Author: Guanhu Yang, Peilin Sun
Key words: #Acupuncture #Pain #PainRelief #TraditionalChineseMedicine #PainManagement #AlternativeMedicine
Introduction
Pain is one of the most common reasons for Americans to access the health care system. It is a leading cause of disability and a major contributor to health care costs (1). The causes for pain can defer on severity and condition, and treatment can range from drug prescription, physical therapy, surgery, and nerve block etc. Presently, people often seek alternative pain management options, such as acupuncture, for its effectiveness, ease of application, and low probability for complication.
Research studies have also proven the effectiveness of acupuncture for pain relief. In a study published by Archives of Internal Medicine in 2012, researchers reviewed the results of placebo-controlled trials involving nearly 18,000 participants on the effectiveness of pain management with acupuncture. The overall result was promising, showing that acupuncture helps relieve pain by approximately 50% (2). Furthermore, many studies have concluded that acupuncture is effective in treating various conditions (3-13), especially for pain relief, such as headache (5), chronic low back pain (6), neck pain (7- 9), chronic knee pain (10-11), hip pain (12), shoulder pain (13) and so on.
To better understand pain in Traditional Chinese Medicine (TCM) theories and practice, this article will discuss the contributing factors of pain, types of pain, and diagnostic features of each condition with respect to TCM theories. In addition, it also provides perspectives and guidance for using acupuncture to treat pain conditions based on the authors’ clinical experiences.
Causes of pain
Pain is the body’s unpleasant warning sign for illnesses such as physical or psychological distress, inflammation, and infection.
In TCM theories, the causes of pain are often discussed through two perspectives: external pathogenic factors and internal disorder.
Pain caused by external pathogenic factors
Understanding External Pathogenic Invasion and Pain
In Traditional Chinese Medicine, pain is a one of the main manifestations of Bi Syndrome (Painful Obstruction Syndrome). Per Inner Canon of Huangdi .Basic Questions . Theories of Bi Syndromes, “the invasion of pathogenic Wind, Cold and Dampness will lead to an obstruction in the meridians and Bi Syndrome may take place.” Bi Syndrome can cause pain, heavy sensation, and limitation of movements.
However, the causes of pain can go beyond external pathogenic factors. Per Inner Canon of Huangdi . Basic Question . Discussion on Acupuncture Methods, “Pathogenic factors can not cause diseases if the vital Qi is sufficient.” Also stated in Inner Canon of Huangdi . Basic Question . Discussion of Four Kinds of Febrile Diseases, “Where pathogenic factors accumulate, the parts of the body must be deficient in the vital Qi.” Thus, deficiency of the vital Qi, which can lead to the inability for body to defeat external pathological damage, can be the root cause to lead to the occurrence of pain (14).
Clinically, the following three elements can be observed when pain is mainly caused by external pathogenic invasion:
Strong pathogenic factors
Insufficient or weak vital Qi (anti-pathogenic Qi)
Improper diet and unhealthy life styles
Weak vital Qi is the only definitive reason for pain syndrome. To illustrate this point, we can observe that people who live in cold, windy and humid areas do not all suffer from pain or Bi syndrome. People who do suffer from pain conditions often have weak vital Qi and/ or unhealthy lifestyles. Therefore, the occurrence of pain syndrome is a result of both external pathogenic invasions as well as underlying energetic factors.
In addition, incomplete elimination of six exogenous factors (wind, cold, summer-heat, dampness, dryness and fire) may cause pain. As we encounter many external pathogenic factors in our daily life, a healthy body is able to eliminate such pathogens effectively. However, when the vital Qi is weak, such exogenous factors may linger in body, which can progressively lead to pain. This is slightly different than the direct invasion of external pathogenic factors. See Table 1 below for a summary of different clinical symptoms for the two scenarios.
Lastly, infectious agents can also cause pain. Take Fibromyalgia Syndromes and Lyme disease for example, preliminary symptoms for both conditions may include fever, headache and fatigue. If left untreated, symptoms may progress to limitation of movements, joint pain, headaches with neck stiffness, and heart palpitations etc.
Types of external pathogenic factors and differentiating syndromes
Traditional Chinese Medicine is based on clinical manifestations. It is crucial to understand each pathogenic factor by analyzing symptoms and signs. In addition, in order to provide a basis for treatment, it is also important to differentiate syndromes of the conditions in accordance to Theory of the Six Channels.
External pathogenic factors
In TCM theories, the main types of external pathogenic factors that cause pain are wind, cold, and dampness.
Wind is the primary cause for pain syndromes. It is a common climatic condition that exists in all four seasons. Wind tends to move, especially upward and outward. It is also subject to rapid changes. Wind often attack the body simultaneously with other pathogenic factors to cause diseases. For example, wind-cold-dampness of arthritis is a common reason for both acute and chronic pain.
Cold prevails in winter and also exists in the other seasons. Cold is a Yin pathogen that tends to impair Yang Qi. When Yang Qi is weakened, cold is likely to damage Heart, Stomach, Spleen or Kidney. In addition, cold is coagulative, and can create blockage and stagnation in the meridians, causing various kinds of pain. Further, cold can create constriction. When cold attacks the body, it causes contractions in muscles, channels and tendons, thus leading to spasm and pain.
Dampness prevails in late summer when the weather is warm and humid. The invasion of dampness is often closely related to the external environment as well as the actual condition of the Middle Warmer. Dampness is heavy, turbid and stagnant in nature. Unlike wind, dampness tends to go downward of body. Symptoms of dampness are usually found in the lower parts of the body. Similar to cold, dampness is a Yin pathogen that impairs Yang Qi, leading dysfunctions in Heart, Stomach, Spleen, or Kidney.
Differentiating syndromes
Based upon Treaties on Febrile and Miscellaneous Diseases by Zhang Zhongjing, pain syndromes can be differentiated based on the condition of the vital Qi of human body as well as the state of the pathogenic factors in accordance with the principle of Yin and Yang.
In clinical experiences, pain caused by external invasion could be subdivided into six syndromes as listed below. A single or a mix of syndromes may be observed from patients. The common types of mixed syndromes are Taiyang and Shaoyang syndrome, Taiyang and Taiyin syndrome, Taiyang and Shaoyin syndrome, and Taiyang and Jueyin syndrome. Table 2 below summarizes the different symptoms of each of the six syndromes:
Pain caused by internal disorder
Besides the external pathogenic factors, internal factors such as prolonged emotional disturbance, eating disorder, improper lifestyle, constitutional dysfunction and unhealed physical injury etc., can lead to pain. In clinical experiences, such internal factors are often cause chronic pain, which can be more complex in nature, and require tailored treatment.
Compared to pain caused by external factors, internal disorders have distinct features:
Gradual onset
Relatively long duration
Pain mostly in organs, or in both organ and superficial parts of the body
Disturbance primarily to the Internal Zang-Fu organs
Relatively difficult to treat
Internal factors can cause pain. Traditional Chinese Medicine believes that emotional state has a close relationship with the viscera organs. Among all the internal disorders, internal injury by seven emotions is one of the primary trigger of pain. Seven emotions, namely: joy, anger, melancholy, anxiety, grief, fear and terror are responses of body to external stimulation. However, when there is overwhelming emotional fluctuation or long-term emotional impairment, internal injuries may occur, leading to functional disorders in viscera organs. A common manifestation of such disorders is pain syndrome.
Emotions also have strong connections with the Five Elements. According to Plain Questions . Yin-Yang Doctrine and Its Relation with Natural Phenomena, “Man has five viscera which may bring on five moods (visceral-Qi) to produce joy, anger, grief, melancholy and fear.” TCM theories believe that Heart is related to joy, spleen to melancholy, lung to grief, liver to anger, and kidney to fear. Therefore, emotions could influence corresponding organs, causing various damages. When it comes to pain syndromes, Heart and Liver are the two primary organs that were involved with emotional disorder. Consequently, Qi, Blood and Fire are the chief pathological results of such condition.
Because of the complex nature of chronic pain, treating such condition is often difficult and requires efforts from both practitioner and patient. Skillful acupuncture techniques are essential for practitioners to cope with complex conditions. However, acupuncture is merely an assistant therapy. The key to healing is the depending on prescription of life styles changes for patients to resolve the internal root cause of pain.
Diagnostic principles and applications
The main diagnostic methods of Traditional Chinese Medicine include inspection, interrogation, auscultation and olfaction, and pulsing and palpation. To achieve a comprehensive and reliable diagnosis, the four methods should be adopted simultaneously in clinical examination. Inspection and palpation, however, are extremely important when it comes to diagnosis of pain syndromes.
Inspection and palpation
Inspection
In Traditional Chinese Medicine, inspection is a diagnosis technique that includes observation of facial expression, vitality, physical state and tongue condition. When analyzing pain syndromes, practitioners should focus on observing the following:
Physical movement
Pain area
Meridians which pass through the painful areas
Local skin changes, especially modifications in color, rash and desquamation, eruption and pigmentation, etc
Overall vitality and spirit
Tongue conditions
Palpation
Palpation is a Traditional Chinese Medicine technique that practitioners use to gather clinical information of their patients by feeling, touching, pushing, and pressing certain parts of the patients’ body. Palpation provides a direct way for practitioners to learn about patients’ body condition as well as local abnormal changes. When diagnosis of pain using palpation technique, the following areas should be prioritized during examination:
Palpating of the painful areas
Palpating Back-Yu Points and Front-Mu Points
Palpating Ah Shi points
Palpating any changes that were observed in muscles, or under the skin, especially the nodulation and local temperature changes
Furthermore, practitioners should pay special attention to the changes discovered on patients’ body during palpation, such as:
Tension or spasm
Discoloration
Swelling
Blisters
Hotness
Stiffness
Flaccidity, softness or tenderness
Any abnormal changes imply some underlying pathogenic factors and provide important basis for developing treatment plan.
Diagnosis of pain syndromes
In TCM theories, pain syndromes can have various causes and manifestations. Therefore, in order to best collect and analyze clinical materials to treat the conditions effectively, TCM practitioners should carefully observe the patient’s body as an holistically, focusing answering the following questions:
Duration of Pain
Severity of Pain
Causative Factors of Pain
Functional Disorder or Organic Sickness
Physical Damage or Mental Disturbance
Subjective Feeling or Objective Observation
By using the TCM diagnostic methods, practitioners should be able to collect comprehensive information to provide an accurate basis for treatment.
Treating pain with acupuncture
TCM has applied acupuncture for thousands of years to treat pain in China. Acupuncture’s pain relief effects have studied by many research groups to understand the underlying mechanisms. A study was conducted by the author Guanhu Yang and his fellow researchers to study the mechanism by observing the effect of electro-acupuncture in local and distant acupoints. Their study indicated that the pain alleviation from acupuncture might be associated with the spinal substance P when electro-acupuncture was applied on local and distant points on rats (15). Additionally, the knowledge of endorphins and enkephalins provide another physiological basis for acupuncture’ pain relief mechanism (16). Further, a study published by Dr. Ji-Sheng Han and his group also observed increased release of neuropeptides when acupuncture or electrical stimulation was applied in acupoints, which elicited profound physiological effects and even activating self-healing mechanisms (17).
The main goals of acupuncture for pain treatment is to remove causative factors of pain in order to rebalance body. Western Medicine treatments, on the other hands, often focuses on relieving pain, without resolving the root cause. To efficiently treat pain syndromes with TCM, the following three principles should be the focused on during treatment: Symptomatically relieving pain, removing causative factors, and regulating Shen.
Relieving pain with acupuncture
The following acupuncture points are often used for quick, effective and potent pain relief:
Luo-Connecting points
Yuan-Source points
Xi-Cleft points
Stream points
Ah Shi points from the local or adjacent areas or distal area, etc.
In most cases, reducing (sedating) method is applied because Qi or Blood stagnation is usually the chief pathological factor for pain syndromes. It is very important to bear in the mind that these points should be selected mainly from these internal organs or meridians which are involved with the pain. For instance, if there is stomach pain, these points could be selected from the Stomach channel chiefly. For more specific areas of pain, see Table 3 below for corresponding acupuncture points.
Removing causative factors for pain
Pain recurrence is likely if the underlying cause is not treated. Thus, resolving the causative factors is the most important goal in the treatment plan. As discussed, pain can have various causative factors from external pathogenic attacks, weak vital Qi, or internal emotional disorder etc. An accurate diagnosis is essential to resolve root causes of pain. When applying acupuncture treatment, TCM practitioner should focus on the following four treatment principles:
Remove causative factor
Restore organ functionality
Repair physiological damage
Reestablish spiritual balance
Besides the aforementioned acupuncture points (Luo-Connecting points, Yuan-Source points, Xi-Cleft points, and A Shi points) to relieve pain, the following points are recommended as a part of the treatment regimen...
Five Shu points
Eight Influential points
Eight confluence points
Front-Mu points
Back-Shu points
Mother or Son points, etc.
Pain syndromes can be treated differently based on clinic manifestations according to its impacts to Zang-Fu organs. Table 4 and table 5 below is created to demonstrate the recommended acupuncture points as well as treatment methods in order to remove the causative factors of pain.
As Qi or Blood stagnation is the chief pathogenic factor of pain, reducing (sedating) method is applied in most cases. Additionally, a combination of reducing (sedating) and reinforcing (tonifying) method should also be considered when it is necessary to reduce the Excess and reinforce the Deficiency simultaneously.
Regulate shen and vital energy
All different kinds of pain and skin irritation are related to Heart based on Traditional Chinese Medicine theories. It is crucial to calm patients’ Heart to regulate their Shen and vital energy. This is similar to the effects that were induced by anesthetic effects in Western Medicine. Patients tend to feel less pain when Shen is regulated and calmed. This is important especially when treating patients with chronic pain or pain caused by emotional disturbance. Furthermore, calmed Heart and regulated Shen also lead to improved sleeping quality, which ultimately helps with pain alleviation.
Based on clinical experiences, the following points have shown to be effective to calm Shen. TCM practitioners can apply two or three of such points during treatment. Sometimes, immediate relief can be observed after application.
HT 3
HT7
PC6
GB20
BL15
Extra Anmian
CV17
KI23
KI24
Such points are effective to encourage patients’ confidence for the treatment. Although regulating Shen often provides quick and effective pain relief, the causative factors still remain and needs to be addressed accordingly.
Other supplementary techniques for treating pain
Per TCM practices, acupuncture treatment is only one of many methods to cope with pain. The following techniques are also components of acupuncture:
Moxibustion
Ear acupuncture
Abdominal acupuncture
Scalpel acupuncture
Wrist and ankle acupuncture
Embedding of grain-needles
Acupotomy
Acupoint injection
Combination of such techniques could improve treatment outcomes. Usually, at least two or three techniques are recommended to apply at same time.
In conclusion, pain is a common condition that almost everyone will experience sometime during their life. The time and efforts required to cure pain varies. Traditional Chinese Medicine care provides a sustainable and natural ways to manage pain, as well as to address the underlying root cause of pain. Battling pain may not be an easy process. It requires comprehensive knowledge base and skillful techniques from the TCM practitioners, as well as efforts from the patients.
Conflict of interest
The authors declare no competing financial interests.
Acknowledgements
The authors would like to thank all reviewers for comments that greatly improved the manuscript, and Ms. Ziye Liu for assistance with preparing this manuscript.
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