens/evils may sink and enter the bone marrow (i.e., deep aspects or Kidney sphere as they are already weak), becoming fixed and irremovable. Phlegm and stasis join and obstruct, congeal, and stagnate influencing Qi and Blood (and stagnation can easily transform into Heat). Evil and Righteous become like mixed oil and flour, and swelling and pain become chronic. Therefore, there is an aspect of Righteous-deficiency as well as of evil (pathogenic) excess to this condition, even when there are Exterior signs and joint swelling.