Chap 6 Joint  problem:

What causes joint pain? What is joint inflammation?

Movable joints are designed for motions which allow the body to move around.   Complex joints enable more complex modes of motion.  For example, cervical spine has seven bones and eight joints which allow the neck to turn many different ways. Hands and feet have so many joints that allow us to do an incredible array of maneuvering.

To accomplish such task, joints have complex and integrated structure; bones which are strong to take physical load, cartilages to cushion contact surfaces between bones, synovial fluid to lubricate the joints, capsules to contain fluids, bursas to store the fluid. Furthermore, vascular systems around the joints supply nutrients and oxygen, neural networks to direct the motions and to provide feedback for status of joints. Don’t forget tendons and ligaments are what keep separate pieces of bones together. It sets the tension between two adjacent bones. They also are responsible for holding the bone pieces in the proper geometric arrangement necessary to accomplish the intended movements.

One important point to remember is that the spacing between the bone is avascular- no blood vessels, no nerves. It does not produce any pain. The joint gap can be totally destroyed and we would not know it. That is why artificial joints are possible. As we ages, the gaping between the joint such as in the knee become narrower and we have no inkling that is happening. Joint pain is not the pain inside the joint spacing. The purpose of joint spacing is that it provides a physical structure which allows the motion feasible and productive.

With arthritis, quite likely, there is inflammation at the surroundings of the joint by definition. The inflammation may or may be not the cause of pain.

The deep joint pain that often felt by some arthritic patients does not come from the space between the joint. It is produced by the nerve receptors which surround the joints. Injuries, strain, sprain of any kind around the joint, tendons, bursa, nerves, muscles all can irritate nerves. The swelling of any origin can cause irritation of nerves.  Muscles that are incapable of relaxing (either through overwork, neurological disorder or coldness)can cause irritation to nerves. All of these events produce the sensation that are not comfortable and contributed to various sensation, soreness,  pain– It can be like knifing, dull, achy, throbbing, distention, cutting, electrical shock, pulsating.

The 1st responder for our body to the pain is the reflex protective shortening of muscles which reduce free motion at the joint. Inflammation process would likely also initiated which dilates blood vessels, allowing more blood, oxygen and body defender-immune apparatus to move in. Unfortunately, too much of these stuff all at one time and the flow becomes congested like traffic in an auto accident scene. The congestion results in swelling. Our nerves then sound alarm with pain and discomfort sensation. This explains why common anti-inflammatory medications which reduce inflammation process relieve joint pain to a certain degree. The “muscle relaxants” also brought certain pain relieve sometimes because it inhibits the contraction of muscles.

However, the most important question left unanswered is why inflammation occurs in the first place for people who never do anything to injure their joints but develop arthritis anyway. Most times, it is explained as “wear and tear”. If it is so simple, people in bed should not have arthritis. On the contrary, they do. Worse off, they would soon have atrophic muscles and degenerated joints throughout the body. It is interesting to watch doctor regularly tell patients that arthritis is caused by “wear and tear” of joints due to use and then turned around and advice patient to do more exercise, more walking to prevent arthritis.

Inflammation has been getting a bad rap. Such reputation did not start today. It was called “Fire” in Traditional Chinese Medicine for thousands of years. So is ancient Greek and Indian. People had been trying to extinguish the bad “fire” in the body for many thousands of years.  It has made lots of money for drug makers these days. Just take a visit at drug stores and you would be surprised to discover how much of the remedies are anti-inflammatory of some sort.

Yet, inflammation is the tool body heals itself. Without it, healing will be very difficult. Anybody who chronically uses anti-inflammatory will notice that. All the side effects attributed to the anti-inflammatory are caused by this reduction of healing process. The most notorious is cortisone. I once had a patient who came with whole body pain, bad joints, moon face, and hump upper back, severe cataract on both eyes. She was on cortisone for half of her life and she was only 50. I was able to reduce her pain and reduce cortisone dependency though acupuncture.

Granted, when the inflammation is overwhelming, it can be debilitatingly painful. In such event, steps have to be taken to bring pain under control. No question about it. Otherwise, normal body function will be impossible. Anti-inflammatory remedies can be necessary under such condition. This applied to the inflammation situation caused by autoimmune disorders as well in some acute phase severe inflammatory incidents.

By the same reason, frequent icing on the body also discourages body healing and should be avoided, unless it is followed by heating afterwards.

How does acupuncture help arthritis?

A lady in her 60s came in for knee pain, hurting day and night. She was referred from regional Kaiser Permanente.  In the past two years, she has had four cortisone shots that have minimal effects, followed with elastic tissue infusion into the joint. I did acupuncture and moxibustion (Acumoxa) on her right knee. Her knee pain disappeared, no pain for four days. Gradually pain started to creep back. Obvious, she had a severe case of arthritis.  This is but one of arthritis cases successfully treated with Acumoxa. Why did acupuncture help her knee and why did the pain come back? Because her condition needs long term continued care.

6.1       Painful joints or arthritis- degeneration

 “Degeneration” does sounds alarming, especially for the patient. In truth, it is not so dreadful at all. It can be minimized with proper care.

What is the degenerate disease? First of all, degeneration is a nature process that can’t be reverted, not even stopped. It is just part of life process- everybody over the growth spurt starts to have degeneration. The only thing that can be done is to prevent the unnecessary degeneration.

So, what causes excessive degeneration? The causes are too many to count. We will revisit this latter. In the end, it is the lack of blood supply that is the culprit. No blood, no oxygen, no nutrients, cells starved and wielder. Tissues weaken and decay. This will raise alarm and induce inflammatory reaction for relatively healthy individuals. Inflammation has been portrayed as villain in causing all kind of mischief. Indeed, it causes capillaries to enlarge, tissues to swell, temperature to rise, color to turn red. For sure, blood flow is increased but unfortunately, it is likely to bring pain with it.

Pain is a double edged sword. It  triggers protection reflex from the muscle which on one hand reduces mobility of the area preventing undue movement of the area but also increase the muscle, tissue tension that has unintended consequence of restricting blood flow.

So, the body has created a dilemma for itself. The art of healing lies in resolving this dilemma. The easy way out is to reduce the inflammation somehow. Such approach makes pharmaceutical companies a lot of money. They have developed varieties of anti-inflammatory medication from aspirin to naproxen, cox-2 inhibitor, all the way to the all powerful cortisones. They work wonderfully in reducing the inflammation but leaving the body to heal the problem without the tool-inflammation.

A 45-year old male was diagnosed with a severely-degenerated cervical disc and was told that surgery is the only option. His neck and right upper arm are painful. The right arm is numb. Numbness extends all the way down to the fingers. He had difficulty falling asleep because of pain.  

Put acupuncture needles on the right hand and elbow, the result was immediate. According to the patient, not only did the pain at the neck shoulder begin to diminish, but also a sensation of warmth traveling down the arm and hands. After 5 treatments, the patient was able to manage with infrequent successive treatments.

Comment:

Degeneration is a dirty word that provides covers for the doctor’s frustration. In truth, our body is in a constant balance act between regeneration and degeneration. Before 16 year of age, more regeneration, after that, more degeneration. This fact can't be changed. Nobody can prevent degeneration. However, most people don't have pain most of the time. Degeneration does not equate pain.  Pain of any origin accelerates degeneration and needs be addressed as soon as possible.

6.2       Golf elbow, tennis elbow

Either one can be very painful. The cause is similar- overuse of certain muscles. The muscle than shorten to protect itself which results in the stress at the respective tendons and the attached bones. The joints become stressed and immobilized from pain. In addition, the antagonistic muscle becomes overly stretched. The tension is then transferred to the attachment of corresponding tendon to the elbow, either medial or lateral epicondyle of the humerus muscle. As the result, either biceps muscle or triceps spasmed and become painful in addition to the corresponding insertion location at the joint.

Palpate and find the tenderest spots and do indirect moxa until the pain subsides. Do exercise to strengthen the underused muscle group and the problem will disappear. Meridians involved typically are Large intestine, Lung, San Jiao or Small Intestine. Again, keep the joint as warm as comfortable, stretching frequently the whole arm, especially the underused muscles is the best way to prevent future problem.

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.