Selection and combination of acupuncture points (Treatment of Pain with Chinese Herbs and Acupuncture)

Selection of acupuncture points

Acupuncture treatment consists of the application of a few points at specific places on the body. Thus, the selection and combination of points in an acupuncture treatment is most important. Since selection of points along the channels is guided by the theory of Zang-Fu organs and channels, it is essential for practitioners to have a full understanding of the following so as to be able to choose the correct points:

•    physiology and pathology

•    the course of the channels

•    the Exterior-Interior relationship of Yin and Yang

•    the function, and difference and characteristics of the points.

Selection of points along the course of the channels is one of the basic principles of acupuncture treatment, and is performed according to the theory that disease is related to channels. In practice the points are selected from the channel to which the affected organ is related; or from related channels according to the relations between the Zang-Fu organs and channels; or from several channels.

There are three principles for point selection: local point selection in the vicinity of the pain, distal point selection and symptomatic point selection. Each may be used in combination, or independently of the others.

Local point selection

This is the selection of points in the locality of the pain—for instance, pain in the head, forehead, neck or arm can be treated by using the points in the vicinity. In cases of elbow pain, LI-Il Quchi and LU-5 Chize can be selected to promote the circulation of Qi and Blood in that region; CV-12 Zhongwan can be selected to treat epigastric pain; GB-20 Fengchi can be chosen to treat headache and neck pain in the occipital region.

This method also includes selection of adjacent points close to the pain. For instance, ST-21 Liangmen can be used as an adjacent point to CV-12 Zhongwan to treat stomach pain; Ll-IO Shousanli can be used as an adjacent point to LI-Il Quchi to treat painful elbow. Adjacent points may be applied independently or in combination with the local points.

Distal point selection

This is the selection of points far from the sides of pain, and usually below the elbow and knees. This method is often used to treat pain caused by disorder of Internal Zang-Fu organs; for instance, ST-44 Neiting and LI-4 Hegu are used to treat toothache due to Stomach-Heat.

Special point selection Stream points

It was stated two thousand years ago in the Neijing that Stream (Shu) points can be used to joint and limb problems. These points are indicated in painful joints, stiff joints, joint deformity, joint swelling as well as injury in the joints. Also, these points can also be used as inducing points to conduct the treatment to the affected parts of the limbs.

Source points

As the name implies, Source (Yuan) points are the points where the Original Qi resides. On the Yang channels, the Source points are the points just proximal to the Stream points. On the Yin channels, they are the same as the Stream points.

The Source points are said to be responsible for regulation of the Original Qi in both the interior organs and the channels, so they are used for the treatment of diseases that affect the organs, and problems in those channels. Generally speaking, Source points are really good only for blockage of the channels resulting from Excessive pathogenic factors. In this treatment, they are often applied together with the Connecting points. This is because the channels are subdivided into channels and collaterals, and whereas the Source points can regulate the channels, the Connecting points can harmonise the collaterals, thus both channels and collaterals are treated together.

Connecting points

The place where a Connecting Vessel splits from a main channel is called Connecting (Luo) point. Each channel has its own Connecting point—the 12 regular channels and two of the extraordinary channels, the Governing Vessel and the Directing Vessel—and there is in addition a Connecting point from the Spleen: the Spleen Connecting vessel. So, in total, there are 15 Connecting points.

Classically speaking, the Connecting points have two major applications:

•    they can be used in the treatment of Interior-Exterior coupled organ problems

•    they can also be used in the treatment of Connecting Vessel symptoms.

Since these points directly connect to the collateral, in fact they have a third function, which is to harmonise and promote the circulation in the collateral. It is true that not all diseases affect the channels and Interior organs. In a lot of cases, pathogenic factors may attack only the collaterals, especially in cases of pain at the superficial levels.

As was mentioned in Source points, when treating pain the Source points and Connecting points are often combined so as to regulate both the channels and collaterals.

Accumulation points

Accumulation (Xi) points (or Cleft points) are the place where Qi and Blood accumulate in the channels. These points are very important in dealing with pain, both in diagnosis and in treatment.

In terms of diagnosis, a sharp or intense pain on pressure, or redness, swelling, hardening, a tingling ‘electric’ feeling or the formation of nodulations indicate Excess, whereas a dull, mild, slight or intermittent pain indicates Deficiency.

In terms of treatment, these points are often used to treat stubborn and acute cases. In treating pain, these points are very effective in relieving pain involving the organs, channels or collaterals. Therefore, in some cases they can be punctured first of all, so as to sedate the pain as soon as possible. However, such treatment can only be considered as symptomatic—that is to say, it doesn’t deal with the cause of the pain. A root treatment should be followed immediately after application of these points.

Eight Gathering points

The following eight points have special functions on the organ or substance for which they are named. They can be applied for pain originating from either Excess or Deficiency. They can in addition be used as the inducing points to lead the treatment to the affected areas.

BL-Il Dashu

This is the Gathering point for the Bones. In case of pain related to bone disorder, use of this point is advisable. For instance, in rheumatoid arthritis there is stabbing finger pain, bone deformity and swelling of the hand. Points should be used that promote circulation of the Blood, smooth the channels and sedate the pain. However, BL-Il should be added simultaneously in order to strengthen the bones.

GB-39 Xuanzhong

This is the Gathering point for the Marrow. This point is often applied to treat pain due to deficiency of Blood, since the Marrow produces Blood. Moreover, since the Marrow nourishes the Bones, thus this point is often combined with some other points to treat bone problems due to deficiency. For instance, lower back pain in senile people is commonly due to weakness of the Liver and Kidney, thus the points to tonify the Liver and Kidney should be used together with GB-39 in order to strengthen the bones. It is clear to see that this point is indicated only in chronic cases.

GB-34 Yanglingquan

This is the Gathering point for the Tendons. It is effective for treating pain in the Tendons originating from both Excessive and Deficient causes. For instance, in the treatment of sciatica, no matter the cause, this point should be coupled with the local point and distal points to eliminate pathogenic factors and relieve the pain. In treating acute ankle sprain, which is usually caused by stagnation of Blood in the channels, this point should be punctured first to relieve the pain, followed by needling at local and distal points to eliminate Blood stasis.

CV-17 Tattzhong

This is the Gathering point for the Qi. This point is mostly used to treat general stagnation of Qi or stagnation of Qi in the chest, Lung, Heart or Liver. So it is clear to see that this point is usually not indicated in deficiency of Qi.

BL-17 Geshu

This is the Gathering point for the Blood. It is indicated in both deficiency of Blood and stagnation of Blood. Also this point is very effective for clearing Heat in the Blood, and is indicated in the generation of Heat caused by over-to-long Blood stagnation, or invasion of Blood by Excess-Heat or Deficient-Heat.

LU-9 Taiyuan

This is the Gathering point for the vessels. Generally speaking, this point is often indicated in pain due to stagnation of Blood in the vessels.

LR-73 Zhangmen

This is the Gathering point for the Zang organs. It is indicated in pain due to disorder of the Zang organs. Of course, it should be be used together with other points to treat the affected organs. For instance, in treating pain due to Damp resulting from weakness of the Spleen, LR-13 can be applied in combination with SP-3, SP-9 and ST-40 to activate the Spleen and resolve the Damp.

CV-12 Zhongwan

This is the Gathering point for the Fu organs. This point has the function of promoting the digestion and transportation functions in the Fu organs. However, it is particularly indicated in pain due to disorder of Stomach and Large Intestine.

Front Collecting points

The Front Collecting (Mu) points are those points that are located on the chest and abdomen where the channel Qi collects. Each Zang-Fu organ has a Front Collecting point. These points can be found directly above or near to the organ to which they are related. Generally speaking, when there is disorder of the organ, there can be found some pathogenic reaction at these points, including tenderness, lumps, hardening, redness, blistering, a hot feeling, depression and swelling. Thus the Front Collecting points can be used for diagnostic purpose to determine whether there is disorder of the interior Zang-Fu organ, or of the channels.

The Front Collecting points can also be used as therapeutic points. In this case, they should be combined with other points to treat the root causes.

Mother-Son points

This is the method expounded in the Nanjing (c. ad 198, new edition Nanjing College of Traditional Chinese Medicine, 1979) based on the combination of the theory of the Five Elements and the nature of internal Zang-Fu organs. In the treatment, the Mother points should be tonified in cases of deficiency of the interior organs, and the Son points should be reduced in cases of Excess in the Interior organs. For instance, the Lung corresponds to Metal. According to Five Element theory, Metal produces Water, so the Water point from the Lung channel is the Son point; this is LU-5 Chize. Thus, in cases of Excess in the Lung, LU-5 should be needled using the reducing method. Furthermore, according to the Five Elements, Earth is the mother of Metal, so LlJ-9 (the Earth point) is the Mother point. In cases of deficiency, LU-9 Taiyuan should be needled using the tonifying method.

Back Transportingpoints

Although the Back Transporting (Shu) points are located on the Bladder channel, they are also the places where Qi passes through all named organs. These points can be used to diagnose and to treat the organ with which they are associated. Disorder of an Interior organ can be detected by finding tenderness, swelling, hardening, blister, or some other abnormality when palpating on the corresponding point. For instance, Liver disorder can often be detected by palpating at BL-18 Ganshu; in most cases, there is tenderness, hardening or discoloration. This point can also be needled to treat disorder of Liver. The Back Transporting points are indicated in pain due to disorder of Interior organs rather than superficial complaints on the channels, skins, muscles and tendons resulting from invasion of External factors.

The four Command points

The Command points govern particular parts of the body. They include the following:

•    ST-36 Zusanli commands the abdomen

•    LI-4 Hegu commands the head, face and mouth

•    LU-7 Lieque commands the head and neck

•    BL-40 Weizhong commands the back of the body.

These points are selected when the parts of the body they command are involved in the problem. Thus they can be leading points to bring the treatment to certain parts of the body. However, they can only be applied together with other points to treat the root causes.

Eight Confluence points

The eight Confluence points are located on the limbs; each is linked with one of the eight extraordinary channels. They are: PC-6, SP-4, TE-5, GB-41, LU-7, KI-6, SI-3 and BL-62. These eight points are very important in the treatment of pain. These eight Confluence points can also be considered as the opening points and leading points of the extraordinary channels. In practice, they can be subdivided into four groups:

PC-6 Neiguan and SP-4 Gongsun. These are indicated in Heart pain, Stomach pain and chest pain. When these two points are combined, they can regulate Qi and Blood in the Heart, Stomach and chest. They can also regulate the Penetrating Vessel (Chong Mai) and cause the Qi to descend, and are indicated in belching, acid regurgitation, nausea, vomiting, and uprising of Qi from the abdomen to the chest.

SI-3 Houxi and BL-62 Shenmai. These are indicated in pain at the inner canthus, pain at the back of the neck, ear pain, shoulder pain and back pain caused either by invasion of External factors, or disorder of the Internal Zang-Fu organs. They are used only to treat pain at places where covered by the Greater Yang channels.

Since this combination can open the Governing Vessel, it is widely used to treat all kinds of back pain due to blockage of this channel.

TE-5 Watguan and GB-41 Zulinqi. These are indicated in pain at the outer canthus, pain behind the ear, cheek pain, and pain at the side of the neck or shoulder. This combination is specially indicated in pain on the sides of the body due to invasion of external factors or stagnation of Liver-Qi and disharmony of the Gall Bladder.

LU-7 Lieque and KI-6 Zhaohai. These are indicated in chest pain, throat pain and pain at the epigastric regions. Generally speaking, this combination is very effective for treating chronic pain above the waist resulting from deficiency of the Yin of Lung and Kidney.

Six Lower Sea points

Each of the three Yang channels of hand and three Yang channels of the foot has a Lower Sea (He) point around the knee. They are:

•    ST-36 Zusanli for the Stomach

•    ST-37 Shangjuxu for the Large Intestine

•    ST-39 Xiajuxu for the Small Intestine

•    GB-34 Yanglingquan for the Gall Bladder

•    BL-40 Weizhong for the Bladder

•    BL-39 Weiyang for the Triple Burner.

Actually, these six Lower Sea points are a kind of symptomatic treatment points. They are usually used in combination with the corresponding Front Collecting or Back Transporting points. For instance, in cases of abdominal pain due to accumulation of Excess-Heat in the Bright Yang Fu organs manifesting as abdominal pain, constipation, thirst, a large appetite, a foul smell in the mouth, a red tongue with a yellow and dry coating and a rapid and forceful pulse, ST-37 should be applied together with ST-25 Tianshu, ST-40 Fenglong, ST-44 Neiting and LI-Il in order to clear the Heat, drain the Stomach and Large Intestine and sedate the pain.

Ah Shi points

Since these points are especially sensitive to palpation and pressing, they usually reveal blockage or disorder of channels or Interior organs. However, the practitioner should remember that a discovery of a sensitive Ah Shi point doesn’t mean the problem is only in the locality, as it can also reflect some disturbance at a distal place or an Interior organ. Moreover, Ah Shi points can be used only as the symptomatic treatment. They have to be used in combination with other points that treat the root causes.

Symptomatic point selection

Selecticm of local and distal point is based upon the distance of the points from the site of the pain; however, some diseases are not local but systemic in nature, and can be treated at those points that have long been associated with relieving a particular disease. Such points include the eight Confluence points and the six Lower Sea points.

Certain individual points have also traditionally been found useful for treating specific symptoms. For instance. GV-14 Dazhui is used for reducing fever, GV-26 Renzhong for reviving unconscious patients, PC-6 Neiguan for relieving nausea and vomiting, ST-40 Fenglong for eliminating Damp-Phlegm in the body and ST-36 Zusanli for activating the Spleen and tonifying the Qi and Blood.

Combination of points

In addition to the method of individual point selection outlined above, there are several traditional methods of combining one point with another in an acupuncture prescription. These techniques are flexible, permitting much variation according to the particular needs of the case.

Combining local points and distal points

This method is the most popular in everyday practice. In this, a point (or points) at or near the place of the diseases (the local point(s)) would be combined with distal points that are traditionally considered to have an effect on the disordered area. For example, in Stomach disease, the local points CV-12 Zhongwan and ST-21 Liangmen, and the distal points PC-6 Neiguan and ST-36 Zusanli could be used together.

When treating pain, the practitioner is advised to use a greater number of distal points to treat acute pain, and a greater number of local points to treat chronic pain.

Combining points on the front with points on the back

The front includes both the chest and abdomen, and the back includes both the back and waist. In this method, points on both the front and back appropriate to a particular disease are used in combination. It employs simultaneous use of the Front Collecting points and Back Transporting points to increase the therapeutic effect of both. For instance, in Spleen disease, both LR-13 Zhangmen on the front and BL-20 Pishu on the back can be needled in tandem. This method of point selection is often used to treat pain due to Internal Zang-Fu organs. If, in contrast, pain is caused by channel problems, for instance channels blockage, symptomatic point selection is more often carried out.

Combining points on the Yang channels and the points on the Yin channels

Each of the channels has a paired channel, and they form a Yin and Yang relationship. By combining a point on a Yang channel with another on its paired Yin channel, the practitioner can obtain a greater effect than if needling either point separately. Examples include: combining ST-36 Zusanli on the Stomach channel with SP-4 Gongsun on the Spleen channel for Stomach disease, or combining LU-9 Taiyuan on the Lung channel with LI-4 Hegu on the Large Intestine channel for cough. The most well-known combination of this kind is between the Source point on the channel primarily affected by a disease, and the Connecting point on the channel with which the first has a Yin-Yang relationship. In this combination, the Source point is called the ‘host’, and the Connecting point is called the ‘guest’. For example, a disease affecting the Lung channel may be treated through that channel’s Source point, LU-9 Taiyuan, in combination with the Connecting point of its Yang partner the Large Intestine channel, LI-6 Pianli. Conversely, a disease affecting the Large Intestine channel could be treated by that channel’s Source point, LI-4 Hegu, together with the Connecting point of the Lung channel, LU-7 Lieque.

Combining points above with points below

‘Above’ refers to points on the arms and above the waist, and ‘below’ to points on the legs and below the waist. However, this method of point combination is mostly commonly practised on the limbs. For instance, in cases of Stomach disease, PC-6 Neiguan on the arm may be combined with ST-36 Zusanli on the leg. For sore throat or toothache, LI-4 Hegu on the hand can be combined with ST-44 Neiting on the foot.

Traditionally, a distinctive use of the above-below combination was made with respect to the confluence points of the eight extraordinary channels. A confluence point on one of these channels affected by a disease above would be combined with a confluence point on another extraordinary channel below. For example, diseases of the Heart, chest and abdomen are related to the Yin Linking channel and the Penetrating channel; therefore, PC-6 Neiguan, the Confluence point of the former on the arm (above), and SP-4 Gongsun, the Confluence point of the latter on the foot (below), are selected as a combination for needling.

Combining points on the left with the diseases on the right

Because channel points are bilateral, it is common to treat diseases of the internal organs by manipulating the same points on both sides in order to strengthen the effect. For example, ST-36 Zusanli on both legs can be needled to treat diseases of the Stomach. Furthermore, because the channels on the right side intersect with those on the left, a point on the right may be chosen to treat disease or pain on the left side of the body, and vice versa. For instance, in the case of hemiplegia, the practitioner may select not only a point on the side affected by the paralysis, but also the same point on the healthyjside.

Combining corresponding points

If the body is subdivided into upper and lower parts, it is clear to see that there is a correspondence between the upper and lower limbs. This implies that, for points on the shoulders, elbows, wrists and fingers in the upper limbs, there are corresponding points on the hips, knees, ankles and toes in the lower limbs— that is, there are points on the shoulders corresponding to points on the hips, elbows to knees, wrists to ankles and finally fingers to toes. Meridians in these corresponding places bear the same names, as Qi and Blood in these places can mutually influence each other.

By combining corresponding points the practitioner can treat painful areas by using points in the corresponding areas rather than in the painful area itself. For instance, in the treatment of shoulder pain along the Large Intestine channel, the practitioner can use the corresponding point from the channel that bears the same name on the hip (i.e. ST-30 Qichong), and vice versa. This method is especially indicated for treating most acute pain syndromes, and gives very good results. In some cases, if the pain is very localised and very acute, needling only one point can sedate pain. Attention should be paid here to diagnosis, as some cases of pain may have ruptured tendons or bone that are fractured or even broken. The following is a list of suggested corresponding points:

•    Shoulder to hip: HT-I Jiquan to KI-Il Henggu, PC-2 Tlanquan to LR-12 Jimai, LU-2 Yunmen to SP-12 Chongmen; LI-15 Jianyu to ST-30 Qichong, TE-14 Jianliao to GB-30 Huantiao, SI-IO Naoshu to BL-36 Chengfu.

•    Elbow to knee: HT-3 Shaohai to KI-10 Yingu, PC-3 Quze to LR-8 Ququan, LU-5 Chize to SP-9 Yinlingquan; LI-Il Quchi to ST-35 Dubi, TE-IO Tianjing to GB-34 Yanglingquan, SI-8 Xiaohai to BL-40 Weizhong.

•    Wrist to ankle: HT-7 Shenmen to KI-3 Taixi, PC-7 Daling to LR-4 Zhongfeng, LU-9 Taiyuan to SP-5 Shangqiu; LI-5 Yangxi to ST-41 Jiexi, TE-4 Yangchi to GB-40 Qiuxu, SI-4 Wangu to BL-62 Shenmai.

Point prescriptions

When selecting points for a prescription, the number of points in prescription should be as few as possible. In practice, four to six points are selected to treat acute pain, or mild pain, or with persons of weak constitution. For treating severe pain, or chronic pain, since they are complicated in pathology, the practitioner should use a larger number of points (eight to ten) to produce stronger stimulation. After a few initial treatments, points may be added or subtracted as the condition requires.

When treating a nervous patient for the first time, the practitioner should needle fewer points, increasing the number in later treatment when the patient feels more accustomed to acupuncture.

Each acupuncture point has its own distinctive characteristics, yet those on the same channel or in the same locality can produce certain effects in common. It is wrong to needle the same point for too many times in the same treatment series, as the efficacy of these points will diminish. Rather, other points with similar characteristics should be substituted, or a similar prescription made up of different points should be used instead.

Frequency of treatment

A small number of cases of acute pain require more than one treatment in a single day. Most cases of chronic pain are treated once every I to 3 days, or even once a week. After giving acupuncture treatment for a period of weeks, treatment should be suspended temporarily to rest the patient.

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