While the range of disorders for which patients seek acupuncture treatment is increasing, many practitioners still find that the majority of their appointments involve musculoskeletal disorders and pain.These disorders may involve acute trauma, slow-healing injuries or more chronic conditions. In any case, acupuncture is frequently the treatment of choice.
In Oriental medical schools, students are frequently taught a variety of treatment strategies, most of them based on the following principle: needle local points plus one or two major distal points on the affected meridian, needle any empirical points, and make use of a relevant microsystem. Different teachers also recommend a variety of other strategies as well, such as cupping, bleeding, e-stim and magnets, depending on their own clinical orientation and the stage of the disorder.
In this series, I will introduce a variety of diagnostic and treatment strategies involving acupuncture, herbal medicine and other Oriental medicine treatments that are useful in treating orthopedic cases and involve a variety of local/distal treatment strategies. While none of these will be new to everyone, they are all important techniques that deserve more widespread implementation in Oriental medicine practice. This column will focus on the strategic use of the xi-cleft point in acute disorders.
The xi-cleft category -- those points where the qi and blood of a channel accumulates, particularly in acute conditions such as trauma or pain from recent injury -- are a primary treatment strategy for acute orthopedic disorders and can provide significant relief for patients in a short period of time. Unfortunately, they are underused by many acupuncturists or used only according to the affected meridian. While some practitioners hold that the yang xi-cleft points are better for pain control and the yin xi-cleft points better for acute conditions such as bleeding, both may be effectively used for treating acute musculoskeletal disorders.
The category is comprised of 12 points for the 12 regular meridians and their tendinomuscular components (L6, LI7, S34, Sp8, H6, SI6, B63, K5, P4, SJ7,GB36, Liv6) and four points for the extraordinary vessels (B59 for the yang qiao; K8 for the yin qiao; G35 for the yang wei; and K9 for the yin wei). Since the latter four points are more useful in treatment strategies involving the extraordinary vessels (i.e., more chronic and structural disorders), they will be treated in a later column. Instead, I will focus on a treatment protocol using the 12 regular meridians which minimizes the number of points needed for an acupuncture treatment and uses those only points which provide prior "evidence" of improving the condition.
Protocol for Using the Xi-Cleft Points
Step I: Identify the affected meridian or meridians. This is not always as simple a task as it seems. Many areas of the body are traversed by more than one meridian. In particular, the pathway of the tendinomuscular channels associated with the 12 regular meridians may be confusing. For example, consider the following: in a shoulder injury, there may be pain and dysfunction in more than one major meridian; and in the treatment of pain in the pectoral muscles, the relationship among the heart, stomach, urinary bladder and pericardium tendinomuscular channels may be confusing and even overlap. Practitioners who are familiar with only the basic pathways of the 12 regular channels would do well to consult the detailed drawings and discussion in: Ni Y, Navigating the Channels of Traditional Chinese Medicine; Deadman P, et al., A Manual of Acupuncture; or Guillaume G, Chieu M, Rheumatology in Chinese Medicine, to get a more comprehensive view of the channel system.
Step II: Identify all of the xi-cleft points related to the site of dysfunction. Besides identifying the xi-cleft points on the affected channels, check the points on related channels as well. The meridian system is an intricately interrelated phenomenon in the body, and the channels have many different relationships that become important when formulating an efficient treatment plan.
The following four relationships may prove to be the most useful for acute musculoskeletal pain:
Left Lung/Right Lung
Therefore, if the channel involved is identified as the lung channel on the left side, one would note the possibility of the following four xi-cleft points being useful for treatment: L6, UB63, LI7 and Sp8. If the involvement also included the large intestine channel, one would also note the following possibilities (besides L6): LI7, S34 and K5. Despite the side on which the dysfunction occurs, the relevant points on both sides of the body should be considered and might lead to treatment on the ipsilateral or contralateral side of the body.
Step III: Palpate and select the point or points that reduce pressure/pain or increase pain-free range of motion. This is the most important step after noting the possible xi-cleft points to use. Each point should be palpated to determine its sensitivity. Be sure to remember when palpating that acupuncture points are "alive" and may not necessarily correspond to their textbook location. In fact, some points may in reality be a cun (Chinese unit) from the theoretical location.
After finding the two or three most sensitive points, find the spot on the site of dysfunction that causes the most discomfort when pressed or the movement that causes the most discomfort. Ask the patient to rate this discomfort or restricted movement on a scale of 1-10. Check each xi-cleft point one at a time, pressing or massaging it while also palpating the pressure/pain point at the site of dysfunction or having the patient move the affected area. Select the xi-cleft points that cause a significant improvement in pressure/pain or pain-free range of motion.
In general there should be about a 50% improvement. If less, the practitioner might want to consider using methods to be discussed in later columns. Thus, in the above example of a problem occuring along the left lung channel, examination might reveal that the points to needle are right L6 and and right Sp8.
Step IV: Needle these distal point with a strong reducing method and use local treatments, whether they be needles, cupping, tui na, liniments, herb patches, magnets, bleeding, diathermy, electrical stimulation, intradermals or some other form of therapy, according to the practitioner's individual style, the appropriateness of techniques to the particular situation and the scope of practice in individual states. Fifteen to 20 minutes is probably sufficient. If local needles are not used, you may, if appropriate, have the patient move the affected area.
Step V: Assign "homework." If the patient consents, it may be a good idea to use a surgical pen, mark the affected xi-cleft points, and instruct the patient that they be massaged gently a few times a day until the next treatment or the situation improves.
This flexible use of xi-cleft points can be combined with other types of treatment and Microsystems. It may also be a useful and rapid treatment modality for acute musculoskeletal pain and dysfunction and can increase a practitioner's range of treatment options.
In my next article, we will discuss the use of the French barrier point system.
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