12: Systemic Pain–Related Disorders

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CHAPTER 12 Systemic Pain–Related Disorders

This chapter discusses a variety of pain symptoms that are encountered in an acupuncture clinic but have not been addressed in previous chapters. The treatment protocol is presented at the end of the chapter.

HEADACHE

General Pathology

Headaches are among the most common complaints presented by patients seeking acupuncture treatments. Some cases respond well to acupuncture treatments, whereas others are rather challenging.

Although brain tissue does not ache, certain structures in the head and outside the skull are sensitive to pain. These include skin, muscles, arteries, the membrane that coats the skull, the eyes, the ears, and the nasal sinus cavities. Pain may result from tension or inflammation of the muscles or arteries of the scalp, or inflammation in the sinuses, ears, or gums.

Pain-sensitive structures inside the skull include arteries, venous sinuses and their tributary veins, parts of the outer membrane at the base of the brain, and cranial and cervical (sensory) nerves. Headache pain may result from dilation or contraction of the arteries, inflammation of brain membranes, or pressure from a tumor or hemorrhage.

The exact nature of headache pain is still unclear. It is believed that headaches occur as the result of an imbalance or changes in brain chemicals called neurotransmitters, such as serotonin and noradrenaline. The unbalanced levels of these brain chemicals cause inflammation of scalp arteries and irritation of the pain-sensitive structures mentioned above. The inflammation or irritation of these structures stimulates the trigeminal nerve, which sends pain impulses to the pain centers of the brain. The pain may be dull, sharp, or throbbing (pulsatile).

A headache is considered chronic if it cannot be relieved or improved after 6 months.

Medical professionals differentiate headaches into four types: migraine, tension, cluster, and organic. Each type of headache has its own pain pattern.

Of the four types of headache, the tension headache is the most common. This headache is characterized by a dull, squeezing knot or pressure pain that involves the forehead, scalp, temples, or back of the head and neck. The cause of this headache is muscle tension, especially the muscles on the neck and shoulder. When physical and/or physiologic tension or stress accumulates in the body, skeletal muscles and smooth muscles (muscles lining the internal organs and blood vessels) become contracted without spontaneous relaxation. This causes low oxygen supply and results in pain in both skeletal and smooth muscles. In such cases some people also feel pain in the stomach; some complain also of pain in the neck or shoulders; and others feel pain only in the head, possibly accompanied by raised blood pressure.

The tension headache responds very well to acupuncture treatments, and the Integrative Neuromuscular Acupoint System (INMAS) protocol proves to be very effective. As discussed in Chapter 3, muscle tension usually changes the homeostatic acupoints (HAs) from the latent phase to the passive phase, making them tender, and INMAS helps to locate these tender points. Locally, the process of needling tender points and the resulting needle-induced lesions effectively relax both superficial and deep muscles all over the body and restore their normal blood and oxygen supply. Systemically, needle-induced neurochemical substances such as endorphins are secreted into the blood stream and cause the relaxation of skeletal and smooth muscles as well as of other systems such as the cardiovascular system, thus normalizing the blood pressure. This combination of local and systemic effects brings about relief of tension headaches.

The underlying cause of migraine headaches is believed to be neurotransmitters, the communicating chemicals within the nervous system. Migraine headaches usually occur as moderate or severe pain on one side of the head, often accompanied by nausea or transient visual disturbance, intolerance to light or sound, or rainbow-like colors called aura in the field of vision. The incidence of migraine headaches is higher in females than in males. One of the reasons for the gender difference is that many female patients experience migraine just before or during their menstrual period, possibly due to fluctuation in the level of female hormones. Patients with a migraine headache may feel tightened scalp muscles just as do patients with a tension headache.

The medical history of patients with migraine headaches often shows that they have suffered for many years, and it may also show accompanying problems such as habitual constipation, insomnia, fatigue, or a food allergy. The chronicity of migraine headaches makes treatment challenging. In addition, physiologic problems, such as constipation, that often accompany migraines render the body resistant to any medical intervention. For example, if a migraine patient is also suffering from constipation, the toxins retained in the body as a result of the constipation may be supplementary triggers for the migraine.

A comprehensive approach is needed when treating patients with migraine pain. For example, during the course of acupuncture treatments the practitioner and the patient should work together to find solutions for contributing problems such as constipation, poor diet, fatigue, and lifestyle factors (e.g., lack of proper physical exercise). Acupuncture will not provide longlasting relief from migraine if these conditions are ignored or persist.

Cluster headaches are more common in male patients. The cluster headache is characterized by a steady stabbing pain around one eye or on one side of the head, sometimes with watering and redness of the eye and nasal stuffiness on the same side of the face. The pain episodes may recur at the same time of day or night.

The cluster headache is believed to be caused by a disorder in the hypothalamus, the part of the brain responsible for regulating hormones and physiologic rhythms such as the sleep-wake cycle. A specific chemical present in the brain and some cranial nerves may cause similar symptoms. This brain chemical binds to special receptors in the neck arteries to control the ratio of oxygen to carbon dioxide in the blood supply of the brain. Smoking, alcohol, or certain foods may trigger a cluster headache, especially in patients whose family history shows a similar pattern.

Acupuncture helps to relieve cluster headaches by similar means to those discussed in treating tension headaches. In addition to the local and systemic effects of acupuncture needling as discussed above, the needling stimulates peripheral nerves, which send impulses directly to the hypothalamus. Thus acupuncture stimulation helps the hypothalamus to restore its normal regulatory function and reduces the symptoms of cluster headache.

Organic headaches account for less than 1% of headache cases. These headaches are caused by problems such as inflammation around the brain, elevated blood pressure, brain edema (swelling), or a brain tumor. The underlying causes of organic headaches are life-threatening, and these patients should be examined by specialists. However, clinical evidence shows that acupuncture can be useful as a supplement to conventional approaches in treating such patients. Acupuncture induces the secretion of endorphins, which relaxes blood vessels, promotes blood circulation, and reduces peripheral resistance to blood circulation. By using INMAS and properly selecting symptomatic acupoints (SAs), an acupuncture practitioner can help to reduce tissue swelling and high blood pressure and to control inflammation.

Treatment Protocol

All types of headache, no matter whether acute or chronic, should be treated as systemic problems. This means that the whole INMAS should be used. Treatment should be administered in either prone or supine positions, depending on the patient’s health. In general, younger or healthier persons can tolerate more needling than weaker or elderly patients.

Prone Position

Homeostatic Acupoints

Use all of the HAs accessible in this position. Pay special attention to the H2 greater auricular, H3 spinal accessory, and H7 greater occipital acupoints because the degree of their sensitivity and the size of the sensitive area may indicate the duration and severity of the condition. The more sensitive or bigger the acupoint, the more treatments will be needed.

Symptomatic Acupoints

Carefully palpate the neck and shoulder region around H2, H3, H7, and H13 to find the tender SAs and needle them. Usually select four to six SAs in the neck for each treatment. If more than six SAs in the neck are needled, some patients will feel soreness in the neck for a few days.

Paravertebral Acupoints

If there are already four to six needles (SAs) in the neck, then select paravertebral acupoints (PAs) along T1-T7. Five needles on each side are enough. If only two needles are used in the neck, two more needles can be used on each side along C1-C7.

Supine Position

Homeostatic Acupoints

Use all of the HAs that are accessible in this position. Pay special attention to the HAs listed below because the degree of their sensitivity and size of the sensitive area may indicate the duration and severity of the condition. The more sensitive or bigger the acupoint, the more treatments are needed. These HAs are H19 infraorbital and H23 supraorbital.

To avoid bruising on the face, smaller needles are suggested for facial needling (1.5 cm in length and 0.2 mm in diameter).

Symptomatic Acupoints

Carefully palpate the facial area on the forehead, cheek, and lower jaw and scalp. The tender SAs should be carefully needled in these areas. Do not needle the area around the ocular orbit to avoid bruising.

TRIGEMINAL NEURALGIA (TIC DOULOUREUX)

Trigeminal neuralgia is a recurring pain on one side of the face. The pain is characterized by brief flashes of excruciating pain in the lips, gums, cheek, chin, or rarely, forehead. The patient may describe the pain attack as ripping, darting, or sharply cutting. An attack may last for seconds or a few minutes, accompanied by contraction of facial muscles. The attack can be spontaneous or provoked by mild stimulation such as shaving or applying cosmetics.

The pain is caused by a disturbance in the function of the trigeminal nerve, which is the major nerve that carries the sensation from the face to the brain, but the cause of trigeminal neuralgia is still not clearly identified. A blood vessel that compresses the trigeminal nerve has been blamed for causing trigeminal pain in some cases.

Trigeminal neuralgia is most often seen in patients over the age of fifty and is more common in women than in men.

Treatment Protocol

The treatment procedure is the same as that used in treating a headache. Practitioners should keep in mind that, in general, fewer needles should be used in elderly or weak patients. In such cases it is better to use fewer needles and offer more treatments (for example, twice a week).

The efficacy of acupuncture in treating trigeminal neuralgia depends on the severity of the condition and the patient’s health. The quantitative evaluation described in Chapter 6 provides a reliable method to predict the result of the treatment. Acupuncture therapy is effective or helpful for patients in groups A, B, and C. Little or no success can be expected with group D patients.

SHINGLES (HERPES ZOSTER) AND PAIN AFTER SHINGLES (POSTHERPETIC NEURALGIA)

Shingles or herpes zoster is an acute viral disease caused by a herpes virus, the same virus that causes chickenpox. Shingles is caused by a re-emergence of the virus, which has been lying dormant for years within the nerve cells. The virus causes inflammation of the spinal ganglion and a vesicular eruption along the area of distribution of the affected spinal nerves. Patients feel excruciating, burning pain or tingling in the affected area.

If pain persists after the eruption or blisters have healed, the condition is called postherpetic neuralgia. This chronic pain results from damage to the nerve fibers caused by the shingles infection.

Shingles appears in persons who have been exposed to chickenpox. The reactivation of the virus may be triggered by trauma, diseases like pneumonia or tuberculosis, injection of certain drugs, or stress, which suppresses immune functions.

Acupuncture therapy accelerates the healing process through several mechanisms. Needle-induced endorphins systemically relax the whole body, which reduces the stress level. This process restores the function of the immune system, which in turn deactivates the virus and brings it under control. Local needling along the infected nerve stimulates an antiinflammatory reaction and helps recovery or regeneration of the damaged nerve fibers.

Treatment Protocol

Select the proper position, prone, supine, or on the side, to expose the affected area for treatment.

Please note that the infection is limited to the dermatome area of the infected spinal nerve(s), so practitioners need to be familiar with the segmental dermatome distribution of the spinal nerves. For example, the breast and nipple area is the dermatome of T4 and the umbilicus is in dermatome T10. The affected area is usually limited to one side of the body and occupies two neighboring dermatomes. For instance, if the infected skin is just below the nipple, it is the dermatome T5 or T6 or both.

Homeostatic Acupoints

Needle all of the HAs in the body accessible in that position.

Symptomatic Acupoints

Use small needles (1.5 cm in length and 0.2 mm in diameter) and insert them all over the affected skin around the infected nerve. As many as 30 or more tiny needles should be used for each treatment according to the size of the affected skin area. Avoid breaking the blisters to prevent spreading the virus. If the blisters do break, use a cotton cuticle to dry the liquid and apply Betadine to the affected area.

Paravertebral Acupoints

Select the paravertebral points corresponding to the infected spinal nerves. For example, if the affected skin is on dermatomes T5-T6, select the PAs from T3-T8.

TEMPOROMANDIBULAR JOINT DISORDERS AND OTHER SYMPTOMS RESULTING FROM DENTAL WORK

The temporomandibular joints (TMJ) are the hinge-like joints that connect the mandible (lower jaw) to the temporal bone of the skull. As in other joints in the body, the bony surfaces of these joints are covered with cartilage and both articular surfaces are separated by a small disk that prevents the bones from rubbing each other. The muscles that move the joints (open or close the mouth) also stabilize the joints.

As with other joints, any disorder or dysfunction of the TMJs will produce pain. The TMJ is susceptible to various disorders such as inflammation, osteoarthritis, or rheumatoid arthritis. Pain also may result from mechanical damage such as wear and tear on the joints, injury, tightened joint muscles, stress, an improperly aligned bite, and poorly fitting braces or other dental appliances.

Patients may complain of a dull aching pain in front of the ear, a clicking sound or grating sensation when opening the mouth or chewing, or difficulty in opening or closing the mouth. Chronic tension and anxiety may cause a patient to habitually clench the jaw or grind the teeth while sleeping. This unconscious overuse of the TMJs also causes pain and dysfunction of the joints, ligaments, and muscles. Some patients also feel tinnitus, headache, nausea, or even vertigo.

Needling into the TMJs and the muscles that operate them reduces muscle tension and the inflammation of muscle and soft tissues that is associated with the joints. Needling improves local blood circulation and increases oxygen supply, which accelerates tissue healing. Acupuncture is able to repair injured soft tissues and restore joint function. Acupuncture needling also slows down the degenerative process in cases of arthritis. TMJ dislocation or misalignment resulting from dental problems should be treated by the appropriate specialists but acupuncture can be used as a supplementary treatment in such cases.

Similarly to patients with other postoperative problems, patients who have had dental surgery can also be benefited by acupuncture. After dental surgery, patients feel numbness in gums, lips, jaw, and facial skin with edema of soft tissues. Dental surgery, by nature, is an acute trauma to the body. The administration of needling immediately after surgery will greatly reduce edema and swelling. Also needling dilates the blood vessels to reduce peripheral resistance to cardiovascular circulation, which helps to reduce water retention in soft tissues. The accelerated water metabolism increases the metabolism of the anesthetics that were used for the surgery, and so the needling immediately or shortly after dental surgery helps to reduce swelling and to eliminate remnant anesthetics in the oral tissues.

Treatment Protocol

Select the proper position, supine or on one side. If the TMJ problem is chronic, all of the HAs accessible in the selected position should be needled because the patient may have other symptoms like headache, fatigue, tinnitus, or nausea. If the TMJ problem is acute and the patient is healthy (group A or B), only local symptomatic points need to be needled.

To find the local symptomatic points, carefully palpate the area around the TMJ, the temporalis and masseter muscles, the neck muscles including the sternocleidomastoid, and the muscles of the back of the neck.

Use needles 2.5 cm in length (0.2 mm in diameter) for the joints proper and for the thicker muscles like the masseter and the sternocleidomastoid. Use smaller needles 1.5 cm long (0.18 or 0.2 mm in diameter) for areas in the face and thinner muscles like the temporalis and scalp muscles or sutures. Needles 3 to 5 cm long can be used for the muscles on the back of the neck.

COMPLEX REGIONAL PAIN SYNDROME

Complex regional pain syndrome (CRPS) has puzzled clinicians and pain scientists more than any other pain condition. The name itself reflects our incomplete understanding of this disorder. It was first described by Civil War surgeons Mitchell, Morehouse, and Kane in 1864.¹ Currently, medical professionals believe that CRPS is caused by some kind of nerve injuries.

CRPS is classified into two types: reflex sympathetic dystrophy syndrome (RSD, type I) and causalgia (type II). The symptoms of both types are similar, and the difference between them is that causalgia can be associated with an identifiable nerve injury.

In Box 12-1, Dr. Sanjay Gupta suggests the diagnostic criteria for CRPS.¹

Box 12-1 Complex Regional Pain Syndrome

Type I: RSD	Type II: Causalgia
Continuous pain, with a hypersensitivity to cold stimuli and nonpainful stimuli eliciting a pain response	Continuous pain, with a hypersensitivity to cold stimuli and nonpainful stimuli eliciting a pain response after a nerve injury, but not necessarily following the nerve distribution
Evidence of swelling and skin changes with a decrease in blood flow to the affected area	Evidence of swelling and skin changes with a decrease in blood flow to the affected area
Absence of a condition that otherwise explains the above symptoms	Absence of a condition that otherwise explains the above symptoms
An inciting event or cause may or may not be present	All three of the above must be present for this diagnosis

The signs and symptoms presented by CRPS patients may include:

1. Pain and tenderness in the hand or foot

2. Tender, thin, swelling, cool, or shining skin in the affected area, accompanied by increased sweating and hair growth

3. Cold, blue, sweaty limb with “burning” or “stabbing” pain

4. Excessive painful response to cold stimuli or light touch

5. The pain becomes worse at night

6. Emotional stress, depression, or lack of sleep increase the feeling of pain. In some cases, the patient may have had an injury, heart attack, or stroke weeks or months earlier. In other cases the preceding injury may have been very minor and the patient may not even remember it

CRPS usually develops in three stages but any one patient may not necessarily follow the same pattern. Stage I, which is also called the dysfunction stage, is characterized by redness, swelling, and pain in the affected area. This stage usually lasts for 3 to 6 months. CRPS symptoms can be completely reversed by acupuncture treatment if treated at this stage. Some of our young patients were completely cured in about 3 months, after receiving acupuncture treatment twice a week for 1 month and once a week afterwards.

Stage II is also known as the dystrophy stage. Patients exhibit cold and blue skin with sweating and severe pain in the affected area. X-rays may reveal signs of osteoporosis or degenerative changes in the bone. This stage lasts for about 6 months. CRPS is still susceptible to medical treatment at this stage.

Stage III, the final stage, is characterized by pain and signs of atrophy such as muscle and bone wasting. The pain may gradually subside but the atrophy continues to progress. According to current medical opinion, this stage is not reversible.

CRPS commonly results from a fracture in the hand or leg, or nerve and soft tissue damage. It also can be caused by repetitive motion such as typing or operating machines. CRPS is also linked to major or minor body injury or trauma such as sprains, dislocation, laceration, contusions, crushing injuries, amputations, gunshots, or diseases such as stroke.

Acupuncture therapy can provide very effective relief to CRPS patients at stages I and II. Acupuncture needling relaxes the painful and tight muscles, which helps remove mechanical pressure on peripheral blood vessels. It also calms the sympathetic tone and increases parasympathetic activities, which help to improve peripheral blood circulation. This increased circulation provides more nutrition and oxygen and accelerates the evacuation of metabolic toxins that are retained in soft tissues. Needle-induced endorphins not only reduce pain but also relax the entire body and remove mental tension.

Treatment Protocol

Warning! The affected area should not be needled. The area is very sensitive and even a very light touch may trigger excruciating pain (allodynia). Any needling in the affected soft tissues will increase the pain. Remember, do NOT insert acupuncture needles into the affected area.

Homeostatic Acupoints

The patient can be placed in a supine, prone, or side position according to the area affected. It is very important to needle all of the HAs accessible in the selected position.

Paravertebral Acupoints

Paravertebral acupoints are probably the most important points in treating CRPS.

Follow the dermatome distribution. For example, if the affected area is on the hand, then use PAs along C4-T2. If the affected area is on the foot, use PAs along L2-S4.

Symptomatic Acupoints

Do not needle the affected area, according to the above warning, but the neighboring, nonsensitive areas should be examined and needled. For example, if the dorsum of the hand is affected, needle the elbow and shoulder area around the HAs.

To increase the effectiveness of acupuncture treatments, two or three treatments weekly are recommended.

1 Gupta S. Complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy. In: Simon WH, Ehrlich GE, Sadwin A, editors. Conquering chronic pain after injury: an integrative approach to treating post-traumatic pain. New York: Avery; 2002:62-64.

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