Acupuncture treatment of

chronic musculoskeletal
pain comparison of
different approaches




By J elena Kasteel

2



Acupuncture treatment of
chronic musculoskeletal pain
- comparison of different approaches














An essay presented to the
Academy for Traditional Chinese Medicine
Qing-Bai

For the purpose of obtaining the certificate of acupuncture
September 2009, Amersfoort

By J elena Kasteel
Supervision by Marijke Fluitsma






3

Contents


Preface 5
Summary 6
Introduction 7

1. Physiology and pathology of chronic musculoskeletal pain 8

1.1 Physiology of pain 8
1.1.1 Pain as seen in Western medicine 8
1.1.2 Pain in Chinese medicine 8

1.2 Bi Syndrome (Painful Obstruction Syndrome) 9

1.3 How to address the chronic nature of musculoskeletal pathology 11
1.3.1 Treating the underlying condition 11
1.3.2 Treating different meridian layers 11

2. A short inquiry into the nature of the meridians 13

2.1 Chasing the meridians 13
2.2 Are meridians linear? 14
2.3 Meridians under microscope 15

3. Different approaches in acupuncture of musculoskeletal conditions 17

3.1 TCM approach 19
3.1.1 The role of meridian palpation 19
3.1.2 The use of the local and Ah Shi points 19
3.1.3 The use of the distal points 20
3.1.4 Treatment according to the meridian layers 21

3.2 Meridian approach 23
3.2.1 The role of meridian palpation 23
3.2.2 The use of the local points 23
3.2.3 The use of the distal points 24
3.2.4 Treatment according to the meridian layers 25

3.3 The trigger points approach 27
3.3.1 The concept of trigger points 27
3.3.2 Diagnosis and palpation of trigger points 28
3.3.3 The treatment of trigger points the view on the local and
distal points and needling techniques 29




4

3.4. Ear acupuncture 31
3.4.1 General overview of the ear acupuncture 31
3.4.2 Nogiers phase models in the treatment of chronic
musculoskeletal pain 32
3.4.3 Chinese model of ear acupuncture in the treatment
of chronic musculoskeletal pain 33

4. Conclusion: The best of both worlds 34

Literature 35




































5
Preface


In a lecture at Academy Qing-Bai in spring 2009 Dr. Li J ie compared TCM to a round
balloon that has been squeezed into a square vase. As a result my imagination was
fuelled as to what the round balloon might look like.

I wish to thank all my teachers at Qing-Bai for giving me insight into Traditional
Chinese Medicine in such a way that I looked forward to each lesson. They inspired
me by teaching in an enlightened manner that encouraged an open mind to different
treatment styles.
Special thanks to Marijke Fluitsma for reading and evaluating this essay.
I am grateful to Sophie for being my faithful companion in the study of acupuncture;
studying is even more fun when done together.
I am indebted to Ingrid for proof-reading and commenting on this writing.
Last but not least, I wish to thank Boris for all his love, support and caring.

































6
Summary


This writing is about different approaches in acupuncture treatment of chronic
musculoskeletal pain. First the physiology of pain is discussed and the diagnostic
significance of it. Musculoskeletal pathology is primarily a meridian pathology; it is
classified under the broader category of Bi syndromes, which are shortly highlighted.
The chronic aspect of it can be approached from two different angles: differentiating
and treating the underlying pathology and/or exploring and treating the full spectrum
of superficial energetics. That means using not only main meridians, but also tendino-
muscular meridians, Luo vessels and extraordinary meridians. This writing focuses
on the latter aspect, the diagnosis and treatment of different layers of meridian
network.

I pose a question about the nature of the meridians and take a short look into few
aspects of it, like how substantial meridians are and if they really have a linear
nature. I believe that the way meridians are seen could influence the way meridian
pathology is treated.

For the purpose of exploring the different possibilities of the treatment of
musculoskeletal pathology I chose to compare four different approaches: TCM
acupuncture, meridian acupuncture, trigger points approach and ear acupuncture.
I compare them on basis of the use of local and distal points and the use of meridian
palpation as a diagnostic tool, especially for determining the place of the Ah Shi
points.

TCM acupuncture and meridian acupuncture have the same roots in the Classics of
Chinese medicine. Their theory in treatment of musculoskeletal conditions doesnt
differ much, but the applications of that theory does: there are differences in the use
of meridian palpation and in the stress on local or distal points.

Trigger points approach involves from the perspective of Western medicine only
needling of Ah Shi points, although it can be incorporated in meridian perspective by
adding distal points. The concept of referred pain is explained and methods of
locating and needling the Ah Shi points are highlighted.

The ear acupuncture doesnt fit neatly in my comparison model due to its specific
nature as a microsystem acupuncture. I included it in my research especially
because of the Nogiers phase model that allows for the differentiation between acute
and chronic conditions.









7
Introduction


Chronic musculoskeletal pain can be a debilitating condition that interferes with good
night sleep and with many daily activities. It is one of the most common complaints
that brings people to the general practitioner. Yet it is a condition that often remains
unresolved by the conventional medical approach. So in search for relief of their pain
many people turn to the so called alternative therapies. In my short career as a
Shiatsu therapist I regularly came across this type of pathology; sometimes I was
able to help people with chronic musculoskeletal pain, at other times my efforts were
fruitless. Studying acupuncture I felt the need to better understand the nature of this
pathology and to see beyond the standard point prescriptions.

To understand a particular subject, it may be helpful to look at it from different angles.
Combining the different perspectives can give one better insight into the subject. For
the purpose of better understanding the pathology and acupuncture treatment of
chronic musculoskeletal pain, I decided to compare different possibilities of
acupuncture treatment of it. For that I chose four different approaches: TCM
acupuncture, meridian acupuncture, trigger point approach and ear acupuncture.
They are not the only possible approaches, but as this writing is based on desk
research, I chose approaches that were best available to me in the form of books.

My greatest interest at this point is to explore the surface energetics of the human
body and the methods to influence it. For this purpose I will compare the four
approaches on the basis of the following parameters:
the use of palpation as a diagnostic method
the manner in which local/Ah Shi points and distal points are chosen

In chapter one I will look shortly into the physiology of pain, as seen in Western
medicine as well as in the TCM. I will discuss the physiology and pathology of
musculoskeletal pain in the context of Bi Syndromes. I will look into ways to address
the chronic nature of this pathology and the ways to address it.

Since musculoskeletal pathology is per definition a meridian pathology, the way
meridians are seen could influence the way the pathology is treated and how
palpation is used as a diagnostic method. In chapter two I will therefore focus on the
nature of the meridians as a theoretical background of my research. I will pose a few
questions on the nature of the meridians without aiming for the clear answers;
unfortunately, it is the subject underrepresented and under valuated in the literature.

Chapter three forms the core of this writing. There I will highlight the acupuncture
treatment of chronic musculoskeletal pain as it is used by the four different
approaches, first placing them in a broader context to understand the angle from
which the musculoskeletal pathology is seen and then comparing them according to
the above mentioned parameters. The sections on the trigger points approach and
ear acupuncture are not subdivided in the same manner as the first two, due to their
different origin and specific nature.


8
1. Physiology and pathology
of chronic musculoskeletal pain


1.1 Physiology of pain

1.1.1 Pain as seen in Western Medicine

Pain is not a well understood phenomena and many theories have been proposed to
explain it. In Western medicine it is usually explained by neural or biochemical
mechanisms. It is stressed that chronic pain is not simply a repetition of acute pain; it
is different from and less understood than acute pain. Still by convention, chronic
pain is defined as being longer than six months in duration.
1


There is a distinction to be made between pain threshold and pain tolerance. The
pain threshold is the least stimulus intensity needed for an individual to perceive pain
and is proven to be much the same in everyone. Pain tolerance is defined as the
emotional response to the pain stimulus and it strongly depends on emotional, social
and cultural factors. The difficulty in assessing and measuring the character and
intensity of pain and effectiveness of anti-pain treatment is its subjective character;
one has to rely on the verbal description of the patient.

There are three types of pain as defined by western medicine: psychogenic pain (due
to a disorder of the mind), neuropathic pain (as a result of damage to either central or
peripheral nervous system) and nociceptive pain (because of the primary activation
and sensitisation of nociceptors they are the sensory neurons that register pain).
2

The pain present in the chronic musculoskeletal pathology is nociceptive pain.

In chronic musculoskeletal pain, when only soft tissue is involved and there is no
evidence of tissue damage to be detected by x-rays or other standard methods, there
is a danger of dismissing the chronic pain as purely psychogenic in origin. That is
why the nature of the so called referred pain has particular importance in
musculoskeletal pathology. It means that the cause of the pain can be located some
distance away from the area where the patient experiences pain and can be easily
overlooked. This I will further explore in chapter 3.3.


1.1.2 Pain in Chinese Medicine

In Chinese medicine pain is explained by the saying obstruction causes pain; if there
is no obstruction there is no pain.
3
In other words, pain is seen as a subjective
feeling of the obstruction in the free flow of Qi and Blood. However, moving Qi and
Blood will not necessarily address the underlying cause of the obstruction of the free

1
Marcus, A, 2004
2
Baldry, P.E, 2005
3
Maciocia, G, Diagnosis in Chinese Medicine, 2004
9
flow. This aspect is described by the terms Ben (root) and Biao (manifestation). In
this case, pain is only the manifestation of the underlying cause. Establishing the
cause of pain determines the treatment principle. The causes of musculoskeletal pain
will be explained in the following section on Bi syndromes.

In chronic musculoskeletal pain conditions, pain is obviously the chief complaint of
the patient; on the other hand, inquiring into the nature of pain is one of the
diagnostic tools in Chinese medicine. Specific characteristics of pain can help
differentiate the presenting condition according to the eight parameters. In
musculoskeletal pathology we can ask about the following characteristics :
4


Location of pain
The precise location of pain is important to determine meridian(s) involved. The
significance of the pain distribution is further elaborated in section 1.3. If the pain is
wandering, it indicates Wind.

Nature of pain
The nature of pain indicates excess (strong, sharp) or deficiency (dull, aching, sore)
of the condition. Precise nomenclature of the different types is not so important as the
patients choose their own words to describe the pain and it is up to the practitioner to
classify it accordingly.

Time of pain
Daytime pain is usually caused by Qi or Blood deficiency and pain at night is mostly
due to Qi stagnation. Blood stasis causes continuous pain that can be worse at night.

Factors affecting pain
There are several factors that can affect pain: pressure, temperature and
movement/rest.
Pain that is aggravated by pressure indicates excess (pathogenic factor or Qi
and/or Blood stagnation), whereas pain alleviated by pressure indicates
deficiency.
Pain alleviated by application of warmth is due to Cold or Yang deficiency;
usually no pain is alleviated by application of cold except acute joint sprains.
5

Pain from invasion by Cold gets worse in Cold weather and pain from Heat
gets worse by application of heat.
Pain that gets worse with movement and better with rest indicates deficiency
of Qi or Blood; if it gets better with movement and worse with rest it indicates
stagnation of Qi, Cold or Blood stasis.


1.2 Bi Syndrome (Painful Obstruction Syndrome)

In Chinese Medicine, musculoskeletal pain is classified under the broader category of
Bi syndrome. It indicates pain, soreness or numbness of muscles, tendons and joints

4
Maciocia, G, Diagnosis in Chinese Medicine, 2004
5
I noticed that general practitioners recommend prolonged application of cold compresses against
pain and swelling in acute cases of musculoskeletal conditions. In my opinion that can only cause
further stagnation of Qi and Blood and slow down the recovery.
10
from invasion of external Wind, Cold or Dampness. Although all three of the
pathogenic factors are usually involved, one of them is predominant. Strictly
speaking, Bi refers to the invasion of the external pathogens, but it includes as well
obstruction caused by trauma, sport injuries and overuse.
6


The aetiology of Bi Syndromes is already seen in the definition: the invasion of the
external pathogens. However the chronic conditions have other possible causes:
- old traumas: the remaining Qi en Blood stagnation predisposes one to
development of Bi after exposure to the pathogenic factors or additional stress
on the muscles
- overwork in general or overuse of a single muscle group leads to deficiency of
Qi en Blood in general or in a particular area; this leaves the meridians
relatively vacuous and prone to development of Bi
- emotional stress and bad posture, causing Qi stagnation or Qi and Blood
deficiency
- especially important in chronic cases, the pathology of Zang fu.
It is interesting to notice that Chinese literature emphasizes the invasion of the
external pathogens and western literature on the subject emphasizes trauma and
overuse.

There are different possible classifications of the Bi syndrome, the usual one being
classification according to the predominant pathogenic factor, i.e. Wind Bi, Cold Bi or
Damp Bi. Heat Bi develops from the previous three types when they turn into the
Heat in the interior. Their characteristics are as follows:
7

Wind Bi (or Wandering Bi), caused by Wind: pain and soreness of muscles
and joints, pain moving from joint to joint; there is limitation of movement
Damp Bi (or Fixed Bi), caused by Dampness: pain, soreness and swelling in
muscles and joints; pain is fixed in one place and aggravated by damp
weather, there is a feeling of heaviness and numbness of the limbs
Cold Bi (or Aching Bi), caused by Cold: severe pain, usually unilateral, in a
joint or muscle, there is limitation of movement
Heat Bi, caused by transformation of any of the previous factors, occurring on
the background of a Yang constitution or Yin deficiency: pain, redness and
swelling of the joints, limitation of movement
8

An other classification is the one according to the organ and tissue involved: Skin Bi
(feeling of cold), Muscle Bi (causing muscle weakness), Sinew Bi (causing stiffness),
Blood-vessels Bi (causing Blood stasis and intense pain) and Bone Bi (causing bone
deformities). Chronic conditions are often equalled with Bone Bi; however, chronic
musculoskeletal pain doesnt have to involve bone Bi. Some patients suffer for years
from meridian pathology that is not detectable as joint swelling or bone deformities.





6
Maciocia, G, The Practice of Chinese Medicine, 2008
7
Maciocia, G, The Channels of Acupuncture, 2006
8
Syllabus Qing Bai Acu 2

11
1.3 How to address the chronic nature of
musculoskeletal pathology

There is not always a distinction made between acute and chronic nature of
musculoskeletal pathology; they are usually differentiated and treated according to
the presenting symptoms. Still, there are two ways in which chronic aspect can be
addressed: treating the underlying internal condition and treating according to the
meridian layer involved. They are not mutually exclusive.


1.3.1 Treating the underlying condition

The question why has the body failed to restore the balance by itself and developed
a chronic pathology has to be properly addressed. When dealing with chronic
musculoskeletal conditions it is important to make an integral diagnosis and treat the
internal condition (the root or Ben) as well. The most common factors present in
chronic Bi are summed up by Maciocia as follows:

General deficiency of Qi and Blood predisposing the body to invasions
of external pathogenic factors
The formation of Phlegm in the joints in the form of swellings due to
improper transformation of Body Fluids
Stasis of Blood due to the long-standing obstruction by the external
pathogenic factors and by Phlegm
Deficiency of Liver and Kidneys, which leads to malnourishment of
sinews and bones, the former causing ache and stiffness, the latter
contributing to the settling of Phlegm in the joints
9


The treatment principle for acupuncture of chronic musculoskeletal pain is to expel
the pathogen (if present) from the meridians, remove the Qi and/or Blood stagnation
that causes the pain and restore meridian dynamics, but it is necessary as well to
nourish or move Blood, resolve Phlegm, tonify Liver and Kidneys, depending on the
predominant underlying condition. Despite of its importance, treating the underlying
internal pathology is beyond the scope of this writing.


1.3.2 Treating different meridian layers

... treating chronic musculoskeletal conditions can be like peeling an onion,
with each new layer revealing a new pattern
10
.

The chronic aspect of musculoskeletal pathology can be addressed by exploring the
full scope of the superficial human energetics in all its layers. Tendino-muscular (TM)
meridians and Luo vessels are per definition involved, but in chronic cases Main

9
Maciocia, G, The Practice of Chinese Medicine, 2008, p. 982
10
Pirog, J .E, 1996, p. 228


12
meridians and extraordinary vessels can also play a role. The characteristics of the
involvement of particular meridian layer in musculoskeletal pathology can be
summed up as follows:
11



General characteristics Distribution of pain
Luo vessels J oint pain, eventually swelling;
In deep Luo: discoloration of
the skin, rigidity and intense
pain
Symptoms are local, but involve
both yin and yang meridians
TM meridians Muscle ache and stiffness,
spasm, feeling of heaviness of
muscles
Mostly unilateral, involving one
or more meridians, but not
crossing the yin-yang border
Main meridians Pain les intense and more
vague than in TM meridians
Diffusely located, the patient is
unable to pinpoint the source
Extra meridians Chronic pain, masses and heat,
trigger-points, loss of function
(frozen joints)
Deep and scattered across
broad surfaces, sometimes
involving both upper and lower
limbs



12


In chapter 3. I will focus entirely on the use of meridian dynamics and on how the
different layers of meridian network can be explored to treat chronic musculoskeletal
pain.



11
Pirog, J .E, 1996, Maciocia, G, 2006
12
Pirog, J .E, 1996, p. 230
13
2. A short inquiry into the nature of the
meridians


2.1 Chasing the meridians

Musculoskeletal pathology is per definition a meridian pathology. But what are
meridians actually? Next to the internal organs and basic substances they are the
fundaments of the Chinese physiology and pathology, yet I found very little written on
their very nature. There are writings about the historical development of the meridian
theory. The layered structure of meridians and the types of Qi it transports are part of
every book on the fundamentals of Chinese medicine and acupuncture. The meridian
pathways are more or les extensively described, but what are those pathways? Can
we say more than that they are pathways of Qi en Blood circulation?

The old discussion about points first or meridians first seems to conceal the more
fundamental question about the very nature of the meridians. There are short clues
scattered through literature like the following one:

Perhaps the channels operate as software, as emergent properties of the
bodys hardware.
13


Modern TCM acupuncturists see meridians as theoretical connections between the
acupuncture points; as imaginary pathways with no anatomical reality, contrary to the
properties of the acupuncture points.
14
On the other hand, different massage
therapists and practitioners of Qi Gong consider meridians as palpable units that can
be clearly felt under active or passive manipulation, independent of the specific
acupuncture points. There are indications that the latter view is the older one:

Acupuncture began as an attempt to understand the invisible currents of
energy that gave life to the world and vitality to the human body. Since these
currents flowed in channels or meridians, acupuncture was originally a form
of meridian therapy. The acupuncture points themselves were merely the
vehicles for adjusting the meridian, functioning like the holes of a flute that
could be open or closed to alter the tone of the meridian flow.
15


Some authors
16
suggests that the lack of attention for the nature of the meridians in
modern literature could be the result of the so called herbalisation of the
acupuncture. In the course of history of the acupuncture there have been tendencies
to unite acupuncture and herbal medicine theory. In post-revolutionary China
acupuncture theory was revised to conform with pattern-identification according to
eight-parametesr, the Zang-fu and the Qi-Blood-Body Fluids, and the acupuncture
treatment became increasingly based on point-prescriptions, much like herbal-
prescriptions.

13
Manaka et al. 1985, p. 54
14
Study material Academy Qing- Bai: ACU 1, study year 2007-2008
15
Pirog, J .E, 1996, p. Xv
16
Ibid.
14

Emphasis on acupuncture points and subsequently on the main meridians carries a
danger of disregard for the so called secondary meridians which stayed as a part of
the theory of TCM, but lost their proper place in the practice of acupuncture and
treatment of musculoskeletal pathology. Seem even states that the modes of
treatment of secondary meridians totally differ from the treatment of regular
meridians.
17
I noticed that secondary meridians are often depicted in acupuncture
books schematically as clearly delineated levels or layers of different depths. That is
in contrasts to the verbal descriptions of their extent and function which portray
meridian layers much more intertwined.


2. 2 Are meridians linear?

Whilst a typical chart of the acupuncture channels, therefore, illustrates only
the superficial pathways of the twelve primary channels, we should remember
that the channel network is considerably more complex than this, and there is
no part of the body, no kind of tissue, no single cell, that is not supplied by the
channels. Like a tree, the trunk and main branches define the main structure,
whilst ever finer branches, twigs and leaves spread out to every part.
18


If we would make the visual representation of the above described meridian network
in every detail, even only the very superficial part of it, it would resemble a three-
dimensional replica of the body. This is in contrast to the standard acupuncture
charts that were meant only as a didactic tool so they dont depict the superficial
paths of the 14 meridians (as described in acupuncture books), but indeed only the
theoretical connections between acupuncture points. This accounts for the quite
awkward trajectory that Yang meridians in part describe. Once we imprint in our
memory the pathways of the main meridians as depicted in acupuncture charts and
atlases, there is a danger of forgetting that they represent the functional model of the
meridian structure and not reality itself.
19
Living human body is, after all, no Tong
Ren.

A typical characteristic of meridians representation is that they are seen as lines;
vertical lines in case of organ meridians an horizontal branches when we speak of
Luo vessels. Even the eight extraordinary vessels are depicted as lines (6 of them
connecting acupuncture points that they share with the organ meridians) in spite of
the saying from Nan J ing that main meridians are like rivers and extraordinary
vessels are like lakes, suggesting not only their reservoir function, but perhaps also
their spatial extent.

However, there is a very interesting remark on the pathway of the Gallbladder
meridian that I found in a footnote in Tietao Dengs Practical Diagnosis:

As with the kidney channel, it is interesting to note that Chinese texts do not
describe the channel as travelling behind the ear and then returning back up

17
Seem, M.D, 2004, p. 20
18
Deadman, P et al., 2007, p. 11
19
The Zen masters repeatedly warn their students not to confuse the Map with the Reality.
15
the head and then turning and descending back down to feng chi (Wind Pool,
GB-20), as the pictures draw it. I believe that this convention of thinking about
the path of the channel in this way stems from the modern system of
numbering the points on the channel and then connecting the dots. It is more
appropriate to think of the channel as a larger, broader entity that simply is
scattered over the area in front of and behind the ear and that there are points
in that area. However, the points do not necessarily follow a numerical
sequence that creates two lines, as we have come to understand the
gallbladder channel.
20


This clearly suggests that the nature of even organ meridians is not so linear as we
are accustomed to think, but it might be instead rather fractal (see cover
illustration).
21
Unfortunately I dont have access to more Chinese texts to further
explore this idea.


2.3 Meridians under microscope

There have been attempts to find the material substrate of meridians. Usually the
meridians were compared with anatomical structures like the vascular system or
neural network .
22
It may not come as a surprise that the discrepancies between
them were too big to give the meridians any anatomical reality. The reason why these
attempts failed can be found in the fact that they used the outdated, yet still
predominant paradigm of material reductionism to explain the energy concepts of
Chinese medicine.

Yet there is a different paradigm, that of system-thinking and non-linear dynamics
that is much more qualified for the job. Modern energy medicine investigated body
processes that couldnt be explained with conventional concepts of neural,
biochemical and endocrine mechanisms and discovered that there were other,
evolutionary much older systems in the body that transferred the energy and
information much faster. Here were are talking about the connective tissue.
23


To summarize, we suggest that neither the Jing nor the Luo, nor all of their
countless branches are mystical entities but instead are material pathways
located within the connective tissue/cytoskeletal fabric. At the microscopic
level, this branching network reaches to the surfaces of cells and extends
across those surfaces, where it is continuous with the cytoplasmic matrix,
nuclear matrix, mitochondrial matrix and the interiors of other organelles. The
long-sought substance of the meridians consists of an intricate set of protein
and other molecules, as well as an adhering film of water.
24


I would like to stress at this point that I am not interested in finding the material
substrate of the meridians; I am looking for ways to see beyond the standard

20
Deng, T, 2005, p. 322
21
Fractal is a mathematical model, a geometric shape that repeats the same pattern (or the same type
of pattern) on all scales.
22
Baldry, P.E, 2005
23
Oschman, J .L, 2003
24
Ibid, p. 133
16
acupuncture charts for a more complete meridian picture and get a better insight in
the meridian dynamics and meridian pathology.

I believe the way in which meridians are perceived will influence the way the meridian
pathology is being treated. If we consider meridians to be just a theoretical
connection between the acupuncture points, the treatment will rely heavily on treating
the acupuncture points. If, on the other hand, we give more reality to the meridians,
the treatment will be concentrated on meridians and meridian systems themselves,
albeit via acupuncture points, but not limited on them and the role of meridian
palpation will get a more prominent role.








































17
3. Different approaches in acupuncture
treatment of musculoskeletal conditions


In the 19
th
century and a big part of the 20
th
century almost the exclusive application
of the acupuncture in the West was for combating pain. It was mostly limited to the
needling of the Ah Shi points, applied without real knowledge of the J ing Luo or the
Zang Fu. In this way it is applied even today in so called medical acupuncture that
uses needling according to the western neuroanatomical concepts and not according
to the theory of Chinese medicine and knowledge of meridians. On the other hand,
the diagnosis and the treatment of the musculoskeletal pain in TCM is quite forward
and often seen as less interesting than the more fancy pathologies of the internal
organs diseases.

What interests me in musculoskeletal pathology and treatment of it, is the way the
acupuncture points are chosen and combined. The combination of points in general
is directed by two basic principles: selecting a point according to its particular action,
function, nature and quality and selecting a point according to its position and
dynamics within the meridian system. These two principles are by no means mutually
exclusive; usually both approaches are combined.
25


The stress placed on needling technique is based on a point-centred view of
acupuncture, whereas the stress placed on the combination of points is based
on a channel-centred view of acupuncture.
26


Acupuncture treatment of chronic musculoskeletal pain is based in short on the
combination of local points, including Ah Shi points and distal points and, especially
important in chronic cases, points according to the underlying pattern. In
musculoskeletal conditions pathology can be situated distally, so proximal points may
coincide with distal points or distal points from paired meridians of the same polarity
may be chosen instead.

The use of the distal points is unique for acupuncture; it reflects the meridian
dynamics of the system as a whole. Distal points open the meridian, eliminate
stagnation of Qi and/or Blood and help to expel pathogenic factors.
27

In acute cases their action is strong; they are combined with local points that support
the eliminating action of the distal points and focus it on the specific area. In chronic
cases the meridian dynamics is more severely impaired and the overall condition is
generally more vacuous; distal points work less strong and local points become more
important. Local points are in the area where Qi en Blood stagnation or pathogens
are lodged and treating them is needed to restore meridian dynamics and relieve
pain.

Seem described balancing local and distal points on the basis of excess or
deficiency:

25
Maciocia, G, The Channels of Acupuncture, 2006
26
Maciocia, G, The Practice of Chinese Medicine, 2008, p. 1134
27
Maciocia, G, The Channels of Acupuncture, 2006
18

In excess conditions
Select more distal points, which are the main points to calm hyperactivity of an
energetic orb. Use less local points, which are selected to direct the calming
action of the distal points. Apply dispersing techniques to the distal points and
neutral technique to the local points.

In deficiency conditions
Select more local points, which are the main points to tonify deficient energetic
function. Apply tonification techniques to these points (warming techniques
including moxibustion). Use less distal points and apply neutral techniques to
these points, to harmonize the local tonifying action.
28


Again, as chronic cases are more vacuous in nature than acute cases, the strategy
for deficiency conditions can be employed.

In the following chapters I will focus on meridian palpation as a diagnostic method in
meridian pathology and subsequently on the use of Ah Shi points. I will concentrate
on the choice of the local and distal points as well as the emphasis on one or the
other as it is employed in the different schools of acupuncture. In a separate section I
will examine the use of the different meridian layers in meridian pathology. Books or
chapters on the musculoskeletal pathology usually present extensive lists of points
according to the body area, meridians and pathogen involved. I will not repeat many
of these lists as I found that there are more differences between the particular
authors and not so many between different schools. The treatment of the underlying
condition, albeit being very important for chronic conditions, is not a part of this
writing.




















28
Seem, M.D, 1987, p. 47


19

3.1 TCM approach


3.1.1. The role of meridian palpation

TCM acupuncture is a modern version of Chinese acupuncture, developed to allow
the practitioners to treat many patients per day, which is definitely a bonus in China.
Even in The Netherlands I have seen Chinese practitioners diagnosing and treating
new patient every 20, or even every 15 minutes (of course they have assistants to do
the administrative side of the work). In that short time there is simply no time for
careful palpation; they have to rely on their theoretical knowledge and experience.
Western practitioners trained in the TCM acupuncture usually take more time for their
patients, yet the stress of the treatment is still based on the same premises.

Palpation is one of the four traditional examination methods; in TCM it is focused
primarily on the palpation of the pulse. In TCM literature there is mention of the
palpation of body parts, skin and acupuncture points to determine temperature,
texture and tenderness, but explicit palpation of the meridians is not often included.

Tietao Deng mentions pressing examination
29
to examine patients head and neck,
hands, feet, chest, abdomen, skin and transport points to determine whether the area
is hot or cold, slippery or rough, soft or hard, hurts with pressure or has lumps or
other abnormalities. This information can add to the diagnosis of the location and
nature of the disease. Yet there is no mention of meridian palpation.

In his more than 1000 pages thick Diagnosis in Chinese Medicine
30
, Maciocia
dedicates 12 pages to the palpation of the meridians. He discusses briefly palpation
of the Luo vessels and superficial Luo vessels by touching, stroking and pressing to
determine temperature, moisture, firmness and possible masses. Palpation of TM
meridians is limited to firm pressure to reveal consistency of the muscles. Maciocia
furthermore mentions the palpation of meridians in Bi syndrome to reveal the Ah Shi
points as to determine the meridian (most) involved.
He proceeds to the palpation of the meridians and states that there are two aspects
to it: palpation of the blood vessel overlying the channel and palpation of the skin. For
the latter, three aspects are distinguished: temperature, texture and tenderness. For
each meridian he mentions specific (point) areas that should be examined and the
diagnostic significance of the findings. For example, the palpation of the Gallbladder
meridian is limited to the palpation of the area around GB-2 Tinghui, which is a rather
small portion of the total superficial trajectory of the meridian.







29
Deng, T, 2004, p. 155
30
Maciocia, G, Diagnosis in Chinese Medicine, 2004
20
3.1.2 The use of local and Ah Shi points

The local acupuncture points have dominance over Ah Shi points in TCM
acupuncture of musculoskeletal pathology.
31
They are chosen according to the area
of pain. There are standard lists of points recommended for the use as local points
for the specific area; these lists can vary according to different authors and are
ultimately dependant on the specific case. As the total amount of the needled points
has to be limited, there are few local points chosen. In musculoskeletal conditions
needling is performed less deep than for the internal conditions and needle
manipulation can be performed.

Ah Shi points dont get a significant role in the treatment of the musculoskeletal
conditions. They are determined by palpation, usually only of the body part where
patient complains of pain. For example in the book Acupuncture case histories from
China
32
there are fourteen cases of Painful Obstruction Syndrome and only in five of
them Ah Shi points are mentioned as part of the acupuncture prescription. In Treating
Pain with Traditional Chinese Medicine
33
, in chapters dealing with musculoskeletal
pain there is no mention of the Ah Shi points.

Apart from needling, other techniques can be used to cover bigger local area:
cupping, guasha en moxa, depending on the present pathogen and desired effect.
Cupping removes Cold and stagnation of Qi en Blood from the meridians; it also
expels Wind from the muscles. Guasha eliminates Cold from the muscles. Moxa can
be used for its action on expelling Cold and moving Blood and in chronic cases for
tonifying the vacuous TM meridians.


3.1.3 The use of distal points

The descriptions in the following two sections are based largely on the Maciocias
The Channels of Acupuncture.
34


Distal points are per definition located on the limbs, below elbows and knees, and
can treat pathology further up the meridian. They are used with reducing method in
acute cases and even method in chronic cases.
35
They are chosen according to the
meridian involved and area involved. Generally, the more distal along the meridian
the point is, the further up the meridian it extends its action, but there are exceptions
to this rule.

When pathology is situated distally, local and distal points may coincide. In that case,
distal points may be chosen from the paired meridian of the same polarity; this
applies especially for the Yang meridians (Tai Yang, Shao Yang and Yang Ming). In
that case one chooses according to the correspondence of joints in the upper and
lower limbs: shoulder =hip, elbow =knee and wrist =ankle.
36


31
Pirog, J .E, 1996
32
J irui, C, 1988
33
Riley, D, 2003
34
Maciocia, G, The Channels of Acupuncture, 2006
35
Ibid., p. 655
36
Ibid., p. 657
21

There are again standard lists of distal points according to the meridian involved and
according to the area involved. Distal points can also be chosen to address and
expel the specific pathogen as follows:


- Wind: the J ing-Well point
- Cold: the He-Sea point
- Dampness: the Shu-Stream or J ing-River point


3.1.4 Treatment according to the meridian layers

In The Channels of Acupuncture
37
Maciocia differentiates the musculoskeletal
pathology according to the meridian layers involved as follows: the TM meridians and
Luo vessels are per definition involved; however in chronic pathology main meridians
and extraordinary meridians can be involved as well. It is often difficult to separate
pathology of one from the other. The more chronic the pathology, the deeper in the
meridian system the pathogen penetrates.
38


TM meridians
The main distal points for activating the TM meridians are J ing-Well points. As TM
meridians overlap and communicate with each other, chronic musculoskeletal
pathology usually involves more than one neighbouring meridian. In that case one
can use upper meeting points of the TM meridians. They strengthen the effect of the
distal points and regulate Qi between different meridians. The upper meeting points
of the TM meridians are as follows:
three Yang of the leg: SI 18
three Yang of the arm: GB 13
three Yin of the arm: GB 22
three Yin of the leg: Ren 3

Luo vessels
In musculoskeletal conditions the pathology of the Luo vessels is intertwined with TM
meridians. The superficial Luo vessels are the first layer of penetration of pathogens;
after they pas the TM meridian layer, they can get lodged in the deep Luo layer. The
discoloration of the skin and the venules that can be seen on the skin surface merely
reflect the pathogens in the deep Luo layer. Trauma or invasion of pathogenic factors
in Luo vessels can cause blood stasis. Luo points are primary points for treating Luo
vessels.

Extraordinary meridians
When chronic symptoms overlap different meridians and stretch over larger surfaces
of the body, extraordinary meridians may be involved. They absorb the excess from
the main meridians.


37
Maciocia, G, The Channels of Acupuncture, 2006
38
Ibid.
22
Du Mai is used to treat neck or backache when it is located on the midline or
on the midline radiating to both sides (but not unilateral). The opening point of
the Du Mai SI 3 and the coupled point Bl 62 are used as distal points.
Dai Mai gets mentioned in The Channels of Acupuncture
39
only for treatment
of hip pain; the opening and coupled points are needled. In Neijing Suwen
40

Dai Mai is listed in chapter 41 for the treatment of back pain if the patient is
unable to arch the back.
Both Yang Qiao Mai en Yang Wei Mai can be used in the treatment of
backache; the symptoms involving Yang Qiao Mai stretch mainly over the
Bladder meridian and the symptoms involving Yang Wei Mai follow mainly the
Gallbladder meridian.
Yang Qiao Mai is indicated when pain involves several neighbouring
meridians, for example in sciatica when the pain involves the Bladder,
Gallbladder and Stomach meridians. The opening point of Yang Qiao Mai Bl
62 is needled on the affected side and coupled point SI 3 on the opposite side.
In case of pronounced stiffness, the Xi-Cleft point of the Yang Qiao Mai can be
used as wel: Bl 59.
Yang Wei Mai can be used to treat Bi-syndrome especially when it involves
the lateral side of the limbs or lateral side of the neck. The opening point TB 5
and the coupled point GB 41 can be used as distal points, eventually adding
the Xi-Cleft point: GB 35.

Although Yang extra meridians are present more often in musculoskeletal pathology
(the same as the Yang main meridians), there are cases when Yin Qiao Mai and Yin
Wei Mai are involved:
Yin Qiao Mai can be used in certain cases of Wei syndrome (atrophy
syndrome) when the muscles of inner aspect of legs are more tense than the
muscles of the outer aspect of legs and the feet of the patient turn inward.
Yin Wei Mai can be used in Bi syndromes with a generalized ache in the joints
with numbness and tingling, but without any swelling or heat in the joints
41


Differentiation according to the meridian layer is not always applied in TCM; Riley
42

and J irui
43
use only main meridians for the treatment of musculoskeletal pathology.













39
Ibid.
40
The Yellow Emperors Classic of Medicine 1995
41
Maciocia, G, The Channels of Acupuncture, 2006
42
Riley, D, 2003
43
J irui, C, 1988
23
3.2 Meridian approach

Although meridian style acupuncture originally referred to the J apanese acupuncture,
the term has since been extended to mean any form of acupuncture that derives its
strategies from classical energetic theory as found in the Nei Jing and Nan Jing,
rather than the herbalised theories of modern TCM.
44


Generally, meridian style acupuncture uses more needles, thinner needles, shallower
insertion and milder stimulus than modern TCM acupuncture. There is also less
manipulation of the needle and distending sensation is not deemed necessary. This
chapter is based mostly on Pirogs The Practical Application of Meridian Style
Acupuncture.
45



3.2.1 The role of meridian palpation

In books on the meridian approach great stress is placed on importance of thorough
palpation of meridians. Yet they leave out the descriptions of the techniques for the
meridian palpation. Apparently, it is considered as something one must learn in
practice from a good teacher. Here is what Pirog writes on meridian palpation:

In modern meridian style acupuncture the traditional concept of ashi points
bas been extended to include any points that exhibit abnormal texture,
temperature, or appearance, even if there is no actual tenderness. Japanese
acupuncturists, for example, place great emphasis on kori, points that are hard
or rubbery to the touch but not necessarily painful. Many meridian therapists
will search for subtle changes in skin temperature or for distended capillaries.
The region of palpation has also been extended, with some therapists
searching for ashi points far from the original site of pain. Since ashi points
and kori are supposed to be sites where energy stagnates and accumulates,
some acupuncturists believe that these points can be found entirely through
intuition. These practitioners will lightly touch the patients skin or hold their
hands above it, feeling for a tingly sensation or draft in their fingers.
46


Obviously, there is great diversity in meridian palpation methods, depending on a
particular acupuncture school and particular teacher.


3.2.1 The use of local and Ah Shi points

The choice of the local points in meridian approach seems to differ most from the
TCM use of local points.
- It is determined by careful palpation for tenderness or tissue change.
- All of the painful points must be needled, not just a few strong points in the
vicinity of the pain.

44
Pirog, J .E, 1996
45
Ibid.
46
Ibid., p. 5
24
- If pain or tenderness is located near but not on a standard acupuncture point,
the exact spot where pain or tenderness is found is needled, not the
acupuncture point. So the local points are determined uniquely in each patient.

In other words, there are no other local points used in musculoskeletal pathology
than Ah Shi points and they can be great in number, depending on the character and
chronicity of the condition.


3.2.2 The use of distal points

Distal points are chosen on the basis of distribution of local/Ah Shi points to
determine the meridian that is most involved. They are not chosen according to the
specific target area; usually the most powerful distal points are chosen. Distal points
are considered to be more draining than local points; one needles as many local
points as deemed necessary, but distal points are limited to one on the upper limbs
and two to three on the lower limbs. As the points with most powerful distal effect, the
following can be chosen:
47




To fine-tune the treatment, distant points can be chosen whose qualities best match
the condition being treated, according to the theory of Five Shu-Transporting points.
Some points that are usually avoided in TCM acupuncture due to the insertion pain
can be still be used because of the use of thinner needles and shallower insertion
depth. The properties of the distant points used for the treatment of Bi Patterns are
summed up in the following table:
48



Jing-well points Support point used to release severe repletion or blockage in the
meridian
Ying-spring
points, including
Ba Feng en Ba
Xie points
Used to expel pathogens out of the meridian (Heat and Cold)
Shu-stream
point of Yang
meridians
1. Bi patterns in general; often used together with the Ying-
spring points
2. for acute episodes of chronic Bi patterns
Shu-stream
point of Yin
meridians
1. chronic Bi patterns where the primary pathogen is dampness;
can be used even if pain is not on the trajectory of the yin
meridian

47
Pirog, J .E, 1996, p. 9
48
Ibid., p. 227
Large Intestine: LI 4, LI 11 Lung: Lu 7, Lu 5
Triple Burner: TB 5 Pericardium: Pc 6
Small Intestine: SI Heart: Ht 7
Stomach: St 36, St 44 Spleen: Sp 6, Sp 9
Gall Bladder: GB 34, GB 39, GB 41 Liver: Liv 3
3Urinary Bladder: UB 40, UB 58, UB 60 Kidney: Ki 3
25
2. chronic Bi patterns involving weakness of the internal organs
(common in chronic knee and lower back pain)
Jing-river
points of Yang
meridians
General Bi patterns, especially when pain is in the limb or when
spasm is present
Jing-river
points of Yin
meridians
Primary treatment point for pain located in the yin meridians
He-sea points Bi patterns in yang meridians; especially useful if the pain is in
the more proximal regions of the meridian (shoulders, hips, neck
or back) or if Bi patterns coincide with Zang Fu disorders
Xi-cleft points 1. most commonly for severe acute pain
2. stubborn stagnant or painful conditions
Group Luo
points
Pain involving more than one meridian of the same Yin-Yang
polarity of the same limb
Luo-connecting
points
1. pain with swelling and visible local capillaries
2. blood stasis or phlegm in the meridian
3. pain involves both Yin and Yang paired meridians
4. pain associated with the Luo vessel



3.2.3 Treatment according to meridian layers

In theory, the treatment of the different meridian levels involved in the chronic
musculoskeletal pain does not differ much from the TCM approach. Again, there is a
great stress on palpation and finding of Ah Shi points. The distribution of Ah Shi
points and the character of pain helps to determine which meridian layer is involved.

TM meridians
If the pain is clearly localized and can be elicited with light palpation, the pathogen is
still lodged in the TM meridians. This is the typical pathology seen in acute cases and
sometimes even in chronic cases. However, chronic pathology usually leaves TM
meridians vacuous; the pain becomes more diffuse and it is difficult to pinpoint the
source. The basic treatment involves tonifying TM meridians by superficial needling
and/or moxa and treating the main meridians as described below.

Main meridians
In chronic cases, the pathogen invades the main meridians which now become
relatively replete, leaving the TM meridian relatively vacuous. The struggle between
defense Qi and the pathogen is less intense. The pain is more vague and more
diffusely located and often cannot be localized without deep pressure; it usually
involves several meridians on the same side of the same limb. Is important to
determine the single meridian that most underlies the problem for the choice of the
appropriate distal points that need to be drained. Alternatively group Luo points can
be added to the distal treatment because they connect all the meridians on the same
side of the same extremity. They can also be used as the only distal point.



26
Luo vessels
The involvement of the Luo vessels in chronic cases is characterized by the pain
occurring on both the Yin en Yang meridians in the same region on the same limb.
The treatment consists in supplementing the local painful points on both Yin and
Yang meridians with needles and/or moxa. As the distal point that needs to be
drained, the Luo point on the Yang meridian is recommended; if that does not help,
the Luo point on the Yin meridian is treated.

Extraordinary meridians
Chronic pain is an indication for involvement of the extraordinary vessels in
musculoskeletal pathology. The Ah Shi points are again the basis for diagnosis and
treatment. Careful palpation will reveal masses and painful points scattered across
broad surfaces of the body and may involve both upper and lower extremities. The
muscle tissue at these points often shows a hard, rubbery quality; bone spurs may be
present. Knowledge of the extraordinary meridians pathways is required to diagnose
the extraordinary meridian involved and to determine the opening and coupled points
that are used as distal points.

































27
3.3 The trigger points approach


3.3.1 The concept of trigger points

Trigger points is a concept from western medicine. It came from the realization that
the cause of the musculoskeletal pain can often be located some distance away from
the area where a patient experiences pain. In terms of TCM we would say that the
relevant Ah Shi points can be located not only locally, but adjacent to or even
proximal or distal to the area of the pain. Trigger points are known to cause other
symptoms than musculoskeletal pain, such as for example headache or dizziness.

In plain words, trigger points are local and permanent contractions in the muscle
fibers that on palpation feel as taut bands or nodules and are responsible for the
typical pain patterns. Detailed medical explanation of the trigger point mechanism is
not necessary for this writing, but it is interesting to note that Travel and Simons
mention impairment of energy metabolism and impaired circulation
49
in TCM words
Qi en Blood stagnation.

The concept of referred pain plays an important role in the pathology of trigger points.
It means that the pathology that causes pain (in this case trigger points) not
necessary coincides with the area where patients report pain. This concept has been
known in Chinese medicine for a long time. Referred pain is explained in medical
literature by neural mechanisms, as errors occurring in the spinal cord or perceptual
errors in the sensory cortex.
50
Referred pain is often difficult to localize and may
move and change as the disease progresses. Initially, it is felt close to the origin of
symptoms, later it moves distally or proximally to the initial area. So this concept is
especially important in chronic cases of musculoskeletal pain.

The concept of Trigger points has been pioneered by Kellgren in 1938 and
extensively researched and published by Travell and Simons in the, by now, classic
work Pain and Dysfunction, The Trigger Point Manual.
51
Travell and Simons state
that muscle pathology is the major cause of pain and dysfunction, yet the physicians
focus their attention on bones, joints, bursae and nerves.
52
The major problem for a
medical explanation is that trigger point pain pattern does not follow the nerve
pathways nor does it necessary occur within the same dermatome, myotome or
sclerotome.
53
Yet the trigger-point referred pain follows a predictable pattern,
researched and described by dr. Travel.

As the main causes of the activation of trigger-points the following are stated:
trauma to the muscles, tendons and/or joints
chronic stresses on muscles, whether by overuse, bad posture or involuntary
muscle tension due to emotional stress
54


49
Travel, J , and Simons, D.G, 1983, p. 34
50
Marcus, A, 2004
51
Travell, J , and Simons, D.G, 1983
52
Ibid., p. 5
53
Ibid., p. 14
54
Trigger points of this origin are often seen in women in upper trapezius muscle.
28
exposure to cold, damp weather and drafts (in TCM: external pathogens)
As indirect causes the following are mentioned:
other trigger points
visceral diseases
nutritional deficiency, periodic hypoglicemia
food and inhalant allergies

The above list resembles the aetiology of Bi syndromes. I believe that trigger points
approach fits easily into the meridian perspective. Trigger point pain patterns have
been extensively researched and published, yet to someone with knowledge of the
meridian pathways it soon becomes obvious that these pain patterns often follow the
pathways of meridians (especially the tendino-muscular meridians or main meridians
or otherwise, I suppose, the minor meridian pathways not described in acupuncture
atlases). So by following the pathway of the meridians passing through the area of
referred pain, one comes a long way in finding trigger points responsible for that pain
pattern.


3.3.3 Diagnosis and palpation of trigger points

There are different types of trigger points, not all of them being active (causing
pain), so it is important to identify the right trigger points responsible for the pain
pattern in question. As Travel and Simons state,

A precise pictorial representation of the patients pain is critical for an accurate
diagnosis of myofascial pain; verbal descriptions are often imprecise and
misleading: a blank body form is used routinely to record the patients pain.
55


56


55
Travel, J , and Simons, D.G, 1983, p. 46
29

Details are important, such as which side of the limb hurts, and whether the
pain skips or concentrates in a joint. It does injustice to the patient and to the
diagnosis to accept vague generalizations at face value.
57


Once the involved muscle or muscle group is identified, careful palpation is needed to
locate the taut bands and nodules in the muscle fibers that are tender on pressure
and may induce the patients referred pain pattern. The usual palpation technique is
performed on the slightly stretched muscle: the fingers of the practitioner gently roll
the skin over the muscle, perpendicular to the muscle belly. The pressure should
start light to asses superficial muscles and slowly increase to reach deeper muscles.
Objective tissue changes are more significant than patients verbal or physical
reaction to the pressure.
58
I found this description to be most straight-forward and
very useful.


3.3.4 The treatment of trigger points the view on the local and distal
points and needling techniques

There are different possibilities of treatment of the trigger points; here I will describe
only the acupuncture treatment. In so-called medical acupuncture or physiotherapy
acupuncture only local points - the sites of trigger points - are needled. That
procedure has been named dry needling. It actually means that the needles are used
according to the principles of western anatomy, not according to the principles of
Chinese medicine and knowledge (or use) of the meridians. This way of needling has
proven to be quite effective; however, using distal points according to the meridian
theory should only increase the effectiveness of the trigger point needling.

For an effective treatment it is deemed important to address the precise spot of the
trigger point:

Trigger point needling is an acquired art. The point must be accurately located
and manually stabilized. This is done with the practitioners non-needling
thumb. Firm pressure is applied just to the side of the tight-band/Kori so that
when the needle approaches the trigger, the muscle fibers do not roll away.
59



The needling can be performed deeply, like it is done in TCM acupuncture. However,
clinical practice showed that the superficial needling to the depth of about 5-10 mm,
not reaching the trigger point itself, and needles left in situ for no longer than 30
seconds gives equally good results, but with much less pain to the patient.
60






56
Travel, J , and Simons, D.G, 1983
57
Ibid., p. 47
58
Marcus, A, 2004, p. 606
59
Ibid., p. 607
60
Baldry, P.E, 2005, p. 133
30

Trigger point needling
61



Marcus proposes several protocols for treating trigger points, for example the
following one:
62


1. First mark the points.
2. Activate the involved tendino-muscular meridian (by needling J ing-Well point)
3. Treat the appropriate spinal segment (or TCM meridian, Organ, Shu or Mu
points associated with the involved muscle) to address the root of the
problem
4. Needle the triggers superficially, with very mild needle stimulation and leave
the needle in place shortly. If some positive affect is achieved, this process is
repeated in the next few sessions.

If the patient does not respond to the mild treatment, deeper needling may be
applied, with more vigorous needle manipulation. One can needle in several
directions to cover the entire area of the tight band around the trigger. Muscle
attachments may be explored and needled if needed.
63


According to Pirog
64
, trigger points are the chronic meridian pathology at the level of
the extraordinary meridians. In view of that statement, the best choice for distal points
would not be the points on the main meridian passing through or nearby the trigger
point, but the opening en coupled point of the involved extraordinary meridian (see
previous chapter).












61
Marcus, A, 2004, p. 607
62
Ibid., p. 607
63
Ibid., p. 608-609
64
Pirog, J .E, 1996
31

3.4 Ear acupuncture


3.4.1 General overview of the ear acupuncture

Auriculotherapy is stimulating the external surface of the ear, or auricle, to treat
pathological condition elsewhere in the body. Besides using acupuncture, stimulation
of the auricle can be done by other modern methods such as electrical, magnetic or
laser stimulation. I will further discuss only the acupuncture treatment of the auricle. I
will leave aside the specific details of diagnosis and treatment and focus only on the
theoretical side in general and on the treatment of the musculoskeletal disorders in
particular.

Historically, acupuncture points on the auricle were used in ancient China and in the
Middle east for therapeutic purposes; however the father of the modern
auriculotherapy is the French physician Paul Nogier. Through meticulous research he
developed a so called inverted fetus map on the external ear which inspired many
further studies throughout he world. After his discovery reached China it instigated a
massive study of the reflex points on the ear which confirmed and complemented
Nogiers map, although the localization of some points may differ from the original
Nogiers model.
65


The auricle is one of the several micro systems in the body that can be used as a
complete system for diagnosis and therapy, following the principle that inside reflects
the outside and a part reflects the whole. The term local and distal points cannot be
applied literally on the ear acupuncture. In a way, all ear points are distal points, not
in classical sense as being located on the extremities, but they are more or less
distant from the area of corresponding pathology.

In auriculotherapy models the auricle is divided into different areas, each of them
representing a specific part of the body, internal organ or a more general body
function. Yet the points on the auricle are not a permanent feature (like the points of
the body acupuncture which can be found on precisely anatomically defined
locations); they can be detected within certain areas only when there is some
pathological process in the corresponding body part. The ear points are found
through changed reactivity in the particular point: increased or decreased pressure
sensitivity or diminished skin resistance to electrical stimulation.
66
If we leave the
electrical devices aside, the points on the auricle are detected through careful
palpation. So we could say that all ear points are Ah Shi points.

Ear acupuncture is a self sufficient system of diagnosis and treatment, but it can
easily be combined with other treatment methods. From the practical standpoint there
are certain advantages of the ear acupuncture such as treating the body part that is
temporarily not accessible or simply too painful for body acupuncture. The use of

65
Rubach, A, 2001
66
Ibid.
32
semi-permanent needles or pallets on the auricle can provide a more continuous
stimulus for a prolonged therapeutic result.


3.4.2 Nogiers phase models
in the treatment of chronic musculoskeletal pain

With further research Nogier discovered different auricular maps than his original one
based on the inverted fetus pattern. They differed considerably from the earlier model
as they assign different auricle zones to different body parts than the original map.
Nogier referred to this different models as phases:
67


- Phase I: the original inverted fetus model represents the tissues and organs of
the physical body. From a Chinese perspective it represents acute, excess
Yang conditions. Phase I points relate to sensory aspects of pain.
- Phase II: the upright man model represents the pathology degenerative
conditions and chronic illnesses. It is related to Yin degenerative conditions.
- Phase III: the horizontal man model represents excess Yang, inflammatory
conditions.
- Phase IV: located on the posterior side of the auricle and is basically the same
microsystem represented by Phase I. The phase IV is used to treat muscle
spasm aspects of a condition.

68



Both Phase I and IV are used to treat acute pain or acute conditions, and the other
two are used for more chronic pain. According to Frank and Soliman
69
, the different

67
Oleson, T, 2003
68
Ibid., p. 73
33
phases do not so much represent the degree of chronicity, but the degree of
degenerative condition. The mildest conditions are represented by phase I, followed
by phase III and the most degenerative conditions are represented by phase II.

Some authors, like Rubach
70
for example, choose to ignore auricular phases, while
others consider them to be most valuable. It seems to me that different phases model
can be of a particular importance in the treatment of chronic musculoskeletal pain.
While paying attention to Phase I could only bring some palliative results, examining
and treating Phases II and III could get into the heart of the problem.

The treatment protocols for chronic musculoskeletal pain include primarily the area of
the corresponding body part. In the Phase I the segmental approach is applied,
which I will not further describe. If Phase I does not yield results, the corresponding
points are searched according to the Phase II or III.
71
Next, the points with analgesic,
anti-inflammatory or muscle relaxing effect are examined and some other points with
a general regulatory function. According to the previous diagnosis specific points can
be employed to complete the treatment. Each session the points are examined again
and reactive points are treated accordingly.


3.4.3 Chinese model of ear acupuncture
in the treatment of chronic musculoskeletal pain

The Chinese researchers were inspired not only by Nogiers model, but also by the
quotation from Classic of Internal Medicine that states that all of the Yang channels
pass through the ear and the Yin channels meet in the ear.
72
The working of the
auricular points is thus explained by the connection of the ear to the meridian system.
That still leaves unanswered the question how the particular points on the ear
transmit their influence to the corresponding parts of the body.

The differences between the original Nogiers inverted fetus model and the Chinese
model is usually explained by the assumption that the points on the Nogiers model
correspond to the physical body parts and the points on the Chinese model
correspond to the energetic functions and connections according to the Chinese
physiology theories. In that manner, Chinese ear acupuncture works by regulating Qi
and promoting proper organ function.

According to Frank and Soliman,
73
the Chinese system offers a simple model that is
best suited for a technical approach to treatment. Treatment depends on the
localization of pain together with meridian(s) involved in the pathology, so the zone of
the corresponding body part and the zone of the organ corresponding with the
involved meridian is treated. Depending on the previous diagnosis made on basis of
the eight parameter and internal organs differentiation, further zones of the ear can
be treated. In combination with body acupuncture, the appropriate local and distal
points are needled.

69
Frank, B.L, and Soliman, N.E, 2006
70
Rubach, A, 2001
71
Oleson, T, 2003
72
Marcus, A, 2004, p. 344
73
Frank, B.L, and Soliman, N.E, 2006
34
Conclusion : the best of both worlds


The purpose of this writing was to get a better understanding of chronic
musculoskeletal pain and acupuncture treatment methods used for it. For that
purpose I chose to compare four different approaches: TCM acupuncture, meridian
approach, trigger point approach and ear acupuncture. Again, my goal was to
compare them, not to judge their effectiveness.

If I have learnt anything from watching the various therapeutic approaches in
action, it is that there are countless ways of perceiving what is going on with
the person who is in front of you and who needs your help and that there are
many ways of stimulating healing responses. (Oschman 2003, p. Xxviii)

Based on this writing I came to the conclusion that for the treatment of
musculoskeletal pathology and especially for the chronic cases, it is important to
explore the whole array of the superficial energetic structure; not only the main
meridians, but the secondary vessels and extraordinary meridians as well. To do that,
one needs theoretical knowledge of the pathways and characteristics of the layers of
meridian network, but at least as much important is the use of palpation to identify the
precise spots where Qi and Blood stagnates. Needling those places dissipates the
stagnation and/or tonifies resulting deficiency and addresses directly the cause of
pain.

It is usually recommended not to mix or confuse different models of differentiation
and treatment of a pathology. In the case of chronic musculoskeletal pain I believe
one can learn from all four different approaches. One can integrate differentiation and
treatment of underlying pathology, which is the strong point of TCM acupuncture, with
a meridian oriented approach to address the exact place of the pathology. Trigger
point approach can provide a practical and accurate methodology of identifying
places of Qi and Blood stagnation and a straight-forward and easy to learn palpation
method. Combining that with an independent system of diagnosis and treatment like
ear acupuncture should only increase the success rate of a treatment.

In short, one can combine the intellectual or scientific approach with the palpatory
and more intuitive approach. The latter seems to be the shortcoming of most Western
doctors. TCM acupuncture does not need to match the Western medical science in
scientific rigor; it can offer much more by relying on its ancient wisdom and trust in
the intuitive.

Do j do y fi hng do y. (Chapter 1, Do D Jing)
74








74
Study material Academy Qing-Bai, BVO study year 2006-2007; in translation: The Tao that one can
speak of is not the eternal Tao.
35

Literature


Books:
Baldry, P. E., Acupuncture, Trigger Points and Musculoskeletal Pain,
Edinburgh etc.: Elsevier/Churchill Livingstone, 2005
Deadman, P., Al-Khafaji, M., Baker, K., A Manual of Acupuncture, Hove:
J ournal of Chinese Medicine Publications, second edition 2007
Deng, T., Practical Diagnosis in Traditional Chinese Medicine, Edinburgh
etc.: Elsevier/Churchill Livingstone, 1999
Ellis, A., Wiseman, N., Boss, K., Fundamentals of Chinese Acupuncture,
Brookline, Massachusetts: Paradigm Publications, 1991
Frank, B.L. & Soliman, N.E, Auricular Therapy: a Comprehensive Text,
Bloomington: Author House, 2006
J irui, C., Acupuncture case histories from China, Seattle: Eastland
Press,1988
Maciocia, G., Diagnosis in Chinese Medicine, Edinburgh etc.:
Elsevier/Churchill Livingstone 2004
Maciocia, G., The Channels of Acupuncture, Spain: Elsevier/Churchill
Livingstone, 2006
Maciocia, G., The Practice of Chinese Medicine, Edinburgh etc.:
Elsevier/Churchill Livingstone, 2
nd
edition 2008
Manaka, Y., Itaya, K., Birch, S., Chasing the Dragons Tail, Massachusetts:
Paradigm Publications, 1985
Marcus, A., Foundation for Integrative Musculoskeletal Medicine, Berkley:
North Atlantic Books, 2004
Norris, C. M., Acupuncture Treatment of Musculoskeletal Conditions, Oxford
etc.: Butterworth Heinmann 2001
Oleson, T., Auriculotherapy Manual, China: Elsevier/Churchill Livingstone,
third edition 2003
Oschman, J .L., Energy medicine in Therapeutics and Human Performance,
Edinburgh enz.: Butterworth-Heinmann, 2003
Pirog, J . E., The Practical Application of Meridian Style Acupuncture, Berkley:
Pacific View Press, 1996
Riley, D., Treating Pain With Traditional Chinese Medicine, Brookline
Massachusetts etc.: Paradigm Publications, 2003
Rubach, A., Principles of Ear Acupuncture, Stutgart etc.: Thieme, 2001
Seem, M.D., Acupuncture Energetics: a workbook for diagnostics and
treatment, Rochester, Vermont: Healing Arts Press, 1987
Travell, J . & Simons, D.G., Myofascial Pain and Dysfunction. The Trigger
Point Manual, Baltimore: Williams and Wilkins, 1983
The Yellow Emperors Classic of Medicine, translation by Ni, M., Boston etc.:
Shambhala, 1995




36

Websites:

www.chinesemedicinetimes.com: Reid, T., The Neglected Art of Channel
Palpation, 20 May 2009
www.books.google.nl
www.yinyanghouse.com


Study material of Academy Qing-Bai:

BVO, study year 2006-2007
ACU 1, study year 2007-2008
ACU 2, study year 2008-2009