Pathogenesis and Tuina Treatment of Shoulder Disorders East West Healing Center By Dr. Leon Chen www.eastwesthealingcenter.net Review of Tuina History Warring States Period: from 475 BC to 221 BC. Tuina manipulation has been recorded in the “Huangdi Neijing” or call “Inner Canon of Yellow Emperor” that is a earliest medicine book in China. Three Kingdoms period, The Jin Dynasty: from 220 A.D to 581 A.D. Tuina technique was improved and Tuina books been appeared, such as “Zhou Hou Fang”. From Song Dynasty to Qing Dynasty: from 960 to 1911, had a lot of Tuina books been appeared and technique much better. Since 1958, Tuina has been get comprehensive development, especially to use modern science approach to the study of Tuina. ZhouHouFang ZhouHouFang ZhouHouFang ZhouHouFang Counter traction for treatment of back pain 元代-危亦林(1277-1347 A.D)《世医得效方》 Yuan Dynasty Waist belt for back pain 元代-危亦林(1277-1347 A.D)《世医得效方》 Yuan Dynasty TuiNa Actions 1) To reduce the pain. 2) To flow blood to particular area. 3) To activate the Qi in the channels. 4) To reduce muscle spasm. 5) To repair the damaged soft tissue. 6) To adjust joints, reset bone. How Does Tuina Work? The tuina can improve the skin and muscle the blood circulation, strengthen the metabolism of tissues and organs, and promote gastrointestinal motility and antiinflammatory effect. How Does Tuina Work of Anti-inflammatory? 1) Increase content of Beta- endorphin (END) and Catecholamine (CA) in blood to help the pain. 2) Decrease content of 5-hydroxytryptamine (5HT) in blood to reduce the pain. TuiNa Methods 1. Single manipulation: 1) 2) 3) 4) 5) 6) 7) 8) 9) Tui: pushing. ①Finger pushing. ②Palm pushing. ③Twin palms pushing. Na: Grasping. ① Fingers. ② Twin palms. An: pressing. ① Finger pressing. ② Palm pressing. ③ Elbow pressing. Mo: Rubbing. Rou: Kneading. Gun: Rolling. ① Side fist. ② Fist. Dou: Shaking. Da: Patting and pound. YaoHuang: Rotating. Tui ( pushing): ①Finger pushing. ②Palm pushing. ③Twin palms pushing. Na: Grasping. ① Fingers. ② Twin palms. An (pressing): ① Finger pressing. ② Palm pressing. ③ Elbow pressing. Mo: Rubbing Gun: Rolling. ① Side fist. ② Fist. Da: Patting and pound. YaoHuang: Rotating 2. Combined manipulation: • AnGunRou: Pressing, Rolling and Kneading. • NaRou: Grasping and Kneading. • Wave: Grasping, Pushing and Rolling. • AnMo: Pressing and Rubbing. 3. Manipulation for the Spine or Joints 1)BaShen: Counter traction ①Joints traction. ②Cervical traction. ③ Lumbar traction. 2) Ban: Adjustment spine or joints. BaShen (Counter traction): Joints traction. Cervical traction. Lumbar traction. Ban: Adjustment Ⅰ Local Anatomy 1.The Structure of Shoulder Coracoid process (1) Bones: Clavicl Humerus Scapula Coracoid process Acromion Glenohumeral joint (2) Ligaments: ①Coracoacromial ligament. ②Coracoclavicular ligament. ③Glenohumeral ligament. ④Coracohumeral ligament. (3) Articular capsule (4) Bursa: Sub-acromial bursa and Sub-deltoid bursa (5) Muscles Deep: Supraspinatus, Infraspinatus, Teres minor and Subscapularis, those are called Rotator cuff. Superficial: Pectoral major, Biceps, Deltoid, Triceps, Trapezius. Pectoral major Biceps Anterior muscles Posterior muscles (6) Tendons: Supraspinatus Tendon, Bicipital Tendon, Subscapularis Tendon (7) Blood Vessels and Brachial plexus Brachial plexus Axillary artery Brachial plexus: • The brachial plexus is composed C5, C6, C7, C8 and T1 spinal nerves. • Those include a radial nerve, a median nerve, a ulnar nerve. ① The radial nerve: C5-C8,T1 of spinal nerves. ② The Ulnar nerve: C8 and T1 of spinal nerves. ③ The median nerve: C5-C8,T1 of spinal nerves Relationship of Cervical Vertebrae and Nerve Roots Conus medullaris Cervical vertebraes Nerve roots Brachial plexus C 4 C4 3 3 5 6 5 7 T1 2 8 3 45 C5 6 7 T1 10 C6 C8 11 12 L1 L2 8 9 S2 54 3 S2 C8 C7 C7 L4 L3 L4 S2 L5 S1 L5 L4 S1 L4 L5 L5 C6 2. Shoulder Movements Abduction: 0-90° Adduction: 0-45° Extension:0-60° Medial Rotation:0-90° (Internal Rotation) Flexion:0-180° Lateral Rotation:0-90° (External Rotation) Ⅱ Differential Diagnosis and Treatment of Shoulder Pain ①Supraspinatus Tendinitis ②Bicipital Tendinitis ③Frozen Shoulder ④Sub-Acromial Bursitis (Sub-deltoid bursitis) ⑤Arthritis of the Shoulder ⑥Cervical Spondylosis 1 Supraspinatus Tendinitis • Definition: The tendinitis is an inflammation of the tendons of the Supraspinatus tendon. The causes of supraspinatus tendonitis can be chronic impingement and degeneracy of the tendon. • Symptoms ① Pain associated with arm movement . ② Pain in the shoulder at night, especially when lying on the affected shoulder . ③ Weakness with raising the arm above the head, or pain with overhead activity. • Examination Tests ①Trigger point on the acromion. ②Lateral of Shoulder pain, or the pain radiate to neck or arm. ③Examination test of shoulder abduction: passive abduction the pain eliminated with shoulder in medial rotation. The other way round, active abduction shoulder in medial rotation posture the pain start 60° to 120° ( pain radian), under 60° and above 120° then the pain disappear. Ossification of Supraspinatus tendon MRI X-ray Tuina Treatment (1) GunRou (Rolling and Kneading) on the Deltoid for 3 minutes. (2) AnRou (Pressing and Kneading) by thumb on the Supraspinatus tendon for 3 minutes. (3) YaoHuang (Rotating): passive rotate shoulder for 2 minutes. (4) Abduction of shoulder by passive associate with Pressing and Kneading for 3 minutes. (5) Dou (Shaking) the arm for 1 minutes. (6) Using heating pad 2-3 per day. Acupuncture treatment • Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes. 2 Bicipital Tendinitis • Definition: Inflammation of the bicipital tendon which is long head tendon of the biceps . It is often associated with some sort of trauma or overuse, and usually associated with rotator cuff disease. Symptoms ①Aching shoulder ②Shoulder pain when lifting heavy objects ③Shoulder pain when performing overhead activities ④Tenderness over bicipital groove. Humeral bicipital groove bicipital tendon Examination Tests Yergason test Neer test Speed test Hawkins test Tuina Treatment ①GunRou: Rolling and Kneading. ②An: Finger pressing. ③Na: Grasping. ④Dou: Shaking. ⑤Yao: Rotating. ⑥Using heating pad 2-3 per day. Acupuncture • Ashi point, IL15, SI10, TE14, LU2, LU3. 3 Frozen Shoulder • Definition: causes limitation of motion in the shoulder joint, that also called adhesive capsulitis. In Chinese medicine, is called Bi Zheng of wind cold, also called “fifty shoulder”. Etiology of Frozen Shoulder • • • • Age and gender Endocrine (hormones) disorders Shoulder trauma or surgery Other systemic conditions Symptoms • Pain in the should. • Most commonly affects patients between the ages of 40 to 60 years old, and it is twice as common in women than in men. • Beginning the shoulder pain, and worse in the night. Later pain less but shoulder movement has been limited. Tuina Treatment • GunRou: Rolling and Kneading. • NaRou: Grasping and Kneading. • Flexion and external rotation of the shoulder associated with pressing and kneading. • Rotating. • Shaking. • Using heating pad 2-3 per day. Acupuncture • Ashi point, IL15, SI10, TE14, LU2, IL4. 4 Sub-acromial Bursitis (Sub-deltoid bursitis) • Definition: Inflammation of the bursa which is located in the sub-acromial or sub-deltoid. It is most often caused by some sort of trauma or overuse of the shoulder. Symptoms • Pain and weakness when the arm is lifted up sideways through a 60 degree arc. • Pain point at acromion or deltoid. • Active arm movement is often restricted in abduction only. Subacromial Bursa Supraspinatus bursa deltoid Bursa of the Coracobrachialis X-ray with contrast medium Tuina Treatment • • • • GunRou: Rolling and Kneading. Finger pressing. Mo: Rubbing. Passive lifted up arm with Finger pressing and kneading. • Rotating. • Shaking. • Using heating pad 2-3 per day. Acupuncture • Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes. 5 Shoulder Arthritis • Definition: Osteoarthritis is characterized by progressive wearing away of the cartilage of the glenohumeral joint. Also called wear and tear arthritis or degenerative joint disease. Diagnosis • Age: It usually affects people over 50 years of age. • Physical examination of the arthritic shoulder usually demonstrates limited motion in all directions with pain. • Crepitus (the crunching sensation inside a joint) is frequently found in shoulder arthritis. • X-ray demonstrates evaluation of the arthritic shoulder. glenohumeral joint Tuina Treatment • GunRou: Rolling and Kneading. • NaRou: Grasping and Kneading. • Flexion and external rotation of the shoulder associated with pressing and kneading. • Rotating. • Shaking. • Using heating pad 2-3 per day. Acupuncture • Ashi point, IL15, TE14, SI10, SI11, IL4. Retaining needles for 20 minutes. 6 Cervical Spondylosis • Definition: that is due to deterioration related wear and tear on the cervical vertebrae (bones) and cartilage or disc of the neck. That affects the brachial plexus lead to nerves pain also. Symptoms • Cervical spondylosis typically affects only the neck, causing pain and stiffness. When nerve compression also is present, signs and symptoms of cervical spondylosis may include: • A stiff, painful neck • Shoulder, arm or chest pain • Tingling and pinprick sensations in the arms, hands. • Numbness and weakness in the arms, hands. Pathogenesis 1) Intervertebral disc herniation: ① Injury; ② degenerative changes. 2) Degeneration of cervical vertebrae: ① Osteophytosis of the vertebral bodies. ② Hypertrophy of the facets and laminal arches. 3) ligamentous and segmental instability. Radiation of cervical nerves Physical Examination 1) Cervical movement: Flexion 35-45°; Extension 35-45°; Lateral bending 45°; Rotation 60-80°. 2) Tension arm test. 3) Percussion head test. 4) Spurling test. 5) Jackson test. 6) Compression shoulder test. 7) Traction test. Tension arm test Percuss head test Jackson test Compression shoulder test Traction test Imaging • A spine or neck x-ray shows abnormalities that indicate cervical spondylosis. • A CT scan or spine MRI confirms the diagnosis. • A myelogram (x-ray or CT scan after injection of dye into the spinal column) may be recommended to clearly identify the extent of injury. • An EMG may also be recommended. Treatment by TCM 1) TuiNa: RouGun (rolling and kneading), NaRou (Grasping and kneading), An (pressing), Ban (adjustment). 2) Acupuncture: GB20 (风池),GB21 (肩井),DU14 (大 椎),SI11 (天宗),LI12 (曲池),TE 14 (外关),LI 4 (合 谷),DU20 (百会),DU (上星). 3) Chinese herbs: ① Wind Bi: FangFengTongShenWan,DuHuoJiShengWan. ② Blood stagnation: FuFangDanShengWan. ③ ShenYang deficiency: ShenQiWan, BuYangHuanWuWan, TanWangBuXinWan. 4) Traction. Ⅲ Cautions or Contraindication • • • • • • Acute injury. Fracture. Tear ligament. Ulcer. Eczema. Hemophilia. Thank you Phone:630-916-0781 E-mail: drchen@eastwesthealingcenter.net Web:www.eastwesthealingcenter.net