For those who treat athletes or older patients with complex pattern presentations, knee injuries and pain are among the most common of complaints. The pain can be on any channel or on more than one of them, and it can be discriminated into one or more of several patterns.
In my experience, successful treatment with acumoxa therapy involves discovering and treating the root pattern(s) and then determining the most immediately pain-relieving branch treatments. A look at each of the most common patterns can lead us to effective root treatments. Palpation, questioning, measurement, and experience are often most important in determining the branch treatments. One without the other is like a bird with only one wing.
Below is one case history exemplifying this treatment model. For more detail on applying these ideas to the treatment of knee pain, a related and much longer article is available at www.bluepoppy.com in the free online quarterly journal through June, 2000.
Representative Case History
The patient was a woman, 51 years old. She was a physical therapist but taking a year long leave of absence to care for a sick parent, which caused her a great deal of stress. She was thin and somewhat fidgety. She had had a partial hysterectomy due to fibroids three years ago.
This patient was fatigued and noticed recently that she bruised easily. She was irritable, nervous, and her pulse was quite bowstring. She had a tendency to cold hands and feet and sometimes had nocturia. She had pain in her left knee on the medial side. It came and went and was sometimes related to inguinal or hip or low back pain when at its worst. It was worse under stress and worse when she was tired or overworked. The entire knee and lower leg got cold easily. Her tongue had teethmarks on its edges and was slightly pale and stagnant looking. The fur was not remarkable.
Pattern Discrimination: Spleen qi vacuity, liver depression qi stagnation, kidney yang vacuity
Explanation: The spleen is the source of engenderment and transformation of latter heaven qi and blood. When the spleen cannot perform this function, there is inadequate qi and blood to nourish the sinews and vessels. With the patient suffering unremitting stress, there is simultaneous liver depression qi stagnation which is shown by the irritability, the bowstring pulse, and the fact that the pain is worse with stress. Finally, during the perimenopausal years, it is common that women experience kidney yin and/or kidney yang vacuity due to the relationship of the kidney essence to uterus and the chong and ren channels. In this patient’s case, we see some spleen-kidney yang vacuity with vacuity cold. As a root treatment to deal with these patterns, I chose three or four points to supplement the spleen and boost the qi, course the liver and rectify the qi, and supplement the kidneys and invigorate yang: needling St 36, Liv 13, Liv 3, and moxa on CV 4. The needles in this case were retained for 12-15 minutes, about as long as the moxa took to burn.
Checking her leg length, the feet approximated within 1/4 inch. Palpation of channels and points revealed mild tenderness at Sp 3, 6, 9, and Ki 7, and more marked tenderness at Liv 3, GB 34, GB 41, and Eyes-of-the-Knee (Xi Yan) on both sides. There is no pain on the yang channels except for the lateral Eye-of-the-Knee. Based on the palpation examination, there are several possible treatments from which to choose. Point choices should be corroborated through palpation. In cases where the patient should be treated 1-2 times per week, I often choose two different treatments and alternate them from one treatment to the next.
In addition to placing a Ku Pun or Bong Rae moxa bowl on CV 4 as a part of the root treatment described above, I placed smaller moxa bowls directly on the Eye-of-the-Knee points where the knee pain was located.
Secondly, to normalize the flow of qi in the related channels, I needled all the tender points with mild stimulation, not retaining the needles for more than 30 seconds. I then palpated points on both the hand yang ming (paired with tai yin spleen channel), and the hand tai yang (paired with foot shao yin kidney channel) to see if there were any tender points around the elbow on the opposite side. This method is based on the idea that the hand and foot paired channels are a single unit and further on the idea of using yang to treat yin. The only point that was significantly tender was LI 11 which I needled contralaterally with retention but no manipulation.
The patient was sent home with a moxa pole to use on the knee daily and advised on diet to supplement the spleen and kidneys.
The patient returned several days later for a second treatment. She felt slightly less fatigued and her hip, inguinal area, and low back were not painful. There was still some pain in the knee and although her stress level was the same, her irritability was less. The tongue was the same as before, as was the pulse.
I chose the same root treatment as the first week, replacing Tai Chong (Liv 3) with Da Du (Sp 2) treated with a gold needle and very shallow insertion. Then, because Zu Ling Qi GB 41 continued to be tender, I chose to treat the yang wei mai/dai mai connections using Zu Ling Qi (GB 41) and Wai Guan (TB 5) only on the affected side. This choice was supported by the facts that there was liver depression qi stagnation and that the shao yang channel can be used to rectify the qi of the jue yin as well and by the fact that GB 41 can be used for pain of the low back, hip and lower leg. I used Ion Pumping Cords placing the black clip on GB 41 and the red on TB 5.
Choosing a very direct approach to channel-based treatment, I then burned several pieces of moxa on the heads of two needles in the Eye-of-the-Knee points instead of using the small moxa bowls.
These two strategies were alternated for a total of seven visits over five weeks. At this point the patient reported that her knee pain was at least 70-75% better, on many days not painful at all, and no longer hindered her lifestyle. In addition, she reported varying amounts of improvement in other symptoms such as fatigue, irritability, and cold hands and feet. The patient decided to suspend treatment for financial reasons, but considered her therapy a success. She has not returned for further therapy up to the present.
Other treatments to try in this case:
If expected results were not being achieved, I might have chosen to needle the Eyes-of-the-Knee on the opposite leg with gentle insertions, not manipulating these needles at all. Sometimes it is better not to stick needles right into the most painful areas.
Another possibility if results had not been satisfactory would be to try alternative root treatments, such as needle supplementation and/or moxa threads on Fu Liu (Ki 7) or San Yin Jiao (Sp 6) and warming moxa or moxa threads on Shen Shu (Bl 23) and Pi Shu (Bl 20). In my treatment strategies I did not use back shu points because I wanted to treat points only on one side of the body in order to save time.
An ear needle or pellet may be used in related ear points such as Kidney, Knee, Spleen, or others depending upon which ear point system you are trained to use.
An interdermal needle may be placed in the actual painful spots on the knees and taped in place.
This method of using pattern discrimination to determine appropriate root treatment plus palpation to determine effective branch treatment has a number of historical antecedents in both China and Japan. This treatment style is flexible and based upon specific and often immediate feedback from the patient’s body both in the selection of points for treatment and in the response to treatment as it is happening. Furthermore, creating a root protocol based on the patient’s pattern gives deeper, more thorough overall treatment, and hence, a better long term outcome.