6.3       Frozen shoulder     

Source: http://orthoinfo.aaos.org/topic.cfm?topic=a00071

This is a problem that typically crops up for a person at around 50 years of age. It therefore commonly called “Wu Shi Jian” or 50-year-old- shoulder in Chinese society. It can come gradually or onset suddenly starting at age of mid 40. Lifting arms become painful. The pain is concentrated at and around the rotator cuff. It can be so severe that brushing the teeth, combing the hair become difficult. Putting on clothes becomes a torture. In severe instances, the pain can be so severe and unrelenting that resting in sleep becomes impossible.

Western doctors may give diagnosis such disorder as tendonitis, rotator cuff syndrome, and bone spurt at the shoulder joint bursitis or simply arthritis.

Frozen shoulder is not difficult to treat. For acute cases, it is a Qi stagnation and “coldness accumulation” issue; “coldness” due to reduced blood flow and Qi stagnation due to pain. Inflammation which is generally blamed for is not the cause of problem but the consequence. When people sleep, shoulder joints are not kept warm by the comforter. They frequently are exposed to the cold air. Unlike human face where blood supply is abundant, shoulder joints blood supply is much more limited. As tissues in the joints sense the lack of blood circulation due to coldness, the inflammation processes started at tissues around the shoulder joints.. With age, this process become a significant issue.

Clearly for most people, this is a chronic situation. People who have higher blood pressure would have better blood flow. They tend to have less of such problem. People who have so called “perfect “blood pressure or having low blood pressure get this problem usually. People who have prior injury to the shoulder joints are even more likely to have problem.  Leaving it unresolved, muscle weakens, become atrophy. Fibrosis sets in. The range of motion at the joint begins to suffer. The strength of the affected arm would diminish as well.

For the initial stage, Move the Qi at the shoulder joint would be sufficient. Acupuncture with or without electrical stimulation can be used to move the Qi. Because this problem came from cold exposure, keeping the joints warm is very important for the therapy. It is also important as a maintenance measure to prevent it from recurring. Apply moxibustion or other mode of heat therapy at the joints would increase the blood circulation and thus is very critical for its speed recovery.  Add some stretching exercise of the arm and shoulder. Such problem would be resolved.

Treatment:

To move the Qi, usual points to move the neck /shoulder points are used (N-S protocol) first. In addition, St 38 on the right leg and SI 6 on the right arm were used.  Occasionally, Ht 3 can be added.

I also applied moxibustion over the upper chest near the affected shoulder close to Lu 1  or Lu 2 and posterior to the shoulder joint just below SI 9. 

While the treatment was applied, it is quite beneficial for the patient to stretch the joints, like lifting the arm or roll the shoulder for as long as such exercises provoke no pain.

Example case:

A 48 year old female complained about shoulder pain which kept her awake at night. She was diagnosed as having frozen shoulder. The pain started after a surgery a few months ago to fix the broken clavicle in an accident. A steel pin was used to stabilize the clavicle.  She needed left hand assists to raise right arm above shoulder level.   She was told that the encapsulation of the joint had caused the frozen shoulder. She also had another operation which fused C6-C7. Otherwise, she appeared healthy, trim.  She confessed to have some bad mood frequently.

Her neck’s sideway range of motion was reduced more restricted turning toward right. Palpation indicated that her chest under the right clavicle was quite painful under pressure.

            Encapsulation might have been caused her inability to raise arm normally. It normally takes a while to develop such problem and would take a long while to recover. However, since the “frozen shoulder” happened after the surgery, encapsulation is not likely to be the original or important cause of her problem. Therefore, this type of frozen shoulder is much easier to resolve. In contrast, typical “frozen shoulder” is due to aging, which involves an element of weakened Q takes much longer to resolve. In TCM, this is a Qi stagnation problem-Qi is stuck, not weakened, which cause the arm to “freeze”. Her shoulder Qi got stuck most likely followed the surgery.

I applied the steps described above. The effect was immediate.  She was amazed at the result; she was able to raise the right arm over the head without the assistance of left hand.

She came in the next week saying that not only she was much happier, everybody in the family was also happier because she was not as cranky any more. She had no pain using right arm during the week after the treatment.

She still had residual pain in the chest and left neck upon palpation. The upper chest pain was related to the surgery, needed time to heal. In TCM, This is a “blood stasis” issue. Heat pads or moxibustion are the best home remedy for such problem. Both should be applied for a certain length of time to assist body to heal.

6.4       Swollen joints and limbs- sudden onset or due to traumatic incidents

When fluid starts to accumulate in the tissue, the skin starts to become tight like inflated balloon. Achiness sets in because of the increased pressure on the nerve. This happens in a traumatic injury situation. It can also happen with other condition that produces inflammation.

The first issue is why people use ICE protocol, icing, compression and elevation to deal with traumatic injury. Such combination reduces the accumulation of the extracellular fluid. It stops the swelling from getting worse. But it is not very productive in reducing the swelling once it forms.

Lymphatic duct is what drains away the extracellular fluids. For it to work, muscle contraction. It gets a boost from heat. Icing slows down the process. This is where icing actually produces counterproductive consequence. The longer the icing, the longer the swelling stays and eventually may become permanent. The longer the affected area been kept motionless, the longer the swelling will stay.

One type of the swelling very difficult to deal with medically is caused by incompetent lymphatic nodes; either through removal from cancer surgery or other disorder like parasitic invasion.

Lymph nodes are like check valves. Removing them is like removing the drainage valves. That makes it unable to drain the tissue fluid from the affected limbs. Manual drainage becomes necessary. Without it, the swelling continues, eventually the fluid settles and becomes stationary tissue, making physical activity difficult.  To slow down such process, one need to keep the affected limb warm, keep its muscles moving, do manual draining, keep limb elevated at rest or wear compressive stocking walking. To certain degree, electro acupuncture across the inguinal or the shoulder joint plus heat therapy will help but the process needs to continue permanently.

Once I had a 50’s female patient who had a left leg twice as big as right leg. Her foot was all swollen, disfigured but regular size. The leg was so heavy that she was unable to lift it. It reminded me of the people suffering from elephantiasis which are caused by parasites (Filarial). This lady lived all her life in Los Angeles, never travel outside of the country. She felt better after acupuncture treatment but never came back for follow up. According to her, it started 20 years earlier when she was remodeling a house and became totally exhausted. It then developed gradually.

6.5       Rheumatoid Arthritis

6.5.1    78 year old lady complained about arm pain that was caused by “rheumatoid   arthritis. “ Both upper arms were hurting, worst on the right, tender to the touch interiorly. She could not straighten this arm because of pain. Left wrist was significantly bulged, significantly reducing hand flexibility. Her left hand was visibly swollen. Other joints were also hurting but not as much like the arm pain that kept her awake at night. Her fingers exhibited medium degree of disfiguration, typical of people with severe  chronic rheumatoid arthritis. Joints were warm to the touch. So was the rest of her exposed skin. She took aspirin and Advil to reduce her pain. She was allergic to many kind of medications. As a matter of fact, her Rheumatoid Arthritis had been a remission for a good number of years until she took prescription drugs about two years ago. It never stopped since.

No complaint of thirsty. Her pulse was fast and thin.

Her history revealed several surgeries in the past: hysterectomy, for the jaw mastoidectomy twice, mandibular surgery once. Her necks range of motion was limited, painful beyond 30 degree of rotation.

Ordinary, Rheumatoid arthritis belongs to category Hot Bi disease in TCM. The goal of treatment is to cool down the body. There are herbs that would have such function. These include Xuan Shen, Sheng Di, Zhi MU, Huang Bai, which would be benefiting to her overall. This is according to the Yin Yang balance strategy. Her body is in Yang excess for the time being. Excessive Yang caused her excessive overgrowth of bone at the joints which caused pain and resulted in the distortion of finger joints. Pain resulted in QI stagnation at the neck, arms, wrist and fingers.

However, her immediate complaint was of a different issue. It was the Qi and Blood stagnation issue.  Moving the stagnated Qi would help her condition significantly. To have a long lasting “cure”, more steps wouldl be needed, like addressing the Yang issue, the disfiguration of joints issue.

So I applied  N-S protocol for her neck and shoulder first. She had increased her neck’s range of motion by 100% to up to 60 degree both directions.  Moxa on the points at the elbow was able to reduce her pain 50% and Moxa on the left wrist, thumbs plus some passive stretching of fingers reduced her pain on the left wrist, increased her flexibility. She felt much at ease writing the check compared to earlier writing patient info sheet before treatment. No more pain.

6.5.2  Another  lady of  48 years old had history of rheumatoid arthritis, she already had surgery on both thighs and knees. Not much help to the pain.  She was walking on cane. She was on Ativan, extra strength Tylenol, Ibuprofen to control pain. Not much help. Sulfa drug caused her hive and swollen tongue, Haldol caused her facial paralysis, Percocet made her mentally confused and Erythymycin made her sick to stomach.

Though she was supposedly having problem with rheumatoid arthritis, there is no sign of excess heat in the body. She actually preferred warmth.  Therefore, applying low back protocol with needles around the knee joints plus warming her knees were enough to improve her pain condition. She was treated twice a month for about one year with good result. No need for cane to walk. She was advised to keep joints warm to prevent them from acting up.

Treating rheumatoid arthritis is a little tricky because in general it is a deficient situation which requires heat therapy, warm environment, warm herbs for body tonification. While at times, the body become Yang excess and needs be tone down using cold herbs. It is important to make careful judgment and treat accordingly. However, from the acupuncture perspective, either way, there is Qi stagnation issue that has to be corrected. If the therapist is totally blind sided by the “rheumatoid “ diagnosis, then the treatment won’t be very successful.

6.6       Gout

Gout happens to people who has too much of uric acid in the blood. Some food produces more uric acid when digested which normally would be cleared through kidney into urine. For some genetic reason, certain population has more uric acid in their blood stream. The problem is that Uric acid is a weak acid, it cannot dissolve in blood in quantity because blood is very mild alkaline. When the concentration of Uric acid exceed its solubility, it will precipitate out as crystal. Since the solubility of uric acid decreases with temperature, it preferably precipitate at the joints and the extremities like feet and hands. These areas of our body are the coldest part of our body. Crystal is a solid substances and acts like sands imbedded in the tissues around the joints and causing pain and inflammation. It makes the patient miserable.

One day a big guy showed up in school’s clinic with painful big toe. He had history of gout that flared up from time to time. Now it was big, red and hot.  I Instructed the student clinician to apply indirect moxa on the big toe. After five minutes the temperature of the big toe started to decrease. At the end of the treatment the redness, swelling and hotness subsided. The pain was also diminished.

On the surface, it appears to be contradictory to use hot moxa stick trying to bring relieve to the hot, swollen gout-ted toe.  It is not. This is the nature way our body functions.  A logical outcome if we remember that the heat from the moxa increase the solubility of the uric acid crystal and dissolve it into the bodily fluid which is been carried away in circulation. Heat also speed up the circulation which quickens the removal of uric acid rich fluid. Furthermore, once the deposited crystal and accumulated fluid were removed, the inflammation that make the toe hot, red and painful disappear.

Therefore, for gout sufferers, it is vitally important to keep the parts of the body like joints warm all the time and have uric acid under control. One day, through gene therapy, the uric acid issue may be totally eliminated.