General concepts of treatment
This topic deals with the basic principles of making a decision about which treatment methods and prescriptions to use. This decision is reached by following the guidance of the TCM holistic concepts about differentiation of the syndromes. The principle of treatment differs from the method of the treatment, as the former refers to the rules of the treatment, whereas the latter refers to the steps of the treatment, which are determined by the principle of treatment. For instance, all kinds of pain, as a rule, are caused by conflict between the Defensive Qi and pathogenic factors, so the basic principle of treatment is to regulate the Defensive Qi and eliminate the pathogenic factors. Following the guidance of this principle, the general treatment method would be to nourish the Qi, tonify the Yang, circulate the Qi and Blood, and so on. However, in practice there are various different types of pain with rather complicated pathologies, and differences in severity and intensity, as well as in the seasons, the exact circumstances and the constitution of patients, so it is impossible that just one or a few fixed treatment methods will treat all kinds of pain. The only way to obtain good therapeutic results, therefore, is to master a number of other principles of treatment, which include:
• searching for the root cause and secondary symptoms
• supporting the Defensive Qi and expelling the pathogenic factors
• regulating Yin and Yang
• determining the treatment in accordance with climate and season, geographical location and individual constitution.
Searching for the root cause and secondary symptoms
The concepts of the root cause and secondary symptoms can have different meanings, but here they mainly refer to the nature and primary aspect of the pain, and the phenomena associated with the pain. Pain should be assessed clinically to determine the primary and the secondary aspects, the root cause, the symptoms, whether acute or chronic so as to ascertain the main contradictions, and then should be treated accordingly. Generally speaking, the root cause should be treated first, and the secondary symptoms second. For instance, if a headache is caused by invasion of Exogenous Cold, the root treatment would be to dispel the Exogenous factor and promote the circulation of Qi and Blood in the head, and this would be done first of all. However, if the secondary symptoms are acute and severe, they would be treated first. Again taking headache as an example, if headache is very severe, treatment should first aim to sedate the pain and only afterwards to dispel the Cold. If both the symptoms and the root cause are serious, they should be treated simultaneously.
Supporting the Defensive Qi and expelling pathogenic factors
The occurrence of pain, according to TCM theory, is an indication of a process of struggle between the Defensive Qi and pathogenic factors, so strengthening the Defensive Qi to defeat the pathogenic factors is the correct method of curing the pain. Strengthening the Defensive Qi means improving the body’s resistance and building up its energy. Once resistance against pathogenic factors is increased, the pathogenic factors are naturally eliminated.
Clinically, the condition both of the Defensive Qi and of the pathogenic factors should be observed carefully, in order to determine whether to strengthen the body resistance or to eliminate the pathogenic factors first. If a patient has weak resistance but the pathogenic factors are not yet very strong, the body resistance is strengthened first. If a patient is suffering Excessive pathogenic factors but the body resistance has not yet been damaged, the primary task is to eliminate the pathogenic factors. But some patients have weak body resistance and the pathogenic factors are also overwhelming, so in these cases both methods need to be employed simultaneously.
Regulating Yin and Yang
The occurrence of pain is, fundamentally speaking, caused by an imbalance of Yin and Yang, either an excess or deficiency. So it is very clear that treatment also needs to restore the balance between Yin and Yang.
Clinically, Excess of Yin makes Yang suffer, and Excess of Yang makes Yin suffer. For such Excess of Yin or Yang, the best treatment is to reduce or remove the Excess. But whilst correcting this Excess, attention should also be paid to whether a corresponding Yin or Yang deficiency exists. If one of these is deficient, the treatment given should be either simultaneous Yang reduction and Yin reinforcement, or Yin reduction and Yang reinforcement.
Also a deficiency of Yin or Yang may cause failure of the other to be controlled, leading to a state of Deficient-Heat or Deficient-Cold. Treatment in this case should be given to reinforce either Yin or Yang so as to eliminate Deficient-Heat or Deficient-Cold. If there is a deficiency of both Yin and Yang then the treatment needs to tonify both Yin and Yang simultaneously.
Determining the treatment in accordance with climate and season, geographical location and individual constitution
CLIMATIC AND SEASONAL CONDITIONS
It was stated in the Ling Shu (1963, p. 27) that in spring the pathogenic factors are most likely to attack the superficial layer. In summer, they are most likely to attack the skin. In autumn, they are most likely to attack the muscles. In winter, they are most likely to attack the tendons and bones. When treating such disorders, the clinician should ensure that the techniques used are consistent with the seasons. Generally speaking, in spring and summer the climate is relatively warm, and the Yang Qi of the body is floating at the superficial level of the body, so shallow acupuncture is applied. If herbs are used during these seasons then herbs that are very pungent and warm and have a strong dispelling action should be avoided. But the climate in autumn and winter is colder and the skin pores are closed, so the Yang Qi of the body remains deep inside, so the deeper acupuncture is better, and if herbs are applied then those that are relatively pungent and warm and strong in their action should be prescribed in preference.
GEOGRAPHICAL LOCATION
The therapeutic method used should be appropriate to the geographical location. Climate and lifestyle vary in different regions, so do the body’s physiological activities and pathological changes, therefore methods of treatment should be varied in accordance with the region. For instance, the weather in Belgium and Holland is rather cold and humid, so many people suffer from Cold Bi and Damp Bi. In this climate dispelling the Cold and elimination of the Damp are of relatively greater importance in the treatment determination. In China, very strong manipulation of the needle is often used in patients who have pain caused by Excessive factors; however, if this were used in the West it would cause a bad reaction for many patients, so the even method is used instead of strong manipulation.
INDIVIDUAL CONSTITUTION
TCM treatment also varies according to a person’s age, sex and personal constitutional condition, which is quite logical. For instance, men and women are different in constitution, women have menstruation and pregnancy, so the treatment method should vary as well. Most women will not be able to stand strong herbal treatment and strong manipulation of the needle. A difference also exists between adults and children.
Therapeutic steps
In modern medicine, there are three usual methods of treating pain:
1. Remove the causes of the pain, such as an ulcer or abscess.
2. Alleviate the pain by reducing or stopping transmission of the pain impulses from the affected region—for instance, by administration of sedatives, or electricity. Antidepressants are often used as an adjunctive treatment; originally they were used only to treat depression, but studies have shown that these medications can alleviate pain in certain situations (Antkiewicz-Michaluk et al 1991, Ardid & Guilbaud 1992, Ardid et al 1992, Bank 1994, Danysz et al 1986). Furthermore, they may have the added benefit of helping the patient to sleep at night. Also antiseizure medication may help relieve certain types of pain by reducing abnormal electrical discharges in damaged nerves.
3. Reduce reception of the impression of pain in the brain by use of drugs.
Medications that are prescribed are usually of two types: painkillers and anti-inflammatory drugs. The first type includes narcotic painkillers, which are often used to treat acute pain or cancer pain and are seldom prescribed for chronic pain. The latter type includes aspirin-like drugs, which are the most commonly used medications of this type. These not only reduce swelling and irritation but can also relieve the pain.
In contrast with Western medicine, TCM practice is to take a detailed history from the patient, including sleep, emotions, diet, exercise, and any operations, and combine this with an examination of the tongue, pulse, skin colour, stool, urine, hair condition, breathing, and so on, before making a diagnosis. In treatment, herbs and acupuncture can be applied in combination or separately; they are used to stimulate the Qi and Blood circulation in the body. The treatment aim is to restore the balance between Yin and Yang in the body, and Qi and Blood circulation in the channels as a whole, thereby influencing the person’s entire health and dispelling the pain. There is some similarity between the method of treating pain in TCM and in Western medicine, in that, in the latter, sedatives are used to calm the brain, and in TCM the same end is achieved by means of methods to calm the Mind (Shen). To calm the Mind is in fact to regulate the physiological function of the Heart; this is because the Heart is the root of the response to the pain.
To treat the pain successfully, simultaneous application of acupuncture and herbal medicine treatment is recommended. To achieve the therapeutic effect the following steps have to be followed:
• remove the pathogenic factors, so as to diminish or eliminate the causes of stagnation of Qi and Blood; this is an important step to avoid a vicious circle
• promote the Qi and Blood circulation, restore Qi and Blood levels and harmonise the Zang-Fu organs and channels
• calm the Mind and regulate the Heart, so as to diminish the pain
• prevent recurrence of the pain.
Treatment procedures
CAUSATIVE TREATMENT
The differentiation process should first be employed to establish the cause for each syndrome. If this step is not followed the treatment may be wrong or inaccurate. Causal treatment is the root treatment, as it is a unique way of preventing a vicious circle, and includes dispelling of Exogenous pathogenic factors, smoothing the emotions, regulating the Internal Zang-Fu organs, and avoidance of inappropriate diet, an irregular lifestyle and injury, so the Qi and Blood can circulate freely, and pain disappears. Generally speaking, in a patient with pain, the root cause should be treated first if the case is chronic, or if an acute case is not of a serious nature.
SYMPTOMATIC TREATMENT
Treatment of the symptoms, or secondary cause, is appropriate in the following circumstances:
• if the patient has a single symptom that does not appear to have any root cause, or
• if the pain is acute, or if the pain though chronic is of a serious nature.
Treatment of the root cause and symptoms at the same time is the most common approach in the treatment of pain, especially in chronic cases. This method is used particularly when the case is rather complicated.
PATHOGENIC TREATMENT
Since the main mechanism of pain is disorder of Qi and Blood circulation, it is necessary to restore this to normal. Treatment includes methods to circulate the Qi and Blood, to eliminate the Qi and Blood stagnation and to tonify the Qi and Blood. When these steps are employed to maintain the free flow of Qi and Blood, the pain vanishes.
Acupuncture and moxibustion are useful for treating local trigger points (Ah Shi points), or other points in the vicinity chosen according to the channel, because they can temporarily restore the normal circulation of Qi and Blood in the body.
TREATMENT TO CALM THE MIND
Acupuncture and herbal medicine can calm the Mind and regulate the Heart so as to inhibit nerve impulses from the disordered Qi and Blood circulation being sent to the Heart. There exist many effective points and herbs that can alleviate pain rapidly. Achievement of this effect doesn’t mean that the causative pathogenic factors are totally eliminated, but rather that the sensitivity to the pain is diminished. However, it is only symptomatic treatment. Based upon this reasoning, some points that calm the Mind and tranquillise the Heart include HT-3 Shaohai, HT-7 Shenmen, PC-6 Neiguan, GB-20 Fengchi, GV-20 Baihui and Extra Sishencong, and these should be combined with the treatment for the aetiology and pathology.
PREVENTATIVE TREATMENT
TCM also emphasises the importance of the prevention of pain. For this, acupuncture and herbal medicine can be applied in combination or in separation. Each of them can regulate the level of Qi and Blood, maintain the free flow of Qi and Blood in the body, improve the body’s resistance from pathogenic invasion, harmonise the internal Zang-Fu organs and smooth the emotions. AU these elements of prevention of TCM significantly make it different from the treatment approach of modern medicine.
Treatment for the prevention of pain varies according to the primary cause of the pain. In headache, for instance, if the cause is Exogenous invasion, then the treatment methods used aim at raising the body’s resistance. In cases of pain caused by stagnation of Qi and Blood due to too much anger, stress and frustration, the preventative treatment method used is to smooth the Liver, circulate the Qi and eliminate the Blood stagnation. If there is blockage of Clear Yang due to accumulation of Damp, the treatment used should include avoidance of eating too-rich or fatty food and elimination of alcohol so as to prevent accumulation of Damp in the body, as well as a method to activate the Spleen and Stomach so as to maintain normal transportation and transformation of food and water. Where there is deficiency of Kidney-Essence, prevention should include reducing excessive sexual intercourse in order to preserve the Essence. In cases of deficiency of Qi and Blood, a method should be used to tonify the Qi and Blood, activate the Spleen and tonify the Kidney-Essence so as to produce more Qi and Blood. In addition the patient should take regular physical exercises to activate the normal circulation of Qi and Blood, and maintain good function of the Zang-Fu organs.
Therapeutic principles
Depending on the aetiology, the clinical symptoms and the localisation of the pain, different therapeutic principles should always be taken into account so as to treat correctly. Some of the main principles are as follows.
TO DISPEL WIND AND ELIMINATE COLD (QU FENG SAN HAN)
This method is used to treat pain syndrome due to invasion of Wind-Cold, which is manifested as an aversion to cold, a slight fever, chills, general body pain, headache, toothache, abdominal pain, joint pain, a thin and white tongue coating and a superficial and tight pulse.
TO DISPERSE WIND AND CLEAR HEAT (QU FENG QING RE)
This method is indicated in pain syndrome due to invasion of Wind-Heat. The manifestations of this are a high fever, an aversion to cold, body pain, joint pain, headache, abdominal pain, a red tongue with a thin and yellow coating and a superficial and rapid pulse.
TO CLEAR HEAT AND REMOVE TOXINS (QÏNG RE JIE DU)
This method is applied to treat pain syndrome due to invasion of Toxic Heat or accumulation of Excessive Heat in the body. The manifestations of this are fever, restlessness, insomnia, headache, thirst, constipation, or redness, hotness, swelling and pain of the face, joints, skin, and so on, a red tongue with a yellow coating and a forceful and rapid pulse.
TO DISPEL WIND AND MOISTEN DRYNESS (QU FENG RUN ZAO)
This method is used to treat pain syndrome caused by invasion of Wind-Dryness. The manifestations of this are an aversion to cold, fever, throat pain with dryness, thirst, a dry nose, chest pain, a dry cough with a nonproductive cough, or a cough with blood breaks in the phlegm, dry skin and mouth, slight constipation, a thin and dry tongue coating and a superficial pulse.
TO DISPEL WIND, ELIMINATE COLD AND RESOLVE DAMP (QU FENG SAN HAN LI SHI)
This method is used to treat pain syndrome resulting from invasion of Exogenous Wind, Cold and Damp. The manifestations of this are an aversion to cold, a slight fever, generalised body pain or joint pain with heaviness, headache with a heavy feeling, or even oedema of the body or the joints, a white and greasy tongue coating and a superficial and slippery pulse.
TO DISPEL WIND, CLEAR HEAT AND RESOLVE DAMP (QU FENG QING RE LI SHI)
This method is applied to treat pain syndrome resulting from invasion of Wind, Heat and Damp, manifested as fever, thirst, painful joints and muscles with redness and hotness, limitation of joint movement, a red tongue with a yellow coating and a superficial and tight pulse.
TO SMOOTH THE LIVER AND REGULATE THE QI (SHU GAN LI QI)
This is the most important method to treat pain syndrome when there is retardation of the Qi circulation, or even stagnation of Qi and Blood. This treatment varies depending on whether Qi stagnation or Blood stagnation predominates. If Qi stagnation is the main problem, and Blood stagnation is secondary, the treatment should focus on the Qi circulation, in combination with a method to circulate the Blood. If the problem is primarily one of Blood stagnation, and Qi stagnation is of lesser importance, treatment should focus on the Blood circulation. However, if there is simultaneous stagnation of both Qi and Blood, the method should also aim to circulate Qi and Blood simultaneously.
TO ELIMINATE BLOOD STASIS AND RESOLVE PHLEGM (QU YU HUA TAN)
This method is used to treat stubborn pain in the joints, muscles, channels and Interior organs, which may persist for years, due to stagnation of Blood with accumulation of Phlegm in the collaterals. According to TCM, persistence of any sickness may cause impairment of the collateral, leading to stagnation of Blood. It manifests as severe muscle pain, joint pain, limitation of joint movement, deformity of the joints, atrophy of the muscles, swelling of the joints and muscle, heaviness of the body, purplish skin, a purplish tongue with a greasy coating and a wiry and slippery pulse. To treat this sort of pain, the only method is to ensure free circulation of the Qi and Blood in the body.
TO TONIFY THE QI AND BLOOD (BU QI YANG XUE)
This method is applied to treat pain syndrome due to lack of nourishment of the body. Because of the Qi deficiency, the power of the Qi to promote Qi and Blood circulation is weakened, leading to slowing of Qi and Blood circulation, so stagnation of Qi and Blood develops. It is obvious that this type of pain is one of deficiency. It manifests as a dull pain, a slight pain, intermittent pain, pain that is aggravated by exertion and alleviated by rest, a feeling of tiredness, shortness of breath, dizziness, poor memory, a pale complexion, a pale tongue with a thin and white coating and a deep, thready and weak pulse.
TO NOURISH THE LIVER AND KIDNEY (ZI YANG GAN SHEN)
Since the Liver stores the Blood, and the Kidney stores the Essence, the Blood and Essence can be mutually nourished, thus it is said that the Liver and Kidney are derived from the same source (Gan Shen Tong Yuan). In cases of deficiency of Liver and Kidney, the tendons and bones will not be properly nourished. This leads to chronic lower back pain, neck pain, knee pain, heel pain, or pain in other joints, weakness of the body, a feeling of tiredness, vulnerability to bone fracture, hair loss, poor concentration, dizziness, tinnitus, a thin tongue coating and a deep and weak pulse.
TO WARM THE INTERIOR AND RELIEVE PAIN (WEN LI ZHI TONG)
This method is used to treat epigastric pain, abdominal pain or lower back pain due to deficiency of the Yang of the Spleen, Stomach or Kidney. The clinical manifestations are chronic pain, alleviation with massage and pressure, a feeling of tiredness, coldness of the hands and feet, an aversion to cold, a pale complexion, diarrhoea, nycturia, lower back pain, impotence, a pale tongue with a thin and white coating and a deep, thready and slow pulse.
In practice the causative factors for different types of pain are seldom pure, but mostly mixed, so the therapeutic rules need to be adapted according to the predominant pathogenic factors.
Beside causal treatment of Wind, Cold, Damp and Heat factors, attention should be directed to the congenital or acquired constitutional factors: also, any underlying diseases must be diagnosed and treated. For example, it is very important to check for deficiency of Stomach Qi, Defensive Qi, Original Qi, the general state of the Ymg Qi or Yang Qi, and so on.
In chronic cases especially, when the pain has persisted for a long time, not only is it important to circulate the Qi and Blood, or warm the channels if there is severe pain due to Cold, but also the following principle must be considered.
CHANNEL-INDUCING METHODS (YIN JING BAO SHI)
This is a complementary therapeutic method and principle, which involves the selection of particular herbs that can direct the other ingredients in a formula to work on the affected channels or sites.
The following herbs conduct the other ingredients in the formula towards particular areas:
• Gu Sui Bu Rhizoma Drynariae directs toward the bones and marrow
• Chuan Niu Xi Radix Cyathulae directs towards the lower limbs
• Chai Hu Radix Bupleuri directs towards the lesser Yang channel
• Bai Zhi Radix Angelicae Dahuricae directs towards the Bright Yang channel
• Gao Ben Rhizoma et Radix Ligustici directs towards the Greater Yang channel.
Channel and point palpation
TCM practitioners must carry out careful examination of the body surfaces so as to detect any abnormalities such as points of tenderness, warmth, skin eruptions and subcutaneous nodules. These phenomena are then linked to the pathology of a neighboring channel.
Method of examination
The thumb is rubbed lightly over the skin along the course of a channel, or the thumb is used together with the index finger to knead the skin gently in order to detect alterations in the superficial cutaneous layers. A greater degree of pressure may be needed to probe the deeper layers of skin. It is important that the pressure be uniform, however, and that the clinician notes any differences between the same channel on the left and right sides of the body. Ordinarily, examination begins along the channels of the back and then proceeds to the chest, abdomen and limbs. Particular attention should be given to special points such as the Back Transporting (Shu) points, Front Collecting (Mu) points, Source (Yuan) points, and Accumulation (Xi) points.
Abnormalities
These include subcutaneous nodules, area of tenderness, hard or flaccid muscle tissue, and indentations, or discoloration of the skin or change in its temperature. Once discovered, it is necessary to determine whether the abnormality reflects symptoms of Excess or Deficiency in the related channel.
Clinical application
The following method is used in examination of the back. The thumb is pressed along the left and right sides of the spinous processes (the medial course of the Bladder channel), generally beginning beside the twelfth thoracic vertebra and working upward to the first thoracic vertebra, and then from the sacrum up to the lumbar vertebrae. When this is complete, the skin surface in the vicinity of the ileu and shoulder blades may be similarly palpated.
In addition to the abnormalities discussed above, attention should be paid to the position of the spinous processes and any abnormalities in the tissue tension of the paraspinal musculature. Such areas may be sensitive to the touch. The practitioner should also check the vertebrae to see whether they are evenly spaced or if there is any scoliosis.
If any abnormalities are found that indicate a strictly local problem these are treated accordingly. The remaining may be regarded as External manifestations of an internal disease:
• commonly, abnormalities discovered between the first and third thoracic vertebrae suggest an illness related to the Heart
• those between the first and fourth are related to the upper limbs
• those between the second and fifth are related to the Lung and bronchioles
• those between the fifth and eighth are related to the Stomach and duodenum
• those between the eighth and tenth are related to the Liver, Gall Bladder and pancreas
• those between the tenth and twelfth are related to the Stomach and intestines
• those between the twelfth and the second lumbar are related to the Kidney and urinary system
• those between the first and fourth lumbar vertebrae are related to the lower limbs those in the sacral region are related to the reproductive organs.
Because these lines running parallel to the spine correspond to the course of the Bladder channel, the Back Transporting points along this channel are frequently palpated for diagnostic purposes, as are the Front Collecting points on the chest and abdomen. In practice, these points are considered the primary diagnostic indicators. The acupuncture points on neighbouring channels may also be checked for reaction—for instance, the Front Collecting point LU-I Zhongfu and the neighbouring point KI-27 Shufu may reflect the condition of the Lung and bronchioles.
When palpating points on the limbs, the Accumulation points are considered to be of primary importance, and the neighbouring points are secondary; for example, the Accumulation point ST-34 Liangqui and the neighbouring point ST-36 Zusanli may both reflect Stomach disease.
