Diseases of Cold Bi
"A fireside chat"
Traditional Chinese Medicine's Diseases of Cold Bi are frequently encountered by the Medical Acupuncturist.
The Cold Bi syndromes are a grouping of illnesses with these common characteristics. Inhibition of blood supply, fondness and alleviation of pain with warmth and a worsening of the pain severity with cold and damp.
Corresponding Western syndromes include; Myofascial pain syndromes, shoulder arm syndrome, cervical brachial syndrome, osteoarthritis, back pain, non-discogenic sciatica plus Sudeks disease (cold), etc.
Most of these syndromes are associated with trigger point activity.
In the myofascial group the trigger point acts as the pain generator. In diseases such as osteoarthritis trigger points frequently act as pain amplifiers.
Calliet in his book Soft Tissue Disability, states that trigger points are caused by the following factors: over-exertion, chilling of fatigued muscles, sustained emotional tension, and aberrant axon reflex (as in disc protrusion with root irritation). The anatomical and physiological make up of trigger points is still being explored. They are not exactly analogous to traditional Chinese Acupuncture's Ashi points.
(Ahshi - Oh Yes or that's it! As palpation of the point reproduces the pain complaint).
Many observers including J. Travell and R. Melzack believe that acupuncture points are frequently trigger points.
Travell's criteria for trigger points includes exquisite focal tenderness, referred pain on pressure, localised E.M.G. activity and the twitch response to palpation.
Many studies have implicated trigger points with chronic pain states.
The syndrome known as Chronic Benign Pain* is nearly always associated with trigger point activity. (Ed. 2015 -Probably currently described as Neuropathic)
The anatomy of trigger points is a problem awaiting elucidation. No definite post mortems changes have been found with any definite consensus. Theories include: Fat herniation through muscle fascia, colloid granules resulting from myofibrils lyses, fibrous nodules, oxidative stress, degenerative changes etc.
In my view trigger points are an expression of function. That a small group of muscle fibres driven to spasm resulting in ischaemia and pain by abnormal axon impulses, could generate enough C fibre activity to cause pain and produce reflex segmental sympathetic outflow but still be absent at post mortems is attractive.
That acupuncture, in particular the Near and Far method, is effective in the treatment of trigger point related illness is becoming well recognised.
Over the last few years I have been asking my patients to fill out pain diagrams. Comparisons of their diagrams with Travell's maps show a high degree of correlation. If the correlation is good then the characteristic trigger point is frequently found.
To further my understanding of these types of pain syndromes I acquired an A.G.A. Thermographer. The Thermographer is capable of producing a high resolution image of the bodies infrared radiation, giving an accurate representation of the bodies surface temperature. The correlations emerging are exciting. The patient's pain diagrams, Travell's maps and the Thermographer frequently concur. It seems that thermography can map some of the bodies reflexes to pain. It can also show the "pain generators" - trigger points and the referred pain mediated by the sympathetic outflows caused by their activity . Thermography can also show some of the reflex events produced by acupuncture.
Traditional Chinese Medicines aim in the treatment of Cold Bi is to remove the obstruction to the flow of Chi and blood and warm and nourish the tissues.
In Western terms remove the trigger point and its associated muscle spasm/shortening, diminish the over active sympathetic outflows and thereby restore normal blood flow.
The Bu needling technique or the warming method, where the needle is painlessly inserted and gently manipulated until needle grasp is obtained causes stimulation of large fibre afferents (GP 11). The consequences of Group 2 afferent activity are inhibition of small fibre activity (pain gate), relaxation of segmental muscle tone, and inhibition of sympathetic segmental outflow. (Sympathetic gate). Precisely the reflexes required for healing.
The Near and Far method of Acupuncture, where the trigger point, and distal analgesia producing sympatholytic points below the elbow or knee are needled, is an ancient method that is currently used in China today for the resolution of common pain states.
The exact effects of trigger point needling are not known. Relaxation of stuck' myofibrils, segmental release of encephalin and dynorphin, localised trauma induced, vasodilatation have been suggested as being responsible for the needles effect which causes an exquisitely tender area in a muscle to disappear. The effect of needling the analgesia producing distal points ( points that are either muscle motor points or have dense cutaneous / muscle nerve innervation) has been well researched. The analgesic effects are mediated by the Endogenous Opiod substances as well as a host of other neurotransmitters and modulators including 5HT, and Nor Adrenalin.
The success of the Near and Far Acupuncture technique and indeed of most treatment techniques that target the trigger point relies on the accurate localisation of the relevant trigger point. Consequently physical examination including palpation must be carried out. Indeed every patient complaining of chronic pain deserves to be physically examined. The utilisation of pain assessment tools such as pain diagrams, Travell's pain charts, the McGill Pain Questionnaire, Visual Analogue Pain Scale are a necessary part of this examination process.
By Simon Strauss MBBS Dip Acup Nanjing 1978