Do we have to up our game?

The question of whether to integrate traditional Chinese medicine (TCM) and biomedicine approaches in the treatment of musculoskeletal conditions is not a new one. Royston Low – osteopath, acupuncturist and contemporary of JR Worsley and JD Van Buren – in his book The Acupuncture Treatment of Musculoskeletal Conditions (1987) observed that TCM has much to say on internal medicine, but little on the treatment of musculoskeletal conditions.

Low also countered the view put forward by TCM purists that biomedical knowledge is unnecessary, stating that ‘particularly where musculoskeletal problems are involved, this is not only complete rubbish, but dangerous rubbish’.  He went on to say that ‘one needs the ability, not to compartmentalize one’s mind, but to view the two streams separately yet simultaneously, to see where one complements the other and to draw on both aspects as required.’ (The Acupuncture Treatment of Musculoskeletal Conditions, page 12)

Is integrated medicine necessary?

Without an awareness at a basic level of what is happening within the body, the application of ‘special points’ or ‘point combinations’ becomes a very hit and miss affair. For example, a point prescription which works in a patient with one clinical presentation of shoulder pain may have no effect on another.

My own personal observation – having taught various courses to acupuncture practitioners and students – is that there still appears to be a lack of knowledge of functional anatomy, together with an anxiety about treating musculoskeletal conditions.

I am still surprised by how many practitioners mention to me that they do not undertake a thorough hands-on, orthopaedic examination of patients with musculoskeletal issues – including exposing the area of concern and range of motion (ROM) testing. Although in fairness this assessment becomes more of a ‘box ticking exercise’ if the practitioner is unable to use their findings diagnostically.

But as healthcare practitioners, we owe it to our patients to ensure that we are able to deliver the most effective care and to aid them in as speedy a recovery as possible.

A clinical example

A patient presents with shoulder pain. An experienced clinician able to draw on their knowledge of treating hundreds of patients to decide which modalities to use, may include:

• needling distally – from a range of points including LI 4 he gu, TH 5 wai guan or TH 6 zhi gou, SI 4 wan gu or SI 5 yang gu or ST 38 tiao kou
• needling locally – possibly TH 14 jian liao, LI 15 jian yu or LI 16 ju gu, SI 9 jian zhen, SI 10 nao shu, SI 11 tian zong or SI 12 bing feng
• adjunctive therapies including moxibustion, electroacupuncture or gua sha

For the example above, it is presumed that there is no underlying organ-system pathology. But the area of pain may not be the source of the problem – and suppressing the pain and not resolving the cause could lead to further adaptation with more severe consequences down the line.

Spondylosis

The shoulder pain could be caused by an impingement on the nerves supplying the arm. Degenerative changes – termed spondylosis – can start as early as one’s mid-30s. Narrowing of the intervertebral foramina – the channels through which the nerves exit the spinal column – compresses the nerve roots causing pain, discomfort and paraesthesia.

Spondylosis can be confirmed by some orthopaedic testing – and in this case, the use of the hua tuo jia ji M-BW-35 points at the relevant spinal segment may help.

Thoracic outlet syndrome

Adapted from image by Matt Callison (SMAC, 2021, www.sportsmedicineacupuncture.com

Alternatively, impingement of the brachial plexus – the network of nerves in the neck and shoulder that carries motor and sensory signals from the spinal cord to the arms and hands – could be caused by pressure where the nerves leave the neck towards the arm – termed thoracic outlet syndrome. There are three main pinch points:

• neck: where the plexus exits between the anterior and middle scalene muscles which can become tight due to excessive use of the upper ribs in chest breathing – possibly through emotional­ stress, asthma or lack of diaphragmatic breathing – or by adaptive shortening brought on by poor posture
• subclavicular area: the plexus can become compressed as it travels between the clavicle and the first rib due to approximation of these structures through, for example, prolonged carrying of heavy backpacks
• subpectoral area: the pectoralis minor muscle may become hypertonic and shortened through poor posture, especially with computer work: the brachial plexus – which passes between the pectoralis minor muscle and the first and second ribs – may be compressed as the patient reaches behind to pick something up, for example from the back seat of a car: in this case release of the muscles can be effectively undertaken using acupuncture and/or manual therapy.

Channel examination

Which are the channels going through the area of pain?

Using channel examination and point pressing, is the pain or range of motion (ROM) modulated? If so, then that channel has been identified as clinically relevant.

Does the corresponding foot/arm channel in the six-level system also modulate the pain or ROM? If so, utilising points on both channels may have a clinically superior effect.

A painful arc

Often acupuncture students are taught to ask patients to undertake some simple gross ROM tests. However, equally often students are not taught what to do with this information.

So what does a painful arc mean clinically? Many would say it could be a supraspinatus issue – but is this cause or effect?

Cause: for a weak supraspinatus, local needling – for example eyes of the shoulder – and strengthening exercises may be prescribed.

Effect: an overworked supraspinatus may be caused by other muscles in its force couple not relaxing – for example the pectoral/latissimus dorsi muscle – and acting as ‘brakes’. Or it could be a weakened infraspinatus muscle not playing its role in controlling the arm during abduction, which can be confirmed by orthopaedic or manual muscle testing (MMT). In this case, it is doubtful that local treatment alone will have a long-lasting effect – unless the other tight muscles are first released and/or the weakened muscles strengthened.

Planning treatment

Once a working differential diagnosis has been decided on then an individual treatment plan is initiated, based on the clinical presentation at that time.

Having a systematic framework to work with – a patient-centric, integrated paradigm – is vital, especially at the beginning. One such approach that I have found useful is HOPS: History, Observation, Palpation, Special tests.

Although in a clinical situation I may change the order slightly – for example undertaking a general channel palpation, pulse and tongue examination during the history taking, or palpating shu-stream points whilst observing ROM – by the end of the first session I will have completed all the elements I need for an accurate differential diagnosis.

Effective practice

I believe medicine is a dynamic thing and we need to embrace new effective ways, whilst retaining tried and trusted methods. All too often a new piece of research throws doubt on a particular technique, only to be overturned a year later. Ebbing and flowing like this, one is in danger of ‘throwing out the baby with the bath-water’.

Conversely, not everything that was written down over the past 3,000 years stands up to rigorous – but fair – scrutiny and hanging onto ineffective procedures can be just as dangerous.

One of my teachers in China, Professor Wang, would always admonish us not to be a clinician that just seeks point protocols, but to question and adapt our treatments to what works effectively for the patient. I personally think we need to be able to use the best of both systems to help us become safe and effective practitioners.

You can learn more about Alex’s integrative methods of diagnosing and treating in his online case study of medial knee pain.

Alex is a traditional acupuncture and tuina practitioner, osteopath and paramedic. Between 2009 and 2013 he spent a month every year – either in China or Europe – studying applied channel theory and channel palpation with Professor Wang Ju Yi, Jason Robertson, Jonathan Chang and at the tuina hospital in Beijing. He completed Arya Nielson’s full gua sha diploma course and went back to university to study osteopathy in 2015. When not lecturing, he practises an integrated approach to treating patients at The Beacon clinic in Malvern.