TCM Acupuncture and Massage

Chapter 65 Bone and Joint Diseases (3)
2. Wall-climbing exercise. The wall-climbing exercise carried out by patients with frozen shoulder at home can replace the exercise of lifting the shoulder joint and climbing stairs in the physical therapy room.This gymnastics mainly uses wall fixation and body gravity to improve the functional status of the patient's shoulder joint abduction and flexion, and at the same time improves the function of the patient's shoulder rotation.The specific practice method is as follows:
(1) Preparatory posture: the patient faces the wall, stands with both legs side by side, the upper body is upright, about 70 cm away from the wall (basically one arm’s distance away), the upper limb of the affected side is slightly bent forward, and the index finger is attached to the wall.Action: The patient’s upper limb on the affected side gradually straightens as the index finger, middle finger and ring finger climb up in turn. When the fingers can no longer climb up, use the palm of the hand to support the wall, bend the knee joints, and use the weight of the body to bend toward the wall. Shoulder press action.Then turn the body to the left about 30 degrees, do lateral shoulder presses, and return to the posture facing the wall, and then turn the body about 30 degrees to the right, and do lateral shoulder presses.Repeat the exercise 8 to 10 times.

(2) Preparatory posture: the patient's affected side should face the wall with shoulders, legs side by side, upper body upright, about 70 cm away from the wall, the upper limb of the affected side is slightly bent, abducted and raised, and the index finger is attached to the wall.Action: The patient's upper limb on the affected side climbs up with the index finger, middle finger and ring finger in turn, and gradually abducts and lifts up. After reaching the maximum limit, support the wall with the palm of the hand, bend both knee joints, and use its own gravity to abduct and lift the shoulder against the wall. Movement; then turn the body forward about 30 degrees, do a side-to-side shoulder press, and restore the affected side to the wall posture; then turn the body back about 30 degrees, and do a side-to-back shoulder press.Repeat the exercise 8 to 10 times.

[-]. Point massage

([-]) Acupuncture therapy

1. Select acupoints from Jianjing, Tianzong, Jiansanzhen, Biyi, Quchi, Shousanli, Hegu Zhongping, and Yanglingquan.

2. Positioning
Jianjing - on the shoulder, the midpoint of the line connecting Dazhui and the acromion.

Tianzong—scapula, in the central depression of the infraspinatus fossa, level with the 4th thoracic vertebra.

Three needles on the shoulder - 2 acupuncture points on the shoulder and 3 inches from the front and back.Shoulder skull point, when the upper arm is abducted, two depressions appear in the front depression.

Brachial diaphragm—on the outer side of the arm, at the insertion point of the deltoid muscle, on the line connecting the Quchi and the shoulder, 7 cun above the Quchi.

Quchi—Bend the elbow, about 0.5 cun outside the transverse crease of the elbow.

Shousanli—the radial side of the back of the forearm, on the line connecting Yangxi and Quchi, 2 cun below the elbow crease.

Hegu—between the first and second metacarpal bones on the back of the hand, about the midpoint of the second metacarpal bone.

Zhongping—1 cun below Zusanli point.

Yanglingquan—the depression anteriorly and inferiorly to the head of the fibula.

([-]) Self-massage
If the joint movement disorder of a patient with frozen shoulder only affects one side, you can use the unaffected hand to perform self-massage on the affected side.Before performing self-massage, patients generally take a hot water bath to perform local hyperthermia on the shoulder joint on the affected side.Then you can choose a set of medical gymnastics for frozen shoulder that is more suitable for you to exercise, and finally perform self-massage for frozen shoulder.The steps and methods of self-massage are:

1. Use the thumb or palm of the healthy side to rub the front and outside of the shoulder joint on the affected side from top to bottom for about 1 to 2 minutes. You can use your thumb to press on the local pain point for a while.

2. Use the pulp of the 2nd to 4th fingers of the healthy hand to massage the various parts of the back of the shoulder joint for about 1 to 2 minutes. If you find local pain points during the massage, you can also use your fingers to press for a while.

3. Knead the upper arm muscles of the upper limb of the affected side with the combined action of the thumb of the healthy side and the rest of the fingers, from bottom to top to the shoulder, for about 1 to 2 minutes.

4. In the case of functional positions such as shoulder abduction or protraction, use the above method to perform massage, and perform activities in all directions of the shoulder joint while massaging.

5. Knead with palm from top to bottom for 1 to 2 minutes.For the parts that cannot be massaged at the back of the shoulder, the front can be patted for treatment.Self-massage can be carried out twice a day, and it will have better results if you stick to it.

Lumbar disc herniation

An overview of the disease

([-]) Relevant knowledge

The intervertebral disc is composed of cartilage plate, nucleus pulposus and annulus fibrosus.The nucleus pulposus is surrounded by the fibrous ring, and its upper and lower sides are surrounded by cartilage plates, forming a sandwich-like structure, located between the upper and lower vertebral bodies.Lumbar disc herniation refers to a series of symptoms and signs caused by the rupture of the fibrous ring of the intervertebral disc and the protrusion of the nucleus pulposus tissue, which compresses and stimulates the nerve roots.Lumbar disc herniation is the most common cause of low back pain.The factor that constitutes lumbar disc herniation is intervertebral disc degeneration, but it is also related to factors such as excessive load on the waist, long-term vibration, spinal deformity, and acute injury.Due to the heavy burden and many activities of the lower waist, the protrusion mostly occurs in the gap between L4-5 and L5-S1.

([-]) Etiology and pathogenesis

Lumbar disc herniation is mainly caused by corresponding damage on the basis of lumbar disc degeneration.To put it figuratively, the human intervertebral disc is like the shock-absorbing spring of a car, which slows down the impact and shock of the human body and bears considerable pressure.As a person ages or is affected by trauma, the elasticity of the "shock-absorbing spring" will gradually weaken. After the age of 20, the lumbar intervertebral disc begins to degenerate, and the elasticity and load-bearing capacity of the lumbar intervertebral disc also declines.Some accumulated injuries in people's daily life and work make the lumbar intervertebral disc repeatedly bear loads such as extrusion, bending and torsion, and cracks may occur at the part of the lumbar intervertebral disc that bears the greatest stress, that is, the posterior part of the fibrous annulus.With repeated load-bearing, the fissures gradually increase, making the annulus fibrosus thinner and thinner. On this basis, with trauma, the annulus fibrosus may be ruptured, and the degenerated nucleus pulposus tissue is formed by the annulus fibrosus. The weak or broken part of the nerve protrudes, compresses the nerve root or cauda equina, causes low back pain and radiating lower limb pain, and even produces symptoms of neurological damage.

The reasons for lumbar disc herniation are as follows: 1. Degenerative changes of lumbar intervertebral disc. Wear and tear, especially on the intervertebral discs in the lower back, resulting in a series of degenerative changes.

2. External force Some people often have long-term improper waist force, excessive force, incorrect posture or body position in daily life and work.For example, the loading and unloading staff bend down to lift heavy objects for a long time, and the driver is in a sitting and bumpy state for a long time.The slight damage caused by these long-term repeated external forces acts on the intervertebral disc over time, aggravating the degree of degeneration.

3. The weakness of the intervertebral disc's own anatomical factors
(1) The intervertebral disc gradually lacks blood circulation after adulthood, and its repair ability is also poor, especially after the above-mentioned metamorphosis occurs, the repair ability is even more powerless.

(2) The annulus fibrosus on the posterolateral side of the intervertebral disc is relatively weak, while the width of the posterior longitudinal ligament is significantly reduced at the L5-S1 plane, and the strengthening effect on the annulus fibrosus is obviously weakened.

4. Precipitating factors
(1) Sudden weight-bearing or waist flashing: Sudden increase in waist load, especially rapid bending, lateral bending or rotation, is the main reason for the formation of rupture of the fibrous annulus.

(2) Lumbar trauma: When the violence is strong and does not cause fracture and dislocation, the degenerated nucleus pulposus may protrude.In addition, a herniated disc may also occur after a lumbar puncture or spinal anesthesia.

(3) Improper posture: In daily life such as getting up, standing up and some work, if the waist is in a flexed position and an external rotation is given suddenly, it is easy to induce nucleus pulposus herniation.

(4) Increased abdominal pressure: Abdominal pressure has a certain relationship with intervertebral disc herniation. Sometimes, nucleus pulposus herniation can also occur when severe coughing, sneezing, constipation, or holding your breath.

(5) Exposure to cold and dampness: Cold or dampness can cause small blood vessels to constrict and muscle spasm, increase the pressure on the intervertebral disc, and may also cause rupture of the degenerated intervertebral disc.

([-]) Clinical manifestations

1. Low back pain and radiating pain in one lower extremity are the main symptoms of the disease.Low back pain often occurs before leg pain, or both may occur at the same time; most of them have a history of trauma, and there may be no clear inducement.Pain has the following characteristics:
(1) The radiating pain is transmitted along the sciatic nerve and reaches the outside of the calf, dorsum of the foot or toes.If the lumbar 3-4 gap protrudes, the lumbar 4 nerve root is compressed, causing radiating pain to the front of the thigh.

(2) All actions that increase the pressure of cerebrospinal fluid, such as coughing, sneezing and defecation, can aggravate low back pain and radiating pain.

(3) Pain intensifies during activity and relieves after rest.Bed position: most patients adopt side lying position and bend the affected limb; individual severe cases have pain in various positions, and can only kneel on the bed with hips and knees to relieve symptoms.Those with lumbar spinal stenosis often have intermittent claudication.

2. Scoliosis deformity.The main bend is at the lower waist, and it is more obvious when bending forward.The direction of scoliosis depends on the relationship between the protruding nucleus pulposus and the nerve root: the protruding nucleus pulposus is located in the front of the nerve root, and the spine bends toward the affected side, and if it bends to the healthy side, the pain will increase; The healthy side is bent, and the pain will be aggravated if it is bent to the affected side.

3. Restricted spinal mobility.The nucleus pulposus protrudes, compresses the nerve root, and makes the psoas muscle protectively tense, which can occur unilaterally or bilaterally.Due to the tense psoas muscles, the physiological lordosis of the lumbar spine disappears.Spinal flexion and extension activities are limited, and radiating pain to one side of the lower extremity may occur during forward flexion or extension.Scoliosis is often limited to only one side, which can be differentiated from lumbar tuberculosis or tumor.

4. Lumbar tenderness with radiating pain.There are limited tenderness points next to the spinous process on the affected side of the intervertebral disc herniation, accompanied by radiating pain to the calf or foot, which is of great significance for diagnosis.

5. Positive straight leg raising test.Due to differences in individual constitutions, there is no uniform degree standard for positive tests, and attention should be paid to the comparison between the two sides.It is positive if the leg lifting on the affected side is limited and radiating pain to the calf or foot is felt.Sometimes numbness and pain in the affected leg occurs when the healthy limb is raised, which is caused by stretching of the nerve on the affected side, which is of great value in diagnosis.

6.神经系统检查。腰3～4突出（腰4神经根受压）时，可有膝反射减退或消失，小腿内侧感觉减退。腰4～5突出（腰5神经根受压）时，小腿前外侧足背感觉减退，第2趾肌力常有减退。腰5骶1突出（骶1神经根受压）时，小腿外后及足外侧感觉减退，第3、4、5趾肌力减退，跟腱反射减退或消失。神经压迫症状严重者患肢可有肌肉萎缩。

If the protrusion is large, or it is a central protrusion, or if the annulus fibrosus ruptures and the nucleus pulposus fragments protrude to the spinal canal, there may be more extensive nerve root or cauda equina damage symptoms, and the numb area on the affected side is often extensive, which may include nucleus pulposus protrusion Below the plane of the affected side buttocks, lateral thigh, calf and foot.Central herniation often has symptoms of nerve damage in both lower limbs, but one side is heavier; attention should be paid to check the sensation in the saddle area, often one side decreases, sometimes both sides decrease, and there is often loss of control of urination, wet trousers bedwetting, constipation, sexual function handicap, or even partial or major paralysis of both lower extremities.

([-]) Diagnosis

Most patients with lumbar disc herniation can make the correct diagnosis based on clinical symptoms or signs.

X-ray films need to take frontal and lateral films of the lumbosacral spine, and left and right oblique films if necessary. Although X-ray signs cannot be used as the basis for diagnosing lumbar disc herniation, they can be used to exclude some diseases.

When it is difficult to diagnose, special examinations such as myeliodol angiography, CT scan and magnetic resonance can be considered to confirm the diagnosis and the prominent part.Patients without obvious abnormalities in the above examinations cannot completely rule out lumbar disc herniation.

([-]) Treatment

The treatment of lumbar disc herniation is divided into non-surgical treatment and surgical treatment.

1. Non-surgical treatment The main purpose of non-surgical treatment is to accelerate the regression of the inflammatory edema of the herniated part of the intervertebral disc and the stimulated nerve root, so as to reduce or relieve the compression of the nerve root and relieve or subside the pain.Nonsurgical treatments include bed rest, traction, massage, physical therapy, anti-inflammatory and pain medications, and epidural steroid injections.

(1) Bed rest: This is the simplest treatment.Biomechanical studies have proved that the half-elevated upper body lying position, or the side lying position with hips and knees flexed can significantly relieve the pressure on the intervertebral disc and nerve roots.Bed rest rests the affected area and also helps inflammation subside.Lying on a hard bed, if you can persist in the treatment, you can expect relief within 3 to 4 weeks.

(2) Traction: Traction includes pelvic traction, vertical suspension traction and mechanical traction. After traction, the intervertebral space will be enlarged, the facet joints will be pulled apart, and the posterior longitudinal ligament will be tensed, which is conducive to the partial restoration of the protruding nucleus pulposus.It can also significantly relieve the pressure on the intervertebral space and nerve roots, thereby relieving symptoms.

(3) Massage, massage and physical therapy: Massage, massage and physical therapy can relieve muscle spasm and reduce the pressure in the intervertebral disc.Massage and massage can change the relative relationship between the protruding nucleus pulposus and the nerve root, and reduce the compression on the nerve root, but if used improperly, it can also aggravate the protrusion and aggravate the symptoms.

(4) Drug treatment: Non-hormonal anti-inflammatory painkillers are also helpful in relieving pain and eliminating inflammation.Appropriate application of diuretics can also reduce nerve root edema and congestion.

(5) Application of epidural hormones: Epidural injection of long-acting hormones and anesthetics (lidocaine or procaine) is a good way to treat lumbar disc herniation, low back and leg pain, and 60-85% have good short-term results , and the long-term effect can reach 30-40%.

The symptoms of the vast majority of patients with lumbar disc herniation are relieved or disappeared after non-surgical treatment, but about 10% of patients still need surgical treatment.

2. Surgical treatment
(1) Principles of surgery

①Surgical treatment should only be considered for patients with severe symptoms if non-surgical treatment is ineffective.

②Before deciding on surgical treatment, both the surgeon and the patient should understand that surgery can only eliminate the symptoms but not cure the intervertebral disc disease and make it return to normal.

③ After the operation, the spine should still be protected. It is not suitable for repeated bending and rotating activities. In particular, it should try to avoid carrying heavy objects in the flexed position of the spine.

(2) Surgical method

①Traditional lumbar discectomy.

② Anterior discectomy.

③ microscopic lumbar discectomy.

④ percutaneous lumbar discectomy.With the advancement of modern surgical technology and auxiliary equipment, surgery tends to only perform limited soft tissue stripping and bony resection on patients, reducing the interference in the spinal canal, thereby reducing the pain of patients.However, the new minimally invasive surgical methods also have certain limitations, and it is necessary to have a good grasp of their indications and continue to improve them in practice.

([-]) Prevention

Lumbar disc herniation is a common and frequently-occurring disease, which can seriously affect the patient's work and quality of life.Therefore, prevention work is very important.

1. Preventive education should actively carry out publicity and education to the predisposed population and patients, and popularize the basic knowledge of the disease, so that they can better cooperate with doctors in treatment and disease prevention.

2. Health check-up Instruct people who are engaged in sedentary, long-standing, and waist sports to protect their backs to prevent repeated injuries and overstrain, and give them regular physical examinations.

3. Combination of work and rest should be careful not to work in a fixed position or work for too long, especially when bending over a desk or bending over, the position should be changed intermittently to rest the tired muscles.

4. Improve the working and living environment and eliminate unfavorable factors. Long-term exposure to wind, cold, damp and other stimuli can often cause low back pain or joint pain, which should be avoided at ordinary times.

5. Use waist support and protection to reduce trauma, and waist trauma should be diagnosed and treated in time.

6. Correcting bad posture is the focus of prevention.Long-term incorrect standing posture, sitting posture, and sleeping posture can make the back muscles in a state of tension for a long time. If things go on like this, the back muscles will be strained, the lumbar spine will be unstable, and this disease is prone to occur.

7. Properly move the waist, enhance the strength of the lumbar back muscles, increase the stability of the spine, and have a good effect on the prevention of lumbar intervertebral discs.

[-]. Point massage

([-]) Acupuncture therapy

1. Acupoint selection Mingmen, Shenshu, Qihaishu, Dachangshu, Guanyuanyu, Yaoyangguan, Zhibian, Huantiao, Chengfu, Yinmen, Weizhong, Fengmen, Yanglingquan, Chengshan, Kunlun .

2. Positioning
Mingmen—waist, on the posterior midline, in the depression under the spinous process of the second lumbar vertebra.

Shenshu—waist, below the spinous process of the second lumbar vertebra, 2 cun laterally.

Qihaiyu—waist, below the spinous process of the third lumbar vertebra, 3 cun laterally.

Dachangyu—waist, below the spinous process of the 4th lumbar vertebra, 1.5 cun laterally.

Guan Yuanyu—waist, below the spinous process of the fifth lumbar vertebra, 5 cun laterally.

Yaoyangguan—waist, on the posterior midline, in the depression under the spinous process of the 4th lumbar vertebra.

Zhibian—lumbosacral region, below the spinous process of the fourth sacral vertebra, 4 cun laterally.

Ring jump—the lateral part of the femur, lying on the side with the femur flexed, at the junction of the lateral 1/3 and middle 1/3 of the line connecting the most convex point of the greater trochanter and the sacral hiatus.

Supporting support—the back of the thigh, the midpoint of the horizontal crease under the buttocks.

Yinmen—the back of the thigh, 6 inches below the support.

Weizhong—the midpoint of the carmine stripes, between the biceps femoris tendon and the semitendinosus tendon.

Damper—on the midline of the outer thigh, 7 inches above the rouge crease, or at the tip of the middle finger when the hand is upright and down.

Yanglingquan—on the outer side of the calf, in the depression anteriorly and inferiorly to the head of the fibula.

Chengshan—the back side of the calf, the top of the depression between the two muscle bellies of the gastrocnemius muscle.

Kunlun—the back of the lateral malleolus on the dorsum of the foot, the depression between the tip of the lateral malleolus and the Achilles tendon.

(End of this chapter)