Essentials of Integrative

Acupuncture Orthopedics I

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Optimizing Distant Needling

For Orthopedics

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Anthony Von der Muhll, L.Ac., DAOM, DNBAO, FAIPM

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My Journey to Teaching this Material

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• Worked as sports massage therapist, physical therapy aide, and athletic training assistant, 1998-2005
• Graduated from Five Branches University, (FBU), California w/MTCM & licensed in 2003; 1st grad of FBUs’ Sports Medicine Certification Program. Supervised in FBU’s Sports Medicine clinic 2005-2018
• Founded Santa Cruz Acupuncture Orthopedics & Sports Medicine Clinic in 2003; continuous practice, including in physician-led physiatry and pain clinics
• National Board Certification in Acupuncture Orthopedics (300 hours) 2006, through Lerner Education.
• Certified Personal Trainer, American College of Sports Medicine, 2006
• Integrative Acupuncture Orthopedics program (96 hours) with Alon Marcus, L.Ac., 2006
• 48 hours of CEU classes (but not certified) w/Richard Tan, L.Ac./Balance Method, used consistently 2009+
• Self-study and use of gua sha, cupping, myofascial trigger and motor point needling 2012+
• Certified as Myofascial Trigger Point Therapist, Myopain Seminars (90-hour Dry Needling program) 2017
• Teaching integrative acupuncture orthopedics and pain management in DACM and DTEAM programs of Five Branches University, Academy of Chinese Culture and Health Sciences, American College of Traditional Chinese Medicine, and Virginia University of Integrative Medicine
• And most important: injuries from running, cycling, swimming, rock climbing, sitting, driving, intermittent stress, performing acupuncture and massage, picking up babies, etc., i.e. life!

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Tx Locally or Distantly for Pain:

That is the Question! (Or is it…?)

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• Among our most complex controversies!
• My personal clinical experience with using both distant & local methods for ortho-neuro pain and disability is:
• They both can work…
• But not always, or equally well for all patients, conditions…
• Combining local and distant works better than using only one or the other, particularly, combinations (like TCM says…) including:
• Axial (spinal) and distant along same spinal segment/jing-luo/jing-jin
• Left and right sides
• Dorsal and ventral aspects
• Aspect of clinical skill: cultivating judgement as to whether, when to use one, both, or neither for any given patient or condition at any given point in time…?

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Alas, poor acupuncturist! Whether tis nobler in the mind to needle locally, or distantly?

–Mangled Shakespeare

What is Distant/Indirect

vs. Local/Direct?

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• “Local” depends on how the patient and practitioner describe, identify, define and diagnose--are we talking about:
• Symptoms? Signs?
• Pathomechanisms?
• As defined by whom, the patient? The practitioner?
• How both patient and practitioner conceive of and describe injury depends on personal and cultural factors, and for practitioners, upon medical training and diagnostic paradigms
• From both the classical Chinese holographic and quantum physics point of view, “distant” vs. “local” is probably a false dualism anyway...however in clinical practice…

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Patients tell us what is “local…”

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• We can simplify this question somewhat of what is “distant” and what is “local” by defining “local” as painful, symptomatic sites as described by the patient themselves–regardless of underlying pathomechanisms or distant pain-generating lesions that may be identified by medical practitioners

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The Classics Tell Us

We can tx both locally and distantly…

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This complex discussion may be summarized as:

• Neijing describes choosing locations distant to the sites of disease, except
• The sections regarding the jing-jin (“sinew meridians” or myofascial tracts) describes only treating tender/diseased locations locally and directly, as they are discovered through inspection and palpation

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So maybe it’s on us to determine which method(s) we can make work best for a given condition for a given patient at a particular point in time…Here’s my personal algorithm.

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Recommendations for Optimizing Distant Needling

For Orthopedic & Neurologic Pain and Disability

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• Based on my personal clinical experience with using these styles of acupuncture:
• Traditional Chinese Medicine (including 5 transporting, xi-cleft, auricular etc.)
• 8 Extra Meridians
• Five Element Acupuncture
• Richard Tan’s Balance Method
• Master Tong Acupuncture
• I am not a “certified” teacher of any of these methods (except we are all “Masters” or “Doctors” of TCM, right?)
• My experience may vary from specialist teachers of these styles
• My recommendations largely grow from my education and experience with Richard Tan’s Balance Method– “it’s as easy as 1-2-3!”
• My experience suggests these recommendations, with some modifications, are likely applicable to all distant styles when used for orthopedics

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Distant Acupuncture for Ortho-Neuro Pain: “1.”

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Identify the most symptomatic, affected jing-luo, jing-jin, and body region

1. With the patient at rest, where is the current worst pain, along which jing-luo, jing-jin (“sinew meridian” or myofascial tract?) Where along a limb or the spine?
2. When the patient moves the painful/affected area, are there other jing-luo/jing-jin that hurt? Particularly those that limit active range-of-motion?

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Often, these are one and the same…but:

• The jing-luo and jing-jin are not identical in their pathways…
• Where pain is felt at rest may differ from where it is felt on movement
• Jing-luo, jing-jin, at-rest, upon-movement: all are clinically-significant
• Treating only “at-rest” pain risks rapid symptom return when the patient gets of the table and starts moving around

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Distant Acupuncture

for Ortho-Neuro Pain: “2.”

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Inspect, palpate distal-to-proximal along affected and related✱ jing-luo, jing-jin for abnormalities, considering:

• Arc of effect: proportionate to distance from spine
• Corresponding joint or limb segment
• Inspect for superficial abnormalities: swelling, discoloration, scaliness, dryness, spider nevi, hair loss, “peau d’orange,” venous engorgement etc.
• Palpate for significant (grade 2+) tenderness (causes reflexive wincing or jumping on pressure), roughness, tightness, resistance, temperature changes, etc.

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The more of these methods indicate the same location, the more likely it is to be a useful location to needle (see following slides)

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This is human, not citrus “peau d’orange!”

Arc of Effect: Proportionate to Distance from Spine

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Corresponding Joint or Limb Segment

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Corresponding Joint & Limb Segments

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• Precision and specificity can be helpful! The more you know of ortho-neuro anatomy, kinesiology, physical exam, diagnosis, the more accurately you can target tissues that are functionally or structurally homologous for inspection, palpation, and potentially, needling.

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• Example: to treat shoulder pain aggravated by external rotation, where the infraspinatus muscle is painful and weak to manual testing, palpate the homologous hip/buttock external rotators: gluteus medius, piriformis.

Tenderness Grading Scale

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• The dividing line between clinically insignificant (0-1) and significant (2+) is that 2+ involves reflexive responses to palpation
• The higher the grade, the more likely needling is to produce a therapeutic response (except that, by definition, the patient will not tolerate needling at grade 4/4 locations.)

TCM? 8 Extras? Master Tung? Microsystems, etc.

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Same principles can generally be applied for treating ortho-neuro complaints:

1. Identify primary symptomatic/affected area
2. Use your preferred method to identify distant meridians, zones, holographic correspondances, etc.
3. Inspect and palpate for tissue abnormalities, and then…

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Distant Acupuncture for Ortho-Neuro Pain: “3.”

Needle to depth and tissue to match the target painful location:

• Needle superficially to treat superficial pain, deep to treat interior pain
• Needle into same tissue type: skin, muscular, tendinous, ligamentous, capsular, bone, nerve✽, venous (but not arterial or organ, of course!)

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✽ Needling nerves should be done gently with small-gauge (<30) needle to just enough elicit brief paresthesia and promptly withdrawn to avoid neuropraxia.

Wrist cross-section

Needle To Corresponding Tissue Depth, Type

Along Affected Spinal Segments:

Dermatome, Myotome, Sclerotome?

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• Superficially/dermatomes: neuralgia, paresthesias, hypoesthesia
• Into muscles/myotomes: myalgia, fasciculations, cramping, weakness
• Into joints, deep connective tissue, to bones, sclerotomes: joint dysfunction, derangement, degeneration

1, 2, 3…Repeat!

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1. Ask patient to move affected area while you manipulate key needles, and to report any change in pain severity, location. Observe for changes in active range-of-motion.
2. Repeat until all previously-painful areas can be moved with minimal (> 75% reduction) or no pain
3. Encourage patient to continue moving target area as long as it remains pain-free during optimal duration of needle retention: > 30 minutes
• Patients will usually also spontaneously rest, which is ok
4. If pain returns in less than 30 minutes:
• Partial return: re-stimulate key needles &/or re-evaluate, add needles
• Return to baseline, severe pain: consider removing needles, changing treatment

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Example: Distant Acupuncture for Neck Pain

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Example: Distant Acupuncture for Neck Pain

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• Chief complaint: R-sided lateral neck pain, aggravated by R rotation, and by stress
• Exam finding: R rotation is limited by ipsilateral pain; other planes unremarkable
• Injured jing-luo, jing-jin: shaoyang. Injured tissue: facet joints
• Treat: shaoyang (TW, GB); shaoyin (H, K); paired zang (Lv)
• Corresponding segments:
• Foot, ankle, calf
• Hand, wrist, forearm
• Palpate for abnormalities in the regions of and/or use classic xue
• Needle to bone/joint depth
• Shaoyang: TW 4, 5; GB 40, 39
• Shaoyin: H 7; K 6
• Associated with anger, stress: Liver: 3, 4, 5

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Example: Distant Acupuncture for Shoulder Pain

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Example: Distant Acupuncture for Shoulder Pain

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• Chief complaint: R shoulder pain, aggravated by R abduction
• Exam finding: R abduction painful at mid-range; supraspinatus tests weak, painful
• Injured jing-jin: shaoyang. Injured tissue: supraspinatus tendonosus, impingement
• Treatment jing-jin: shaoyang (TW, GB); shaoyin (H, K); paired zang (Lv)
• Corresponding segments:
• Theory: buttock; clinical experience: proximal calf works better
• Palpate for abnormalities in the regions of and/or use classic xue
• Needle to muscle depth
• Shaoyang: GB 34
• Shaoyin: K 9, 10
• Liver: 6, 7

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Systemic Patterns of Pain & Dysfunction

From Dr. Tan’s “Global Balance” Acupuncture

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• Disclaimer: I am not a certified instructor of Dr. Tan’s acupuncture
• I encourage taking classes from qualified instructors of Dr. Tan’s methods, who can explain the classical derivation of these prescriptions based upon the Yijing and transporting points
• I am sharing only my clinical experience, and applications of my understanding of 3 patterns where signs/symptoms appear heavily-mediated by mood and personality factors
• These protocols can be combined w/other forms of treatment; often work well on their own
• Good response: suggests systemic pathologies: mood, CNS sensitization, inflammation
• Weak or no response: suggests more local structural problem
• Acupuncture: Left-right can be flipped, but contralateral arm-leg relationships should be kept
• Herb Rx: boldface = Dr. Tan’s representative formula. Other formulae that appear to fit the patterns are from my study of Dr. Huang Huang’s classical jing-fang prescriptions. In all cases, I list only psycho-emotional presentation; correlation w/other Hx, Ex findings is needed for Rx

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Jueyin-Shaoyang Dysfunction: Fight!

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Personality: Rigid, rule-oriented, impatient, hard-working, demanding; everything is black or white, no middle ground or easy compromise

Mood/thought: “Things are supposed to be/go a certain way, and I get angry/ impatient/frustrated when they aren’t/don’t.” Hostile depression.

Behavior in clinic: Show up on-time; fold clothes neatly; expect rapid, linear improvement and are willing to work hard, endure discomfort for it; cursing.

Signs/symptoms: Tight muscles, neck; tension headaches; anger disorders.

Consider xiao yao wan, chai hu family formulae such as xie xin tang, si ni san

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Jueyin-Yangming Dysfunction: Fight? Flee? Freeze?

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Personality: Anxious, fearful, untrusting, labile, hypervigilant, confused, anti-authority

Mood/thought: “Things are supposed to be/go a certain way, but I’m afraid they’re not, and that angers and terrifies me. I don’t know what to do!” Emotionally sensitive, negative fixations.

Behavior in clinic: Jittery, obsessive, can’t stop talking rapidly; or “deer in the headlights” scared and distrustful of diagnosis and treatment; needle-phobic, strong startle response.

Signs/symptoms: Anxiety, labile depression; sleep and digestive problems

Consider chai hu jia long gu mu li tang; or ban xia family formulae

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Jueyin-Yangming Presentation: Rx to Consider

Common indications: anxiety-depression, insomnia

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• Chai hu jia long gu mu li T: paralytic depression > anxiety; frustration; introverted, wooden affect; fatigue, nightmares, restlessness; panic and bi-polar disorders
• Ban xia hou po T: labile, fearful, paranoid, OCD, bizarre Sx, white coat HTN; repetitive speech, rapid eye movements and irregular facial expressions
• Ba wei chu fan T: anxiety > depression; nervousness, panic, irritability
• Ba wei jie yu T: sensitive, cautious; multiple symptoms aggravated by emotional stress; labile
• Gui zhi jia long gu mu li T: history of sexual trauma/dysfunction; panic disorder
• Si ni S: mild, young healthy patient who worries about minor symptoms; tense, stressed
• Wen Dan T: phobias, PTSD, OCD, gullible, reactive to external stress, somatizes stress
• Xiao chai hu T: cyclical irritability; mood affects appetite/is affected by hunger
• Zhi zi hou po T: restless irritability, agitation, schizophrenia

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Shaoyang-Shaoyin Dysfunction: Frozen.

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Personality: Older, disabled, retired; apathetic, lethargic, depressed.

Mood/thought: “Things were supposed to be/go a certain way, but everything’s gone wrong. I’ve fought and lost, still angry, but I give up, I’m burned out.” Self-pity, resentment despair.

Behavior in clinic: Slow-responders, negative bias, prone to dropping out, petulant irritability.

Signs/symptoms: Chronic, unresolving low back pain, fatigue; apathetic depression; muscle atrophy and weakness.

Consider tian wang bu xin dan, fu zi formulae

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Course of Treatment, Patient Education

For Distant Acupuncture for Orthopedic Pain & Disability

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• Pain relief may initially be brief: 1-3 days is typical (< 1 day may = tx failure)
• Frequent, consistent treatment (2-3 x/week for 4-6 weeks) may be needed for longer-lasting improvement.
• Interval of relief = frequency of treatment: e.g. 3 days relief = tx every 3 days
• If pain relief is only modest, or only measured in hours, followed by return-to-baseline, consider switching to local/direct treatment.
• If pain relief is significant, but only lasts the remainder of the day/night, frequent repetition may work
• If pain relief lasts several days, and/or pain does not return all the way to baseline, consider repeating distant treatment, unless/until a plateau is reached.
• If pain relief reaches a plateau, consider switching to local treatment

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Combining Local + Distant Acupuncture in Same Visit

For Orthopedic Pain & Disability

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Advantages

• More complete approach to both local, distant, and systemic contributions

Disadvantages

• Can take a long time and a lot of needles!
• More difficult to tell which needle locations/techniques are important to the patient’s improvement, vs. those that may be ineffectual or responsible for adverse reactions

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Combining Local + Distant Acupuncture in Same Visit

Considerations and Recommendations

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• Local disruptive needling, e.g. myofascial trigger point, joint stabilization/mobilization, 7-star needling, can cause significant discomfort
• (Same is true for strong gua sha, tui na, cupping)
• After limits of tolerance are reached, consider:
• Adding, retaining distant needles
• Retaining some local needles and connecting them to an electroacupuncture device
• Provides further stimulation that is more comfortable and can be controlled by patient
• Both allow for a “wind-down time” of relaxation and stress reduction

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Combining Distant w/Electroacupuncture in Same Visit

Considerations and Recommendations

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1. Electroacupuncture (EA) sensation and stimulation is usually much stronger than needles that are inserted and retained, unless they are constantly or frequently manipulated manually
2. EA effects probably override the effects of any retained needles not hooked up to the stimulator
3. One approach used frequently by the author:
1. Insert needles first which will not be used with an electro-stimulator (e.g., scalp, ear, and distal needles, addressing systemic patterns, etc.)
2. (Apply any supplementary modalities (gua sha, tui na, heat, massage, cupping, etc.))
3. Finish with local needles, which are then hooked up to the electro-stimulator
4. By the time electro-stimulation is commenced, the non-electrified needles will have had 10-30 minutes to have their effects before they are overridden by the stimulator

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Combining distant w/electroacupuncture is addressed in greater detail in a companion class:

Electroacupuncture for Orthopedic Conditions.

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Alternating Local + Distant Needling in Separate Visits

For Orthopedic Pain & Disability

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Advantages

• More complete approach to both local, distant, and systemic contributions
• Allows easier identification of which needle locations/techniques are important to the patient’s improvement, vs. those that may be ineffectual or responsible for adverse reactions
• Requires less time and needles at any given visit

Disadvantages

• Can take more acupuncture visits to achieve desired outcomes

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