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News Letter, Vol. 8 (2), March, 2017, © Copyright

Jun Xu, M.D., Hong Su, C.M.D., Lic. Acup. http://www.rmac.yourmd.comwww.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

How Can Acupuncture treat Occipital Neuralgia?

后头痛

 

 

Linda, a 45-year-old female dental assistant, came to me complaining of severe headaches that started at the back of her head and continued down a portion of her neck.  The pain also radiated up to her scalp, around her ears and sometimes into the bilateral temporal area.  The pain was off-and-on, but occurred every day.  The pain ranged from dull to sharp, and was sometimes located directly behind the right eye.  As a dental assistant, she constantly turned her head to the right when dealing with patients.  This caused the headache to become more severe, and she was frustrated that it interfered with her daily work.  She had consulted several doctors about her condition, and had been prescribed Naprosyn, Percocet and Neurotin, but none of them alleviated her condition.

These headaches intensified when Linda was under stress, which was often because of her job: if she had many patients waiting for her and felt under pressure, the headaches worsened.

When I examined Linda, I discovered that when I pressed her scalp at the base of the skull and suboccipital area, the pain radiated to the back, front and side of her head, and also to the right side of the eye.  When I pressed hard on the suboccipital area (the base of the skull) the pain was exacerbated and I could feel the bilateral temporal artery palpating.

The patient probably suffers from occipital neuralgia, which is a cycle of pain spasms originating in the suboccipital area, caused by an inflammation of the occipital nerves.  The two pairs of occipital nerves (each nerve contains a greater and lesser occipital nerve) originate in the second and third vertebrae of the neck.  These nerves supply areas of the skin along the base of the skull and behind the ear, but are not always connected directly with the structures inside the skull. However, they do interconnect with other nerves outside the skull and continue into the neuro-network.  Eventually they can affect any given area along the scalp, mainly on the bilateral temporal area behind the ear and sometimes connect to the nerve branch on either side of both eyes.

Occipital neuralgia may occur continuously, often as the result of the nerve impingement, especially from arthritis, muscle spasm, or as the result of a prior injury or surgery.  Sometimes these conditions will impinge the occipital nerve root, leading to severe headaches at the back of the head, leading to muscle spasm.  Linda exhibits the severe form of occipitical neuralgia, most likely because her profession causes her to tilt her head in the same manner for a good part of her day. This stress causes the occipital nerve to be impinged, sending a constant signal to the nerve network in her scalp, leading to headaches and the pain behind her right eye.

The clinical diagnosis of this condition is based on palpation by the doctor of the bilateral occipital nerve root, which will induce or trigger the headache. Doctors currently use various treatments.  One option is to inject 1% lidocaine 5cc into the occipital nerve root, which decreases or relieves the pain, confirming the diagnosis.  A second option is to use surgery to cut or burn the nerve with a radial wave probe.  A third option is to use a small injection of Botox or a similar medication.  Western medicines include anti-inflammatory or narcotics such as Percocet or Darvocet, Naurontin, anti-epilepsy medication, etc.  For the majority, these medications do not work well, though occasionally they can reduce the occurrence and frequency of the occipital neuralgia.

Some patients respond to physical therapy and massages to decrease the spasm of the neck muscle, which might temporarily relieve the occipital neuralgia.  Though doctors may recommend surgery, many patients resist this type of treatment.

According to Traditional Chinese Medicine, occipital neuralgia belongs in the category of the side headache, i.e. the Shao Yang Gallbladder meridian headache.  Gallbladder meridians are distributed around the sides of the head, and excessive heat in the gallbladder can lead to headaches.  The gallbladder meridian originates from the outside of the eye, and continues up the temporal nerve area, around the lateral skull area, down the occipital nerve area, down through the trunk and to the outside of the leg.  If there is excessive heat along this meridian, there will be an imbalance of yin and yang.  For example, if the patient undergoes stress, muscle spasm or arthritis, the nerve and the gallbladder meridian will be impinged.  This, in turn, will cause the gallbladder to heat up, leading to excessive heat, an imbalance of yin and yang and a severe headache.

Another meridian identified in occipital neuralgia by Traditional Chinese Medicine is the urinary bladder meridian, which starts from the inside corner of the eye, continues through the middle and the top of the scalp, and follows down the back of the trunk and into the back of the leg.  Due to the connection between the gallbladder and urinary bladder meridians, heat in one will cause heat in the other to rise, generating pain around the eye, the temporal area and the scalp, and making the ensuing headache severe and highly unbearable.  Therefore, the principal acupuncture treatment is to relieve this excessive heat in the gall bladder and urinary tract.

穴位

表格

The main acupuncture points used for treatment are: Du 20 Bai Hui, GB 20 Feng Chi, GB1 Tong Zi Liao, GB 8 Shuai Gu, Extra point Tai Yang, GB 34 Yang Ling Quan, SI 3 Hou Xi, Lu 7 Lie Que, Kid 6  Zhao Hai, Li 3 Tai Chong.

Linda underwent my treatment three times a week for one month, resulting in immediate, short-term relief of her headaches.  However, the headaches continued to plague her because of her strenuous work.  In addition, her irregular menstrual cycle and hormonal changes led to more severe headaches.  Thus, I also treated her for hormonal changes by utilizing a Chinese herb Da Zhi Xiao Yao San.  The combination of acupuncture and herbal therapy seemed to be effective and, after about two months of treatment, Linda reported that her headaches occurred only infrequently and were very mild, and that she was satisfied with her treatments.

Usually, acupuncture, with or without the addition of herbal supplements, can alleviate the problems and pain associated with these headaches.  However, sometimes it is best to combine acupuncture with a nerve block (utilizing 4cc of 1% lidocaine plus 10 mg Kenalog mixed together) injected into both sides of the occipital nerve origin.  One month of this combined treatment should give the patient 95% relief from his/her symptoms.

Tips for acupuncturists:

  1. You should identify the location of the pain and tenderness, and treat the headache accordingly.  For example, the frontal headache belongs to the Yang Ming meridian; the temporal side headache belongs to the Shao Yang meridian; the top scalp headache belongs to the Jue Ying meridian.
  2. Always use Du 20 Bai Hui for all the different types of headaches. This is based on my personal experience over 20 years of practice.

Tips for patients:

  1. You should be very specific when describing the tender points on your head because each tender-point location belongs to a different meridian, and treatment varies based on each location.
  2. Massaging the Tai Yang and UB 20 Feng Chi points for 20 minutes, 2 to 3 times a day, will greatly decrease the headache.

 

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News Letter, Vol. 8 (1), March, 2017, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Cervical Dystonia

Cervical dystonia woman

Lisa L. is an 18-year-old female, who had been complaining of neck pain for the past six years.  The patient reports that, six years ago, when she woke up, she suddenly realized that her neck jerked to the left. The jerk happened very often; her neck would jerk two or three times every 5-10 minutes.  The jerk was involuntary and occurred more frequently especially when she was tired or under stress. However, if she had a good night’s rest, felt energized, and focused on something (e.g. her favorite sports), she would not experience the sudden, involuntary neck movements. Only when she sat still, did her neck start to jerk.

Lisa’s neck muscle always feels very tight, and the tightness can be very painful. She has been to many doctors and has tried everything, such as physical therapy and multiple medications, without any improvement. She therefore came to me for evaluation and treatment. Upon physical examination, I noted that the left side of the patient’s sternocleidomastoid muscle had hypertrophied. It felt like a thick rope on the left side of her neck. I also noted that other muscles had undergone hypertrophy: the levator scapular and splenius capitis at the cervicals. Throughout the entire physical examination, there was no jerk or involuntary contraction on the left side of the patient’s neck.

What Lisa is suffering from is called cervical dystonia, which is the most common form of focal dystonia.  Cervical dystonia is characterized by abnormal and spasmodic squeezing of the muscle that leads to muscle contractions in the head and neck area. The movements are involuntary and are sometimes very painful, causing the neck to twist repetitively, resulting in abnormal posture.  Overall, this may affect a single muscle, a group of muscles, such as those in the arms, neck, and legs, or even the entire body.  Patients with dystonia often have normal intelligence and no associated psychiatric disorders.

The causes of cervical dystonia are currently unknown.  There are two types of cervical dystonia:

Primary cervical dystonia: This type of cervical dystonia is not related
to any identifiable, acquired disorders affecting the brain or spinal cord such
as stroke, infection, tumor, or trauma. In some cases, primary cervical dystonia
is genetic, caused by abnormal genes such as dystonia DYT1. However,
because not all carriers of the DYT1 gene develop cervical dystonia, it
is likely that other genes or environmental factors may play a role in the
development of cervical dystonia.

Secondary cervical dystonia: Unlike primary cervical dystonia, secondary
cervical dystonia has obvious causes such as stroke, tumor, infection in the
brain or spinal cord, traumatic brain injury, toxins, birth defect, etc.  There
may be a period of months between the injury and the onset of the dystonia.

Tests and diagnosis:

The first step when diagnosing cervical dystonia is to determine if any of the causes that may lead to secondary dystonia are evident.  The following tests may be used to screen and/or diagnose for secondary cervical dystonia:

1.Toxins and infections screening: blood or urine samples will confirm the presence of toxins and infections.

2.Tumor screening: an MRI will identify and visualize tumors of the brain or spinal
cord.

3.Genetic testing: can be used to identify DYT1, which is critical to the diagnosis
of primary cervical dystonia.

4.Electromyography (EMG) testing: measures electrical activity of muscles.  An EMG can help diagnose muscle or nerve disorders.

Medications:

Many different medications have been used to treat cervical dystonia but most are not effective:

1.Cogentin and Kemadrin are examples of drugs that decrease the level of acetylcholine. These have helped some patients but have sedating side effects.

2.Valium, Ativan, Klonopin, etc., regulate the neurotransmitter GABA.

3.Sinemet, Laridopa, etc. either increase or decrease dopamine levels.

4.Carbamazepine is an anticonvulsant.

Botox injections:

Botox injections can usually stop the muscle spasms by blocking acetylcholine, relieving the symptoms for approximately three months. Very experienced doctors should administer the Botox injections. If Botox is used for more than a one-year period, it will gradually become less effective because the patient’s body will begin producing auto-antibodies against it.

Other treatments:

In some severe cases, surgery may be an option.  Surgery is the last resort and is used to selectively denervate the nerve supplying the muscle.

Another treatment option is deep brain stimulation.  This involves implanting an electrode in the brain connected to a stimulated device in the chest that generates an electrical pulse.  These electrodes will temporarily disable nerve activities by damaging
small areas of the brain.

Chinese medicine:

According to traditional Chinese medicine, cervical dystonia is caused by excessive liver wind. The liver controls the movement of all tendons, muscles and joints in the human body. Excessive liver wind overstimulates the tendons, muscles and joints, constantly activating the muscles. We use the following methods to treat our cervical dystonia patients.

  1. Acupuncture

The principle acupuncture treatment used to treat cervical dystonia reduces the excessive liver wind and thereby decreases the activities of the tendons, muscles and joints. The acupuncture points are along the meridians of the liver and gall bladder, such as the Feng Chi and Tai Chong points.

In addition, because patients with cervical dystonia have abnormal head and neck movements, acupuncture must also be used along the Du meridian, which controls head movement. The Du meridian supplies the entire brain. If the energy of the Du meridian is excessive, the entire head will move abnormally. Therefore, the acupuncture treatment should also include the Da Zhui and Hou Ding points from the Du meridian.  These points will adjust and regulate the Du meridian, the yang, activate the tendon function, and balance the input and output of the energy of the Du meridian.

The acupuncture treatment should also include the Xin Shu, a direct outlet acupuncture point from the heart and the Shen Shu, a connecting point from the kidney. Sheng MenTai Xi and the points listed above are involved in the circuitry of the heart and kidney, and will decrease the fire surrounding these organs, keeping the yin and yang in harmonious balance. Some local points in the neck and head such as Tian ChuangTian RongTian Ding, and Fu Tu, should also be used for their localized calming functions.

This combination of local and distal acupuncture points will greatly decrease the symptoms associated with cervical dystonia.

  1. Moxibustion:

艾灸

Moxa is a Chinese herb similar to cigarette to warm certain points in the human body. We suggest to use the following device to moxa the neck sternocleidomastoid muscle for 30 minutes. Patients should learn how to use it before you use for yourself.

  1. Guasha (Scrape) :

刮痧

Following  the length of  sternocleidomastoid muscle, use the Guasha plate to scrape down 30 times then up 30 times, 5 sessions per day.

 
The patient was treated with acupuncture at the above points for approximately two months, three times a week. After the last treatment, the number of neck contractions had significantly decreased. Now, she only experiences mild neck jerks and contractions, allowing her to perform her daily activities in a normal manner.

Tips for acupuncturists:

  1. Acupuncture cannot treat all forms of cervical dystonia. The milder the disease, the better the treatment results. Physicians should find the cause if the patient is suffering secondary cervical dystonia.
  2. Using heating pads and massages after the acupuncture treatment increases its effectiveness.

Tips for patients:

1.The earlier the treatment, the better the treatment results.

  1. Help yourself with Guasha, Moxa, massage and heating pad.

 

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 Dear Friends:

You are cordially invited by Jun Xu, M.D. to talk and signing of his new book: “Magic Needles, Feel Younger and Live Longer with Acupuncture”

at Auditorium of Christ Church, 254 East Putnam Avenue, Greenwich, CT on Sunday, June 26, 2011 at 10:30 AM. Dr. Xu will also present lecture of ” Neck Pain after Computer Use, Allergy and Sinusitis, How May Acupuncture and Chinese Herbs Help You?” Please join this exciting event.

Jun Xu, M.D. and Staff

News Letter, Vol. 3 (6), June, 2011, © Copyright

 

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720 begin_of_the_skype_highlighting            (203) 637-7720      end_of_the_skype_highlighting

 

 

 

 

     Burning sensation at right lateral thigh                

 

Fig 6.1

Janina S., a 54-year-old female, has been experiencing a tingling sensation and numbness on the outside of her right thigh for six months.  The pain sometimes burned, sometimes was dull and extended to the groin area and the buttock.  It often became worse when Janina did much walking or standing and she felt altered sensation in the front and lateral of thigh.  Sometimes she woke up in the night feeling pain on the lateral front of the thigh.  She consulted her primary care physician who told her she probably had a pinched nerve on her lower back and was given physical therapy, which did not help her at all.  She had an X-ray and an MRI which showed negative findings, so she was frustrated at not getting to the cause of her problem or given any treatment for it.

She was then referred to me for examination and treatment.  I found no tenderness on the lower back or lateral side of the thigh, and no decreased range of motion of the lower back, hip or knee, except that there was slightly  decreased sensation of the anterior and lateral thigh.  I concurred with her regular physician that she probably had a pinched nerve, but need further explanation to the patient.

This nerve is called the lateral femoral cutaneous nerve, which passes underneath the inguinal ligament and might be compressed, thus causing the numbness, tingling and burning sensation in the lateral and anterior thigh.  In most people this nerve passes through the groin to the upper thigh without any compression, but there is a condition, named as meralgia paresthetica, i.e. the lateral femoral cutaneous nerve is trapped and becomes pinched under inguinal ligament.

Fig. 6.2 Anatomy of the lateral femoral cutaneous nerve.

http://emedicine.medscape.com/article/1141848-overview

Fig. 6.3 Sensory distribution of the lateral femoral cutaneous nerve.

Common causes of this compression include the following:

  1. Tight clothing.
  2. Obesity
  3. Pregnancy
  4. Scar tissue around the inguinal ligament
  5. Walking, cycling or standing for long periods of time.
  6. Other conditions such as diabetes, alcoholism and thyroid disorder.

The diagnosis of meralgia paresthetica is based mainly on physical examination and patients’ complaints, especially as laboratory studies such as blood tests and imaging studies – MRI’s, X-rays – are not very specific, though an EMG and nerve conduction studies may be helpful in making a diagnosis.

History

  • When the LFCN is entrapped, patients usually feel pins, needles, numbness, tingling, sometimes burning, sharp pain sensation at the lateral thigh. Because individual LFCN distribution might be different, some patients may have the above symptoms, i.e.paresthesias at frontal and/or back of the thigh, or groin area.
  • Symptoms are typically unilateral.  However, they may be bilateral in up to 20% of cases.
  • Biking, Swimming, walking, standing, running  may aggravate the symptoms; sitting tends to relieve them.

Physical Examination:

  • Numbness, tingling sensation, i.e. paresthesias, can be revealed  at frontal and lateral thigh.
  • Occasionally, patients are very sensitive to touch, and feels burning, and sharp pain with palpation, i.s. hyperesthetic in this area.
  • Tapping over the upper and lateral aspects of the inguinal ligament or slightly over extending the thigh backward, which stretches the nerve, may reproduce or worsen the paresthesias.
  • Pelvic compression testing is positive. By deep palpation just below the anterior superior iliac spine at the groin area may reproduce the symptom.
  • Motor strength in the involved leg most likely is normal.

Treatment with western medicine:

  1. Lifestyle and home remedies such as avoidance of tight clothes, weight loss, maintaining a steady low weight and avoiding standing or walking for long periods can be helpful.
  2. Medications.  There are many helpful medications for this condition, including corticosteroid injections which can reduce inflammation and temporary relief of pain, also tricyclic antidepressants and Neurotin.
  3. Physical therapy
  4. When the pain is severe, a focal nerve block can be done at the inguinal ligament with a combination of lidocaine and corticosteroids. This should temporarily relieve the symptoms for several days to weeks. Ultrasound guidance for the blockade may be beneficial in patients with regional anatomical variations.

Traditional Chinese medicine:

  1. Acupuncture body acupuncture:

The acupuncture points usually I choose are: Sp 12 Chong Men, Sp 13 Fu She, GB 29 Ju Liao, GB 31 Feng Shi, GB 32 Zhong Du, Arshi, GB 34 Yang Ling Quan, Sp 10 Xue Hai and Liv 3 Tai Chong.

These insertions are combined with electrical stimulation for 30 minutes three times a week for about four weeks.

Points Meridan/No. Location Function/Indication
1. Chong Men Sp 12 Superior to the lateral end of inguinal groove, on the lateral side of the femoral artery, at the level of the upper border of symphysis pubis Abdominal pain, hernia, dysuria, local groin pain
2. Fu She Sp 13 0.7 inch laterosuperir to Chong Men, 4 inch laeral to the midline of the body Lower abdominal pain, hernia, local groin pain
3. Ju Liao GB 29 In the depression of the midpoint between the anterosuperior iliac spine and the great trochanter Pain and numbness in the thigh and lumbar region, paralysis, muscular atrophy of the lower limbs
4. Feng Shi GB 31  On the midline of the lateral aspect of the thigh, 7 inch above the transverse politeal crease. When the patient is standing erect with the hands clse to the sides, the point is where the tip of the middle finger touches Pian and soreness in the thigh and lumbar region, paralysis of the lower limbs, beriberi, gereral prutitus
5. Zhong Du GB 32 On the lateral aspect of the thigh, 5 inches above the transverse popi\liteal crease, between vastus lateralis and biceps femoris muscles Pain and soreness of the thigh and knee, numbness and weakness of the lower limbs, hemiplegia
6. Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
7. Xue Hai Sp 10 When the knee is flexed, 2 inch above the medial edge of patella. Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
8. Tai Chong Liv 3 On the dorsum of the foot, in the depression distal to the junction of the first and second metatarsal bones. Headache, dizziness and vertigo, insomnia, congestion, swelling and pain of the eye, depression,, infantile convulsion, deviation of the mouth, pain in the hypochondriac region, uterine bleeding, hernia, enuresis, retention of urine, epilepsy, pain the anterior aspect of the medial malleolus

Fig 6.4

Fig 6.5

  1. Blossom needles should tap the front and lateral of the thigh skin, allowing the lateral femoral cutaneous nerve distribution.

Fig. 6.6

Janina underwent treatment with both acupuncture and blossom needle tapping and was much improved after five visits.

Tips for patients:

  1. You have to talk to an MD physician to find out other possible diagnosis, such as Lumbar Sacral radiculopathy, Sciatica and peripheral polyneuropathy, etc.
  2. Check if you are wearing a tight cloth, sometimes, you only need wear a loose cloth.
  3. If you are overweight, you may have to lose weight.
  4. If you like bike or other repetitive exercise, please pay attention to the inguinal area, you have to rest a while then restart your exercise.

Tips for Acupuncture practitioners:

  1. Make sure you have a clear diagnosis, if the patient has other illness instead of lateral femoral cutenous neuropathy, the above treatment will not work.
  2. You may have to use both body and blossom needles to treat your patients.

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News Letter, Vol. 3 (3), March, 2011, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

 

 

 

Hip Pain and Osteoarthritis


Luke L, a moderate obese, 45-year-old male had pain in his right hip for five years. The pain was of gradual onset and it sometimes radiates down through his right groin and right lateral thigh.  He feels stiff and tight, and has difficulty walking and climbing the stairs.  When in college, Luke was a football player, and now he still plays a lot of tennis and running.  He sometimes felt pain in his right hip, however, he did not pay much attention to it.  Over the last five years,  the pain has intensified and recently becomes worse, to the extent of disturbing his sleep and limiting him to the point where he could only walk for a short distance.

He first consulted an orthopedic doctor who ordered an X-ray, which showed the joint space was narrowing with bone spur and subchondral sclerosis.

His doctor told him this was typical osteoarthritis of the hip, and, because the pain was so severe,  Luke was given one steroid injection right away.  He felt better for two months, but the effects of the shot wore off and the pain once again became worse.  He returned to his orthopedic doctor and received second steroid injection. His orthopedic doctor   told him that he probably needed a total hip replacement.  As Luke is only 45 years old, he is  reluctant to have the hip replacement, therefore, he consulted me.

On examination, I noticed when he walked he had a short swing of his right leg and he only could bear his weight on right leg with very short time, the short swing and  stance phase on the affected side is called antalgic gait.  In checking his range of motion, there appeared to be decreased external and internal rotation of the hip and the pain is elicited on the range of motion.  An X-ray confirmed that Luke had severe osteoarthritis of the right hip.

There are different causes for hip osteoarthritis, however, the most common cause is secondary (i.e. from an injury).

  1. Primary osteoarthritis is aging related osteoarthritis. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates. After a certain period, the water content might also “dry out” after the cartilage gradually disappears, eventually, cartilage begins to degenerate by flaking or forming bone spurs. In advanced cases, there is a total loss of cartilage cushion between the bones of the joints.
  2. Secondary Osteoarthritis, i.e. the Repetitive use of the worn joints over the years, such as runners, tennis players, mountain climbers and martial art performers, etc,  can irritate and inflame the cartilage, causing joint pain and swelling. Loss of the cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths (bone spurs, also referred to as osteophytes) to form around the joints. Osteoarthritis occasionally can develop in multiple members of the same family, implying a hereditary (genetic) basis for this condition. The following are the secondary causes of hip osteoarthritis

1.      Sports or other sports-related injuries such as Luke’s – who was a marathon runner, who spent much time running– gradually changed the alignment of the hip and eventually leads to wear and tear on the joint surfaces.

2.      Avascular necrosis.  Many patients who drink alcohol excessively, and undergo steroid injections at the hip joint or took oral steroid for long period of life time, such as Lupus, or organ transplant recipients, might experience this condition, avascular necrosis is a death of the femoral head without sepsis.  This is caused by interruption of the vascular supply to the femoral head.  Luke had two such injections, which may have caused worsening of the hip osteoarthritis and possible avascular necrosis.

3.      There are other causes, such as obesity, trauma, surgery, gout, diabetes and high uric acid, all of which can cause osteoarthritis.

Fig 3.1

Treatment of osteoarthritis depends on the stages of the condition and the age of the patient.

In the early stages, the following are indicated:

1.      Weight reduction and the avoidance of activities that exert excessive stress on the joint cartilage.  For Luke this meant he needs to lose 30-40 pounds (he lost 35) and stop playing tennis and running.  Instead he was encouraged to peddle a stationary bicycle and swim.  He rode his bike about 45 minutes a day and swam 3-4 times a week, and these activities, plus the weight he lost, put much less strain on his hip.

2.      Anti-inflammatory medications such as aspirin, acetaminophen and naproxen, also anti-inflammatory lotions, dicolfenac and pain patch, Flector may help to decrease pain.

3.      Injections: Hyaluronic acid injection is a chemical which can work by temporarily restoration of the thickness of the joint fluid and allow better joint lubrication and impact capability.  Steroid injections can decrease the inflammation, thereby decreasing the pain of the joint.

Ultrasound machine may clearly identify the space of the hip joint and your physician can easily insert the needle into the hip joint and make an accurate injection at the hip joint under the guidance of ultrasound machine. Therefore, if you consider an injection of the hip joint, you should ask your physician if he or she uses the ultrasound guided technique.

Fig 3.2

4. Physical therapy:

4-way Hip Exercises on Mat

Start off with 3 sets of 10 reps for 30 reps total.  Next session try 2 sets of 15 reps, then after that session try 1 set of 30 reps.  Continue to progress by adding an ankle weight such as 2.5# and work up again from 3 sets of 10, 2 of 15 to 1 of 30, finally progressing to a 5# ankle weight and repeat the repetition cycle.

Hip Flexion involves lying on your back with one knee bent and the working leg straight being lifted up to the height of the opposite knee than down slowly.

Hip Extension involves lying on your stomach and lifting one leg up about 10-12” then down slowly.

Hip Abduction and Hip Adduction both involve lying on your side.  Hip Abduction involves the top leg being lifted up around 20” then down slowly.  Hip Adduction involves crossing the top leg over the bottom leg and performing the exercise by lifting the bottom leg off the table about 10” then down slowly.

Fig 3.3

http://www.sportsinjuryclinic.net/cybertherapist/corestability.php

http://www.best-leg-exercises.com/ankle-weights.html

4-way Hip Exercises Standing

After building the strength to perform 5# for 30 reps continue to progress by performing the 4-way Hip Exercises Standing with a TheraBand working the same repetition scheme.  Performing these exercises in standing offers numerous benefits; from closely mimicking functional activities of daily living to improving balance.  You can have a chair for support, but gradual try not to hold on to it.  By not holding the chair you will feel the additional benefit of the stabilizing muscles around the hip that is supporting the body being worked; as well as the leg with the TheraBand performing the movement.

The first two pictures shown are Hip Flexion then Hip Extension.  The following two are Hip Abduction then lastly Hip Adduction Exercises.

Fig 3.4

http://www.runnersworld.com/article/1,7124,s6-241-286–13410-0,00.html

http://www.resistancetubes.com/exercises.html

http://www.sportsinjuryclinic.net/cybertherapist/front/knee/anterior_cruciate_ligament/strengthening.php

Another two great exercises to include both help improve rotation in the hips are the Clam Shell and the Seated External Rotation Exercise.  The Clam Shell can easily be performed with the 4-way Hip Exercises on the Mat.  In this movement keep the feet together but rotate the top knee up then down slowly.  A weight or TheraBand can easily be added to increase the difficulty of the movement.

Fig 3.5

http://blog.victoriawellness.com/tag/hip-abduction/

With the Seated External Rotation Exercise keep the knees close as you move the foot away from the other foot to help work such muscles as the piriformis.

Fig 3.6

http://www.runnersworld.com/article/1,7124,s6-241-286–13410-0,00.html

5.      Arthroscopy. Arthroscopy of the hip is a minimally invasive, outpatient procedure that is relatively uncommon. The doctor may recommend it if the hip joint shows evidence of torn cartilage or loose fragments of bone or cartilage.

6.      Osteotomy. The procedure involves cutting and realigning the bones of the hip socket and/or thighbone to decrease pressure within the joint. In some people, this may delay the need for replacement surgery for 10 to 20 years. Candidates for osteotomy include younger patients with early arthritis, particularly those with an abnormally shallow hip socket (dysplasia).

In late stage of hip osteoarthritis, the following is indicated:

Following the progress of osteoarthritis of the hip, when the patient has pain even at rest and difficulty walking upstairs, it is recommended that the patient use a cane and consult a surgeon about replacement of the hip joint.  Total hip replacement is now performed almost as a matter of routine, which can bring dramatic pain relief and improved function. The followings are the surgical options of hip replacement.

1.     Hemi-Arthroplasty

Fig 3.7

From: http://www.eorthopod.com/content/hemiarthroplasty-hip

  • As its name implies, hemi, or “half” of an arthroplasty. This procedure is usually performed as treatment for a hip fracture.  The femoral head, due to irreparable damage to the blood supply, yet the patient’s acetabulum (socket) is in good condition, and not in need of a prosthetic cup implant.

The fractured femoral head is removed, a corresponding head implant is inserted into the remained femur bone canal, reamed to accommodate a prosthetic stem. These parts are either cemented into place, or “press-fit” to stimulate bone in-growth into the prosthesis. It is a very stable combination, and allows for early mobilization of the typical elderly patient to reduce the risks of other medical complications.
2. Traditional Hip Replacement

Fig 3.8

http://www.hosmatnet.com/Joint.htm

Traditional total hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip in order to dislocate the hip joint.

Once the joint has been opened up and the joint surfaces exposed, the ball at the top of the thigh bone, or femur is removed. A cup-shaped implant is then pressed into the bone of the hip socket. It may be secured with screws. A smooth plastic bearing surface is then inserted into the implant so the joint can move freely.

Next, the femur is prepared. A metal stem is placed into the femur, or the thigh bone, to a depth of about 6 inches. A metallic ball is then placed on the top of the stem. The ball-and-socket joint is recreated. The stem implant is either fixed with bone cement or is implanted without cement. Cementless implants have a rough, porous surface. It allows bone to adhere to the implant to hold it in place.

2.     Minimally Invasive Hip Replacement

Fig 3.9

http://www.cleburneorthopedics.com/hip_replacement.html

Minimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions. Candidates for minimal incision procedures are typically thin, young, healthy individuals. The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. You should consult your orthopedic doctor for the possibility of this particular procedure. The benefit of the procedure are less pain, shorter hospital stay and better cosmetic and faster rehabilitation.

Treatment by traditional Chinese medicine:

Acupuncture must be combined with the above treatment to get better results. Acupuncture, as other treatments, can not prevent the arthritis develop further, however, acupuncture can dramatically decrease arthritic pain, decrease the swelling and inflammation,  and effectively delay the surgical procedure.

There are two types of pathology of hip arthritis as per Traditional Chinese Medicine:

  1. Cold stasis: the typical symptoms are hip pain when the weather gets cold, windy or rainy. Many patients said: “ I do not need the weather man, I know it will be rainy or snow”. This is because the patients’ defensive system is not strong enough, weather changes make skin and joints sensitive, therefore, the invasive pathogens will be easier to get into the joints and make the joints stiff and pain.
  2. Hot stasis: the typical symptoms are swelling, hot and pain at the joints accompanied with low fever, red and painful touch at the joints, thirsty, annoy, depressed, constipated, hot urination, dry skin, wasted muscle, etc.

Acupuncture Points:

Main points: GB 30 Huan Tiao, GB 34 Yang Ling Quan, Arshi at the hip joint

Specific points for Cold Stasis:  GB 20 Feng Chi, UB 18 Ge Shu, Sp 10 Xue Hai, Liv 3 Tai Chong,  UB 23 Sheng Shu, Ren 4 Guan Yuan.

Specific points for Hot Stasis: Ren 6 Qi Hai, Sp 6 San Ying Jiao, Ki 3 Tai Xi, Du 14 Da Zhui.

Points Meridan/No. Location Function/Indication
1 Huan Tiao GB 30

At the junction of the lateral 1/3 between the great trochanter and the hiatus of the sacrum.

Pain of  the lumbar region and the thigh, muscular atrophy of the lower limbs, hemiplegia
2 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
3 Feng Chi GB  20 In the depression between the upper portion of m. sternocleidomastoideus and m. trapezius, on the same level with Fengfu (Du 16) Headache, vertigo, insomnia, pain and stiffness of the neck, blurred vision, glaucoma, red and painful eyes, tinnitus, convulsion, epilepsy, infantile convulsion, febrile diseases, common cold, nasal obstruction, rhinorrhea.
4 Ge Shu UB 18 1.5 inch lateral to the midline, at the level of the lower border of the spinous process of the ninth thoracic vertebra Jaundice, pain in the hypochondriac region, redness of the eye, blurring of vision, night blindness, mental disorders, epilepsy, back  pain, spitting of blood, epistaxis
5 Xue Hai Sp 10 When the knee is flexed, 2 inch above the medial edge of patella. Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
6 Tai Chong Liv 3 On the dorsum of the foot, in the depression distal to the junction of the first and second metatarsal bones. Headache, dizziness and vertigo, insomnia, congestion, swelling and pain of the eye, depression,, infantile convulsion, deviation of the mouth, pain in the hypochondriac region, uterine bleeding, hernia, enuresis, retention of urine, epilepsy, pain the anterior aspect of the medial malleolus
7 Sheng Shu UB 23 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the second lumbar vertebrta Nocturnal emission, impotence, enuresis, irregular menstruation, leucorrhea, low back pain, weakness of the knee, blurring of vision, dizziness, tinnitus, deafness, edema, asthma, diarrhea
8 Guang Yuan Ren 4 On the midline of the abdomen, 3 inches below the umbilicus Lower abdominal pain, indigestion, diarrhea, prolapse of the rectum, enuresis, nocturnal emission, frequency of  urination, retens\tion of urine, hernia, irregular menstruation, dysmenorrheal, uterine bleeding, postpartum hemorrhage.
9 Qi Hai Ren 6 On the midline of the abdomen, 1.5 inch below the umbilicus Abdominal pain, enuresis, nocturnal emission, impotence, hernia, edema, diarrhea, dysentery, uterine bleeding, irregular menstruation, dysmenorrheal, amenorrhea, morbid leucorrhea, postpartum hemorrhage, constipation, flaccid type of apoplexy, asthma
10 San Yin Jiao Sp 6 3 inches directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibiaFigure 24.22 Abdominal pain, distension, diarrhea, dysmenorrheal, irregular menstruation, uterine bleeding, morbid leucorrhea, prolapse of the  uterus, sterility, delayed labor, night bed wet, impotence, enuresis, dysuria, edema, hernia, pain in the external genitalia, muscular atrophy, motor impairment, paralysis and leg pain, headache, dizziness and vertigo, insomnia
11 Tai Xi Ki 3 In the depression between the medial malleolus and tendo calcaneus, at the level of the tip of the medial malleous.Figure 24.21 Sore throat, toothache, deafness, tinnitus, dizziness, spitting of the blood, asthma, thirst, irregular menstruation, insomnia, nocturnal emission, impotence, frequency of micturition, low back pain.
12 Da Zhui Du 14 Below the spinous process of the seventh cervical vertebra, approximately at the level of the shoulders Neck pain and rigidity, malaria, febrile diseases, epilepsy, afternoon fever, cough, asthma, common cold, back stiffness.

Fig 3.10

Fig 3.11

Fig 3.12

Luke underwent my treatment so his pain temporarily decreased and the goal for this patient was to delay the total hip replacement procedure as long as possible.  Therefore, Luke swims, rides his stationery bike and continues his weight loss, all of which put off the necessity of an operation for another two or three years.

Tips for patients:

1.      Osteoarthritis of the hip is a progressive inflammation of the hip, for which there is no cure.  Acupuncture can help – with other treatments –in delaying and decreasing the pain, however, the progress of worn cartilage is unpreventable.

2.      For patients in their fourth or fifth decades, total hip replacement should be delayed as long as possible, because the mechanical joints usually last only about 15 years.  If the patient undergoes this procedure too soon, you will expect to have it repeated in a decade and a half, so it would be best to put it off as long as is feasible.  A second operation might increase the risks for surgery and its side effects.

3.      Weight loss, swimming and peddling a stationery bicycle are the keys for the patient to help yourself. The patients should not perform the sports with high impact on the hip, such as  running, jumping, etc.

Tips for acupuncturists:

1.      There are many hip diseases that also cause pain, such as greater trochanteric bursitis, piriforms syndrome, iliopsoas bursitis and tendonitis, avascsualr necrosis of the femoral head and hip fractures, so it is important to properly differentiate among all the forms of hip pain.

2.      You must differentiate the cold type from the hot one, because the treatments are different.

Read Full Post »

News Letter, Vol. 3 (1), February, 2011, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Carpal Tunnel Syndrome

http://www.0831120.com

Jessica is a 35 year old computer programmer, who for the last 15 years, works roughly 10 hours a day at the computer.   For last 2 years, she started to feel right hand numbness and tingling sensation along her thumb, index and middle fingers. This sensation often occurs while holding a steering wheel, phone, newspaper or upon awakening. She very often “shakes out” her right hand to try to relieve symptoms, especially when the pain interferes with sleep waking her up. As the disorder progresses, the numb feeling becomes constant. She sometimes also feels right wrist pain radiating up to arm and shoulder, and also down to palm, especially at end of the day after spending a long time typing. She has difficulty holding a book or cup and very often drops her book or other objects. She tried to massage her hand and wrist, however, she felt no improvement. She then came to me for evaluation and treatment.

I performed a physical examination, finding out while I squeezed her right palm together and held for 2 mins, she started to feel numbness and tingling sensation at thumb, index and middle fingers. By comparison, her muscles of  right thumb and lateral palm are slightly atrophy and the sensation is decreased by using pinpoint.  Suspecting this patient had carpel tunnel syndrome, I also performed the following two tests:

1. Tinel’s sign. I used my hammer to tap lightly at the middle line of the wrist above the carpal tunnel, so the patient felt the sensation of tingling or pins and needles following to the first three fingers.

Fig 2.1

http://www.flickr.com

2. Phalen’s maneuver.  I asked the  patient to flex the wrist about 60-80 degrees, then waited for one minute, which caused her to feel numbness and tingling following along the median nerve distribution.

Fig.2.2

http://www.flickr.com

Jessica most likely suffered from carpal tunnel syndrome. Carpal tunnel is a tunnel located at the midline of palm adjacent to the wrist, median nerve lies inside the tunnel.  The median nerve is a mixed nerve, meaning it has a sensory function and also provides nerve signals to move your muscles (motor function). The median nerve provides sensation to your thumb, index finger, middle finger and the middle-finger side of the ring finger.

Fig. 2.3

http://www.thepainsource.com

Pressure on the nerve can stem from anything that reduces the space for it in the carpal tunnel.

There are several causes of carpel tunnel syndrome:

1.      Most are idiopathic (not knowing the cause)

2.      Genetic predisposition.  Many families have this tendency toward carpel tunnel syndrome.  About 50% of those who develop the condition are women, where this complaint runs in the family. It may be that your carpal tunnel is more narrow than average.

3.      Professionally related.  Though there is some controversy over this, certain professions such as data entry technicians, secretaries, construction workers etc. have high liability toward carpel tunnel syndrome.  Repetitive flexing and extending of the tendons in the hands and wrists, particularly when done forcefully and for prolonged periods without rest, can increase pressure within the carpal tunnel. Injury to your wrist can cause swelling that exerts pressure on the median nerve.

4.      Diseases related conditions such as trauma, pregnancy, multiple myeloma, amyloid, rheumatoid arthritis, acromegaly, mucopolysaccharidosis or hypothyroidsm compress the median nerve, and all can cause the symptoms of carpel tunnel syndrome.  If the cause of the disease is treated, then carpel tunnel syndrome will gradually disappear.

How is carpal tunnel syndrome diagnosed?

1.      Most important: Your symptoms.  As mentioned above, if  you have numbness and tingling sensation at thumb, index, middle and half of the ring fingers, if you wake up and shake your hand try to relieve hand pain and numbness, if  you very often drop off the object, such as books, cup, pen, etc., the diagnosis of carpal tunnel syndrome is suspected.

2.       By physical examination:  Sometimes tapping the front of the wrist can reproduce tingling of the hand, and is referred to as Tinel’s sign and Phalen’s sign of carpal tunnel syndrome. Symptoms can also at times be reproduced by the examiner by bending the wrist forward (referred to as Phalen’s maneuver).

3.      Nerve Conduction Velocity test (NCV)and Electromyogram (EMG) :

The golden standard for the diagnosis of carpel tunnel syndrome is electrophysiological testing, i.e. nerve conduction and electromyography.  Usually a physical examination, coupled with the patient’s complaints on her condition, are sufficient to make an accurate diagnosis.  However, the final diagnosis depends on the electrophysiological testing. The test not only will tell you the diagnosis, but also the types of treatment and prognosis, if your condition needs physical therapy, acupuncture, brace, steroid injection, or surgery, etc. if your condition is reversible or non-reversible, etc.

There are two parts of electrophysiological tests, i.e. Nerve Conduction Velocity Study (NCV) and Electromyography (EMG). It usually is performed by Physiatrists, i.e. Physical Medicine and Rehabilitation Doctor, or Neurologists with special training on the test.

NCV involves with mild to moderate electrical current stimulation at patient’s median nerves at the elbows and wrists of both side, then a computer will record the responses of the nerves and compare the velocity, amplitude and latency. By comparing with normal standard, also the patient’s left side median nerve with right side, your physician will identify injury at the median nerves if you have any.

EMG test applies a very fine needle into your muscles at the palm, arm and neck. The needle contains a microscopic electrode, which picks up both normal and abnormal electrical signals given off by a muscle. If there is nerve damage, the muscles supplied by the nerve will send out abnormal signals. Because median nerve originates from cervical spine, i.e. on the neck and go through entire arm and  lateral palm, therefore, some muscles will be examed with the needles.

The test usually will take about 30 min to one hour depending on how severe your condition and how extensive of a study your physician would choice. You may feel mild discomfort with the test, however, 99.9% of my patients easily take the test from my hand.

4. Blood tests may be performed to identify medical conditions associated with carpal tunnel syndrome. These tests include thyroid hormone levels, complete blood counts, and blood sugar and protein analysis. X-ray tests of the wrist and hand might also be helpful to identify abnormalities of the bones and joints of the wrist.

How is carpal tunnel syndrome treated?

Carpal tunnel syndrome can be classified as three types: mild, moderate and severe, depends on their symptoms and electrophysiological testing.

For mild and moderate cases, the following treatments are recommended:

1.      Immobilizing braces.  A wrist splint can help limit numbness by preventing wrist flexion, which might compress the median nerve.  The patient should wear a night splint, usually called a cock-up splint and the wrist should be hyperextended above 30 degrees.  Worn overnight for 7-8 hours, the nerves are rested and, in the morning, the patient feels much relieved and the symptoms will gradually improve.

Fig. 2.4

http://www.healthwise-everythinghealth.blogspot.com

2.      Physical Therapy

It is very important to improve mobility in the wrist flexors by means of stretching to rid of any restrictions and inflammation being placed through the carpal tunnel where the tendons of the wrist flexors and median nerve pass through.  To perform this stretch pull the fingers and thumb back to you with your palm facing away from the body.  This stretch for the wrist flexors can be progressed to placing the hand on a wall or a table.  A strong but comfortable stretch should be performed 2-3 times a day and held for 30-60 seconds.

Fig. 2.5

http://www.revolutionhealth.com/articles/stretches-to-ease-wrist-and-arm-fatigue/zm2290

In addition to stretching the wrist flexors, great research on Nerve Gliding has shown quicker decreases in levels of pain, increased grip strength, improved function, while decreasing need for surgery.  Patients performing Nerve Gliding Exercises underwent surgery over 30% less then those not performing the technique (Rozmaryn LM, Dovelle S. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J Hand Ther. 1998 Jul-Sep;11(3):171-9).

Fig. 2.6

http://daiseypt.com/articles/cts_conservative.htm

Modalities that have evidence behind them to effectively treat carpal tunnel are Ultrasound, Iontophoresis and Low Level Laser Therapy.  The American Academy of Orthopedic Surgeons recommends Ultrasound as a treatment option to assist with short and medium term benefits of carpal tunnel.  Iontophoresis with Hydrocortisone was very effective in mild and moderate stages of carpal tunnel.  Low Level Laser Therapy study results include decreased pain, numbness and tingling and improved function, grip strength, EMG results and patient satisfaction.

Fig. 2.7

http://ericksonchiropractic.com

Fig. 2.8

http://www.riversidechirorehab.com

Carpal Mobilizations have been shown to improve symptoms related to carpal tunnel.  A qualified physical therapist can perform such mobilizations to improve joint mobility and remove compressive joint forces off the median nerve at the thumb, wrist and elbow.

Fig. 2.9

http://www.rumsua.org/Upcoming_Book_.php

Other manual techniques with great research behind them in their effectiveness to treat carpal tunnel are categorized as bodywork or soft-tissue treatments.  Active Release Technique (ART) and Graston Technique are two such techniques fitting into this category.  Both ART and Graston showed improvements in mobility, strength and nerve conduction latencies at the wrist by working to remove restrictions and adhesions in the muscles and tendons of the wrist flexors. (Burke, Buchberger, et al. A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome. 2006.)

Fig. 2.10

http://www.sportfitrehab.com/ActiveReleaseTechnique/tabid/1356/Default.aspx

Fig. 2.11

http://www.therapytimes.com/content=0802J84C48768694404040441

Eighty-one percent of CTS patients in a private study attained

80 to 100% of decreased pain and increased function goals

in 10 treatments with the Graston Technique®.”

AOTA Annual Conference and Exposition [carpal tunnel syndrome poster presentation]. 2000 Apr. http://www.grastontechnique.com/Findings.html

Strength of the forearm muscles is important to assess.  With carpal tunnel there is an imbalance with the wrist flexors being predominantly stronger then the wrist extensors.  The wrist extensors must be strengthened to maintain balance to the forearm and wrist.  This will be accomplished by performing 2-3 sets of 10 repetitions with increasing levels of resistance bands or dumbbells.

Fig. 2.12

http://www.physioadvisor.com.au/8122850/wrist-strengthening-exercises-wrist-rehabilitati.htm

There is also great research showing the positive effect of Eccentric Strengthening Exercise to the Wrist Flexors to improve both Strength and Length of the muscle.  Eccentric Muscle Contraction is when the muscle is being activated while lengthening.  This would be performed by slowly lowering the wrist to the starting position over a period of 5 seconds for 2 sets of 10 repetitions.

Fig. 2.13

http://www.emedx.com/apex/apex_exercises/apex_wrist_flexor_strengthening.htm

It is also important to assess posture overall.  Many symptoms of carpal tunnel syndrome can be the result of improper posture at the shoulders and neck.  A few simple exercises to help correct any imbalances at the shoulders and neck should be part of the carpal tunnel program such as Shoulder External Rotation and Upper Traps Stretch.

Fig. 2.14

http://www.sportsinjuryclinic.net/

Fig. 2.15

http://www.wholistichealthworks.com/dealing_with_a_pain_in_the_neck.htm

Even with all the treatment approaches listed previously, if the underlying problem, such as inappropriate stresses placed to the body while at work, are not corrected the problem will resurface.  Physical Therapist also play an important part in educating the patient on proper ergonomics and even visit work sites to properly set up office spaces to ensure proper arm and wrist position.

Fig. 2.16

http://blog.scad.edu/bcasam20/2011/02/01/

Fig. 2.17

http://chirohealthwellness.com/custom_content/c_97882_sitting_survival_workshop_for_your_emplo.html

3.      Western medicine also uses nonsteroid  anti-inflammatory drugs such as Aleve and naproxen, or even some steroid drugs taken orally.

4.      Localized steroid injections.  Steroid injections can be used for mild and moderate forms of this syndrome, and are very effective for temporary relief. However, these injections are not recommended for severe carpel tunnel syndrome.

Fig. 2.18

http://www.aafp.org

5.      Acupuncture.  Acupuncture is also very effective for mild to moderate forms of this syndrome.  The points used are PC 7 Da Ling and PC 6 Nei Guang Usually after inserting the needles at these two points, it is effective to introduce electrical stimulation whose direction should be toward the fingertip.  The patient should feel the needle sensation radiating to the tips of the fingers and sometimes feels swelling and sore and experiences electrical shock to the fingertip.  This treatment is most effective three times a week for a month, while during the nighttime she should wear a cock-up splint for sleep.  Many patients get excellent results from the combination of these two treatments.

Table 2-1

Points Meridan/Number Location Function/Indication
1 Da Ling Pericardium 7 In the middle of the transverse crease of the wrist, between the tendons of palmaris longus and flexor carpi radialis Cardiac pain, palpitation, stomach ache, vomiting, mental disorders, epilepsy, stuffy chest pain in the hypochondriac region, convulsion, insomnia, irritability, foul breath, pain of the elbow, arm and hand.
2 Nei Guang Pericardium 6 2 inch above the transverse crease of the wrist, between the tendons of palmaris longus and flexor radialis Cardiac pain, palpitation, stuffy chest, pain in the hypochondriac region, stomach ache, nausea, vomting, hiccup, mental disorders, epilepsy, insomnia, febrile diseases, irritability, malaria, contracture and  pain of the elbow, arm and hand.
3 Qu Ze Pericardium 3 On the transverse cubital crease, at the ulnar side of the tendon of biceps brachii Cardiac pain, palpitation, febrile diseases, irritability, stomach ache, vomiting, pain in the elbow, arm and hand, tremor of the hand and arm.

Fig. 2.19

For severe carpel tunnel syndrome, surgery is the best option.  There are  two major type surgeries, i.e. open hand surgery and endoscopic surgery.
In carpal tunnel release, your surgeon cuts the tissue that holds joints together (carpal ligament) to relieve the pressure on your median nerve. You’ll have local or regional anesthesia, and you’ll usually go home soon after your surgery. Surgery usually results in significant improvement in your symptoms, but you still may experience some residual numbness, pain or weakness.

In endoscopic surgery, your surgeon performs carpal tunnel release through one or two small incisions in your hand or wrist using a device with a tiny camera attached to it (endoscope) to see inside the carpal tunnel.

Jessica underwent my treatment for a total of 12 visits and used a cock-up splint at night and rested her hand for one month without typing.  Gradually her symptoms lessened and she felt much less numbness and tingling sensation; her hands recovered their strength as well.

Tips for both acupuncturists and patients:

1.                              A clear diagnosis is necessary.  Some patients feel numbness and tingling in their fingers and hands without having carpel tunnel syndrome.  These sensations might be due to rheumatoid arthritis, osteoarthritis and other causes and if the diagnosis is not correct, the acupuncture and a cock-up splint cannot help.

2.                              The insertion of the acupuncture needles for the two points PC7 and PC 6 should not be too deep, about ½ inch, however, the electrical stimulation should be as strong as possible and as tolerable so it will bring enough energy to flow through the carpal tunnel and decrease the swelling of the hand.

3.                              I usually encourage the patient to wear the cock-up splint not only at night, but as much as is practicable during the day, while driving, doing housework, etc. which will greatly improve the patient’s rest on the median nerve and the carpal tunnel.

Read Full Post »

News Letter, Vol. 3 (1), January, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Low back pain-spine compression fracture

Collapse of the bone in the spine

http://www.yanduguke.com

Linda S. is a 70 year old female, who complains of low back pain the day after she bent down to pick up her 1 year old granddaughter. She felt sudden onset low back pain; she had no history of low back pain before. She immediately felt entire low back spasm and was unable to bend forward and move her back. She had difficulty sitting and standing, the only position she felt comfortable was lying on the bed. She called her daughter right away; she was put on bed rest, she thought she might have low back sprain, she would get better after rest on the bed overnight. However, at the second day, she still felt the pain was sharp and stabbing, she could not move. Therefore, she was brought to me for evaluation and treatment.

By inquiry of her pain, she reported her pain was constant, and the pain also felt at the right hip, accompanied with stomach ache, slightly shortness of breath. But there were neither pain radiating down to legs nor urinary nor bowel incontinency; she denied any numbness or tingling sensation. The patient had history osteoporosis for 20 years, she was advised to take vitamin D 400 units and calcium 800 mg per day, forgetting many times to take them. Her daily exercise is swim and stationary bike one or two times per week.

I examed her, she had curved back to the right side of spine, i.e. kyphosis by medical term,  her muscles on the right side of back were very spasmodic, however,  the muscles on the left side of the back were looser, she looks like to have a hunchback. I was not able to identify a specific spot of her back pain, only at the vague area of  entire low back. Also her muscle strength was unable to be checked because of pain. She did not have any abnormal sensation at either leg.

The above signs and symptoms indicated that she might have diagnosis of Spinal  Compression Fracture. I immediately ordered CT-scan of her spine, which showed the following,

http://www.haodf.com

The CT-Scan depicted the wedge shaped vertebra, and confirmed my diagnosis of low back spinal compression fracture.

The Causes of Spine Compression Fracture:

The underline pathophysiology spinal compression fracture is osteoporosis, i.e. the vertebral bones lost their bone substance, the shape of the bones is existed, but the bones can not hold certain weight added to their body. The sponge liked bone at the low back spine can not sustain any acute stress, such as sudden bending forward to tie shoe lace, pick up something from the floor, etc.  The reasons for osteoporosis are as following,

1.      For women, the leading risk factors are menopause, or estrogen deficiency, cigarette smoking, physical inactivity, use of prednisone and poor nutrition. For men, except all the above nonhormonal factors, low testosterone levels also may be associated with osteoporosis.

2.      Renal failure and liver failure, which would make nutritional deficiencies, leading to decreased bone remodeling and increased osteopenia.

3.      Genetics, osteoporosis can be observed in closely related family members.

4.      Malignance, i.e. malignant tumors, might metastasize to the spine, such as myeloma, lymphoma, renal cell, prostate, breast, lung cancers.

5.      Infections: chronic osteomyelitis may result in spinal compression fracture.

The following are the major symptoms of spinal compression fracture:

  • Sudden, severe back pain.
  • Worsening of pain when standing or walking.
  • Loss of height.
  • Deformity of the spine – the curved, “hunchback” shape.
  • Some pain relief when lying down.
  • Difficulty and pain when bending or twisting.
  • Neurologic problems may manifest in many ways:
    • Reduced leg strength (paresis) or complete weakness (paralysis) is an obvious problem.
    • Loss of sensation in the lower extremities and in the perianal area (saddle anesthesia) can be just as important.
    • Urinary retention and urinary and fecal incontinence are very important signs that indicate the need for emergency surgery.

Most patients only had the following slight activities, and then the pain starts:

  • Slipping on a rug or making a misstep.
  • Lifting a suitcase out of the trunk of a car.
  • Lifting a bag of groceries.
  • Getting up from sitting position
  • Bending to the floor to pick something up.
  • Lifting the corner of a mattress when changing bed linens.
  • Getting in or out of car

Signs of Multiple Spinal Compression Fractures

Some patients might have multiple spinal compression fractures without notices. However, by careful examination, you may find the following,

  • Kyphosis (curved back, or hunchback): These fractures often create wedge-shaped vertebral bones, which makes the spine bend forward (Kyphosis). Sometimes, your body might twist the spine to the side leading to Scoliosis.  Eventually, neck and back pain may develop as your body tries to adapt the posture changes of the dynamic train of  entire spine.
  • Height loss: With each fracture of a spinal bone, the spine loses some of its height. Eventually, after several collapsed vertebrae, the person’s shorter stature will be noticeable.
  • Hip pain: The shorter spine brings the rib cage closer to the hip bones. If rib and hip bones are rubbing against each other, there will be discomfort and pain.
  • Breathing problems: If the spine becomes severely compressed, lungs may not function properly and breathing can be seriously affected, such as shortness of breath, sometimes the poor spine position may make people prone to infection, such as pneumonia or bronchitis.
  • Stomach complaints: A shorter spine can compress the stomach, causing a bulging stomach and digestive problems like constipation, poor appetite, acid reflexes, and weight loss.

Treatment of Spinal Compression Fractures

1. The best treatment is prevention. This is best accomplished by treating osteoporosis with exercise, calcium, and medications.

1).        Medications for osteoporosis
Calcium 1000 mg per day should be taken for women before menopause and a 1200 mg per day for women who are postmenopausal.
Vitamin D 800 IU for women before menopause and 1000 IU vitamin D for postmenopausal women.  Men up to age of 50  should increase vitamin D and calcium intake to 800 IU of vitamin D and 1000 mg of calcium per day.

Bisphosphonates, such as alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Reclast), which slow the rate of bone thinning and can lead to increased bone density. These medicines may be used in men and women.

2).        Regular weight bearing exercise. Increased walking, jogging, tai chi, stair climbing, dancing, and tennis. Muscle strengthening exercises include weight training and other resistive exercise.  Weight bearing exercise programs not only increase bone density but also improve both heart and lung functional ability and muscle strength. You may walk with a one to three pound of sand bag tied on your each calf for 2 to 3 miles a day, it will greatly improve your bone density if you stick to the program longer enough.

3).        For prevention, you should take all preventative procedures such as checking and correcting vision and hearing, evaluating any neurological problems, reviewing any prescription medications for side effects that may affect balance, and providing a check list for improving safety at home.  Wearing undergarments with hip pad protectors may protect an individual from injuring the hip in the event of a fall.  Hip protectors may be considered for patients who have significant risk factors for falling or for patients who have a previously fractured hip.

4).        Avoidance of tobacco use and excessive alcohol intake.  Alcohol and cigarettes inhibit osteoblast cell activities and improve osteoclast cell functioning.  Osteoclast cells usually destroy the bone density and osteoblast cell build up the bone density.

2. Alleviating the pain: Usually, treatment is aimed at alleviating the pain, and preventing injuries in the future, we use physical therapy, acupuncture, medications, etc.

1). Physical Therapy

Recent research has shown many benefits of using Whole-Body Vibration (WBV) to increase strength and decrease bone mineral density losses from astronauts, athletes to those recovering from injury.  Holding a quarter squat position for 30 seconds on a WBV machine set at 50 Hz would be equivalent to performing 1,500 squats without the stress on the joints.  WBV is very effective to increase BMD in post-menopausal women even in comparison to a walking regimen (http://www.biomedcentral.com/1471-2474/7/92/, http://www.ncbi.nlm.nih.gov/pubmed/15040822?dopt=AbstractPlus)

http://www.powerplate.com/resources/htm/research/research-cards/research-health-whole-body-vibration-proves-effective-for-the-elderly.htm

http://search.barnesandnoble.com/Using-Whole-Body-Vibration-in-Physical-Therapy-and-Sport/Alfio-Albasini/e/9780702031731/?itm=1&USRI=whole+body+vibration

Wearing a back brace is a very effective means to prevent unwarranted motions of the spine during early healing.  Be cautious of keeping a patient in a brace for an extended period of time typically over 6-8 weeks to avoid secondary complications of immobilization.  Maintaining a neutral spine is very important and must be taught how to properly perform functional activities such as getting in and out of bed while keeping the spine straight by using a technique called the “log roll” to go from lying on ones back with knees bent to log rolling to their side then pushing with their upper arm to a seated position and finally to standing.

http://www.pvhs.org/documents/Orthopedics/ThorasicSpineSurgery.pdf

In addition to learning how to properly perform activities of daily living such as getting in and out of bed it is very important to work on core stabilizing with exercises such described in the previous newsletter dealing with low back pain with failed back surgery syndrome with link at http://drxuacupuncture.com/2010/12/19/low-back-pain-again-after-back-surgery/

Performing a balance test such as the Berg Balance Test or Tinetti Test will give objective measurement of current balance level and risk of falls.  Preventing the risk of falls is very crucial as fractures are more likely with low bone mineral density levels.

There are many ways to improve balance and progressions to do so.  A basic progression would be standing with feet at shoulder width in front of a counter or couch so that you can use your hands to catch yourself if you experience a loss of balance or better yet, have a spotter.  Once able to hold that shoulder width stance without loss of balance, take a narrow width stance progressing to your feet being right next to each other for 1 min.  Taking a smaller base of support, such as bringing the feet closer, makes the exercise more challenging.  From there you can balance on a single leg taking turns between the left and right foot.  Next you are ready to try the shoulder width stance with your eyes closed working again to the narrow width stance with eyes closed.

http://www.diabetesmonitor.com/diet-and-lifestyle/exercise/national-institute-of-aging-guidelines/chapter4_balance_plantar.htm

Next, assume a stance where one foot is in front of the other such as a walking stride and again work balance with eyes open then narrowing the stance till one foot is directly in front of the other in a heel to toe fashion called tandem stance.  Once able to accomplish tandem stance with eyes open go back to walking stride stance and work to tandem stance with eyes closed.

http://www.exercise-to-a-healthier-life.com/tandem-stands.html

Another way to progress with balance exercises is to go from a flat stable surface such as the ground to an unstable surface such as a balance board or foam pad.  An unstable surface will increase muscle activity in the ankles, knees, hips and core making the exercise more challenging.

http://www.physicalcompany.co.uk/products/product_detail.asp?productId=ABPE

In addition to performing core and balance exercises, it is important to increase the strength in the upper spine and shoulders.  Using a theraband is easy but more importantly effective for increasing muscle strength.  A series of Lat Rows, Lat Pulls, and Shoulder External Rotations are three effective exercises to be performed 3-4 x week for 3 sets of 10, progressing to 2 sets of 15 and finally 1 set of 30 in a row.  Start off with a lighter theraband and work you way up to a higher resistance theraband such as progressing through yellow, red, green, blue to black.

http://www.thera-band.com/store/products.php?ProductID=28Standing Row with Theraband http://www.health24.com/fitness/Exercises/16-1339-1344,33165.asp

Standing Lat Pulls with Theraband    http://www.sbortho.com/educational_resources/strength_exercises.html

External Rotation with Theraband    http://www.health.com/health/library/mdp/0,,zm2387,00.html

2). Acupuncture

Hua Tuo Jia Ji points are sets of specially designed points used to treat spine disease. By palpation, you should feel the tender points around the  spinal process, then insert the needles into the disc about 0.5 inch deep and one up and one lower levels of the spinal process, plus 0.5 inch of the lateral sides of the three levels,  i.e. total 9 needles inserted into the tender points around the spine and adjacent area.

I also selected the following points: Sheng Shu, Qi Hai Shu, Chi Bian, Huan Tiao, Yang Ling Quan, Fei Yang, Ju Liao, Jue Gu, and Cheng Fu.

Table 25-1

Points Meridan/No. Location Function/Indication
1 Hua Tuo Jia Ji Experienced 

Points

Along the spine, use the most painful vertebral spinal as midpoint, then locate the upper and lower spinal process and 0.5 inch on the either side, you may choose two spinal process as the starting points. See Pic 4-1 Specifically treat for local neck and low back pain, and pain along the spine.
2 Sheng Shu UB 23 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the second lumbar vertebrta Nocturnal emission, impotence, enuresis, irregular menstruation, leucorrhea, low back pain, weakness of the knee, blurring of vision, dizziness, tinnitus, deafness, edema, asthma, diarrhea
3 Qi Hai Shu UB 24 1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the third lumbar vertebra Low back pain, irregular menstruation, dysmenorrheal, asthma
4 Zhi Bian UB 54 Lateral to the hiatus of the sacrum, 3 inch lateral to the midline of spine Pain in the lumbosacral region, muscular atrophy, motor impairment of the lower extremities, dysuria, swelling around external genitalia, hemorrhoids, constipation
5 Huan Tiao GB 30 At the junction of the lateral 1/3 between the great trochanter and the hiatus of the sacrum. Pain of h elumbar regiin and the thigh, muscular atrophy of the lower limbs, hemiplegia
6 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
7 Jue Gu 

( Xuan Zhong)

GB 39 3 inch above the tip of the external malleolus, in the depression between the posterior border of the fibula and the tendons of peronaeus longus and brevis Apoplexy, hemiplegia, pain of the neck, abdominal distension, pain in the hypochondriac region, muscular arophy of the lower limbs, spastic pain fo the leg, beriberi
8 Cheng Fu UB 36 In the middle of the transverse gluteal fold Pain in the lower back and gluteal regioin, constipation, muscular atrophy, pain, numbness and motor impairment of the lower extremities

3). Pain Medicines

Pain medications. A carefully prescribed “cocktail” of pain medications can relieve bone-on-bone, muscle, and nerve pain, explains F. Todd Wetzel, MD, professor of orthopaedics and neurosurgery at Temple University School of Medicine in Philadelphia. “If it’s prescribed correctly, you can reduce doses of the individual drugs in the cocktail.”

Over-the-counter pain medications are often sufficient in relieving pain. Two types of non-prescription medications — acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) — are recommended. Narcotic pain medications and muscle relaxants are often prescribed for short periods of time, since there is risk of addiction. Antidepressants can also help relieve nerve-related pain.

If the pain is severe, and collapse is becoming problematic, procedures called vertebroplasty or kyphoplasty may be considered. In these procedures an interventional radiologist restores the height of the bone and injects cement into the vertebra to stabilize the fracture and prevent further collapse.

Surgical Treatment for Spinal Compression Fractures

When chronic pain from a spinal compression fracture persists despite rest, activity modification, back bracing, and pain medication, surgery is the next step. Surgical procedures used to treat spinal fractures are:

  • Vertebroplasty

Figure 25.16

From: https://www.healthbase.com

After general anesthesia, or simply under sedation, a special bone needle will be inserted into the soft tissues of the back guided by x-ray, along with a small amount of x-ray dye, which will allow the position of the needle to be seen at all times. Then, a small amount of orthopedic cement, called polymethylmethacrylate (PMMA) will be pushed through the needle into the vertebral body, then the cement will be solid after a few mins. The cement will be filled in the fractured vertebrae, and sustained the body weight over night. Each vertebral body is injected on both the right and left sides, just off the midline of the back.

The cement is sometimes mixed with an antibiotic to reduce the risk of infection, and a powder containing barium or tantalum, which allows it to be seen on the x-ray.

Within a few hours, patients are up and moving around. Most go home the same day.

  • Kyphoplasty

From: www. sarasotaspine.com

Similar to vertebroplasty, Kyphoplasty is performed under local or general anesthesia. Using image guidance x-rays, two small incisions are made and a probe is placed into the vertebral space where the fracture is located. The bone is drilled and a balloon, called a bone tamp, is inserted on each side. These balloons are then inflated with contrast medium (to be seen using image guidance x-rays) until they expand to the desired height and removed. The balloon does not remain in the patient.   It simply creates a cavity for the cement and also helps expand the compressed bone.

The spaces created by the balloons are then filled with PMMA, the same orthopaedic cement used in vertebroplasty, binding the fracture. The cement hardens quickly, providing strength and stability to the vertebra, restoring height, and relieving pain.

The above procedures provide new options for compression fractures and are designed to relieve pain, reduce and stabilize fractures, reduce spinal deformity, and stop the “downward spiral” of untreated osteoporosis. In my experience, many patients reported miracle results after the procedures.

  • Spinal fusion surgery

From: http://www.neurosurgery.ufl.edu/

This procedure is used primarily to fuse or immobilize two or more vertebrae and to eliminate the pain caused by abnormal motion of the vertebrae.  Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction with the body’s natural bone growth (osteoblastic) processes to fuse the vertebrae.

The above procedures may help you a lot with a decrease of pain, and improve  your  spine stability and flexibility. However, the procedures may not solve all your problems. Sometimes, you may feel very much pain after the procedures. Therefore, it is necessary to have acupuncture treatment in order to reduce the pain.

TREATMENT OF LINDA

Linda first underwent physical therapy 2x  per week for 4 weeks in another physical therapy facility, she underwent many trunk forward bending and backward extension exercises, however, she felt more pain on the low back after her physical therapy. I did CT scan again, I found out her low back compression fracture was worse than the first CT scan. I immediately informed her stop doing the forward bending exercise, because this exercise causes the further compression fracture.

She was referred to interventional radiology for veterbroplasty treatment. She felt much better after the surgery. However, after 2 months of the surgery, she complained  of low back pain again. She came to me for treatment again.

I then started her with physical therapy 2x per week for another 4 weeks and in the mean time, acupuncture treatment 2x  per week for 4 weeks, Fosamax also was prescribed for her long term use. After about 6 weeks treatment, her pain is much subsided and she is more flexible.

Tips for the patients:

      1. You must give up the bending forward exercise of low back, and try to avoid bending forward postures, for example, do not pick up heavy object from floor, tight your shoes, etc.
      2. You must check your BMD (Bone Mineral Density) measurements at spine, hip, or forearm by DXA devices.
      3. Please read my news letter article no. 4, which will give you the information about how to take care of osteoporosis, please see the attached link: http://drxuacupuncture.com/2009/04/27/case-discussion-4/.

Tips for the acupuncture practitioners :

1.      Acupuncture could decrease the pain, but it can not change the shape of the compression fractured spinal spine.

2.      Do not advise the patients not go to the surgery, because the surgery might be the necessity for the treatment of long run.

3.      Teach the patients that do not bend their low back forward, which will worse the low back compression fracture. The patient should avoid the bending forward exercise.

4.      The patients should be advised to wear lumbar sacral  brace to protect the low back during acute stage of the low back pain.

5.      Acupuncture is not  the only treatment for spinal compression fracture, an integrated treatment might get better results.

Read Full Post »

News Letter, Vol. 2 (12), December, 2010, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Dear Friends and Patients:

Happy Holidays!

This is the last newsletter for 2010. We are very happy to introduce Dr. Robert Blizzard, who recently joined in our practice. Dr. Blizzard graduated from the University of Connecticut with a Bachelor’s Degree in Exercise Science, and continued on to receive his Doctoral of Physical Therapy at Franklin Pearce University. He is a full time licensed physical therapist in RMAC. We believe his knowledge and experience will help you to fulfill your goal to be completely recovered from your injury. Dr. Blizzard joined us to write this newsletter too.

From now on, we will leave our comment space on under the news letter at our website, http://www.DrXuAcupuncture.com.  you are welcome to leave  your questions or comments .  We will try our best to answer your questions.

We wish you happy holidays!

Jun Xu, M.D.

Hong Su, C. M. D.

Robert Blizzard III, D.P.T.

Low back pain with failed back surgery syndrome (FBSS)


From: http://www.yorkshirehighlanders.co.uk

Peter is a 56-year-old male who complains of low back pain for three years.  The pain started from the low back and radiated down to the right leg, which made it difficult sitting, walking, and standing.  The pain also interferes with his sleep, especially while he changes positions in the bed, and therefore he went to his primary care physician. He was referred to physical therapy for about three months of treatment.  However, the pain was not getting better and still he felt pain is sharp and stabbing, and that radiated down to the right lateral thigh and the lower leg.  The pain was constant.  In the meanwhile, he gradually felt his leg was weak and he had difficulty standing from the sitting and driving position.

Then one day he realized his underwear was wet because he had difficultly controlling his urinary bladder and he had decreased sensation at right lateral lower leg.  Therefore, his primary care physician referred him to a neurosurgeon.  An MRI was done, which showed two large right L4/L5 and L5/S1 herniated disc with impingement of right L5, S1 nerve roots.  He was advised to have surgery, L5/S1discectomy.

However, he was afraid of the surgery, then he consulted another neurosurgeon, who suggested to have laminectomy because the MRI, which showed two levels, L5 and S1, with  severe right foraminal L5-S1 nerve impingement and  degenerative changes between L5 and S1 and S1 and S2, which are the reasons for urinary incontinence.

He was thinking, however, he would like to wait a few more months to see if this would be getting better.  He restarted physical therapy again, and also he had epidural injection at those two levels and his pain seemed  better slightly.  However, he felt the right leg is weaker, he sometimes loses control of his urine.  Therefore, he decided to have surgery.

Laminectomy was performed one year ago.  After the surgery within one month, he had immediate pain relief and also he could control his urine and the bowel movement.  The patient was very happy about the surgery.

However, after six months, he started to feel low back pain again and this time he felt the pain is a gradual onset, dull and achy without any radiating down to the leg and he had no bowel or bladder abnormalities, but he still feels some weakness and mild numbness and tingling sensation on the right lateral leg. He visited his neurosurgeon, who told him this pain sometimes occurred after surgery about 6 months, and if he continued to do the physical therapy, the pain should be getting better.

The patient started to do physical therapy again after six months and he did muscle strengthening and stretching on the low back.  However, one day, he felt the pain suddenly getting worse after waking up and the pain is like stabbing with burning sensation around the L3-L4, L5-S1 middle spine and paraspine, and since then, he has had difficulty bending forward and backward, sitting to standing, and driving.  The patient then revisited his surgeon and he was prescribed Tylenol with Codeine.  After he took this pain medication, he felt better.  However, he started to feel drowsy and he had difficulty driving and concentrating on his work, and gradually he also started craving for this drug.  If he did not take for one day, he felt uncomfortable not only in the low back but the entire body and also he felt depressed and low energy.  Therefore, he came to me for evaluation and treatment.

I performed  physical examination, I saw the scars on the both sides of the L4, L5, and S1 para-spine, by palpation,  there was tenderness around L3-L4 and L5-S1 para-spine.  There was no palpation pain at bilateral sciatic areas.  He can bend his low back forward only about 40 degrees and bend his back backward only about 10 degrees.  He had no problem to walk on tippy toes and heels.  He had no decreased sensation at both legs.  I compared the MRI of presurgery and postsurgery,  There was no impingement of the nerve roots anymore.  Based on all the above information, I thought the patient was suffering with post-lumbosacral laminectomy syndrome, also called “failed back surgery syndrome” (FBSS), refers to chronic back and/or leg pain that occurs after back (spinal) surgery.

Before I introduce the Failed Back Surgery Syndrome, I would like to let you understand the basic knowledge of low back surgery;

There are seven types of low back surgery.

1.      Discectomy.

2.      Foraminotomy.

3.      Intradiscal electrothermal therapy.

4.      Nucleoplasty.

5.      Radiofrequency lesioning.

6.      Spinal fusion

7.      Spinal laminectomy, etc.

Discectomy
This is a procedure done to relieve pressure on a nerve root that’s being compressed by a bulging disc or bone spur. In order to relieve this pressure, the surgeon removes a small piece of the lamina (the bony roof of the spinal canal) from above the obstruction.

Figure 24.1

http://indiahealthtour.com/treatments/spine-surgery/endoscopic-micro-discectomy-surgery.html

Foraminotomy
This is type of surgery is undertaken to enlarge the foramen (the bony hole) where a nerve root branches out from the spinal canal. Joints thickened with age, or bulging discs, may cause the foramen to narrow, thereby pressing on the nerve. This pressure can cause pain, numbness or weakness in the extremities. In order to relieve the pressure, the surgeon removes small pieces of bone over the nerve through a small slit, which allows her to cut away the blockage.

Figure 24.2

From: http://www.laser-spine.com/spinehealth/treatments/endoscopic_foraminotomy/

IntraDiscal Electrothermal Therapy (IDET)
IDET is used to treat pain caused by a cracked or bulging spinal disc. This therapy involves inserting a special needle into the disc via a catheter. Once inserted, the needle is heated to a high temperature for approximately twenty minutes, effectively thickening and sealing the disc wall. This procedure reduces inner disc bulge and spinal nerve irritation.

Figure 24.3

From: http://www.advanced-pain-care.com/Intradiscal.htm

Nucleoplasty
Nucleoplasty is used to treat lower back pain resulting from mildly herniated or contained discs. During this procedure, a wand-like instrument is guided by x-ray imaging and inserted through a needle into the disc in order to create a channel. This facilitates the removal of inner disc material. Several channels may be made, depending on the amount of material needing to be removed. After removal, the wand heats and shrinks the tissue of the disc wall in order to seal it.

Figure 24.4

From: http://www.kcpain.com/kcp_help5c.php

Radiofrequency (RF) Lesioning
This procedure is used to interrupt of nerve conduction and the transfer of pain signals. Electrical impulses are used in order to destroy the nerves located in the affected area. A special needle is inserted into the localized nerve tissue, with the guidance of an x-ray. This area is then heated for 90 to 120 seconds, destroying the nerve tissue. This may result in cessation of pain for 6-12 months.

Figure 24.5

From: bnsmedical.com

Spinal fusion
Spinal fusion is a procedure which is done in order to support a weak spine and/or to prevent painful movements. However, spinal fusion requires a long recovery period, and may result in a permanent loss of spinal flexibility. The procedure involves the removal of the spinal disc between two vertebrae, and the subsequent fusion of those vertebrae. Methods of fusion include either bone grafting and/or using metal devices secured by screws.

Figure 24.6


From: http://skillbuilders.patientsites.com/Injuries-Conditions/Lower-Back/Lower-Back-Issues/Lumbar-Spinal-Stenosis/a~51/article.html
Spinal Laminectomy
This procedure is used to relieve pressure on the spinal cord and nerve roots. Also known as spinal decompression, this type of surgery involves the removal of the lamina to increase the size of the spinal canal.

Figure 24.7

http://www.eorthopod.com/content/lumbar-laminectomy

Treatments for Faild Back Surgery Syndrome (FBSS)

In 1992, Turner et al. published a survey of 74 journal articles which reported the results after decompression for spinal stenosis. Good to excellent results were on average reported by 64% of the patients. (Turner, J., et al., Spine 1992; 17:1-8 ) Therefore, there are about 36% of the post back surgical patients, who might suffer some degrees of back pain, usually after 6 months of surgery.  For some patients, the pain might achieve the peak intensity as pre-operation after two-year surgery.

Failed back surgery syndrome (FBSS),  is characterized by intractable diffuse, dull and aching pain or sharp, pricking, and stabbing pain in the back and/or legs accompanied with varying degrees of functional incapacitation.  Recurrent herniated disc and symptomatic hypertrophic scar can produce similar low back symptoms and radiculopathy as before the surgery. Gradually increasing symptoms beginning a year or more after discectomy are considered more likely a result of scar radiculopathy, while a more abrupt onset at any interval after surgery is more likely due to recurrent herniated disc. Multiple factors can contribute to the onset or development of FBS, such as residual or recurrent disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness and spinal muscular deconditioning.

The treatments of Failed back surgery syndrome (FBSS),  include physical therapy, acupuncture, minor nerve blocks, transcutaneous electrical nerve stimulation (TENS), behavioral medicine, non-steroidal anti-inflammatory (NSAID) medications, membrane stabilizers, antidepressants, and intrathecal morphine pump. Use of epidural steroid injections may be minimally helpful in some cases. Here, we will mainly introduce physical therapy, pain medications and acupuncture treatment.

1. Physical therapy:

Spine surgery changes the anatomy of the spine but does nothing to improve activation of deep core stabilizing muscles.  That is one of the benefits of physical therapy for re-training the body to properly activate the deep core muscles that stabilize the spine.  The two deep co-stabilizing muscles of the spine are the Transverse Abdominis (TrA) and Multifidus

Spinal braces are an option to wear especially immediately following surgery to improve recovery. A corset helps to brace the lumbar spine by increasing the pressure in the abdomen, and thus reducing the amount of weight placed through the spine.

Figure 24.8The Transverse Abdominis is often called the “human corset” as it is the only abdominal muscle attaching to the posterior spine and runs transverse around the body.

Figure 24.9

http://www.unm.edu/~lkravitz/Media/transverse.gif http://www.exerciseyourpainaway.co.uk/muscles.htm

Draw-Ins

These exercises can be performed in any position and progressed once the very important concept of TrA activation is achieved. The two starting positions are quadruped and supine.  Stabilizing the spine by activating TrA and Multifidus occurs without rotating the hips, tensing the shoulders or holding ones breath but from slowly drawing-in the deep core muscles of the abdominal wall.

Figure 24.10http://www.strattonpt.com/images/uploads/images.3.jpg

Figure 24.11

http://staceyspt.com/Exercise/LowerBack.htm

Figure 24.12http://www.sportstek.net/pressure_biofeedback.htm

Draw-Ins with Alternating Upper Extremity/Lower Extremity Movement

These movements build upon a solid foundation of spinal stabilization from the previous exercises.  Start off first by performing a Draw-In and holding that contraction while moving the Upper Extremities (UE) only, then work on the Lower Extremities (LE) finally moving on to simultaneous movement of both UE/LE.  Quadruped Alternating UE/LE Movement is also called “Bird-Dog” while “Dead-Bug” is the name of Supine Alternating UE/LE Movement.  It is important to maintain a neutral spine from hips to shoulders and for the core to take in the force when an extremity is lifted and not involve a rotation component to the opposite hand or knee.  This will occur if done improperly or rushed to without developing strength and control through the previous mentioned exercises.  Both the Bird-Dog and Dead-Bug can be progressed from a solid stable surface such as the ground or exercise mat to an unstable surface such as foam dyna-discs or a foam roller to increase the activation of core stabilizing muscles thus making the exercise more challenging and effective.

Figure 24.13 Bird-DogFigure 24.14  Dead-Bughttp://michaelwoodspg.blogspot.com/ http://www.canada.com/health/3390881.bin

Kneeling and Standing Chops/Lifts

Once properly able to stabilize the spine with Alternating UE/LE Movements, progression to more functional activities is deemed ready.  Theses moves involve working through all planes of movement while stabilizing the spine.

A resistance cable is used with the hands at arms length from the body starting over one shoulder and working diagonally across the body to the opposite knee, engaging the TrA and keeping from rounding the back forward.  In a Cable Lift the hands start at the knee and work diagonally up to the opposite shoulder.

Cable Chops

Figure 24.15

http://www.menshealth.com.sg/fitness/best-exercises-your-core

Figure 24.16

http://fms.riaguy.com/articles/fitness/2010-03-15_balanced_body_series.introduction_to_the_chop_and_lift

Cable Lifts from Kneeling and Standing

Figure 24.17

http://eas.com/training/strength/rotational-lift–split-squat-cable http://www.whatsupusana.com/2009/04/pregnancy-and-exercise.html

Soft-Tissue Mobilization

Adhesions and scar tissue development are very common following any surgery.  Development of these adhesions can lead to decreased mobility and compression on nerve roots causing increased stiffness and pain. A few simple techniques to rid adhesions/trigger points/scar tissue and improve recovery along the spine are from using a foam roller or having manual work specific to your individual needs.

Figure 24.18 Figure 24.19

http://www.foamroller.co.uk/ http://www.boulderbodyworks.com/physical-therapy.html

2.   Medications:

A. Acetaminoph: (one brand name: Tylenol) helps many kinds of chronic pain.

B. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Examples include aspirin, ibuprofen (two brand names: Motrin, Advil) and naproxen (one brand name: Aleve). NSAIDs come in both over-the-counter and prescription forms. These medicines can be taken just when you need them, or they can be taken every day. When these medicines are taken regularly, they build up in the blood to levels that fight the pain of inflammation (swelling) and also give general pain relief. Please remember that you always take it with food or milk because the most common side effects are related to the stomach. 

C. Narcotics: Narcotics can be addictive. For many people who have severe chronic pain, these drugs are an important part of their therapy. If your doctor prescribes narcotics for your pain, be sure to carefully follow his or her directions. Tell your doctor if you are uncomfortable with the changes that may go along with taking these medicines, such as the inability to concentrate or think clearly. Do not drive or operate heavy machinery when taking these medicines.

When you’re taking narcotics, it’s important to remember that there is a difference between “physical dependence” and “psychological addiction.”

Physical dependence on a medicine means that your body gets used to that medicine and needs it in order to work properly.
Psychological addiction is the desire to use a drug whether or not it’s needed to relieve pain. Narcotic drugs often cause constipation (difficulty having bowel movements). If you are taking a narcotic medicine, it’s important to drink at least 6 to 8 glasses of water every day. Try to eat 2 to 4 servings of fresh fruits and 3 to 5 servings of vegetables every day.

C. Other medicines

Many drugs that are used to treat other illnesses can also treat pain. For example, carbamazepine ( Neurotin )is a seizure medicine that can also treat some kinds of pain. Amitriptyline is an antidepressant that can also help with chronic pain. It can take several weeks before these medicines begin to work well.

3. Acupuncture Treatment:

There are three types of Failed back surgery syndrome (FBSS) according to Traditional Chinese Medicine.

Figure 24.20

Figure 24.21

Figure 24.22

Figure 24.23

Figure 24.24

Figure 24.25

Type 1: Coldness and Wetness of FBSS:

Patients feel cold, heavy, and  pain at entire low back, difficulty turning over on the bed or standing up from sitting position, getting worse during the cold weather, stiffness at low back, hip and knee joints.

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun, plus Du 26 Ren Zhong, GB 34 Yang Ling Quan, and UB 58 Fei Yang.

Table 24.1

Points Meridan/No. Location Function/Indication
1. Da Chang 

Shu

UB 25 1.5 inch lateral to midline of the body on the back, at the level of the spinous process of the fourth lumbar vertebra 

Figure 24.20

Low back pain, abdominal distension, diarrhea, constipation, muscular atrophy, pain, numbness and weakness at legs, sciatica
2. Huan Tiao GB30 At the junction of the lateral 1/3 and medial 2/3 of the distance between the great trochanter and the hiatus of the sacrum. 

Figure 24.23

Low back  pain, thigh pain, muscular atrophy of the lower limbs, hemiplegia
3 Wei Zhong UB 40 Mid point of the transverse crease of the popliteal fossa, between the tendons of biceps femoris and semitendinosius muscles 

Figure 24.23

Low back pain, motor impairment of t he hip joint, contracture of the tendons in the popliteal fossa, muscular atrophy, pain, numbness and motor impairment of the lower extremities, hemiplegia, abdominal pain,k vomiting, diarrhea, erysipelas.
4 Kun Lun UB 60 In the depression between the external malleolus and calcaneus tendon 

Figure 24.23

Headache, blurring of vision, neck rigidity, epistaxis, pain in the shoulder, back and arm, swelling and pain of the heel, difficult labor, epilepsy.
5 Ren Zhong Du 26 A little above the midpoint of the philtrum, near the nostrils 

Figure 24.24

Mental disorders, epilepsy, hysteria, infantile convulsion, coma, apoplexy-faint, trismus, deviation of the mouth and eyes, puffiness of the face,  low back pain and stiffness
6 Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula 

Figure 24.22

Hemiplegia, weakness, numbness and pain of the lower extremities, swelling and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile convulsion
7 Fei Yang UB 58 7 inch directly above Kun Lun on the posterior border of fibula, about 1 inch inferior and lateral to Cheng Shan (UB 57) 

Figure 24.23

Headache, blurring of vision, nasal obstruction, epistaxis, back pain, hemorrhoids, leg weakness

Type 2: Kidney Deficiency of FBSS:

Patients’ pain demonstrate weakness,  and pain at nonspecific-pointed area, difficulty standing, feel better while lying on the bed, the pain is dull and achy, cold in four extremities

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun plus St 36 Zu San Li, Sp 6 San Yin Jiao, and Ki 3 Tai Xi. ( Please see tables 24.1, and 24.2)

Table 24.2

Points Meridian/No. Location Function/Indication
1. Zu San Li St 36 On finger-breadth from the anterior crest of the tibia in tibialis anterior muscle 

Figure 24.22

Gastric pain, vomiting, hiccup, abdominal distension, diarrhea, dysentery, constipation, mastitis, enteritis, knee joint and leg pain, edema, cough, asthma, waste syndrome, poor digestion, hemiplegia, dizziness, insomnia, mania
2. San Yin Jiao Sp 6 3 inches directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibia 

Figure 24.22

Abdominal pain, distension, diarrhea, dysmenorrheal, irregular menstruation, uterine bleeding, morbid leucorrhea, prolapse of the  uterus, sterility, delayed labor, night bed wet, impotence, enuresis, dysuria, edema, hernia, pain in the external genitalia, muscular atrophy, motor impairment, paralysis and leg pain, headache, dizziness and vertigo, insomnia
9 Tai Xi Ki 3 In the depression between the medial malleolus and tendo calcaneus, at the level of the tip of the medial malleous. 

Figure 24.21

Sore throat, toothache, deafness, tinnitus, dizziness, spitting of the blood, asthma, thirst, irregular menstruation, insomnia, nocturnal emission, impotence, frequency of micturition, low back pain.

Type 3: Blood Stagnation of FBSS:

There is sharp, stabbing pain at specific area in the low back and buttock. The pain is very severe, so that nobody could touch the tender area, difficulty bending, sitting and standing, and turning over in the bed.

Acupuncture points: UB 25 Da Chang Shu, GB 30 Huan Tiao, UB 40 Wei Zhong, UB 60 Kun Lun plus Sp 10 Xue Hai, UB 17 Ge Shu, LI 4 He Gu, UB 57 Cheng Shan.

(Please refer to tables 24.1, 24.3)

Table 24.3

Points Meridian/No. Location Function/Indication
1 Xue Hai Sp 10 2 inch above the mediosuperior border of the patella (Knee Cap) 

Figure 24.21

Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
2 Ge Shu UB 17 1.5 inch lateral to the middle line of the body on the back, at the level of the lower border of the spinous process of the 7th thoracic vertebra 

Figure 24.20

Vomiting, hiccup,belching,difficulty in swallowing, asthma, cough, spitting of blood, afternoon fever, night sweating, measles
3 He Gu LI 4 On the dorsum of the hand between th e1st and 2nd metacarpal bones, approximately in the middle of the 2nd metacarpal bone on the radial side. 

Figure 24.25

 

Headache, pain in the neck, redness swelling and pain of the eye, epistaxis, nasal obstruction , rhinorrhea, toothache, deafness, swelling of the face, sore throat, arotitis, trismus, facial paralysis, febrile die\seases with anhidrosis, hidrosis, abdominal pain, dysentery, constipation, amenorrhea, delayed labour, infantile convulsion, pain, weakness and motor impairment of the upper limbs.
4 Cheng Shan UB57 Directly below the belly of gastrocnemius muscle, on the line joining Wei Zhong UB40 and calcaneus tendon, about 8 inch below Wei Zhong UB40 

Figure 24.23

Low back pain, spasm of the gastrocnemius, hemorrhoids, constipation, beriberi.
  1. Transcutaneous Electrical Nerve Stimulation (TENS):

TENS is thought to disrupt the   pain transmitting to the brain delivering a different, non-painful sensation to the skin around the pain site. In essence, it modulates the way we process the pain sensations from that area, i.e. it closes the pain gate to the brain. It can also trigger the brain to release endorphins. Endorphins act as natural painkillers, and help promote a feeling of well-being.

Figure 24.26

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5. Local Nerve Block

An epidural nerve block is the injection of corticosteroid medication into the epidural space of the spinal column. This space is located between the dura (a membrane surrounding the nerve roots) and the interior surface of the spinal canal formed by the vertebrae.

After a local skin anesthetic is applied to numb the injection site, a spinal needle is inserted into the epidural space under fluoroscopic (x-ray) guidance, using a contrast agent to confirm needle placement. Local anesthetic and corticosteroid anti-inflammatory medication are delivered into the epidural space to shrink the swelling around nerve roots, relieving pressure and pain.

Figure 24.27

http://www.treatingpain.com

6. Intrathecal Morphine Pump

Pain pump delivery of narcotic drugs is a rather new option available to persons with cancer and non-cancer pain. It is also called intraspinal (within the spine) or intrathecal (within the spinal canal) delivery. It was first used in 1979 after the discovery of narcotic receptors in the spinal cord. The use of an implant device to deliver medications directly in the area of the spinal cord was first used in 1981 for cancer pain. Since then, the pain pump has been used for chronic non-cancer pain such as failed low back surgery syndrome and spasticity from neurological conditions like multiple sclerosis, spinal cord injury, and cerebral palsy.

Figure 24.28

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About Peter’s Treatment:

Peter underwent our treatment with both acupuncture and physical therapy. The typical protocol was as following,

  1. Peter was first put in the bed with heating pad on the low back for about 10 to 15 mins, his low back muscles were gradually loosening, then massage was given to further relax his low back muscles.
  2. After massage, acupuncture treatment was given, the most important points were selected based on the above principal. He was given needles with electrical stimulation for 20 to 30 min, his energy flow,  therefore,  is activated and the pain is gradually decreased.
  3. He then was transferred to physical therapy area, started to strengthen his abdominal and low back muscles with the above guidance.
  4. He was given the above treatment for about 20 sessions, he felt greatly improvement after the treatment. He has had more flexibility and much less pain. His pain scale decreased to 2/10 from 10/10. He was pain free for one year, and he sometimes returns to my office for tuning.

Tips for patients who had low back surgery, but still feel a lot of pain on the low back:

  1. MRI of low back spine is necessary to check any new injuries, such as new herniated disc, degenerative changes of other levels, any loosening of the screws, and spinal stenosis.
  2. Be very cautious for the subsequent low back surgery. Sometimes, you may be advised to have the second surgery for your low back. From my personal experience, I did not see many successful cases after the secondary even third low back surgery.
  3. Try to find a physiatrist MD, who also practices acupuncture. Physiatrist MDs are trained in US for Musculoskeleton Medicine. They not only understand your problem but also more specifically treat you with acupuncture. They also could guide your physical therapist for the treatment.
  4. The combination of physical therapy, massage and acupuncture treatments are very important, because these combined treatments could not only relax your muscles but also maximize your abilities to perform core body strengthen.
  5. Different patients like different sequence  of the treatment, it is not absolutely necessary to have massage, acupuncture, then physical therapy, because everybody is different. It depends on your personal preference. The most important is that you have to have the combined treatment to benefit the most.
  6. If you drive a distance for longer than 30 min, it is wise to have the lumbosacral corset, i.e. low back brace on,  the brace will protect your low back and prevent further injuries.

Tips for acupuncturists:

  1. You must clearly understand the patient’s pathological mechanism. Some patients are not allowed to have flexion exercise, some patients not for extension exercise.
  2. Heating pad and massage are very important to induce energy and relax low back muscles.
  3. LI 4 is a very important point to increase the secretion of endorphin and inhibit the up going reticular formation to send the pain signal to the brain.
  4. Electrical stimulation on the back points is a must.

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