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Painful Obstruction (Bi) Syndromes - Part Two

by Alon Marcus

 

Treatment of Painful Obstruction According to TCM Pattern Diagnosis

The following discussion covers commonly seen clinical presentations which often consist of mixed clinical patterns. Integration of these TCM treatments is often helpful in the management of musculoskeletal disorders. The herbal for­mulas on their own may be insufficient clinically. Painful Obstruction (Bi) Syndromes (musculoskeletal) are due in general to external pathogenic Wind, Cold, Damp, and/or Heat which obstruct the channels and collaterals/network-vessels, causing blockage of Qi and Blood circulation. Bi syndromes manifest as pain, soreness, aching, numbness or heaviness of muscles, sinews, and joints, and/or swelling and burning pain.

While theoretical simple classifications are found in text books (e.g., Cold-Bi, Wind-Bi, Damp-Bi, Hot-Bi), in reality distinct diagnostic classifications are difficult to make and are seldom seen in the clinic. Identifying the inter-relation­ships of the various possible patterns is most important. Flexibility in treatment and timing is essential. Herbal and acupuncture medicine can be helpful in the treatment of articular and soft-tissue rheumatological disorders. The Classic of Internal Medicine states:

When needling Painful Obstruction (Bi) syndromes, first one has to palpate the six channels below and observe Emptiness and Fullness, [to see] whether Blood-stasis is in the big (Main) network-vessels and if [the vessel] is obstructed in its flow, [or whether there is] Emptiness with the pulse being entrapped and empty. Harmonizing is done by restoring the connection (freeing the flow) using [the] hot pack [method].

For all of these reasons, close examination of the patient’s condition is always important before initiating a treatment protocol. The treatment of pain in TCM is predi­cated most often on the saying, “If there is free flow there is no pain.” Therefore, formulas and treatments that restore flow are used.

All herbal formulas in the following section are used reg­ularly by the author. They are derived from the formulary of Guangzhou Municipal Hospital, physicians in that hospital, general literature, and the author’s experience. Commentary regarding physical findings reflects the author’s experience. Finally, it is the author’s experience that patients with a his­tory of a sudden onset of nontraumatic articular pain (which may have occurred just before an examination or some time previously) often suffer from syndromes in which Gui Zhi Shao Yao Zhi Mu Tang (Cinnamon Twig, Peony and Anemarrhena Decoction, see note 11) can be used as a guiding formula, and which can be modified for predominance of Wind, Cold, Heat, Dampness, or stasis. If the onset of articular pain is more insidious, a close analysis of the patient with a view to the predominance of Deficiency or Pathogenic Factors is important.

Wind-Dampness

Articular and soft tissue syndromes are often said to be vari­ations of Wind-Damp Obstruction. In its pure personation, this pattern is usually seen in the beginning stages of the dis­ease. Patients may suffer from joint pains that increase with changing weather, and during rainy days. When there is a predominance of Wind, there would be migrating joint pains. Under this condition, it is common to add Blood herbs to Painful Obstruction Wind formulas, because it is said that “to treat Wind,” one should “first treat Blood.” Depending on the patient’s constitution, Organ health, other Pathogenic Factors, and anatomical variations, symptoms and signs can vary. Depending on severity and acuteness, soft tissue and joint end-feels may range from normal to slightly tight and limited. Since this pattern is more common in the beginning stages of Painful Obstruction (especially with Wind predom­inance), it is not uncommon to see fairly normal joints and muscles. A patient with Wind-Damp pathogens may show a thick, white tongue coat. Other patients may have a swollen tongue with a thin white coat. The pulse may be slow, slip­pery, wiry, or soft. A representative formula is Juan Bi Tong (Remove Painful Obstruction) which can be used with the appropriate variations given below.

Qiang Huo (Radix et Rhizoma Notopterygii) 9g
Du Huo (Radix Angelicae Pubescentis) 9g
Qin Jiao (Radix Gentianae) 12g
Sang Zhi (Ramulus Mori) 12g
Hai Feng Teng (Caulis Piperis) 12g
Dang Gui (Radix Angelica Sinensis) 9g
Chuan Xiong (Radix Ligustici) 6g
Bai Shao (Radix Paeoniae Alba) 15g
Chi Shao (Radix Paeoniae Rubra) 9g
Mo Yao (Gummi Olibanum) 3g
Gui Zhi (Ramulus Cinnamomi) 9g
Xi Xin (Herba cum Radix Asari) 3g

For severe pain add Ye Di Jin Niu (Zanthoxylum Netidom) 30g. For predominance of Dampness with increased swollen joints and muscles, fatigue, strong aggravation from weather changes or during cold rainy days use:

Yi Ren (Semen Coicis) 15g
Cang Zhu (Rhizoma Atractylodis) 9g
Fang Ji (Radix Stephaniae Tetrandrae) 12g
Gui Zhi (Ramulus Cinnamomi) 9g
Du Huo (Radix Angelicae Pubescentis) 12g
Hai Feng Teng (Caulis Piperis) 12g
Dang Gui (Radix Angelicae Sinensis) 12g
Mu Tong (Caulis Akebiae) 6g
Huang Qi (Radix Astragali) 15g
Fu Ling (Poriae Cocos) 15g
Ji Xue Teng (Caulis Spatholobi) 15g

For severely swollen joints with joint effusion and a capsular pattern of restriction remove: Du Huo (Radix Angelicae Pubescentis), Cang Zhu (Rhizoma Atractylodis), Fang Ji (Radix Stephaniae Tetrandrae). Add: Ju Hong (Exocarpium Citri Rubrum) 9g, Kun Bu (Herba Laminariae) 20g, Bai Jie Zi (Semen Sinapis Albae) 12g, Dan Nan Xing (Prepared Rhizoma Ari­saematis) 12g and Zao Jiao Ci (Spina Gleditsiae) 12g.

Acupuncture

Commonly used points and methods are: Sedation tech­niques at Quchi (LI 11), Xialian (LI 8), Hegu (LI 4), Waiguan (SJ 5), Tianjing (SJ 10), Fengmen (UB 12), Feishu (UB 13), Daxhui (DU 14), Fengfu (DU 16), Fengchi (GB 20), Fengshi (GB 31), Leique (LU 7) and Ashi points. Tonification technique at Zusanli (ST 36). For predominance of Dampness, use sedation technique at Yinlingquan (SP 9), Shuifen (REN 9), Leique (LU 7), Yangliangquan (GB 34), Fenglong (ST 40) with tonification tech­nique at Pishu (UB 20).

Wind-Damp-Cold

This pattern is most often seen as a progression of the first pattern or in patients with pre-existing Yang-deficiency, but again is rarely seen in its pure presentation. When there is a predominance of Cold, the pain will be more severe than Wind-Damp and may affect the low back and lower extremi­ties (although any joint can be affected). The pain improves with warmth and movement. The tissues feel tight and the joints are stiff because of the tightening affect of Cold. There is usually little or no swelling, but, if Dampness predomi­nates, there can be swelling and joint effusion. Wind-Damp-Cold is often seen with arthrosis,

especially in the early stages. Joint end-feel may be normal or hard depending on acuteness and underlying pathology. Since endogenous Cold-Dampness is often accompanied by Spleen or Kidney-Yang-deficiency, the muscles (flesh) and/or bones, or both, may be involved. With Spleen involvement, the patient may have digestive symptoms and pain, mostly in the muscle. When the Kidneys are involved, the bones are affected. Pain is often felt throughout the limbs and deep in the joints and low back. The condition is then usually seen in later stages. The urine may be scanty but clear or profuse and clear. Rep­resentative formulas are Prepared Aconite Decoction (Fu Zi Tang), Minor Invigorate the Collaterals Special Pill (Xiao Huo Luo Dan) and Aconite Decoction (Wu Tou Tang) which can be used with the appropriate variations.

Radix Aconiti Carmichaeli Praeparata (Zhi Chuan Wu) 9-30g (see note 12)
Radix Aconiti Kusnezoffii Praeparata (Zhi Cao Wu) 9-30g
Honey-fried Herba Ephedrae (Zhi Ma Huang) 9g
Ramulus Cinnamomi (Gui Zhi) 12g
Rhizoma Zingiberis (Gan Jiang) 9g
Radix Astragali (Huang Qi) 15g
Poriae Cocos (Fu Ling) 15g
Rhizoma Dioscoreae Hypoglaucae (Bei Xie) 15g
Myrrha (Mo Yao) 3g
Honey-fried Radix Glycyrrhizae (Zhi Gan Cao) 6g

For severe pain add Zanthoxylum Netidom (Ye Di Jin Niu) 30g. For joint swelling add Rhizoma Artisaematis (Tian Nan Xing) 6g, Semen Coicis (Yi Yi Ren) 30g, and Spina Gleditsiae (Zao Jiao Ci) 12g.

For psoriatic arthritis:

Radix Astragali (Huang Qi) 20g
Ramulus Cinnamomi (Gui Zhi) 12g
Radix et Rhizoma Notopterygii (Qiang Huo) 15g
Radix Angelica Sinesis (Dang Gui) 15g
Flos Carthami (Hong Hua) 10g
Semen Persicae (Tao Ren) 10g
Radix Gentianae (Qin Jiao) 15g
Olibanum (Ru Xiang) 10g
Honey-fried Radix Glycyrrhizae (Zhi Gan Cao) 6g
Kochiae (Di Fu Zi) 12g
Zaocys (Wu Shao She) 15g

For Rheumatoid arthritis with a predominance of Cold (see note 13) use:

Herba Ephedrae (Ma Huang) 4g
Radix Stephaniae Tetrandrae (Fang Ji) 12g
Cortex Cinnamomi (Rou Gui) 4g
Fried Squama Manitis (Chuan Shan Jia) 6g
Cornu Cervi Degelatinatum (Lu Jiao Shuang) 6g
Radix Rehmanniae (Shu Di Huang) 30g
Rhizoma Zingiberis (Gan Jiang) 4g
Fried Semen Sinapis Albae (Bai Jie Zi) 15g
Radix Aconiti Lateralis Praeparata (Fu Zi) 15-30g

For painful Swelling, Blood-stasis and ecchymosis add: Rhi­zoma Curcumae Longae (Jiang Huang) 12g, Rhizoma Zedoriae (E Zhu) 9g, Herba Lycopi (Ze Lan) 15g.

For dry mouth or to prevent side-effects from Aconiti (Fu Zi) add: Cortex Phellodendri (Huang Bai) 12g,

Rhizoma Anemar­rhenae (Zhi Mu) 15g (see note 14), Rhizoma Rhei (Da Huang) 6g.

Acupuncture

Acupuncture with moxa can be used. Commonly used points and methods are: Sedation technique at Hegu (LI 4), Waiguan (SJ 5), Fengmen (UB 12), Feishu (UB 13), Huantiao (GB 30), Fengshi (GB 31), Yangjiao (GB 35), Liangqiu (ST 34) and Ashi points. Moxa at Zusanli (ST 36), Mingmen (DU 4), Guanyuan (REN 4), Qihai (REN 6), Pishu (UB 20) and Dazhui (DU 14).

Wind-Damp-Cold—Interior Heat

This pattern is commonly seen in the clinic and may present in patients with joint and soft tissue pains and symptoms of Wind-Cold-Damp, but with signs such as tongue, lips, eyes, or pulse showing Interior-Heat. These are patients with Exte­rior Bi-syndromes and excess-Heat internally. Often, Heat is lodged in the Large Intestines and Stomach due to dietary habits or from Liver and Gall Bladder stagnant-Qi with transformative-Heat. This pattern can also be seen in patients with Yin-deficient constitutions. The joints and soft tissues are not red, hot, or particularly swollen. The patient’s bowels and urine may show signs of Heat. There may be red eyes, mouth sores, red chapped lips, and thirst. There may be hid­den pathogens with Exterior Wind-Damp-Cold, especially in patients with weak immune systems (Yin/Yang-deficiency, weak Defensive/antipathogenic-Qi). Depending on acute­ness, the soft tissues and joint end-feel may be tight, short­ened, normal, or sometimes overly loose and weak. The tongue body may be red, dry, and possibly with a yellow or off-white coat. The pulse may be rapid, overflowing, slip­pery, or tidal, or may be deep and forceful. This pattern is also said to develop from warm and dry formulas, and/or pharmaceutical drugs, particularly steroid medications. A representative formula is Major Notopterygium Decoction (Da Qiang Huo Tang) which can be used with the appropri­ate modifications:

Gypsum (Shi Gao) 25g
Radix et Rhizome Notopterygii (Qiang Huo) 9g
Radix Gentianae (Qin Jiao) 12g
Radix Angelica Pubescentis (Due Huo) 9g
Radix Clematidis (Wei Ling Xian) 9g
Radix Ledebouriellae (Fang Feng) 9g
Radix Rehmanniae Glutinosae (Sheng Di Huang) 15g
Semen Gardenia (San Zhi Zi) 6g
Radix Scutellariae (Huang Qin) 9g
Radix Angelicae Sinesis (Dang Gui) 12g
Radix Paeoniae Rubrae (Chi Shao) 9g
Radix Salvia (Dan Shen) 15g
Cortex Moutan Radicis (Mu Dan Pi) 6g
Herba cum Radix Asari (Xi Xin) 3g

For constipation add: Radix et Rhizoma Rhei (Da Huang) 9g

For severe pain add: Radix Paeonia Alba (Bai Shao) 30g, Radix Glycyrrhizae (Gan Cao) 9g

For muscle spasms add: Zaocys Dhumnades (Wu Shao She) 3g, Buthus Martensi (Quan Xie) 3g, Scolopendra Subspinipes (Wu Gong) 3g (note lower doses).

Acupuncture

Commonly used points and methods are: Sedation technique at Dazhui (DU 14), Quchi (LI 11), Hegu (LI 4), Tianshu (ST 25), Fengmen (UB 12), Waiguan (SJ 5), Yanglingquan (GB 34), Yinlingquan (SP 9), Xuehai (SP 10) and Ashi points, followed by tonification at Zusanli (ST 36), Sanyinjiao (SP 6), Pishu (UB 20).

Cold or Deficiency Transforming Into Heat

This pattern is also commonly seen and may present in patients that are generally Deficient or whose Interior is Cold. Both Deficiency and Interior Coldness can result in poor vitality of body milieu leading to accumulations-trans­formation-Heat. It may be difficult to ascertain if Deficiency of transformation-Heat is predominant. Often Heat signs may obscure the underlying Deficiency. The patient is often restless, slightly thirsty, or just complains of dryness, weak­ness, evening fevers (a feeling of warmth) and may have night sweats. The pain is often mild to moderate and becomes worse after activity, possibly accompanied by heat symptoms and signs, but may improve with heat application as well. The tongue and lips are dry and possibly red. The pulse tends to be thready and rapid. A modification of Angelicae Sinesis Pluck Pain Decoction (Dang Gui Nian Tong Tang) may be used:

Radix Angelicae Sinesis (Dang Gui) 9g
Rhizoma seu Radix Notopterygii (Qiang Huo) 9g
Wine prepared Radix Sophorae (Ku Shen) 9g
Radix Puerariae (Ge Gen) 9g
Rhizoma Atractylodis (Cang Zhu) 9g
Radix Atractylodis Alba (Bai Zhu) 9g
Radix Ledebouriellae (Fang Feng) 9g
Rhizoma Anemarrhenae (Zhi Mu) 9g
Cortex Phelodendri (Huang Bai) 6g
Rhizoma Alismatis (Ze Xie) 9g
Rhizoma Cimicifugae (Sheng Ma) 3g
Radix Ginseng (Ren Shen) 3g
Herba Artemisiae Capillaris 15g
Radix Achyranthis Bidentatae (Huai Niu Xi) 9g

For Rheumatoid arthritis with mixed Heat and Cold, from Cold transforming into Heat (or exterior Cold interior Heat), and internal confinement of Damp-Toxins, seen in either the acute or chronic stages with severe pain, rigidity and/or joint deformity use:

Wine prepared Rhizoma Rhei (Da Huang) 6g
Squama Manitis (Chuan Shan Jia) 6g
Spina Gleditsiae (Zao Jiao Ci) 15g
Radix Stemonae (Bai Bu) 24g
Cortex Cinnamomi (Rou Gui) 4g
Caulis Spatholobi (Ji Xua Teng) 15g
Flos Lonicerae Japonicae (Jin Yin Hua) 15g
Radix Rehmanniae (Shu Di) 30g
Cortex Dictamni Radicis (Bai Xian Pi) 30g
Fried Semen Sinapis Albae (Bai Jie Pi) 12g
Radix Aconiti Lateralis Praeparata (Fu Zhi) 12g

For strong Heat with elevated ESR add: Rhizoma Smilacis Glabrae (Tu Fu Ling) 15g, Gypsum (Shi Gao) 20g.

For significant Cold with normal ESR add: Herba Ephedrae (Ma Huang) 6g, Herba Asari (Xi Xin) 4g, Herba Cistanches (Rou Cang Rong) 12g, Rhizoma Zingiberis (Gan Jiang) 9g.

Acupuncture

Commonly used points and methods are: Sedation technique at Quchi (LI 11), Hegu (LI 4), Tianshu (ST 25), Waiguan (SJ 5), Yanglingquan (GB 34), Yinlingquan (SP 9), Xuehai (SP 10) and Ashi points, followed by tonification at Zusanli (ST 36), Sanyinjiao (SP 6), Pishu (UB 20), Shenshu (UB 23).

Wind-Damp-Cold—Chronic Disease—Blood-stasis, Qi-stagnation

This pattern is one of the most commonly seen in clinical practice and presents in patients with chronic

painful arthral­gias. The pain patterns are mixed, showing characteristics of Wind-Damp-Cold and Blood-stasis-Qi-stagnation. Often the patient shows signs of Deficiency as well. Since chronic dis­ease often results in Blood-stasis, and since it is said: “to treat Wind first, treat Blood...when Blood moves, Wind resolves,” Blood moving herbs are added, especially with a history of trauma or in chronic disease—with or/without clear signs of Blood-stasis (i.e., pulse tongue signs). Because Qi moves the Blood and Qi and Blood are mutually depen­dent, herbs that regulate Qi are added as well. It is important to remember that this pattern may be seen in patients with or without clear signs of Blood-stasis (tongue and pulse) and/or with or without fixed pain. Soft tissues are often hardened

(fibrous) and less flexible. There are signs of long-term hypoxia. Muscular and tendinous triggers have a more defined edge that can be palpated and often feel hard. Joint end-feels are often hard and may or not be painful. This pat­tern is sometimes seen in patients with instability as well. Joint end-feels are then often hard and ROM may be abnor­mally increased or decreased. There are often painful twinges and sudden, transient loss of strength. The following type of formula can be used in patients with Painful Obstruc­tion (Bi) syndrome that has not responded to Wind-Damp obstruction formulas and/or chronic Cold type formulas. The representative formula is Drive Out Blood Stasis from a Painful Body Decoction (Shen Tong Zhu Yu Tong), which can be used with the appropriate modification. If used topi­cally vinegar can be added:

Radix Gentianae (Qin Jiao) 12g
Rhizoma Ligustici Wallichii (Chuan Xiang) 9g
Semen Persicae (Tao Ren) 9g
Exrementum Trogopteri seu Pteromi (Wu Ling Zhi) 12g
Rhizoma Corydalis (Yan Hu Suo) 12g
Rhizoma et Radix Notopterygii (Qiang Hou) 6g
Radix Angelica Dahuricae (Bai Zhi) 9g
Radix Clematidis (Wei Ling Xian) 9g
Radix Angelica Sinensis (Dang Gui) 9g
Radix Paeoniae Rubrae (Chi Shao) 9g
Radix Salvia (Dan Shen) 15g
Cortex Moutan Radicis (Mu Dan Pi) 6g
Herba cum Radix Asari (Xi Xin) 3g
Myrrha (Mo Yao) 3g
Lumbricus (Di Long) 9g
Rhizoma Cyperi (Xiang Fu) 9g
Radix Astragali (Huang Qi) 15g
Radix Cyathulae Officinalis (Chuan Niu Xi) 9g

For symptoms of muscle spasms or cramps, add: Agkistrodon (Bai Hua She) 6g, Scolopendra (Wu Gong) 3g, Buthus Mar­tensi (Quan Xie) 5g, Radix Paeoniae (Bai Shao) 20g.

Acupuncture

Commonly used points and methods are: Sedation technique at Geshu (UB 17), Ganshu (UB 18), Chengshan (UB 57), Xuehai (SP 10), Diji (SP 8), Quchi (LI 11), Hegu (LI 4), Daheng (LI 15), Qinglengyuan (SJ 11), Zulingqi (GB 41) and Ashi points. After sedation, the same points are given moxa with direct-skin moxa or by warming the needles. For deficiency add: Sanyinjiao (SP 6), Shenshu (UB 23), Pishu (UB 20), Mingmen (DU 4), Shanzhong (REN 17).

Another common combination is Dazhui (DU 14), Shenzhu (DU 12), Shendao (DU 11) and two extra points 4-finger breadths lateral to Shenzhu (DU 12), and two extra points 4-finger breadths lateral to Shendao (DU 11). Bleeding and cupping Gaohuangshu (UB 43) is helpful as well.

Wind-Phlegm-Obstruction—Chronic Disease/ Numbness

While Phlegm is said to be quite common, this pattern is seen mostly when neural involvement results in numbness. The pattern is seen when puffy swelling, numbness, tremors, and possibly itchiness are predominant. Phlegm usually results from constitutional weakness of the Spleen/pancreas, or from dietary irregularities that damage the digestive func­tions of the Spleen and Stomach. Phlegm can also arise from Heat or Cold congealing Fluids and from Qi-stagnation that fails to move Fluids. Phlegm obstruction can block Nutri­tive-Qi and Blood with resulting numbness and swelling. Other symptoms such as light headedness, dizziness, vertigo, chest discomfort, or nausea may or may not be seen. Soft tis­sues and joint capsules are often nodular, soft with very sen­sitive subcutaneous tissues as demonstrated by skin-rolling (pinch test). Nodules are moveable but may feel hard. The muscles in general lack tone. Joint end-feels may be hard or soggy, depending on the amount of effusion and may or may not be painful. The tongue may be dark and swollen, and its coat may be greasy. The pulse may be wiry, slippery, or soft. A representative formula is Pinellia, Atractylodis Macro­cephalae, and Gastrodia Decoction (Ban Xia Bai Zhu Tian Ma Tang) and can be used with the following variations:

Rhizoma Pinellia (Ban Xia) 9g
Rhizoma Gastrodiae (Tian Ma) 9g
Rhizoma Artsiaematis (Tian Nan Xing) 9g
Rhizoma Atractylodis Alba (Bai Zhu) 9g
Poriae Cocos (Fu Ling) 15g
Rhizoma Zingiberis (Sheng Jiang) 6g
Pericarpium Citri Erythrocarpae (Ju Hong) 6g
Fructus Zizyphi Jujubae (Da Zao) 4g
Radix Ledebouriellae (Fang Feng) 6g
Rhizoma Acrori Graminei (Shi Chang Pu) 6g
Radix Clematidis (Wei Ling Xian) 9g
Herba Artemisiae (Yin Chen Hao) 12g

For symptoms consisting of muscle spasms, add: Agkistrodon (Bai Hua She) 5g, Buthus Martensi (Quan Xie) 4g, Scolopen­dra Subspinipes (Wu Gong) 3g.

For severe pain, add: Zanthoxylum Netidom (Ye Di Jin Niu) 30g.

For joint swelling or nodules, add: Semen Coicis (Yi Yi Ren) 30g, Bulbus Fritillariae Thunbergii (Zhe Bei Mu) 15g, Concha Ostreae (Mu Li) 20g.

For pronounced numbness, add: Radix Paeoniae Rubrae (Chi Shao) 9g, Radix Ligustici (Chuan Xiang) 9g, Radix Angelica Sinensis (Dang Gui) 9g, and Folium Clerodendri Trichotomi (Chou Wu Tong) 9g.

Acupuncture

Commonly used points and methods are: Sedation technique followed by moxa at Fenglong (ST 40), Zusanli (ST 36), Feishu (UB 13), Gaohuangshu (UB 43), Pishu (UB 20), Fuyang (UB 59), Zhongwan (REN 12), Yaoyangguan (DU 3) and Ashi points. Sedation technique at Fengchi (GB 20), Fengshi (GB 31), Xiyangguan (GB 33), Yangfu (GB 38), Lieque (LU 7), Hegu (LI 4), Quchi (LI 11), Waiguan (SJ 5). Tonification technique at Zusanli (ST 36), Pishu (UB 20).

Qi-Stagnation-Cold

This pattern is quite common and presents mainly in patients with morning pain or with posain. Soon after the patient gets up from bed and moves, as warmth and nourishment return to tissues, the pain disappears or is greatly reduced at the affected joint until the next morning, or until a posture is again maintained for a prolonged period. Often the patient can perform most daily activities pain free (or with mild pain), as is commonly seen in self-reducing disc with morn­ing low back pain. The patient may or may not show other symptoms of Qi-stagnation and Cold. Joint and soft tissues are often cold and contracted only during symptomatic peri­ods. During symptomatic periods, joint end-feel may be hard (or just tight) and may or may not be painful. Some patients with morning pain who also suffer from pain that is worse after heavy exertion (especially fixed back pain) may have “Kidney-taxation pain.” A representative formula is Modi­fied Minor Invigorate the Collaterals Special Pill (Jia Wei Xiao Huo Luo Dan) and can be used with the following vari­ations:

Radix Aconiti Carmichaeli Praeparata (Zhi Chuan Wu) 9g
Radix Aconiti Kusnezoffii Praeparata (Zhi Cao Wu) 9g
Ramulus Cinnamomi (Gui Zhi) 12g
Fructus Alpiniae Oxyphylae (Yi Zhi Ren) 9g
Rhizoma Cypri (Xiang Fu) 9g
Radix Lindrae (Wu Yao) 12g
Rhizoma Zedoriae (E Zhu) 9g
Rhizoma Sparganii (San Leng) 9g
Radix Paeoniae Alba (Bai Shao) 30g
Fasciculus Vascularis Luffae (Si Gua Luo)15g
Flos Caryophylli (Ding Xiang) 3g
Lumbricus (Di Long) 12g
Cortex Phellodendri (Huang Bai) 4g
Radix Gentianae (Long Dan Cao) 4g

For a sensitive patient or with minor pain and disability, take out: Radix Aconiti Carmichaeli Praeparata (Zhi Chuan Wu) and Radix Aconiti Kusnezoffii Praeparata (Zhi Cao Wu).

For fatigued patients with a sense that great effort is needed to accomplish physical activity and when pain increases by activ­ity (Kidney-taxation encumbrance pain) Young Maid Pill (Qing E Wan) can be used by itself or added to the above for­mula. This formula contains Psoralea (Bu Gu Zhi), Cortex Eucommia (Du Zhong), Walnut (Hu Tao Rou) and Garlic (Da Suan) (see note 15).

Acupuncture

Commonly used points and methods are: Sedation tech­niques followed by moxa at Taichong (LV 3), Xingjian (LV 2), Hegu (LI 4), Ganshu (UB 18), Yanglingquan (GB 34), Huantiao (GB 30), Yangjiao (GB 35), Zulingqi (GB 41), Xiaxi (GB 43) and Ashi points. Tonification and moxa at Guanyuan (REN 4), Mingmen (DU 4), Dazhui (DU 14), Shenshu (UB 23), Zhishi (UB 52), Zusanli (ST 36).

Wind-Damp-Heat

This pattern is mainly seen in the acute or early stages of Bi-syndromes and usually presents in patients with active inflammation. The joints are warm, swollen, and have a hard end-feel that is painful. There is usually a capsular pattern. Patients often complain of pain that is severe. The muscles are often lax when not under load, but spring into spasm when the affected joint is under load. In severe cases, muscle weakness and wasting/atrophy may be seen. The pulse may be rapid and soft, or rapid and slippery, or wiry. The tongue may be red and have an off-white or yellow greasy coat. A representative formula for the early stage is Disband Painful Obstruction Decoction (Xuan Bi Tang) and the following variations can be used:

Gypsum (Shi Gao) 25g
Semen Coicis (Yi Yi Ren) 20g
Excrementum Bombycis Mori (Can Sha) 9g
Rhizoma Pinelliae (Ban Xia) 9g
Fructus Forsythiae (Lian Qiao) 9g
Fructus Gardeniae (Zhi Zi) 9g
Radix Gentianae (Qin Jiao) 12g
Radix Ledebouriellae (Fang Feng) 9g
Ramulus Cinnamomi (Gui Zhi) 9g
Herba Ephedra (Honey fried is preferable) (Ma Huang) 6g

When Damp-Heat is chronic or severe, a modification of Four-Marvel Pill (Si Miao Wan) and Relax the Channels and Invigorate the Blood Decoction (Shu Jing Ho Xue Tang) can be used. This formula can be used for lumbar or lower extremity disorders. The author often uses variations of the formula below for patients with radiculopathy from disc dis­ease. Some patients do well when Minor Invigorate the Col­laterals Special Pill (Xiao Huo Luo Dan) is given at the same time:

Cortex Phellodendri (Huang Bai) 12g
Rhizoma Arisaematis (Tian Nan Xing) 6g
Semen Coicis (Yi Yi Ren) 20g
Rhizoma Atractylodis (Cang Zhu) 12g
Radix Achyranthis Bidentatae (Niu Xi) 12g
Lumbricus (Di Long) 12g
Bombyx Batryticatus (Jiang Can) 9g
Radix Paeoniae Alba (Bai Shao) 20g
Radix Angelicae Sinensis (Dang Gui) 9g
Rhizoma Anemarrhenae (Zhi Mu) 9g
Rhizoma Dioscoreae Hypoglaucae (Bei Xie) 15g
Rhizoma Dioscoreae Nippnicae (Chuan Shan Long) 20g
Radix Gentianae (Long Dan Cao) 6g
Radix Paeoniae Rubrae (Chi Shao) 9g
Poriae Cocos (Fu Ling) 12g
Radix Glycyrrhizae (Gan Cao) 6g
Herba cum Radix Asari (Xi Xin) 3g

For symptoms of muscle spasms and numbness, add: Fructus Chaenomeles (Mu Gua) 9g, Radix Ligustici (Chuan Xiong), Cortex Lycii Radicis (Di Gu Pi) 20g, Agkistrodon (Bai Hua She) 9g, Scolopendra (Wu Gong) 3g, Buthus Martensi (Quan Xie) 4g.

For Damp-Heat psoriatic or rheumatoid arthritis:

Rhizoma Atractylodis (Cang Zhu) 10g
Cortex Phellodendri (Huang Bai) 12g
Radix Gentianae (Qin Jiao) 15g
Dictamni (Bai Xian Pi) 20g
Semen Coicis (Yi Ren) 20g
Smilax (Tu Fu Ling) 30g
Rhizoma et Radix Notopterygii (Qiang Huo) 15g
Flos Carthami (Hong Hua) 10g
Semen Persicae (Tao Ren) 10g
Olibanum (Ru Xiang) 10g
Polyporus (Zhu Ling) 15g
Radix Cyathulae (Chuan Niu Xi) 20g
Sophorae (Ku Shen) 12g

For Heat-toxin psoriatic arthritis:

Flos Lonicerae Japonicae (Jin Yin Hua) 30g
Herba Traxaci Mongolici cum Radice (Pu Gong Ying) 20g
Fructus Forsythia Suspensae (Lin Qiao) 20g
Radix Isatis seu Baphicacanthi (Ban Lan Gen) 20g
Radix Rehmanniae Glutinosae (Sheng Di) 20g
Rhizoma Anemarrhenae (Zhi Mu) 15g
Dendrobii (Shi Hu) 15g
Gypsum (Shi Gao) 60g
Radix Paeoniae Rubrae (Chi Shao) 20g
Miltiorrhizae Salviae (Dan Shen) 20g
Cortex Moutan Radicis (Dan Pi) 20g
Bubali (Shui Niu Jiao) 30g

For Wind-Heat psoriatic or rheumatoid arthritis:

Flos Lonicerae (Jin Yin Hua) 20g
Tripterygium Wilfordii (Lei Gong Teng) 20g
Radix Rehmanniae Glutinosae (Sheng Di) 30g
Rhizoma Anemarrhenae (Zhi Mu) 15g
Serpentis (She Tui) 10g
Radix Dendrobii (Shi Hu) 15g
Gypsum (Shi Gao) 30g
Radix Paeoniae Rubrae (Chi Shao) 20g
Miltiorrhizae Salviae (Dan Shen) 20g
Cortex Moutan Radicis (Dan Pi) 20g
Kochiae (Di Fu Zi) 20g

 

Acupuncture

Commonly used points and methods are: Sedation tech­niques/bleeding at Dazhui (DU 14), Lingtai (DU 10), Ganshu (UB 18), Xuehai (SP 10), Yinlingquan (SP 9), Quchi (LI 11), Hegu (LI 4), Neiting (ST 44), Well (distal/ nail) and Ashi points.

Wind-Damp-Heat—Chronic Disease, Blood-stasis

This pattern is seen most often in the middle to late stages of rheumatoid or other chronic inflammatory type arthritis. The joints are swollen, red, painful, and possibly deformed. Joints often show a combination of hard and soggy end-feels. Soft tissues and muscles are often weak and lack tone, or they can be shortened, painful, congested, and hard. The pulse and tongue may or may not show signs of Heat and Dampness. Modification of Two-Marvel Powder (Er Miao San), or Free the Channels and Stop Pain Decoction (Tong Jing Zhi Tong Tang) can be used.

Cortex Phellodendri (Huang Bai) 15g
Rhizoma Atractylodis (Cang Zhu) 12g
Lumbricus (Di Long) 12g
Caulis Lonicerae (Ren Dong Teng) 15g
Radix Clematidis (Wei Ling Xian) 9g
Cortex Cinnamomi (Gui Pi) 6g
Rhizoma Arisaematis (Tian Nan Xing) 9g
Radix Gentianae (Long Dan Cao) 12g
Poriae Cocos (Fu Ling) 15g
Radix Gentianae (Qin Jiao) 12g
Semen Persicae (Tao Ren) 12g
Flos Carthami (Hong Hua) 6
Rhizoma Ligustici Wallichii (Chuan Xiang) 6g
Radix Angelicae Dahuricae (Bai Zhi) 9g
Herba cum Radix Asari (Xi Xin) 3g

For acute flare, take out: Radix Ligustici (Chuan Xiang) 6g, Radix Angelicae Dahuricae (Bai Zhi) 9g, Cortex Cinnamomi (Gui Pi) 6g. Add: Gypsum (Shi Gao) 25g, Flos Loncerae (Jin Yin Hua) 12g, Caulis Lonicerae (Ren Dong Teng) 15g, Fruc­tus Forsythiae (Lian Qiao) 9g, and Ramulus Cinnamomi (Gui Zhi) 9g

For Joint deformities and spasms, take out: Cortex Cinnamomi (Gui Pi), Radix Gentianae (Long Dan Cao), Flos Carthami (Hong Hua), Radix Angelicae Dahuricae (Bai Zhi), and Herba cum Radix Asari (Xi Xin). Add: Radix Paeoniae Rubrae (Chi Shao) 9g, Radix Paeoniae Alba (Bai Shao) 20g, Angelica Sinesis (Dang Gui) 15g, Agkistrodon (Bai Hua She) 6g, Scol­opendra (Wu Gong) 3g, Buthus Martensi (Quan Xie) 4g, Eupolyphaga seu Opisthoplatia (Tu Bie Chong) 4g, Herba Epimedii (Yin Yang Hou) 9g, Rhizoma Frynari (Gu Sui Bu) 12g, and Radix Polygonum Multiflorum (He Shao Wu) 12g.

An alternative for rheumatoid arthritis is:

Herba Oldenlandiae Diffusae (Bai Hua She She Cao) 20g
Radix Rehmanniae Glutinosae (Sheng Di Huang) 15g
Herba Oldenlandiae Diffusae (Tu Fu Ling) 12g
Radix Paeoniae Alba (Bai Shao) 12g
Radix Paeoniae Rubrae (Chi Shao) 9g
Semen Coicis (Yi Yi Ren) 20g
Caulis Lonicerae (Ren Dong Teng) 15g
Caulis Sinomenii (Qing Feng Teng) 9g
Radix Clematidis (Wei Ling Xian) 9g
Herba Pyrolae (Lu Xian Cao) 20g
Lumbricus (Di Long) 6g
Ramulus Cinnamomi Cassiae (Gui Zhi) 6g
Radix Glycyrrhizae (Gan Cao) 3g

For severe cases, add Tripterygium Wilfordii (Lei Gong Teng) 12g.

For gout add Herba Oldenlandiae Diffusae (Tu Fu Ling) 20g, Rhizoma Dioscoreae Hypoglaucae (Bei Xie) 15g, Cortex Fraxini (Qin Pi) 9g (16).

For rheumatoid or psoriatic arthritis, or fibromyalgia with Wind-Heat (Dampness) and Blood-deficiency, a guiding mild approach is:

Radix Gentianae (Qin Jiao) 6g
Radix Ledebouriellae (Fang Feng) 9g
Ramulus Uncariae Cum Uncis (Gou Teng) 6g
Radix Paeoniae Alba (Bai Shao) 6g
Semen Cassiae Torae (Cao Jue Ming/Jue Ming Zi) 12g
Semen Ziziphi Spinosae (Suan Zao Ren) 12g
Flos Chrysanthemi Morifolii (Ju Hua) 6g
Fructus Hordei Vulgaris Germinatus (Mai Ya) 12g
Semen Biotae Orientalis (Bai Zi Ren) 9g
Radix Clematidis (Wei Ling Xian) 6g
Radix Glycyrrhizae Uralensis (Gan Cao) 3g

Or:

Semen Ziziphi Spinosae (Suan Zao Ren) 12g
Poriae (Fu Ling) 9g
Herba Artemisiae Capillaris (Mian Yin Chen) 8g
Radix Trichosanthis (Tian Hua Fen) 9g
Radix Glycyrrhizae Uralensis (Zhi Gan Cao) 4g
Fructus Hordei Vulgaris Germinatus (Mai Ya) 10g
Ramulus Uncariae Cum Uncis (Gou Teng) 6g
Rhizoma Anemarrhenae (Zhi Mu) 5g
Semen Beninacasae (Dong Gua Ren) 12g
Semen Cassiae Torae (Cao Jue Ming/Jue Ming Zi) 12g
Radix Aurantii (Zhi Ke) 6g
Ramulus Taxilli (Ji Sheng) 6g
Rhizoma Corydalis (Yan Hu Suo) 9g

 

Acupuncture

Commonly used points and methods are: Sedation tech­niques/bleeding at Juque (REN 14), Xiawan (REN 10), Geshu (UB 17), Xuehai (SP 10), Yinlingquan (SP 9), Quchi (LI 11), Hegu (LI 4), Well (distal-nail) and Ashi points. Use cupping/bleeding at Gaohuangshu (UB 43) and over swollen areas. Tonify Zusanli (ST 36), Sanyinjiao (SP 6), Guanyuan (REN 4), Pishu (UB 20).

Wind-Damp-Cold—Weakness of Liver, Kidneys, Qi, and Blood

While this pattern is said to occur in the majority of elderly patients, clinical utility of herbs to treat such patients has been limited in this author’s experience and observation of other practitioners. The Invasion of the Sinews and bones by Pathogenic Factors implies, to some extent, a weakness of the Liver and Kidneys, which control these tissues. Formulas that address the Liver, Kidneys, Qi, and Blood are frequently used. This pattern is seen most often in elderly patients or in patients with chronic arthrosis. The main symptoms are Cold-pain in the back and knees, and generalized stiff joints. Some patients may complain of a sense of numbness/ache and a feeling fatigue or heaviness. The pain improves with heat and may worsen in changing weather or rainy days. The joints and soft tissues are cold and not particularly swollen, except in more severe stages and then are very difficult to adequately treat (severe DJD). Joints usually show a hard end-feel. Depending on chronicity, soft tissues may be tight or lack normal tone. Bony outgrowths (spurs) are common. The pulse may be weak (deep, fine, soft, thready) or hidden (not obvious, very deep). The tongue may be pale. A repre­sentative formula is Angelica Pubescens and Sangjisheng Decoction (Du Huo Ji Shen Tong) and the following modifi­cations can be used:

Angelicae Pubescentis (Due Huo) 12g
Ramus Loranthi (Sang Ji Sheng) 12g
Radix Gentianae (Qin Jiao) 12
Radix Ledebouriellae (Fang Feng) 9g
Radix Ligustici (Chuan Xiong) 9g
Radix Rehmanniae (Shu Di Huang) 12g
Ginseng (Ren Shen) 6g
Radix Achyranthis Bidentatae (Niu Xi) 12g
Ramulus Cinnamomi (Gui Zhi) 9g
Radix Paeoniae Alba (Bai Shao) 15g
Fructus Lycii (Gou Qi Zi) 9g
Radix Dispsacus (Xu Duan) 9 g
Radix Polygonum Multiflorum (He Shao Wu) 12g
Stamen Nelumbinis (Lian Xu) 3g

For severe pain, add: Zanthoxylum Netidom (Ye Di Jin Niu) 30g.

For Swelling, add: Semen Coicis (Yi Yi Ren) 20g and Rhi­zoma Dioscoreae Hypoglaucae (Bi Xie) 12g.

For psoriatic arthritis with Liver and Kidney deficiency, Blood-stasis and Wind-Dampness:

Radix Rehmanniae Glutinosae (Sheng Di) 20g and (Shu Di) 20g
Radix Angelicae Sinensis (Dang Gui) 15g
Cortex Eucommiae Ulmoidis (Du Zhong) 12g
Fructus Corni Officinalis (Shan Zhu Yu) 12g
Fructus Lycii (Gou Qi Zi) 15g
Radix Gentianae (Qin Jiao) 15g
Rhizoma seu Radix Notopterygii (Qiang Huo) 12g
Flos Carthami (Hong Hua) 10g
Semen Persicae (Tao Ren) 10g
Olibanum (Ru Xiang) 10g
Rhizoma Ligustici Wallichii (Chuan Xiong) 12g

Acupuncture

Commonly used points and methods are: Sedation technique at Hegu (LI 4), Waiguan (SJ 5), Fengmen (UB 12), Feishu (UB 13) and Ashi points. Tonification and Moxa at Zusanli (ST 36), Sanyinjiao (SP 6), Taixi (KI 3), Fuliu (KI 7), Mingmen (DU 4), Guanyuan (REN 4), Qihai (REN 6), Pishu (UB 20), Ganshu (UB 18), Shenshu (UB 23), Dazhui (DU 14).

Damage of Yin and Essence with Cold-Damp

This pattern is commonly seen in the clinic and is not easily addressed. The patient complains of arthritic pains with local signs of Dampness and Cold (or aggravation in cold weather), but the pulse and tongue and possibly other symp­toms and signs show Damage to Yin. There usually is joint deformity. Modification of Yang-Heartening Decoction (Yang He Tang) can be used:

Radix Aconite Lateralis (Fu Zi) 15-30g
Radix Scrophulariae (Xuan Shen) 30g
Radix Rehmanniae (Shu Di) 30g
Colla Cornu Cervi (Lu Jiao Jiao) 12g
Cortex Cinnamomi Cassiae (Rou Gui) 5g
Fried Rhizoma Zingiberis (Pao Jiang) 2g
Semen Sinapis Albae (Bai Jia Zi) 6g
Herba Ephedra (Ma Huang) 3g
Radix Glycyrrhizae (Gan Cao) 3g

Acupuncture

Commonly used points and methods are: Sedation tech­niques at Taixi (KI 3), Yinlingquan (SP 9), Yanglingquan (GB 34), Xuehai (SP 10), Gaohuangshu (UB 43). Tonification at Zusanli (ST 36), Shenshu (UB 23), Ganshu (UB 18), Sanyinjiao (SP 6).

Bibliography

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 (Blue Poppy Press 1991); Musculoskeletal Disorders: Healing Methods from Chinese Medi­cine, Orthopaedic Medicine and Osteopathy (North Atlantic Books 1998); Foundations for Integrative Musculoskeletal Dis­orders An East-West Approach (North Atlantic Books 2004). 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.

End Notes

11. Ingredients are: Cinnamomi (Gui Zhi) 12g, Ephedrae (Ma Huang) 6g, Aconiti (Fu Zhi) 6-30g, Anemarrhenae (Zhi Mu) 4-20g, Paeoniae (Bai Shao) 12g, Atractylodes (Bai Zhu) 12g, Ledebouriellae (Fang Feng) 12g, Zingiberis (Sheng Jiang) 6g, Glycyrrhizae (Gan Cao) 3g.

12. Aconiti (Chuan Wu, Cao Wu, and Fu Zi) are often used in very high doses to achieve the desired effect in pain syndromes. They should be cooked for over two hour to reduce their toxicity, especially if used in large doses. To balance their drying effects, high doses of Rehmanniae (Sheng or Shu Di) and Anemarrhenae (Zhi Mu) can be added. If symptoms of Stomach Heat or thirst develop, Shi Gao may be added. At high doses they should be used short-term only.

13. As can be seen the fact that RA is an inflammatory type arthritis does not mean that it is treated with cooling formulas in TCM.

14. Anemarrhenae (Zhi Mu) is an important herb for treating pain as it can clear connecting/network-vessels Heat, nourish Yin, clear Dampness, arrest pain, and calm the patient.

15. These patients often suffer from ligamentous pain. The pain is worse in the morning, better with movement or slight exercise, worse with strain, and is usually felt in a fixed location. There may be a numb-like sensation, as well. Young Maid Pill (Qing E Wan) is often cooked or baked with pork kidneys.

16. Qin Pi can be used for RA, rheumatic myositis, and gout. It can increase the excretion of uric acid via the urine.

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